Nursing Investigation Results -

Pennsylvania Department of Health
WILLIAM PENN CARE CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WILLIAM PENN CARE CENTER
Inspection Results For:

There are  113 surveys for this facility. Please select a date to view the survey results.

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WILLIAM PENN CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a revist and a complaint survey completed on February 28, 2020, it was determined that William Penn Care Center corrected the deficiencies identified during the survey of January 8, 2020, but continued to be out of compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services by failing to notify the primary care physician about treatment recommendations made by a wound care practitioner for one of 14 residents reviewed (Resident 14), resulting in the recommendations not being followed in a timely manner.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated October 19, 2019, revealed that the resident had moderate cognitive impairment, was at risk for pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure), and currently had a Stage 4 pressure ulcer (wound that extends through all layers of the skin and muscle) on her coccyx (tailbone).

Physician's orders dated November 29, 2019, included an order for the coccyx area to be cleaned with normal saline solution (salt and water solution), to apply a protective skin wipe (liquid that forms a protective barrier) to the skin surrounding the Stage 4 pressure ulcer, apply collagen (a protein used to assist in wound healing) to the base of the wound, apply calcium alginate (a substance that absorbs fluids and provides a moist environment to promote wound healing), and cover with a foam border dressing (a protective dressing that promotes a moist enviornment for wound healing). The dressing was to be changed every night shift. Physician's orders, dated December 10, 2019, changed the wound treatment for the coccyx to include that the calcium alginate was to be "fluffed" into the wound and not packed in tightly.

Physician's orders dated December 1, 2019, revealed that the resident had a wound on the right thumb that was to be treated daily, and an order dated December 11, 2019, changed the treatment to cleansing with normal saline solution, applying a protective wipe to the skin around the wound, packing the wound bed with collagen, then applying calcium alginate to the wound. The wound was to be covered with a 4 x 4 inch dry dressing and secured with tape.

Referral/response letters dated December 13, 2019, revealed that Resident 14 was seen by a physician from a wound care service, and on December 20, 2019, the resident was seen by a certified registered nurse practitioner (CRNP - a nurse with an advanced training who can diagnose and order treatments). Both letters included recommendations that the previously ordered wound treatments be changed to cleanse the areas on the coccyx and right thumb with normal saline, apply collagen to the wound bases, then silver alginate (in addition to absorbing fluids, the silver provides antibacterial properties) packing, and cover with a dry dressing. The dressings were to be changed daily.

However, the resident's Treatment Administration Record (TAR) for December 2019 revealed that treatments with calcium alginate (instead of silver alginate) were completed through December 28, 2019, and there was no documented evidence that Resident 14's attending physician was notified about the recommendations from the wound care service until a physician's order to use silver alginate was given on December 29, 2019.

Interview with the Director of Nursing on February 28, 2020, at 2:00 p.m. revealed that the facility could provide no documented evidence that Resident 14's attending physician was notified about the wound service's recommendations in a timely manner.

28 Pa. Code 211.12(d)(3)(5)Nursing services.



 Plan of Correction - To be completed: 03/24/2020

R14 is no longer in facility.
Education will be provided to licensed Nursing staff and new/ agency staff regarding new or changed wound recommendations from consulting physician, physician signatures upon consult, implementation of new orders and updating care plans.
To prevent this practice from reoccurring Physicians are being contacted upon receipt of Recommendation to confirm orders. New orders and wound care notes are written after confirmation of recommendations.
Audits will be completed by Director of Nursing/Designee weekly after wound rounds to ensure recommendations are signed by physician, nursing notes completed, care plans are updated & revised accordingly. Audit results will be reviewed with Quality Assurance committee for recommendations.
Root cause analysis has been completed.

In preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' healthcare choices were promoted by failing to note the correct information regarding cardiopulmonary resuscitation for one of 14 residents reviewed (Resident 2).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 2, 2020, revealed that the resident had moderate cognitive impairment, could understand, and could be understood by others. A Pennsylvania Orders for Life-Sustaining Treatment (POLST - a form that contains documentation of the resident's or the legal representative's choices regarding life-sustaining treatment, including if cardiopulmonary resuscitation (CPR) should be performed for a person who has no pulse and is not breathing), dated January 31, 2020, indicated that the resident was not to be resuscitated (DNR - Do Not Resuscitate), indicating that the CPR was not to be performed. The POLST form was signed by the resident's power of attorney (a person who is legally authorized to make decisions on the behalf of a person who can no longer make their own decisions) and was signed by the physician on January 31, 2020.

A summary of physician's orders, signed by the physician on February 11, 2020, indicated that the resident was to have CPR performed in the event that she had no pulse and was not breathing, and the dashboard section of the resident's electronic health record (contains basic identification information and the resident's CPR status) also indicated that CPR was to be performed.

Interview with Registered Nurse 1 on February 25, 2020, at 8:52 a.m. confirmed that Resident 2's clinical record indicated that CPR was to be performed.

Interview with the Director of Nursing on February 25, 2020, at 8:58 a.m. confirmed that the physician's order in Resident 2's clinical record was not correct, and the resident should have had a physician's order for DNR in accordance with the POLST.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 211.5(f) Clinical records.

28 Pa. Code 211.12(d)(3)(5) Nursing services.








 Plan of Correction - To be completed: 03/24/2020

R2 POLST (Pennsylvania Orders for Life-Sustaining Treatment) was reviewed and updated to reflect current order. Resident remains in facility in stable condition.
Audit of current residents have been completed to ensure healthcare choices are current related to Code Status and Physician orders. Licensed staff will be re-educated on obtaining POLST(Pennsylvania Orders for Life-Sustaining Treatment) signatures and updating change when they occur.
To prevent this practice from re-occurring POLST (Pennsylvania Orders for Life-Sustaining Treatment) will be reviewed for completion upon admission to ensure family and physician signatures are present on POLST (Pennsylvania Orders for Life-Sustaining Treatment) and orders will be reviewed to ensure both are accurate and updated in Electronic medical record system. A review of the POLST( Pennsylvania Orders for Life-Sustaining Treatment)will be part of the Care plans review process and updated accordingly with each care plan review.
Audits will be completed daily by Director of Nursing/Designee daily times 30 days, weekly times 2 weeks and Monthly. Audit results will be reviewed with Quality Assurance committee for recommendations. Root cause analysis has been completed.

In preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.


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