|§ 483.25 Quality of care |
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Based on clinical record reviews and review of facility's documentation, it was determined that the facility failed to provided one of nine residents reviewed (Resident R 1) with two person assistance during dressing which resulted in actual harm to Resident R1 falling out of bed, requiring emergency medical services, transfer to the hospital and diagnosis of C1 and C2 neck fractures. Further, the facility failed to ensure that an order given by the Certified Registered Nurse Practicioner was followed, for one of nine residents reviewed, resulting in actual harm to Resident R2 who experienced severe left leg pain, resulting from a left tibia/fibula fracture. (Resident R2)
Review of Resident R1's clinical record revealed that the resident was admitted on January 23, 2015 with the diagnoses include but not limited to anemia (a reduction in red blood cells), dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), history of falls, contracture of the right hand, muscle weakness and abnormalities of gait and mobility.
Review of the quaterly Minimum Data Set (MDS-a periodic assessment of the resident's needs) completed on April 25, 2019 revealed that the resident was cognitively impaired; there were no behavior symptoms identified and no indication that the resident reject care. Resident R1 was totally dependent for bed mobility, dressing, personal hygiene and full body bath/ shower requiring one person assistance. The resident was totally dependent with transfers and toilet use requiring 2 person assistance. The resident's balance for surface to surface transfer (transfer between bed and chair or wheelchair) was coded not steady, only able to stabilize with staff assistance.
Review of the resident's care plan initiated July 12, 2019 identified the resident with Activities of Daily Living with self care performance deficit related to aggressive behavior, dementia and contracture. The interventions included in the resident's plan of care included to transfer the resident via mechanical lift with 2 person assist, bath/shower the resident with assistance of 1 staff member, for bed mobility the resident required assistance of 2 staff for reposition and to be turn in bed, for dressing the resident required assistance of 2 staff members and 2 staff members with personal hygiene.
Review of physician's notes revealed a Certified Registered Nurse Practitioner (CRNP) note dated July 2, 2019 documented, "patient has no medical problem to report." "Nursing staff reports that the resident is verbally aggressive and refuses care." Further review of the CRNP's note indicated that the resident had a history of major depression with psychotic features "will consult psychiatry to review medications related persistent verbal aggression and refusal of care. Dementia-progressive."
Reviewed of nurse's notes dated July 21, 2019 completed by licensed staff, Employee E4 revealed "at approximately 7:30 am, [Employee E4] was called the resident's room by the CNA (nursing assistant) to assess the resident because she had a fall, upon entering the room [Employee E4] observed the resident lying on her right side on the floor next to her bed, resident was noted with a large hematoma to her forehead, resident assessed for pain and resident denied pain at the time...supervisor called to assess the resident's injury, resident assisted back into bed with 2 person assitance and resident was combative during transfer, supervisor assisted for injury and stated to call 911 rescue, MD (physician) and RP (responsible party) notified of resident's condition and transfer, CNA questioned as to what happened and the CNA reported that while she was getting the resident dressed for the morning, she had the resident sitting on the side of the bed while supporting her in an upright position and at that time she proceeded to fix the back of the resident's shirt; the CNA stated that she leaned over the resident in an attempt to fix the back of the resident's shirt, and art that time the resident bit her in the chest, the CNA reported that she jumped back in reaction to the resident biting her causing her to let go of the resident, at that time the resident lost her balance and fell to the floor, 911 rescue was called and arrived to the unit at approximately 7:45 am.
Further review of nursing notes dated July 21, 2019 at 11:02 a.m. noted that "at approximately 10:30 a.m. the resident's physician form the hospital called and informed the Employee E4 that the resident had a C1,C2 (spinal vertebrate at the top of the neck) fracture and the resident was being admitted to the hospital.
Review of hospital record revealed "patient reportedly bit her aide during a transfer from bed and was dropped. She reported neck pain, was found to have a scalp hematoma (a collection of blood outside of a blood vessel), acute type 2 odontoid fracture (a break that involves the second vertebrae (Cervical 2) high in the neck), and nondisplaced fracture posterior ring C1 left and right.
Reviewed facility's investigation into the fall sustained by Resident R1 including witness statements revealed a statement obtained from nursing staff Employee E3 who reiterated "I was giving care to the resident I sit the resident up right position with my support I lean to the back to fix her shirt the resdient became combative and bit me on my chest I jumped back cause me to let go of the resident. So the resident lost her balance and fell to the floor." Employee E4 indicated on her statement that the resident could not sat up by herself.
Further review of Employee E3 revealed that Employee E3 also stated that prior to this incident, she was bitten on the arm by the resident in the presence of the charge nurse. Employee E3 indicated that her skin was not broken and that she did not feel like going through making a report.
Review of the charge nurse, Employee E4's statement revealed that she witness the resident bite the care nurse on her arm. The event occurred between July 1st and July 3rd. The charge did not document the behavior. She stated " I forgot to put it in."
Review of the statement from the care nurse that provided care to the resident during night shift, Employee E5 revealed that he did not wash and dress the resident that morning because the resident was combative. He also said that he did not report the resident's behavior to the charge nurse.
The facility failed to ensure that Resident R1 was provided with two person assistance during dressing which resulted
in actual harm to Resident R1 falling out of bed, requiring emergency medical services, transfer to the hospital and diagnosis of C1 and C2 neck fractures.
Review of Resident R2's clinical record revealed that the resident was admitted to the facility on February 27, 2011. with the diagnoses include dementia, cerebral vascular accident (stroke) with right hemiparesis (paralysis/weakness to one side of the body) and anemia.
A review of the resident's quaterly Minimum Data Set dated May 10, 2019 revealed that the resident required extensive assistance with 2 person assistance with bed mobility and transfers; total dependence with 2 person assistance for toilet use and full body bath/shower. Resident was non-ambulatory.
Review of the nurse's note for July 12, 2019 10:40 p.m. revealed that the nurse assistant notified the licensed nurse that "resident was complaining of pain during evening care. Resident was assessed for injury. No injury noted. Resident often cries out during evening care. Resident was put to bed without further incident."
Reviewed the "Incident/Accident" report dated 7/16/2019 and witness statements revealed the resident attended a group activity on 7/12/19 and returned to her nursing unit between 3:30 p.m. and 4:00 p.m. The resident participated in the activity while being seated in her wheelchair and did not complain of any pain.
Review of the written statement from the nurse aide assigned to the resident, Employee E9 stated that after dinner on 7/12/19, she noted that the resident's leg was not on the footrest. When she attempted to place the foot on the leg rest the resident screamed out in pain. She and two other nurse aides lifted the resident into bed. The resident continue to screamed about her leg after being laid down. The nurse aide notified the charge nurse. The charge nurse looked at the leg, touch it and the resident scream out. A second care nurse that was in the room also stated that when the charge nurse touched the resident's leg, the resident started hollering.
Review of nursing notes dated on July 13, 2019 at 1:47 p.m., revealed "charge nurse asked supervisor to assess resident left lower extremity, upon my assessment resident range of motion performed to left hip and left leg. Resident started screaming very loudly and left leg swollen warm to touch, positive pedal pulses. CRNP (certified registered nurse practioner) notified, ordered bilateral hip x-ray and bilateral leg x-rays...Resident medicated for pain, nurse will continue to monitor."
Review of July 2019 Medication Review Report confirmed that a physician's order was obtained for x ray to bilateral hip and legs to rule out fracture on July 13, 2019.
The result of Resident R1 bilateral hip x-ray report dated July 13, 2019 revealed no acute fracture of the right or left hip. There was evidence that an x-ray was obtained of the resident bilateral legs as ordered by the physican on July 13, 2019.
Review of nurse's note dated July 13, 2019 at 10:13 p.m. indicated that the physician was made aware that there was no acute abnormality seen on x-ray. There were no nurse's notes on July 14th or 15th regarding the resident's activity level, comfort level or condition.
Further review of nursing notes revealed that on July 16, 20119 at 1:30 p.m., the Unit Manager, Employee 13 noted that the staff reported that the resident received morning care; ate 70% of breakfast and lunch; received incontinent care with no complaint of pain. At 7:07 p.m. licensed nursing staff, Employee E14 noted that the resident was in severe pain. Further review of nursing notes dated July 16, 2019 at 10:21 p.m. Employee E14 revealed, "resident received in bed awake and alert upon my arrival. I overheard the care nurse speaking of the resident showing s/s (signs and symptoms) of extensive pain to her left leg, how it had been reported to a charge nurse previously, and that an x-ray had been completed and came back no injuries. I had not received any reports of this situation and it was not on the 24 hour report since I returned back on Monday 7/15/2019. Upon learning this I assess the resident's leg. I asked the resident was she having pain in her leg and she shook her head yes. When I pulled back the sheet, I immediately observed the left lower anterior leg was indented, yellow in color, warm to the touch, with intense pain upon touch. The resident screamed out from the touch of my index finger.... [physician] notified, new order given for stat x-ray to left knee, tibia/fibula, and foot."
Nursing note dated July 16, 2019 at 11:43 p.m. revealed that the x-ray technician was not able to complete all views as order due to excruciating pain on movement. The resident's physician notified and order obtained to send resident to hospital. Review of nursing note dated July 17, 2019 at 1:16 a.m. revealed that the resident was transported by ambulance to the hospital at approximately 12:00 a.m. Further review of this note indicated "her radiology report came back with the conclusion: Acute fractures of the left lower leg."
Review of the x-ray report dated July 16, 2019 confirmed acute fractures of the left lower leg.
Review of hospital documentation revealed that on July 20, 2019 resident had left tibia open reduction and intramedullary fixation and open treatment of left fibular fracture.
The facility failed to ensure that an order given by the Certified Registered Nurse Practicioner was followed, resulting in actual harm to Resident R1 who experienced severe left leg pain, resulting from a left tibia/fibula fracture.
28 Pa Code 201.14 (a) Responsibility of licensee
Previously cited 06/20/19
28 Pa Code 201.18 (b)(1) Management
28 Pa Code: 211.10(d) Resident care policies
Previously cited 02/06/19
28 Pa Code 211.12 (d)(1) Nursing services
Previously cited 02/06/19
28 Pa Code 211.12 (d)(2) Nursing services
Previously cited 02/06/19
28 Pa Code 211.12 (d)(5) Nursing services
Previously cited 02/06/019
| ||Plan of Correction - To be completed: 10/11/2019|
The facility submits the following Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements.
Resident R1 had been treated at the hospital and then readmitted back to the facility. Resident R1's care plan has been revised to reflect 2 person assist with dressing.
Residents identified as requiring two person assist for dressing will be reviewed to ensure their plan of care reflects number of staff needed for dressing.
Nursing staff will be reeducated on ensuring plan of care reflects number of staff needed to provide assistance with dressing.
Random weekly audit will be done by Unit Manager/Designee to ensure plan of care reflects number of staff needed for dressing. Audit findings will be reported in monthly QAPI x3.
Resident's R2s x-rays were completed and treated at the hospital. Resident has returned to the facility.
Clinical records of resident with orders for xray will be reviewed to ensure views completed reflect NP/MD order.
Nursing will be educated to ensure that x-ray reports reflect views as ordered by NP/physicians.
Daily audits of xray orders received will be done by Unit Manager/Designee to ensure diagnostic report matches requested view/sites. Identified discrepancies will be addressed immediately. Findings will be reported in monthly QAPI x3.