Nursing Investigation Results -

Pennsylvania Department of Health
SOUTHMONT OF PRESBYTERIAN SENIORCARE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SOUTHMONT OF PRESBYTERIAN SENIORCARE
Inspection Results For:

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SOUTHMONT OF PRESBYTERIAN SENIORCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on June 30, 2022, it was determined that Southmont of Presbyterian Seniorcare, was not in compliance with the 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(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of the facility policies, clinical record review, and staff interviews, it was determined that the facility failed to provide necessary supervision and an environment free of accidental hazards, to ensure that hot liquids were not accessible, resulting in actual harm for one of four Residents (Resident R47).

Findings include:

Review of facility policy "Skilled Nursing-Adverse Events", dated 1/2020, indicates "definitions: Adverse event: unexpected occurrence that resulting in serious injury or loss of customer satisfaction."

Review of policy "Skilled Nursing- Feeding guidelines", dated 1/2020 and re-reviewed 12/3/21, indicated that the Purpose of the policy was to assure safe oral food intake, and the policy indicates that: Residents that require assistance to consume their meal must have a seated assistant, unless otherwise instructed by nursing team leader.

Review of Stanford Health Care Burn Stages - Second degree (partial thickness) burns - defines a second degree burn as:
"Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful."

Review of Resident R47's profile face sheet indicated that they were admitted 7/22/21, with diagnosis Parkinson's disease (progressive disease marked by tremor, muscular ridged and not precise movement), unspecified dementia without behavioral disturbance (person loses the ability to think, remember, learn, make decisions, and solve problems) muscle weakness (lack of muscle strength), and history of TIA (clot blocks the blood to part of the brain). Review of Resident R47's quarterly MDS assessment (minimum data assessment - periodic assessment of resident care needs) indicated the diagnoses remained current.

During a review of the quarterly MDS Section G Functional Status Activities of Daily Living (ADL)- Eating dated 2/15/22, indicated Resident is in need of extensive assistance, and a one person assist with eating.

Review of information submitted by the facility on 3/29/22, indicated that Resident R47's leg was burned when reaching for hot soup.

Review of facility documentation "Southmont Temperature Log" dated 3/28/22, Dinner Meal Food Items Serving Temperature: indicates that Chicken Florentine Soup: Kitchen =207, Begin = 190, End = 156.

Review of facility documentation "Quality Peer Review Committee Bruise and Skin Tear Investigation" dated 3/28/22, indicated that "Resident pulled soup bowl across the table and spilled in his lap. Burn to top and lateral side of right leg." The facility documentation indicated that the only two staff who provided services to Resident R47 up until the time of the incident were: Nurse Aide Employee E4 and a casual Licensed Practical Nurse (LPN) Employee E8.

Review of facility documentation "Witness Statement" dated 3/28/22, revealed " Resident was yelling out "hot". Staff was serving dinner when resident was heard staff found resident with soup overturned on his lap poured towards his R thigh. Resident said, "It just happened when I yelled". Staff immediately removed soup bowl off resident placed towel on resident took him to be changed Nurse charge notified promptly. Second witness statement dated 3/28/22, indicated was serving dinner heard Resident yelling hot. No other witness statements were included in the facility documentation.

Review of facility documentation "quarterly dietary assessment" dated 2/1/22, indicates Resident R47 is "confused and combative at times, and is fed by staff."

During an interview on 6/29/22, at 12:43 p.m. Registered Nurse Unit Manager Employee E3, confirmed that facility documentation indicated Resident R47 wound had yellow slough - with blister.

Review of Resident R47's care plans for ADL's in place on 3/28/22, indicated that: Problem statement: "I am unable to feed myself" with supportive statement of: provide verbal cues and encouragement for resident to self-feed. Monitor for fatigue. Staff to feed resident remainder of meal. Staff assistance of one for eating.

During an interview on 6/29/22, at 12:49 p.m. Nurse Aide Employee E4 indicated that staff put down soup in front of Resident R47. Resident R47 grabs at food items and staff sit with him to assist with eating. Staff was not sitting with Resident R47 when staff was passing meals. The staff person who put the soup down was LPN Employee E8 who does not work full time, and the next thing NA Employee E4 heard was Resident R47 yelling hot.

During an interview on 6/30/22, at 12:00 pm. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to maintain an environment free from accidental hazards which resulted in actual harm to Resident R47 received a second degree burn from soup during a meal.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18 e (1) Management.

28 Pa. Code 211.10 c (d) Resident care policies.

28 Pa. Code 211.12 (d)(1)(5) Nursing services













 Plan of Correction - To be completed: 08/16/2022

Following the incident regarding resident R47 on 3/28/2022, the following took place: (1) the resident was cleaned and changed, (2) the physician, charge nurse, and family were notified, (3) wound treatments were ordered. Reeducation was also provided after the incident. R47 has since passed away. Team member workflows in the dementia neighborhood have been adjusted to allow for increased supervision of the dining area while meals are being served, helping to ensure the environment remains as free of accident hazards as is possible. An initial audit will be completed to ensure adequate supervision of the dining rooms to ensure the dining room remains as free of accident hazards as is possible. The audit will rotate between all 3 meals. Re-education will be provided to staff by "Lewis Litigation Support and Clicial Consulting, LLC" on Wednesday July 27th about Requirement Free of Accident Hazards/Supervision/Devices. An audit of the dining room meal service will be completed by the Director of Nursing or designee daily times 5, weekly times 3, and monthly times 2 thereafter. The audit will rotate between all 3 meals. The results of the audit will be brought to QAPI for discussion and review.
483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of facility policy, clinical records, facility documentation and staff interviews, it was determined the facility failed to do a complete and thorough investigation for two of four incidents reviewed (Resident R15 and Resident R47).

Findings include:

Review of facility policy " Adverse Events" dated 1/2020, indicated that the purpose was to establish guidelines for investigations of adverse events to prevent future occurrences, determine the facts and /or causes of the event, to identify trends, to determine what went right, to discover the need for additional education or disciplinary action and to comply with regulations. The policy is to identify adverse events and to conduct a thorough and timely investigation credible analysis to develop, implement and monitor the effectiveness of an appropriate action plan.

Review of Resident R15's profile face sheet indicated that diagnosis of unspecified Intellectual disabilities, which remains current as of the most recent MDS (minimum data survey - a brief period assessment of resident needs) dated 4/22.

Review of facility - clinical notes dated 7/23/21, indicated that Resident R15 inserted crayon into her vagina - requiring a trip to the emergency room and additional physician consults.

Review of Resident R47's profile face sheet indicated that they were admitted 7/22/21, with diagnosis Parkinson's disease, unspecified dementia without behavioral disturbance, muscle weakness, and history of TIA. Review of Resident R47's quarterly MDS assessment (minimum data assessment - periodic assessment of resident care needs) indicated the diagnosis remained current.

Review of information submitted by the facility on 3/29/22, indicated that Resident R47's leg was burned when reaching for hot soup.

Review of facility documentation " Quality Peer Review Committee Bruise and Skin Tear Investigation" dated 3/28/22, indicated that "Resident pulled soup bowl across the table and spilled in his lap. Burn to top and lateral side of right leg."

Review of facility documentation "Witness Statement" dated 3/28/22, revealed " Resident was yelling out "hot". Staff was serving dinner when resident was heard staff found resident with soup overturned on his lap poured towards his R thigh. Resident said, "It just happened when I yelled". Staff immediately removed soup bowl off resident placed towel on resident took him to be changed Nurse charge notified promptly. Second witness statement dated 3/28/22, indicated was serving dinner heard Resident yelling hot.

No incident report was noted for Resident R15's incident of crayons inserted into her vagina.

Review of the incident report for Resident R47's burn - failed to identify how the incident occurred - who placed the soup by Resident R47, and if they were aware of Resident R47's ADL's (activity of daily living needs).
.

During an interview on 6/30/22, at 12:05 p.m. the NHA (Nursing Home Administrator) and DON (Director of Nursing) were informed that the facility failed to complete a thorough investigation of two incidents for Resident R15 and Resident R47.
28 Pa. Code:201.14(a) Responsibility of licensee








 Plan of Correction - To be completed: 08/16/2022

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 the findings/conclusions set forth in the statement of deficiencies. The plan of correction has been prepared and/or executed solely because it is required by the provisions of Federal and State law.

On 7/20/2022 incident report was completed for R15 based on documentation and notes from investigation at time of event. On 7/22/2022, the Director of Nursing added who placed the soup and how it occurred to the investigation folder resident R47. An initial audit will be completed by the Director of Nursing or designee of the last 7 days of incidents and accidents to ensure thorough incident reports were completed. Re-education will be provided to nursing administration by the administrator or designee about completing thorough resident incident/accidents reports. An audit will be completed by the Director of Nursing or designee weekly times 4 and monthly times 2 thereafter of incidents and accidents to ensure thorough incident reports were completed. The results of the audit will be brought to QAPI for discussion and review.
483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns: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.
483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;
Observations:

Based on facility policy, clinical record review, facility documentation and staff interview it was determined that the facility failed to maintain the highest practicable mental and psychosocial well-being for one of four Residents (Resident R15).

Findings include:

Review of the facility policy "Social Services - Description of Social Work Programs" dated 1/2020, indicated that evaluating and alleviating the psychosocial factors which affect and/or are affected by the medical condition of the resident/patient. /communication and collaboration with community, health and welfare agencies in an effort to develop, use and improve services for the residents/patients and their families.

Review of Resident R15's profile face sheet indicated that diagnosis of Unspecified Intellectual Disabilities, which remains current as of the most recent MDS (minimum data survey - a brief period assessment of resident needs) dated 4/22.

Review of facility - clinical notes dated 7/23/21, indicated that Resident R15 inserted crayon into her vagina - requiring a trip to the emergency room and additional physician consults.

Review of information submitted by the facility on 12/15/21, indicated that Resident R15 was seen with another Resident's hand down her pants and the other resident's hand on breasts.

Review of Clinical Interdisciplinary Notes indicated the following:

7/23/21- When the nursing assistant was performing PM peri care the resident was yelling out in pain while wiping, only to find a crayon inserted in her vagina. Nurses were notified and charge nurse was made aware of incident and care to assess the situation. .. When trying to retrieve the crayon the other nurse pulled it out and half of the crayon was there. Resident stated that there were three crayons placed in private area. Resident to transfer to hospital.
7/26/21- Spoke with resident's mother. This morning regarding recent ER visit, upset as resident has never displayed this behavior in the past, voicing she has history of putting things in her ears and up her nose, but never in her private area.
7/28/21- When assisting Nurse Aide, resident was screaming in pain and fear, we used warm soapy water to clean vaginal area, also odor of vaginitis light pink /tan discharge and denuded skin. Resident screamed and cried the entire time. Tramadol given for comfort resident still sobbing in bed.
8/11/21- Resident tearful tonight ... has been in and out of male resident room (staff reminds Resident R15 not to go in and other resident curtain is closed.
8/12/21 - Resident R15 returned from gynecologist consult. Received orders to treat genitalia and inner thighs redness and scaly skin . Doctor encourages staff to change resident as frequently as possible due to incontinence.
8/14/21- child- like mentality. At times has tearful episodes, can be difficult to console or redirect at times. Began course of antifungal Tx for redness to inner thighs, peri area. .
8/17/21- Resident R15 POA (power of attorney) wanted to know why she was not notified of Resident R15 rash in groin area. POA stated that doctor said there is no way Resident put crayons down there because she could never do that, and why doesn't ' t Resident get changed more often.
8/20/21- Nurse Aide came to nurse and DON to help with resident R15 during am care. Resident R15 pubic hair was matted with some drainage - noticed a few areas of concern.
8/23/21- Resident R15 crying on and off. Resident had strong vaginal odor.
8/26/21- Child- like mentality with reportedly increasing attention seeking behaviors, spontaneous crying jags, yelling. Can be difficult to redirect at times, on occasion use diversional activities helpful. Requires maximum assist with ADLs at times tearful and resistant with care. On occasion Resident R15 has painted with stool, smearing it on her bed, siderail, self - including face.
9/11/22- Nurse Aide reported that when Resident R15 was approached this morning to change brief Resident R15 hit staff in the abdomen. Resident R15 was redirected by Nurse Aide and then became tearful.
9/14/21- Childlike mentality Requires max assist to total care for ADLs on occasion has been resistant and at times combative with care. Transfers with assist of two. Propels self about room and unit, reportedly wanders into rooms of other residents despite reminders. At times paints with her BM.
9/15/21- When staff approached resident to place in bed and cleaned, resident began screaming and screeching very loudly , even though staff was not directly touching her. This nurse and another Nurse Aide helped to calm down resident, and resident was changed. Resident has history of yelling, combative with care tonight.
9/20/21- ... childlike mentality, does tend to play in BM.
9/26/21- Requires assist for ADLs at times can be combative with staff. Can be difficult at times to redirect, episodes of tearfulness. ... At times wanders into the rooms of residents ... at times paints with stool.
10/14/21- ... childlike mentality. Requires assist for ADL's, can become agitated and combative during care. Transfers with assist of tow, OOB (out of bed) to wheelchair during the day and able to propel self about unit, at times entering other resident's room despite reminders.
11/11/21- Nurse Aide reports that she just finished checking on resident, changed her brief and during that time resident had hit her.
11/24/21- Resident approached another resident, slapped her on the left arm
11/26/21- Alert and verbally responsive with a childlike mentality. Periods agitation, recently hit another resident and on occasion has hit Nurse Aides during care. At times resident becomes tearful with attempts to redirect, and at times exhibits attention seeking behaviors.
11/27/21- resident crying for much of shift, difficult to redirect refused to get OOB and initially refused care
11/30/21- Resident was observed by a staff member purposely pushing w/c into another resident's w/c then grabbing own leg as if other resident hurt her and started to cry, when staff told resident that they saw what happened, she stopped crying instantly and propelled herself away from other resident.
12/2/21- Reported by Nurse Aide that resident was combative during care, hitting at Nurse Aide repeatedly. When this nurse spoke with resident about hitting she puts her head down refusing to make eye contact, but when subject is changed she lifts head and offers huge smile.
12/8/21- resident refusing to get OOB this morning, when Nurse Aide approached initially, resident began to scream and threw objects that were nearby
12/8/21- resident showered due to playing in stool, on bathroom floor, in hair hands bed linens
12/11/21- resident very combative with care this shift. Smacked nurse aide when trying to help change
12/12/21- resident refusing to get OOB this shift. Very combative with staff. Hitting and swinging at agency aide. Behaviors have increased over past weeks with staff
12/14/21- alert and aware with childlike mentality . Resident with adverse behaviors at times, yelling out, hitting staff, resisting care. Can be difficult to redirect at times. Incontinent with reported episodes of resident painting with bowel movement.
12/14/21- resident continued episodes of combativeness, resistance with care. Staff unable to determine what provokes behavior
12/15/21- resident continues to have combative episodes with staff, was hitting and grabbing at staff
12/15/21- this resident was removed from sitting beside another resident due to inappropriate interaction
12/16/21- resident was combative with care this morning requiring three nurse aides to complete care. Staff asked for a male employee to assist with transfer from bed and resident smiled and was compliant
12/17/21- Call placed to doctor regarding residents combative behavior. Doctor does not feel that resident tis depressed but feels that resident may benefit from psychologist visits. Mother is okay with psychologist visit but does not think it will help due to residents mentation. Mother voiced she has spoken with resident and requested that "she stay away from men and she wouldn't get into trouble" mother then stated , "I doubt that she will listen though" Mother also requesting to be present during care to see how resident acts and if she can offer suggestions
12/18/21- resident again has been combative with care this morning, nurse aide had to request help form another male nurse aide to complete am hygiene, resident was cooperative with care from male nurse aide
12/20/21- resident refused care with this morning from aide, and this nurse again, multiple attempts made.
12/26/21- resident was combative this morning with care, hitting staff and crying out
12/31/21- spoke at length to residents mother regarding continued behaviors, continues to be combative with care, reportedly last evening resident smeared bowel movement all over recliner chair as well as herself, including face
1/4/22- mother and nurse also discussed resident's behaviors of playing in her stool and refusing to get up and refusing care, swinging at and hitting staff
1/14/22- resident refused to get OOB this morning, initially slapping at caregiver ... When caregiver approached after lunch meal , resident was attempting to hit caregiver ...Resident had smeared bowel movement all over her hands and face prior to staff entering room
1/17/22- resident once again has put her hands in her pants and smeared all over her face, near her eyes, all over her bed, in her hair, floor wall and cloths
1/18/22- resident smeared bowel movement on self this morning, arms, hands and face - voicing "I'm bad"
1/26/22- Has a child- like mentality. Can be tearful at times
1/27/22- resident found playing with BM smearing it on tray table.

Review of clinical documentation from 7/23/21 through 1/4/22, indicated Resident R15 was sent out to doctor's appointments, and provided with follow up for having crayons in her vagina.

During an interview on 6/29/22, at 12:30 p.m. Registered Nurse Unit Manager Employee E3 Indicated that Resident R15 was referred to psych services for behaviors and incident on 12/15/21. During the same interview it was indicated that Resident R15 masturbates in the evening, frequently after staff have assisted putting her into bed.

Throughout the survey clinical documentation was requested for resident R15's behaviors.

Review of the clinical record failed to indicate how the faciliy monitored and provided psychosocial interventions for Resident R15 behaviors. No other documentation was provided during the survey.

During a review of a therapy note dated 1/4/22, no information was noted regarding behaviors - of playing in feces, being combative, or of incident with other resident on 12/15/21, or of resident inserting crayons in her vagina or masturbating in the evenings. No other information was noted in the clinical record for how the facility assisted the resident with the above behaviors.

During a phone interview on 6/30/22, at 9:17 a.m. with the Psychologist - he confirmed that he did not recall being informed of resident incident with sticking foreign object in vagina, nor the incident in December with another resident and inappropriate touching, or of Resident R15 playing in feces for an extended period of time. When asked psychologist stated that the above information is information that he would include in an evaluation. Psychologist was brought in because Resident R15 was depressed and withdrawn - had he been informed of behaviors he would include in his evaluation.

Review of care plans identified the following problems:
Behavior Problem
I exhibit physically abusive behavior; as evidenced by hitting residents dated 12/22/21, with interventions dated 1/19/22.
I resist care from others dated 12/22/21, with interventions dated 1/19/22.
I play in my bowel movements and throw it on the floor and on my table and baby dolls dated 2/13/22, and resolved 2/13/22.
I will sit outside of room 432 until the resident gets up and I drop colored pictures and notes at 432 doors dated 5/14/22.
I exhibit socially inappropriate behavior as evidenced by sexual behavior dated 7/23/21, resolved date of 1/26/22.

Miscellaneous problems
I wander into others rooms dated 7/11/21, resolved date of 7/11/21.

During an interview on 6/30/22, at 12:15 p.m. Director of Nursing was informed that the facility failed to maintain Resident R15's highest practicable mental and psychosocial well-being, failed to identify resident's behaviors with inserting foreign objects in vagina, playing with feces, or with the incident with inappropriate touching.

28 Pa. Code 221.11(d) Resident care plan

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








 Plan of Correction - To be completed: 08/16/2022

Resident R15 was referred to our psychologist who has already seen her and completed a comprehensive assessment. His additional recommendations will be added to her plan of care such as "encourage resident's continued participation in formal and informal activities and social interactions." Resident R15 has not displayed similar mental/psychosocial behaviors recently. We do not currently have any other residents with intellectual disability in house. An initial audit for in house residents that trigger on the MDS for psychosocial well-being and targets will be completed by the Director of Nursing or designee to assure plans of care are in place and psych services are consulted as necessary. Re-education will be provided to licensed nursing staff and social services by the Director of Nursing or designee about ensuring appropriate care plans are in place for residents that trigger on the MDS for psychosocial well-being. An audit of 5 new admissions will be completed by the Director of Nursing or designee weekly times 4 and monthly times 2 thereafter to ensure appropriate psychiatric referrals are made for those that trigger on the MDS for psychosocial well-being. The results of the audit will be brought to QAPI for discussion and review.

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