Nursing Investigation Results -

Pennsylvania Department of Health
SOUTHEASTERN PENNSYLVANIA VETERANS' CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SOUTHEASTERN PENNSYLVANIA VETERANS' CENTER
Inspection Results For:

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SOUTHEASTERN PENNSYLVANIA VETERANS' CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to two complaints, completed on July 16, 2021, it was determined that Southeastern Pennsylvania Veteran's Center, 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 clinical record review, observations, and staff interview, it was determined the facility failed to develop interventions to prevent falls for one of six residents reviewed causing actual harm of a hip fracture to Resident 23.

Findings include:

Review of facility policy entitled "Falls Prevention," dated September 2017, revealed nursing will do falls assessments with admission, quarterly, and PRN (as needed) on all residents. Any resident scoring 10 points or above is considered a high risk for falls. The interdisciplinary team (IDT) will review resident falls during every morning report, the IDT will discuss to determine root cause of fall, any needed interventions and any system changes that may be necessary to decrease falls and/or prevent serious injury from falls. An individualized, person centered nursing care plan will be initiated and updated as needed.

Review of Resident 23's Quarterly Minimum Data Set assessment (MDS-periodic assessment of resident care needs), dated January 28, 2021, revealed the resident could independently transfer and walk in his room and around the facility. The resident also had a BIMS (brief interview for mental status) score of 3 indicating the resident had severe cognitive decline.

Review of Resident 23's care plan developed April 7, 2015, identified the resident being a high risk for falls with interventions developed to prevent falls.

Review of Resident 23's progress notes revealed a nursing entry dated March 29, 2021 at 4:00 p.m. stating "this nurse heard a loud noise coming from the resident's room. Resident was lying on the floor on his right side close to the bathroom door. RNS (Registered Nurse Supervisor) and physician notified. Resident c/o (complained of) right leg pain when in bed. X-ray of bilateral (both) hips to r/o (rule out) hip fracture done as per order."

Further review of Resident 23's progress notes revealed a nursing entry on March 29, 2021 at 9:05 p.m. stating "x-ray result received: acute fracture at the base of the femoral neck (broken hip). MD ordered to send to ER for evaluation."

Further review of Resident 23's progress notes revealed an entry dated March 30, 2021, at 12:09 a.m. stating resident "will be admitted. Admitting diagnosis is acute displaced right femoral neck fracture." (broken hip)

Further review of Resident 23's progress notes revealed a nursing entry dated April 1, 2021, at 7:23 p.m. that indicated the resident returned from the hospital. Resident was admitted to the hospital for right hip fracture requiring arthroplasty (surgical repair).

Review of the facility's investigative report for Resident 23's fall revealed the fall occurred at 4:00 p.m. on April 1, 2021. Review of all facility documentation revealed there was no final determination of a cause and there were no new interventions put into place after this fall as should have been completed per facility policy.

Review of Resident 23's care plan revealed there was no evidence that new interventions were developed and added to the care plan after this fall.

Review of Resident 23's Significant Change MDS dated April 12, 2021 completed upon return from the hospital after the fall on March 29, 2021 resulting in hospitalization on March 30, 2021, revealed the resident now required two people to extensively assist when resident would transfer and walk in room and limited assistance when walking in the facility.

Review of Resident 23's fall risk assessment dated April 1, 2021 revealed the resident had a score of 22 which determined the resident to be at high risk for falls.

Review of Resident 23's progress notes revealed a nursing entry on April 8, 2021, at 4:10 p.m. stating "this nurse saw resident lying on the floor on his back close to bed."

Review of Resident 23's facility investigative report April 9, 2021 revealed the fall occurred at 4:10 p.m. on April 8, 2021. Review of a fall assessment committee note dated April 9, 2021, revealed there was a therapy screen ordered and to consider the use of signage due to poor safety awareness.

Review of the Root Cause/Signature Page event Report revealed new interventions of, give resident verbal reminder not to ambulate or transfer without assistance and PT (physical therapy) will give Broda Chair (a chair that is larger and more padded then a wheelchair and can tilt back to a lying position) There was no determination of a root cause of the fall as should have been completed per facility policy.

Review of Resident 23's clinical record revealed there was no documented evidence the resident received a Broda Chair. Observations of Resident 23 during all days of the survey revealed the resident was in a regular wheelchair and not a Broda chair. Interview with the Director of Nursing and Nursing Home Administrator on July 16, 2021, at 12:30 p.m. confirmed Resident 23 never received a Broda Chair.

Review of Resident 23's fall care plan revealed there was no evidence of new interventions developed after the fall of April 8, 2021.

Review of Resident 23's progress notes revealed a nursing entry dated May 6, 2021, at 4:11 p.m. stating "the resident was sitting in the dining room on A side and had an unwitnessed fall. when this writer arrived at the scene the resident was laying on his left side on the floor. Resident stated no injuries"

Review of the facility's investigative report for the May 6, 2021 fall revealed there was no evidence of an investigation to determine the cause of the fall and no evidence of new interventions developed to prevent falls as should have been completed per facility policy.

Review of Resident 23's care plan revealed there was no evidence of new care plan interventions developed after the fall of May 6, 2021.

Review of Resident 23's progress notes revealed a nursing entry dated May 29, 2021, at 5:42 p.m. stated "resident found on the floor after using the restroom. Resident has complaints of pain in his left hip and left wrist. STAT (immediate) x-ray orders obtained."

Review of Resident 23's progress notes revealed a nursing entry dated May 30, 2021 at 3:45 a/.m. stating "resident off the unit at 11:40 p.m. to the emergency room for evaluation and treatment"

Further review of Resident 23's progress notes revealed a nursing entry on May 30, 2021, stating "received call back from hospital. Resident is awaiting orthopedic consult and will probably wait until Tuesday 6/1/21 for ORIF (Open Reduction Internal Fixation- surgical repair of hip fracture)".

Interview with the Nursing Home Administrator and the Director of Nursing on July 16, 2021, at 12:30 p.m. confirmed there were no new interventions developed and care planned for Resident 23 after the falls of March 29, April 8, and May 6, 2021.

The facility failed to thoroughly review, determine cause, or develop new or effective fall prevention interventions after the fall with fracture on March 29, 2021. This facility failure resulted in a decrease in transfer and walking ability but with increased fall risk resulting in subsequent non injury falls on April 8, and May 6, 2021. Resident 23 suffered actual harm during a fall on May 29, 2021 resulting in another hip fracture requiring surgical repair.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1) (e)(1) Management

28 Pa. Code 207.2(a) Administrator ' s responsibility

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.11(d) Resident Care Plan

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

















 Plan of Correction - To be completed: 08/09/2021

- An interdisciplinary team meeting was held to review falls of resident R23 in order to determine the Root Cause and initiate interventions to prevent further falls. Interventions were care planned accordingly.

- A review of all residents that have had a fall in the last fourteen days will be completed by the interdisciplinary team to identify other residents having the potential to be affected by the same deficient practice and to ensure that preventative interventions were implemented and are care planned.

- The Fall Policy will be reviewed and revised as necessary. The interdisciplinary team and licensed staff will be educated by Nursing Leadership on F tag 0689, fall interventions and the revised Fall Policy.


- All Falls will be reviewed on an ongoing basis at the morning meeting by the interdisciplinary team to ensure that preventative interventions were implemented post fall and that they are care planned accordingly. Furthermore, a falls committee meeting consisting of at minimum nursing members, therapy, pharmacy and quality assurance will be conducted on a monthly basis to review interventions and efficacy of overall fall program and to discuss individual resident fall concerns. Any negative findings will be reviewed at the monthly Quality Assurance meeting for additional recommendations.


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