Nursing Investigation Results -

Pennsylvania Department of Health
BALL PAVILION, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BALL PAVILION, THE
Inspection Results For:

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BALL PAVILION, THE - 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 December 5, 2019, it was determined that The Ball Pavilion, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


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 observation, review of clinical records and facility policy, and resident and staff interviews, it was determined that the facility failed to allow residents the right to make choices about aspects of his or her life in the facility that are significant to the resident for one of 19 residents (Resident R10).

Findings include:

Resident R10's clinical record revealed an admission date of 12/21/17, with diagnoses that included heart failure, irregular heart rate, dementia, a lung disease, and peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs).

A quarterly Minimum Data Set (MDS- periodic assessment of resident care needs) dated 11/27/19, indicated that Resident R10 had a Brief Interview for Mental Status (BIMS-tool used to assess cognitive status) of 13 (a score from 13 to 15 indicates intact cognition, or mental status).

Observation on 12/03/19, at 11:19 a.m. at the A Hall nurse's station revealed Resident R10 sitting in his/her wheelchair in front of a rolling tray table containing a plate with a piece of toast and a cup of coffee.

During an interview on 12/03/19, at 11:25 a.m. Resident R10 shared that staff told him/her that he/she overslept so he/she had to eat breakfast here at the nurses's station. Resident R10 also stated that he/she didn't like eating in the hall at the nurse's station, and that he/she wanted to get up in time to eat with his/her friends in the dining room. He/she stated, "I don't care to eat out here, but you got to eat somewhere. I like to get up early to eat breakfast with my friends. I've told them that."

During an interview on 12/04/19, at 3:00 p.m. Resident R10 shared that he/she didn't get up today until between 9:00 a.m. and 9:30 a.m. and that staff woke him/her at that time and that he/she did not wake up on his/her own. "I told them last night that I wanted up by 7:30 so I could eat with my friends." He/she stated that staff told him/her they tried, but he/she doesn't remember getting awakened up at that time. "I want up by 7:00 a.m., I was in the military, I want them to wake me and ask but make sure I am awake when I answer. I do not want to sleep in. Why can't they wake me at 7:00 a.m. when they are allowed to at 9:00 a.m.? What's the difference?"

During an interview on 12/05/19, at 11:00 a.m. the Director of Nursing (DON) confirmed that staff are permitted to wake residents up at a designated time and that residents who don't require supervision or assistance with eating are permitted to eat in their room.

During an interview on 12/05/19, at 1:15 p.m. the DON indicated waking times are chosen by residents and that employees have been inserviced this year regarding this aspect of their lives.

28 Pa. Code 201.29 (j) Resident rights

28 Pa. Code 201.18 (b)(1)(3) Management

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 1/10/19






 Plan of Correction - To be completed: 01/30/2020

F 0561 Right to Self-determination

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: A "Star Service" was added for resident R10 Per her request that she would like to be "awakened everyday by 9am for breakfast and that she wants to eat in dining room." Star Service means that a note indicating this was posted in her closet, (alongside a post indicating her transfer status). This was added to the Nurse Aide's task list, which they must document on daily, and added to the resident's Care Plan on 12/18/19. Also, "Star Service," and the principals of Person Centered Care were reviewed at the Monthly Nurse Aide meeting son December 17th, 2019.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? In order to identify other residents having the potential to be affected by the same deficient practice, Social Services will interview current residents to determine if their preferences for waking times, bed times, and dining are being honored. If the resident states they are not, social services will facilitate getting an order on the CNA task list and updating the resident's care plan to reflect their wishes. It may also be a "star service" for a resident if needed. Social Services will complete the interviews of residents by January 30th, 2020.
Also, beginning January 1, 2020, Social Services will interview all new residents and/or their family members to determine if they have a preferred wake up time, preferred bed time, and dining preference. If preferences are verbalized on admission, Social Services will facilitate these wishes through the CNA task list and the resident's care plan.

To make sure that the deficient practice does not recur, the Director of Nursing will write a policy for Nursing Staff regarding Person Center Care and honoring resident wishes for awakening time, bedtime, and dining preferences. Nurses will be educated on the new Policy at Nurse Skills review days on January 14th and 15, 2020. Nurse Aides will be educated on the new policy at monthly Nurse Aide meetings on January 27th, 2020.
Also, Social Services will interview 5 alert and oriented residents from each unit per week and ask them if their wishes for waking time, bed time, and dining preferences have been honored. The results of these interviews will be recorded and reported to the DON weekly who will investigate any reasons why resident preferences were not met. The DON will follow up with Nursing staff and discipline as necessary.
These weekly audits will continue through February 28th, 2020.

What Quality Assurance Process will be put in place for review? This will be reviewed at monthly QAPI meetings with the Director of Nursing reporting on the audits.

483.25 REQUIREMENT Quality of Care: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.
483.25 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.
Observations:


Based on review of clinical records and staff interviews, it was determined that the facility failed to follow physician orders for four of 19 residents (Residents R10, R12, R23 and R63).

Findings include:

Resident R12's clinical record revealed an admission date of 1/31/03, with diagnoses that included Type 1 diabetes (condition where the body makes very little or no insulin that's needed for blood sugar to enter the cells in your body for energy), cerebral palsy (birth defect that affects movement and muscle tone or posture), muscular dystrophy (condition where abnormal genes cause progressive weakness and loss of muscle mass), and high blood pressure.

A physician's order for Resident R12 dated 4/20/19, identified that staff are to notify the physician for blood sugars less than 60 milligrams/deciliter (mg/dL). Resident R12's clinical record revealed that on 11/01/19, at 7:00 a.m. his/her blood sugar was 48 mg/dL. The clinical record lacked evidence that the physician was notified of Resident R12's blood sugar level.

During an interview on 12/05/19, at 12:59 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the clinical record lacked evidence that staff contacted the physician regarding Resident R12's blood sugar of 48 mg/dL.


Resident R63's clinical record revealed an admission date of 12/20/18, with diagnoses that included dementia (a group of symptoms that affect memory, thinking and interferes with daily life), Type 2 diabetes (affects how your body uses blood sugar or glucose), and depression.

A physician order, dated 10/22/19, identified that the physician should be notified if Resident R63's blood sugar was less than 70 mg/dL or greater than 400 mg/dL. Between 11/11/19 and 12/4/19, there were four instances when Resident R63's blood sugar was less than 70 mg/dL and 13 times their blood sugar level was greater than 400 mg/dL. The clinical record lacked evidence that the physician was notified of the above low and elevated blood sugar levels.

During an interview on 12/3/19, at 4:00 p.m. the Director of Nursing confirmed the above information.


A facility policy entitled "Charting After a Resident Fall or Head Injury" dated 6/20/19, indicated that staff are to chart on a resident every shift for 72 hours or three days after a fall. Charting includes neuro checks (neurological assessments for level of consciousness, pupil reaction to light, motor functions of extremities/hand grasps, and pain response).

Resident R10's clinical record revealed an admission date of 12/21/17, with diagnoses that included heart failure, irregular heart rate, dementia, a lung disease, and peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs).

Resident R10's clinical record revealed that he/she experienced a fall on 6/28/19, in his/her room which resulted in a head injury. A nursing progress note dated 7/3/19, at 4:09 a.m. indicated that the physician was in to assess Resident R10 "earlier in the shift" (shift being 7:00 p.m. to 7:00 a.m.) and had ordered neuro checks to be completed for an additional 72 hours. The next documented neuro checks in Resident R10's clinical record was dated for 7/4/19, at 5:07 a.m. or 25 hours after the previous neuro check was completed. Additionally, the last neuro check documented was dated for 7/05/19, at 4:10 a.m., or approximately 24 hours less of the ordered 72 hours.


Resident R23's clinical record revealed an admission date of 8/05/16, with diagnoses that included dementia, psychosis (serious mental disorder characterized by a loss of contact with reality), anxiety, and high blood pressure.

Resident R23's clinical record revealed that he/she experienced a fall in his/her bathroom on 7/09/19, at 6:41 p.m.

A physician's order dated 7/10/19, at 5:35 a.m. for Resident R23 stated that staff are to complete neuro checks for 72 hours. Facility documentation revealed that staff did not complete neuro checks for 46 hours between 7/10/19, at 5:54 a.m. and 7/12/19, at 4:42 a.m., and only completed neuro checks on 7/12/19, at 2:00 p.m. or 15 hours and 35 minutes less of the 72 hours.

During an interview on 12/04/19, at 1:30 p.m. RNAC Employee E1 confirmed that staff should be performing neuro checks as physician ordered every shift (some units are 12 hour shifts and some are eight hour shifts).

28 Pa. Code 211.5(f) Clinical records
Previously cited 1/10/19

28 Pa. code 211.12(d)(1)(5) Nursing services
Previously cited 1/10/19









 Plan of Correction - To be completed: 01/24/2020

F0684 Blood Sugar monitoring.


What corrective action will be accomplished for those residents found to have been affected by the deficient practice? For resident R63, the physician was asked to clarify the order for notification, and on 12/9/19, a new order was received to call if blood sugar was > 500 or if resident was symptomatic. Also, the Nurse who recorded the blood sugar of 48 for that resident on 11/1/19 was coached for not following the physician's order. For resident R12, physician was asked to clarify order. The order for calling remained the same, but physician changed blood sugar monitoring to less often (at 7am Mondays, Wednesdays and Fridays and at 4pm on Tuesdays and Thursdays). Staff is still to notify Physician if bloods sugar is >400 or <60. All Nurses were re-educated on the policy "Glucometer/Assure Platinum/Test Strips Blood Glucose Monitoring with Parameters" at the Nurse's meeting on December 12th, 2019.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? An audit will be conducted of all resident orders, and any resident who has an order to check blood sugars daily or more often will be pulled for physician review. Physician will be asked to review order for appropriateness and to clarify desired parameters for notifications. This will be done by the Support LPN and Medical Assistant and will be overseen by the Director of Nursing and will be completed by January 24, 2020.


In order to prevent this from happening to another resident, the policy "Glucometer/Assure Platinum/Test Strips Blood Glucose Monitoring with Parameters" was reviewed at the December 12th Nurses meeting. Furthermore, the policy will be revised to include required documentation as to whether the resident is symptomatic with blood sugar levels and whether a return call is received from the physician. This policy will be revised by the Director of Nursing by January 6th, 2020 and all Nurses will be educated on it by the Director of Nursing during January Nurse Skills review days on January 14 & 15, 2020.

What measures will be put into place or what system changes will you make to ensure that the deficient practice will not recur? Audits of blood sugar checks will be conducted for the months of February-April 2020. This will be conducted by the Support LPN and overseen by the Director of Nursing. Each week, 5 residents on each unit will be checked for blood sugar readings that are out of parameters. If readings are found to be out of parameters, follow up will be conducted to see if staff followed policy. If staff did not follow policy, reeducation and appropriate disciplining will be done by the Director of Nursing.

What Quality Assurance Process will be put in place for review? What Quality Assurance Process will be put in place for review: This will be reviewed at monthly QAPI meetings with the Director of Nursing reporting on the audits. We will keep this on our agenda for February April 2020.



F0684
"Charting after a Resident Fall or Head Injury"

What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident R10 had a Neurological assessment completed on 12/6/19 by an R.N., which is documented in her medical record and was found to be within normal limits for her baseline. Resident R23 had a Neurological assessment completed on 12/11/19 by an R.N., which is documented in her medical record and was found to be within normal limits for her baseline.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? An audit will be conducted of resident falls within the months of October, November, and December of 2019. Records of 10 Resident falls from each month will be checked for charting according to the policy. This will be done by the Director of Nursing and will be completed by Support LPN and will be completed by January 24, 2020. Nursing staff that did not follow the policy for post fall charting will be disciplined accordingly. Also, a new Neurological Assessment will be done on the resident and recording in their medical record if it has not been done since their last fall.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The Policy "Charting after a Resident Fall or head injury" will be reviewed and revised if any changes are needed by the RNAC and Director of Nursing by January 1, 2020. All Nurses will be reeducated on the policy by the Director of Nursing during the January Nurse Skills review days on January 14 & 15, 2020.


What measures will be put into place or what system changes will you make to ensure that the deficient practice will not reoccur? Audits of post fall charting will be conducted for the months of January-March 2020. This will be conducted by the Support LPN and overseen by the Director of Nursing. Each week, 5 falls on each unit will be checked for proper documentation. If documentation has not occurred according to policy, reeducation and appropriate disciplining of staff will be done by the Director of Nursing.

What Quality Assurance Process will be put in place for review? What Quality Assurance Process will be put in place for review: This will be reviewed at monthly QAPI meetings with the Director of Nursing reporting on the audits. We will keep this on our agenda for February April 2020.


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