Pennsylvania Department of Health
DUBOIS NURSING HOME
Patient Care Inspection Results

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DUBOIS NURSING HOME
Inspection Results For:

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DUBOIS NURSING HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on complaint survey and an incident survey completed on April 10, 2024, it was determined that Dubois Nursing Home was not in 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:


483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on a review of clinical records and investigation documents as well as staff interviews, it was determined that the facility failed to implement a care plan for one of five residents reviewed (Resident 2) who was an assist of two for transfers, resulting in a fall with fracture. This deficiency is being cited as past noncompliance.

Findings include:

An annual Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 2, dated March 1, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs including transfers, and had diagnoses that included dementia and high blood pressure. A care plan, dated November 15, 2023, revealed that the resident was to be transferred by two staff and a front-wheeled walker.

An incident report for Resident 2, dated March 27, 2024, at 4:30 p.m., indicated that the resident was yelling to go to the bathroom. Nurse Aide 1 went in to assist the resident and asked Licensed Practical Nurse 2 (who was in the hallway doing her medication pass) how the resident transferred and was told she was an assist of one. Nurse Aide 1 proceeded to assist the resident to the bathroom and transferred her to the toilet. During the transfer from the toilet to her wheelchair, Resident 2 lost her balance and fell. Nurse Aide 1 stated that she tried to steady her but was unable to.

A nursing note for Resident 2, dated March 27, 2024, at 4:30 p.m., indicated that the resident had a fall in the bathroom. She had complaints of left lower extremity pain. The resident had a left lower extremity deformity and a lump to her left forehead. The physician was notified and ordered the resident to be transferred to the local emergency room.

A nursing note for Resident 2, dated March 28, 2024, at 12:42 a.m., revealed that she had a left tibia and fibula (the two bones from the knee to the ankle) fracture that is non-operable and the resident will be returning to the nursing home.

A witness statement completed by Nurse Aide 1, dated March 28, 2024, indicated that Resident 2 was yelling that she had to go to the bathroom and her call bell was ringing. She asked Licensed Practical Nurse 2 how the resident transferred because she did not know the resident and was not assigned to her. She asked if she was an assist of one and Licensed Practical Nurse 2 said yes. She stated that she got slipper socks from the resident's drawer and put them on the resident. She transferred the resident into her wheelchair and transferred her to the bathroom. The resident stood and got on the toilet with no issues transferring. She stated that she stayed with Resident 2 until she was finished using the bathroom then stood the resident up with the wheeled walker and cleaned her up. The resident stated she needed to sit down, so Nurse Aide 1 sat her down and rang the call bell for assistance and waited awhile and no one came to assist her. She stated that she checked the hallway and went to the nurse's station for assistance. The resident began yelling that she wanted off the toilet. As she assisted the resident off the toilet her legs began to buckle and the resident fell, and she was unable to stop her. She stated the resident hit her head. She went to get the licensed practical nurse and registered nurse. She was then informed that the resident was to be a transfer assist of two staff members. She stated that she did not have access to the resident's care plan on the iPad and she did not know how to find the transfer status in the charting.

A witness statement completed by Licensed Practical Nurse 2, dated March 28, 2024, revealed that she heard the resident yelling out to go to the bathroom and Nurse Aide 1 asked her if she goes to the bathroom. Licensed Practical Nurse 2 indicated that she does use the bathroom because she has helped with toileting her in the past. She then heard Nurse Aide 1 yell that the resident fell. She went with the registered nurse to assist the resident. Licensed Practical Nurse 2 denied telling Nurse Aide 1 that the resident was a one assist for transfers.

Interview with the Nursing Home Administrator on April 10, 2024, at 1:29 p.m. confirmed that the resident was to be an assist of two staff members and that the transfer status was not followed per Resident 2's care plan.

A review of the facility's plan of correction included the following:

Reeducation and competencies for transfer status and verifying transfer status in the charting system were completed for all nursing staff, including agency nursing staff.

Audits of all agency staff were completed to verify their access to the facility's charting system.

A process was added to the orientation program to verify the staff member has access to the facility's charting system.

Audits have been conducted on accessing resident transfer status in the charting system.

Interviews with nursing staff on April 10, 2024, revealed that they had been educated and were aware of how to locate a resident's transfer status in the charting system.

A review of the facility's corrective actions revealed that they were in compliance with F656 on April 2, 2024.

Interview with the Nursing Home Administrator on April 10, 2024, at 1:29 p.m. revealed that staff education was completed, and ongoing audits will be discussed during the monthly Quality Assurance meeting.

28 Pa. Code 201.24(e)(4) Admission Policy.

28 Pa. Code 211.12(d)(5) Nursing Services.



 Plan of Correction - To be completed: 04/24/2024

Past noncompliance: no plan of correction required.
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 investigation documents and residents' clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of five residents reviewed (Resident 2), resulting in a fall with fracture. This deficiency was cited as past non-compliance.

Findings include:

An annual Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs) for Resident 2, dated March 1, 2024, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs including transfers, and had diagnoses that included dementia and high blood pressure. A care plan, dated November 15, 2023, revealed that the resident was to be transferred by two staff and a front-wheeled walker.

A nursing note for Resident 2, dated March 27, 2024, at 4:30 p.m., indicated that the resident had a fall in the bathroom. She had complaints of left lower extremity pain. The resident had a left lower extremity deformity and a lump to her left forehead. The physician was notified and ordered the resident to be transferred to the local emergency room.

A nursing note for Resident 2, dated March 28, 2024, at 12:42 a.m., revealed that she had a left tibia and fibula (the two bones from the knee to the ankle) fracture that is non-operable and the resident will be returning to the nursing home.

An incident report for Resident 2, dated March 27, 2024, at 4:30 p.m., indicated that the resident was yelling to go to the bathroom. Nurse Aide 1 went in to assist the resident and asked Licensed Practical Nurse 2 (who was in the hallway doing her medication pass) how the resident transferred and was told she was an assist of one. Nurse Aide 1 proceeded to assist the resident to the bathroom and transferred her to the toilet. During the transfer from the toilet to her wheelchair, Resident 2 lost her balance and fell. Nurse Aide 1 stated that she tried to steady her but was unable to.

A witness statement completed by Nurse Aide 1, dated March 28, 2024, indicated that Resident 2 was yelling that she had to go to the bathroom and her call bell was ringing. She asked Licensed Practical Nurse 2 how the resident transferred because she did not know the resident and was not assigned to her. She asked if she was an assist of one and Licensed Practical Nurse 2 said yes. She stated that she got slipper socks from the resident's drawer and put them on the resident. She transferred the resident into her wheelchair and transferred her to the bathroom. The resident stood and got on the toilet with no issues transferring. She stated that she stayed with Resident 2 until she was finished using the bathroom then stood the resident up with wheeled walker and cleaned her up. The resident stated she needed to sit down so Nurse Aide 2 sat her down and rang the call bell for assistance and waited awhile and no one came to assist her. She stated that she checked the hallway and went to the nurse's station for assistance. The resident began yelling that she wanted off the toilet. As she assisted the resident off the toilet her legs began to buckle and the resident fell, and she was unable to stop her. She stated the resident hit her head. She went to get the licensed practical nurse and registered nurse. She was then informed that the resident was to be a transfer assist of two staff members. She stated that she did not have access to the resident's care plan on the iPad and she did not know how to find the transfer status in the charting.

A witness statement completed by Licensed Practical Nurse 2, dated March 28, 2024, revealed that she heard the resident yelling out to go to the bathroom and Nurse Aide 1 asked her if she goes to the bathroom. Licensed Practical Nurse 2 indicated that she does use the bathroom because she has helped with toileting her in the past. She then heard Nurse Aide 1 yell that the resident fell. She went with the registered nurse to assist the resident. Licensed Practical Nurse 2 denies telling Nurse Aide 1 that the resident was a one assist for transfers.

Interview with the Nursing Home Administrator on April 10, 2024, at 1:29 p.m. confirmed that the resident was to be an assist of two staff members and that the transfer status was not followed per Resident 2's care plan.

A review of the facility's plan of correction included the following:

Reeducation and competencies for transfer status and verifying transfer status in the charting system were completed for all nursing staff, including agency nursing staff.

Audits of all agency staff were completed to verify their access to the facility's charting system.

A process was added to the orientation program to verify the staff member has access to the facility's charting system.

Audits have been conducted on accessing resident transfer status in the charting system.

Interviews with nursing staff on April 10, 2024, revealed that they had been educated and were aware of how to locate a resident's transfer status in the charting system.

A review of the facility's corrective actions revealed that they were in compliance with F689 on April 2, 2024.

Interview with the Nursing Home Administrator on April 10, 2024, at 1:29 p.m. revealed that staff education was completed, and ongoing audits will be discussed during the monthly Quality Assurance (QA) meeting.

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



 Plan of Correction - To be completed: 04/24/2024

Past noncompliance: no plan of correction required.

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