Nursing Investigation Results -

Pennsylvania Department of Health
ALLIED SERVICES CENTER CITY SKILLED NURSING
Patient Care Inspection Results

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ALLIED SERVICES CENTER CITY SKILLED NURSING
Inspection Results For:

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ALLIED SERVICES CENTER CITY SKILLED NURSING - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a revisit and abbreviated complaint survey completed on June 23, 2022, it was determined that Allied Services Center City Skilled Nursing corrected the federal deficienices cited during the survey of May 5, 2022, but continued to be out of compliance with the following requirement of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the Title 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(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.
Observations:

Based on review of clinical records and staff interview it was determined that the facility failed to fully develop and implement a resident's person-centered comprehensive care plan to meet the individualized needs for assistance with activities of daily living for one resident (Residents 5) out of two sampled.


Findings include:

A review of clinical record revealed that Resident 5 was admitted to the facility on March 19, 2020, with diagnoses to include depression, rheumatoid arthritis, obesity, gout (a common form of inflammatory arthritis that is very painful), muscle weakness, lack of coordination and history of falling.

An Annual Minimum Data Set assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 21, 2022, indicated that the resident was cognitively intact, required extensive assistance of two staff for bed mobility, transfers, toilet use, and one person assist for dressing, bathing, and personal hygiene.

Further review of Resident 5's clinical record revealed that she had multiple falls at the facility, occurring on May 25, 2022, May 26, 2022, June 1, 2022, and June 15, 2022, with a scratch sustained during the fall of June 1, 2022.

A nurse note dated May 25, 2022, at 4:58 PM, indicated the resident was eased to the floor in shower room during shower by a nurse aide. The resident was unable to bear weight for short period.

A nurse note dated May 26, 2022, at 10:49 PM, indicated the resident rolled out of bed before the nurse aide could reach her around bed. The resident did not hit her head. The resident voiced no pain when assessed, with no complaints when returned to bed.

A nurse note dated June 1, 2022, at 9:15 AM, indicated that while transferring the resident to the toilet, with assist of 2 staff members, the resident's knees gave out and she gently lowered to floor. Superficial scratch noted to right buttock.

A nurse note dated June 15, 2022, at 6:27 PM, indicated that the resident was in dayroom, seated in a wheelchair (w/c) with activities. The resident began sliding out of the wheelchair and the activity aides and nurse gently eased her to the floor. No complaints of discomfort and pain at this time. No injuries noted.

Review of Resident 5's comprehensive care plan and Kardex (a tool used by staff to direct the care needed for the specific resident) for the resident's problem of being at risk for falls and need for assistance with activities of daily living (ADL's), initiated on March 25, 2020, revealed that the resident's care plan and Kardex failed to identify the level of staff assistance required for the resident's safety in bed mobility and showering.

Additionally, the resident's care plan and Kardex dated March 25, 2020, revealed that the resident required toileting with the assist of a sit to stand lift, and transfer with extensive assist of 2 staff members, which were both discontinued on June 3, 2022.

Interview with the Nursing Home Administrator (NHA) on June 23, 2022, at approximately 1:00 PM confirmed that the resident's care plan and Kardex failed to identify the resident's needs for staff assistance with showering and bed mobility to ensure that the resident was provided the necessary staff assistance to prevent accidents and falls. The NHA also verified that the care plan and Kardex were not current, and had not been revised to accurately reflect the discontinuation of the sit to stand lift, and transfer with extensive assist of 2 staff members,

An interview with the Nursing Home Administrator (NHA), on June 23, 2022, at approximately 1:55 PM, confirmed the facility failed to develop, review/revise and implement an individualized person-centered plan to meet the resident's safety needs while assisting with activities of daily living.




28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services

28 Pa Code 211.11(d)(e) Resident care plan




 Plan of Correction - To be completed: 07/19/2022

1. Resident 5's care plan and Kardex have been updated to identify the resident's needs for staff assistance with showering and bed mobility. Her care plan and Kardex have also been revised to accurately reflect the discontinuation of the sit to stand lift and transfer with extensive assist of 2 staff members.

2. An audit will be completed for all resident's care plans and Kardexes to ensure that they accurately identify the resident's needs for staff assistance with showering, bed mobility, and transfers.

3. Licensed Nursing staff will be re-educated on the need for all resident's care plans and Kardexes to accurately identify the resident's needs for staff assistance with showering, bed mobility, and transfers.

4. Audits of sampled resident's care plans and Kardexes will be completed five times per week by the DON or designee; to ensure that they accurately identify the resident's needs for staff assistance with showering, bed mobility, and transfers. Results of these audits will be reviewed by the Quality Assurance Committee for two (2) months and then reevaluated.


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