Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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SARAH A. TODD MEMORIAL HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated survey completed on February 10, 2020, in response to one complaint, it was determined that Sarah A Todd Memorial Home 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:

483.21(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.

Based on clinical record review and staff interview, it was determined the facility failed to ensure services are provided in accordance with each resident's written plan of care for one of three residents reviewed (Resident 2).

Findings Include:

Review of Resident 2's clinical record revealed diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and hyperlipidemia (high levels of fat particles in the blood).

Review of Resident 2's care plan, dated June 3, 2019-present, revealed "Transfers: Stand-aid lift and 2 assist. Left arm sling must be removed before all transfers. One CNA must guide her left arm during the transfers."

Review of Resident 2's facility form titled "Incident/Accident Report" dated January 10, 2020, revealed that Nurse Aide (NA) 1 finished giving Resident 2 a shower and was lifting the Resident with the stand aid by herself, when Resident 2 began sliding out of the harness onto the left side. NA 1 lowered Resident 2 to the floor.

During an interview with the Director of Nursing on February 10, 2020, at 10:45 AM she confirmed that NA 1 was not following Resident 2's care plan at the time of the incident.

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

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

 Plan of Correction - To be completed: 02/28/2020

All staff on Resident 2's unit were educated and performed a competency on how to properly transfer Resident 2 in the Stand-aid lift. NA 1 was re-educated and given a competency. All CNA's who complete transfers with Resident 2 sign off on a transfer sheet which indicates that 2 people completed the transfer.

All residents who use a Stand-aid lift are now a 2 person assist.

CNA's were educated on all resident's using a Stand-aid are now a 2-person lift. CNA's were also re-educated on the fact that they are responsible for knowing and following each resident's care plan.

The RN nurse supervisor or designee will do 4 audits weekly for one quarter to ensure that transfers are completed properly, per the residents' care plans. The results will be reported to the Quality Assurance and Performance Improvement committee.

This corrective action will be completed by 2/28/20.

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