Pennsylvania Department of Health
LAURELDALE SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

LAURELDALE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 141 surveys for this facility. Please select a date to view the survey results.

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LAURELDALE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated survey in response to a complaint completed on August 16, 2024, it was determined that Laureldale Skilled Nursing and Rehabilitation Center 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 as they relate to the Health portion of the survey.

Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:
Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to keep one of three sampled residents free from neglect, which resulted in actual harm of a head injury. (Resident 1)

Findings include.

Clinical record review revealed that Resident 1 had diagnoses that included muscle wasting, hypertension (high blood pressure), history of transient ischemic attacks (temporary interruptions of blood supply to the brain), atherosclerotic cardiovascular disease (a condition of increased plaque in the arteries of the heart, potentially causing heart attacks), and chronic respiratory failure. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated August 3, 2024, indicated that the resident had a history of falls and required maximum assistance to use the toilet. The care plan identified that Resident 1 was at risk for falls and required assistance with activities of daily living (basic self-care tasks such as personal hygiene and using the toilet), and that staff was to use two people to assist the resident to walk and transfer from one surface to another.

On August 6, 2024, a nurse noted that the resident fell in the bathroom while a nurse aide was attempting to assist him onto the toilet. On August 9, 2024, the resident was evaluated by a physical therapist. The therapist noted that the resident was having more difficulty with transferring from one surface to another (such as getting on and off the toilet) and that staff was to use two or more helpers. On August 11, 2024, a nurse noted that the resident was having difficulty standing and needed additional help.

On August 12, 2024, a nurse noted that the resident fell at 10:28 a.m., while being assisted with toileting. According to the facility incident investigation, only one nurse aide was assisting the resident at the time. While transferring off the toilet, the resident's knees buckled and he fell, striking his head on the floor. The nurse practioner noted that the resident suffered a hematoma (a collection of blood under the skin) and bleeding on his head. At the time, the nurse practioner also noted that the resident was "dazed" and was having difficulty breathing. The resident was monitored by staff but refused to be transported to a hospital for further evaluation. At 11:30 a.m., the resident stopped breathing and staff was unable to revive him. According to the facility investigation into the fall, the nurse aide who provided the assistance was aware of the need for two staff members and assisted the resident off the toilet alone despite the need for two people.

In an interview on August 16, 2024, at 1:00 p.m., the Director of Nursing stated that at the time of the fall, two staff should have assisted the resident instead of one.

28 Pa. Code 201.14(a) Responsibility of licensee.

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

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

Plan of Correction - To be completed: 09/10/2024

1.Resident R1 expired on 8/12/24. CNA that performed the transfer without a second staff member was terminated.
2. An initial audit was completed by the Director of Nursing/Designee on all current residents to verify lift/transfer assessment was accurate and reflected on the care plan and kardex.
3.Nursing staff were re-educated by the Director of Nursing/Designee on NSG234 Safe resident handling/transfer Equipment with review of Two trained persons are required to operate a total lift or sit to stand lift, regardless if manufacturer instructions state only one person is needed.
Nursing staff will be re-educated by the Director of Nursing/Designee on OPS300 Abuse Prohibition with emphasis of Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
4.The Director of Nursing/designee will conduct random weekly audits on 5 residents a week for the next 60 days to verify that 2 staff members are present during transfer when resident requires a mechanical lift.Results of the audit will be reported to the Quality Assurance Performance Improvement Committee.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§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, facility documentation review, and staff interview, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents related to falls for one of three sampled residents which resulted in actual harm of a head injury. (Resident 1)

Findings include.

Clinical record review revealed that Resident 1 had diagnoses that included muscle wasting, hypertension (high blood pressure), history of transient ischemic attacks (temporary interruptions of blood supply to the brain), atherosclerotic cardiovascular disease (a condition of increased plaque in the arteries of the heart, potentially causing heart attacks), and chronic respiratory failure. The Minimum Data Set (MDS) assessment (a periodic evaluation of resident care needs) dated August 3, 2024, indicated that the resident had a history of falls and required maximum assistance to use the toilet. The care plan identified that Resident 1 was at risk for falls and required assistance with activities of daily living (basic self-care tasks such as personal hygiene and using the toilet), and that staff was to use two people to assist the resident to walk and transfer from one surface to another.

On August 6, 2024, a nurse noted that the resident fell in the bathroom while a nurse aide was attempting to assist him onto the toilet. On August 9, 2024, the resident was evaluated by a physical therapist. The therapist noted that the resident was having more difficulty with transferring from one surface to another (such as getting on and off the toilet) and that staff was to use "two or more helpers." On August 11, 2024, a nurse noted that the resident was having difficulty standing and needed additional help.

On August 12, 2024, a nurse noted that the resident fell at 10:28 a.m., while being assisted with toileting. According to the facility incident investigation, only one nurse aide was assisting the resident at the time. While transferring off the toilet, the resident's knees buckled and he fell, striking his head on the floor. The nurse practioner noted that the resident suffered a hematoma (a collection of blood under the skin) and bleeding on his head. At the time, the nurse practioner also noted that the resident was "dazed" and was having difficulty breathing. The resident was monitored by staff but refused to be transported to a hospital for further evaluation. At 11:30 a.m., the resident stopped breathing and staff was unable to revive him.

In an interview on August 16, 2024, at 1:00 p.m., the Director of Nursing stated that at the time of the fall, two staff should have assisted the resident instead of one.

CFR: 483.25(d) Accidents
Previously cited 6/27/24

28 Pa. Code 201.14(a) Responsibility of licensee.

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

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

Plan of Correction - To be completed: 09/10/2024

1. Resident R1 expired on 8/12/24. CNA that performed the transfer without a second staff member was terminated.
2. An initial audit was completed by the Director of Nursing/Designee on all current residents to verify lift/transfer assessment was accurate and reflected on the care plan and kardex.
3.Nursing staff were re-educated by the Director of Nursing/Designee on NSG234 Safe resident handling/transfer Equipment with review of Two trained persons are required to operate a total lift or sit to stand lift, regardless if manufacturer instructions state only one person is needed.

Nursing staff will be re-educated by the Director of Nursing/Designee on OPS300 Abuse Prohibition with emphasis of Neglect is defined as the failure, indifference, or disregard of the Center, its employees, or service providers to provide care, comfort, safety, goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
4.The Director of Nursing/designee will conduct random weekly audits on 5 residents a week for the next 60 days to verify that 2 staff members are present during transfer when resident requires a mechanical lift.Results of the audit will be reported to the Quality Assurance Performance Improvement Committee

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:
Based on clinical record review, facility documentation reivew, and staff interview, it was determined that the facility failed to ensure that the responsible party was notified of a change in condition and a fall for one of three sampled residents. (Resident 1)

Findings include:

Clinical record review revealed that Resident 1 had diagnoses that included muscle wasting, hypertension, history of transient ischemic attacks, atherosclerotic cardiovascular disease, and chronic respiratory failure. On August 6, 2024, at 3:15 p.m., a nurse noted that the resident fell after using the toilet. According to the facility investigation into the fall, the resident's responsible party was not notified of the fall until the following day at 3:30 p.m. In an interview on August 16, 2024, the Director of Nursing stated that staff was to notify the responsible immediately after a fall.

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

Plan of Correction - To be completed: 09/10/2024

1.Resident R1 expired on 8/12/24. Family was notified on 8/7 at 330pm of the fall that occurred on 8/6/24.
2.An initial audit will be completed by the Director of Nursing/Designee on current residents with falls over the last 7 days to review the notifications to the responsible parties were timely.
3.Licensed nursing staff will be re-educated by the Director Of Nursing/Designee on NSG122 Change In condition notification policy, to review that the center is to provide appropriate and timely information about changes relevant to the patient's condition, this includes falls.
4. The Director of Nursing/designee will conduct weekly random audits for the next 60 days on residents with falls to ensure responsible parties were notified timely. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee.

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