Pennsylvania Department of Health
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MESSIAH LIFEWAYS AT MESSIAH VILLAGE
Inspection Results For:

There are 116 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


MESSIAH LIFEWAYS AT MESSIAH VILLAGE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Complaint Survey completed on April 23, 2024, it was determined that Messiah Lifeways at Messiah Village 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 related to the health portion of the survey process.

Plan of Correction:

483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs:

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.

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(3) Food prepared in a form designed to meet individual needs.

Observations:

Based on facility job description review, clinical record review, review of facility investigation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure a beverage was provided to residents in a form to meet the resident's individual need, which resulted in harm, evidenced by aspiration (when food, drink, or foreign objects are breathed into the lungs) requiring hospitalization for one of three residents reviewed (Resident 1).

Findings Include:

Review of the facility's job description for a dietary aide with an effective date of August 24, 2023, revealed "Responsible for setting, servicing and cleaning the dining rooms; between meals assists with meal preparation....Follows established procedures during food preparation, meal service and clean up."

On September 15, 2023, Employee 3 (Dietary Aide) signed an acknowledgement of her dietary aide job description.

Review of Resident 1's clinical record revealed that he was admitted to the facility on March 29, 2024, with diagnoses that included dysphagia (difficulty swallowing), Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Parkinsonism (an umbrella term that refers to brain conditions that cause slowed movements, stiffness, and tremors), and hyperlipidemia (a condition in which there are high levels of fat particles [lipids] in the blood).

Review of Resident 1's physician orders revealed a diet order with a start date of April 11, 2024, for a carbohydrate controlled diet, mechanical soft texture, honey/moderate consistency.

Review of Resident 1's meal ticket for dinner on April 11, 2024, revealed that he was to be served honey thick, diet iced tea.

Review of Resident 1's nursing progress note dated April 11, 2024, revealed that Resident 1's family member came out of the Resident's room asking for a nurse to come check on Resident 1, stating that he was "not acting right." The family member stated she wasn't sure if it was due to Resident 1 drinking his drink or if he was having another TIA (Transient ischemic attack - mini stroke). The family member stated that Resident 1 had taken a few sips of his iced tea and then began to cough. The family member then stated she realized that the iced tea that was on Resident 1's dinner tray was not thickened. Resident 1 became unresponsive and the family member notified the nurse.

Further review of the progress note revealed that, upon nursing assessment, Resident 1 was pale with audible gurgling/wheezing and Resident 1 was unresponsive. Respirations were elevated and Resident 1 was using his accessory muscles to breath. Oxygen saturation was noted to be in the 40's (normal is 95-100%). Oxygen was applied at 5 liters via a face mask with the oxygen saturation increasing to the low 90's. Resident 1 was becoming more responsive and able to answer questions. The on-call provider was made aware and Resident 1 was transferred to the hospital for further evaluation and treatment.

Review of Resident 1's hospital discharge summary dated April 15, 2024, revealed that Resident 1 was admitted to the hospital with a diagnosis of aspiration pneumonitis (inflammation of the lung due to inhalation of solids and liquids).

Resident 1 was discharged from the hospital and returned to the facility on April 15, 2024.

Review of the facility's investigation revealed a witness statement from Employee 1 (Nurse Aide) dated April 12, 2024, stating that she was told that Resident 1's family member requested a room tray for Resident 1. Employee 1 notified dining staff who prepared the tray. Employee 1 then delivered the tray while Employee 2 (Registered Nurse) was in the room with Resident 1 and his family member. Employee 1 asked the family member if she could place the tray on Resident 1's bedside table, and the family member said yes.

Further review of Employee 1's statement revealed that it was Employee 3 who prepared Resident 1's dinner tray.

Review of Employee 2's witness statement, revealed that Employee 1 dropped off the tray and Resident 1's family member "stated she would set it up." Employee 2 confirmed that, after the incident, the iced tea on Resident 1's tray was noted to be thin liquid.

The iced tea does not come pre-thickened. Dietary staff are responsible for adding a pack of thickener into the iced tea to convert the liquid to honey consistency.

On April 23, 2024, at 10:43 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) provided the facility's plan of correction that was put into place as a result of the facility's investigation, which determined that Resident 1 was served the wrong texture of drink on his dinner tray.

The facility's education and audits were reviewed during the survey.

Starting on April 15, 2024, dining and clinical staff were educated on thickened liquids and meal tickets, ensuring that staff are double checking the liquids against the meal ticket before delivery to a resident.

On April 15, 2024, audits were started on trays to ensure the correct texture of food and fluids were being served to the residents.

On April 18, 2024, Employee 3 received education via a facility form titled "Job Coaching Form." The form revealed that on April 11, 2024, Employee 3 was preparing room trays and a Resident who was on honey thick liquids was given a tray that had thin liquids, resulting in the Resident aspirating and being transferred to the hospital.

Further review of the form revealed Employee 3 was educated that, "Effective immediately, it is expected that you will serve residents the appropriate thickened liquid, either using the pre-packaged beverages, or by a thickening agent per the instructions on the pack for the appropriate level of thickness."

Employee 3 signed acknowledgement of the job coaching/education on April 18, 2024.

Prior to the abbreviated survey, the facility failed to provide the ordered texture of liquid to Resident 1, resulting in harm to the Resident as evidenced by aspiration pneumonitis. The facility reported the incident timely, investigated the incident thoroughly, and initiated interventions in an effort to prevent a future incident.

Review of facility documentation revealed that on April 19, 2024, the facility had completed education for staff and continued audits to ensure compliance.

During the abbreviated survey, audits, staff education, and diet orders were reviewed. Staff interviews, Resident record review, and observations revealed no concerns with food and drink texture for the sampled residents.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management

Plan of Correction - To be completed: 04/30/2024

Past noncompliance: no plan of correction required.

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