Nursing Investigation Results -

Pennsylvania Department of Health
SPIRITRUST LUTHERAN THE VILLAGE AT SHREWSBURY
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SPIRITRUST LUTHERAN THE VILLAGE AT SHREWSBURY
Inspection Results For:

There are  66 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.
SPIRITRUST LUTHERAN THE VILLAGE AT SHREWSBURY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure and Civil Rights survey and an Abbreviated survey in response to a complaint and two incidents completed on July 25, 2019, it was determined that SpiriTrust Lutheran, The Village at Shrewsbury 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
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 observations, a review of clinical records, resident incident/accident reports, and staff and resident interview, it was determined that the facility failed to provide adequate staff supervision and implement established door safety interventions to prevent an elopement for one of 41 residents reviewed (Resident 390). This elopement failure placed the resident who was ambulatory and had the physical capabilities to open the door, at potential for serious harm, which placed the facility resident in immediate jeopardy for future unsupervised exits from the facility.

Findings include:

Review of Resident 390's clinical record revealed diagnoses which included vascular dementia (a decline in thinking skills caused by cerebrovascular disease, a condition in which blood vessels in the brain are damaged and brain tissue injured, depriving brain cells of vital oxygen and nutrients) and essential hypertension (high blood pressure that doesn't have a known cause).

Review of Resident 390's admission MDS (assessment tool used to determine residents' care and service needs), dated June 26, 2019, revealed a BIMs of three out of a possible score of 15, indicating the resident is severely cognitively impaired and mobility rating of 3, indicating the need for extensive assistance and no upper body impairments.

Review of Resident 390's elopement risk assessment, dated June 22, 2019, revealed a score of 13 placing Resident 390 into the category of high risk for wander. Further review of this document revealed in Section B. Mental Status: The resident cannot follow instructions and in Section E. The resident has a history of wandering.

Review of Resident 390's plan of care revealed a Focus point: I am at risk to wander away from my community due to impaired cognition, history or elopement, wondering. Date initiated June 20, 2019. With a goal: I will not leave the community unsupervised thru the next target date. Date initiated June 20, 2019, target date October 8, 2019.
Review of a facility provided report revealed on July 7, 2019, at 8:20 PM Nurse Aide (NA) 1 was taking laundry out and noticed Resident 390's empty wheelchair and alerted other staff to start searching for Resident 390. At 8:25 PM, NA 2 and Licensed Practical Nurse (LPN) 1 were searching for the resident and walked through the 118 hallway and when they went thru the exit door, at the opposite end of the hallway, they saw Resident 390 standing outside of the facility, in the rain, holding onto a fence approximately 45 feet away. At that time Resident 390 was brought back into the building in his wheelchair. Resident 390 was assessed by Registered Nurse (RN) 1 at that time and no injuries were observed. At the time of the elopement, the alarm on Doorway 118 was not set to sound the alarm when the door was opened.

During interview with the Nursing Home Administrator (NHA) on July 24, 2019, at 1:19 PM revealed that her expectations were that the door to the 118 hallway would always remain closed with the alarm turned on and that any staff member who hears the alarm sounding would respond to verify what is causing the alarm to sound.

On July 24, 2019, at 3:34 PM the NHA and Director of Nursing (DON) were notified of the Immediate Jeopardy and asked to provide an action plan of correction. This Action Plan included the following:

1. Resident was brought back to the building and RN assessment completed and no injuries noted. Resident denied pain and resident's MD and POA were notified.

2. Current alarms were removed from the door on July 24, 2019.

3. The door the resident left the building from will be secured as of July 24, 2019, by being manned 24 hours a day by a team member until a new system can be placed on Tuesday, July 30, 2019.

A full house audit was completed on Wander Risk Scales on July 9, 2019. At risk residents were discussed by IDT (Interdisciplinary team) on July 9, 2019 and on July 10, 2019, to determine appropriate interventions and care plans updated as needed. Re-education completed for licensed staff on elopement standard on July 12, 2019. Education to nursing and non-nursing team members to not turn the door alarm off completed on July 13, 2019. Signage was placed on the door alarm that it must always be activated on July 8, 2019. Random audits of 5 wander risk evaluations/interventions weekly x 4 weeks, then monthly x 2 months. Audits of door alarms will be completed daily until doors secured with locking mechanisms. Audits will be taken to QAPI (the merger of two approaches to quality management, Quality Assurance and Performance Improvement) for further recommendations and review.

A Security Service was consulted and provided a proposal on July 18, 2019. Installation for keypad with lever and door closer is scheduled for Tuesday, July 20, 2019. This system will not open unless combination is punched which allows for the release of the door.

A log will be maintained for the team member manning the door to sign during their shift. The team member manning the door will not be able to leave the station until the team member's relief has been notified and secured. Two signatures will be required before the team member starts and ends their shift. Security logs will be submitted to QAPI for further review and recommendations. Once door locking mechanism is installed, the door will be monitored for proper functioning daily x four weeks and weekly x 8. Results of audits will be brought to QAPI for review and further recommendations.

On July 24, 2019, at 8:00 PM. The Action Plan was accepted.

On July 25, 2019, at 8:30 AM observations and interviews with staff were done to determine if the Action Plan was implemented. Observation at 8:30 AM revealed that staff was positioned at doorway 118 limiting entry and exit to only authorized persons. Interview with NA 5 and NA 6 on July 25, 2019, at 10:18 AM revealed that they were aware that before the alarm being removed from doorway 118 it was always supposed to remain on and that now that it is removed there must always be a team member present securing the door. Interview with NA 7 on July 25, 2019, at 10:23 AM revealed that she was aware that a team member was present at doorway 118 limiting entry and exit to only authorized persons and that before the alarm being removed it was always mandatory for it to be active.

On July 25, 2019, at 11:30 AM the Immediate Jeopardy was lifted.

The facility failed to provide adequate staff supervision and implement established door safety interventions to prevent an elopement of one resident (Resident 390). This elopement failure placed the Resident 390 who was ambulatory and had the physical capabilities to open the door, at potential for serious harm, which placed the facility resident in immediate jeopardy for future unsupervised exits from the facility..

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 8/2/18, 7/27/17.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 11/29/18, 8/2/18, 7/27/17.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 3/12/19, 7/27/17.

28 Pa. Code 201.18(b)(3)(d) Management.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 11/29/18.

28 Pa. Code 201.29(d) Resident rights.

28 Pa. Code 207.2(a) Administrator's responsibility.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 8/2/18.

28 Pa. Code 211.12(a) Nursing services.

28 Pa. Code 211.12(c) Nursing services.
Previously cited 3/12/19.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 3/12/19, 8/2/18, 7/27/17.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/27/17.
































 Plan of Correction - To be completed: 09/09/2019

1. Resident 390 was brought back to the building and RN Assessment completed and no injuries noted. Resident denied pain and residents MD and POA were notified.
2. Current alarms were removed on the door 7/24/2019.
3. On July 30 a new system was placed on the door with locking mechanism that would not allow for manual disalarm.


At the time of the elopement full house audit completed on Wander Risk Scales on 7/9/19. At risk residents were discussed by IDT on 7/9/19 and 7/10/19 to determine appropriate interventions and care plans updated as needed. Re-education completed for licensed staff on Elopement Standard on 7/12/2019. Education to nursing and non-nursing team members to not turn the door alarm off completed on 7/13/19. Signage was placed on the door alarm that it must be activated at all times on 7/8/2019.
Random audits of 5 wander risk evaluations/interventions weekly x 4 weeks then monthly x 2 months. Audits of door alarms will be completed daily until doors secured with locking mechanisms. Audits will be taken to QAPI for further recommendation and review.

Markle's Security Service consulted and provided proposal on 7/18/19. Installation for keypad with lever and door closers completed Tuesday July 30, 2019. This system will not open unless combination is punched which allows for the release of the door.

Education to team members on new door mechanism. Security log updated to include daily audit of proper door function.
Directed in-service on accident /hazards/supervision scheduled for skilled nursing team members on August 13, 2019 and August 14, 2019.


A log was maintained for the team member manning the door to sign during their shift prior to new locking mechanism being installed. The team member manning the door remained at the station until the team members relief has been notified and secured. Two signatures were required before the team member starts and ends their shift.

Security Logs will be submitted to QAPI for further review and recommendations. Door locking mechanism is installed and the door will be monitored for proper functioning
daily times four weeks and weekly times 8. Results of audits will be brought to QAPI for review and further recommendations.




483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on observation, review of facility policy, and interview it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for one of one reach-in refrigerator, one of one walk-in refrigerator in the main kitchen; and one of one reach-in refrigerator in the Main Dining Room; and one of one nourishment pantry refrigerator in the nursing unit.

Findings include:

Review of the contract Foodservice Company's policy Maximum Storage Period of Dried Foods, revised December 2018, revealed that juices, and fruit drinks are good for up to 7 days once opened; and salad dressings once opened refer to the expiration date.

Review of the contract Foodservice Company's policy Use of Hair Restraints, revised December 2018, revealed "Hair nets, caps, chef hats and/or beard restraints must be worn when any employee is in the food production and kitchen area."

Observation in the reach-in refrigerator in the Main Dining Room on July 22, 2019, at approximately 9:05 AM revealed: One container of honey thickened milk open with no open or use by date; One container of honey thickened milk open with an open date of June 20th, use by date of June 27th was scribbled out then written September 15th; One container of nectar thickened orange juice open with no open or use by date; One container of nectar thickened apple juice, with no open or use by date; One container of nectar thickened water open with no open or use by date; Two containers of nectar thickened cranberry juice open with no open or use by date; 1 container of nectar thickened apple juice open with no open date, a use by date of Jan 12, 2019; One container of honey thickened orange Juice with no open or use by date; five of five shelves contained a black substance, that was able to be wiped off, on and underneath each shelf, and orange and red liquid on the inside floor of the refrigerator.

During an interview with the General Manager 1 (GM) 1 on July 22, 2019, at approximately 9:10 AM revealed that the facility has an expiration date check list, and the used by date for open juice/beverages is 7 days, it was also revealed that the shelves are on a cleaning schedule but should be cleaned as need.

During an interview with Nursing Home Administrator on July 25, 2019, at approximately 9:36 AM revealed that when beverages are opened they should be dated with an open or use by date. It was also revealed that if the refrigerator or shelves become dirty between the scheduled cleaning time they should be wiped down or cleaned as needed.

During an observation on July 22, 2019, at approximately 9:24 AM in the kitchen reach-in refrigerator three shelves contained a brown substance and a white substance that could be wiped off.

During an interview with the General Manager 1 (GM) 1 on July 22, 2019, at approximately 9:24 AM it was revealed that the shelves should be cleaned.

During an observation on July 22, 2019, at approximately 9:30 AM in the walk-in refrigerator in the kitchen there were 4 shelves, 2 on each side of the refrigerator, that contained a reddish-brown colored substance that didn't wipe off and an accumulation of dust and food residue that wiped off.

During an interview with the General Manager 1 (GM) 1 on July 22, 2019, at approximately 9:30 AM it was revealed that the refrigerator shelves are on a cleaning schedule. At that time it was also revealed that the shelves are worn and discolored, and they don't clean well.

On July 22, 2019, at approximately 9:30 AM in the walk-in refrigerator in the kitchen the following observations of salad dressings were made: One container of creamy Caesar salad dressing that was open with a sticker on container that revealed an open date of June 11, 2019, a use by date of November 11, 2019, and stamped on the container a manufacturer's date of April 3, 2019; One container of Italian salad dressing that was open with an open date of July 6, 2019, a use by date of August 10, 2019, and stamped on the container a manufacturer's date of April 3, 2019; One container of French salad dressing that was open with an open date of June 28, 2019, a use by date of July 28, 2019, and stamped on the container a manufacturer's date of May 7, 2019; One container of Blue Cheese salad dressing that was open with an open date of June 14, 2019, a use by date of December 14, 2019, and stamped on the container a manufacturer's date of December 14, 2019; One container of Honey Mustard salad dressing that was open with an open date of July 6, 2019, a use by date of December 10, 2019, and stamped on the container a manufacturer's date of May 7, 2019; One container of Honey Mustard salad dressing that was open, with no open or use by date.

During an interview with the General Manager 1 (GM) 1 on July 22, 2019, at approximately 9:35 AM it was revealed that the Food Service company's guideline for use by date of salad dressing once opened is the product expiration date. It was also revealed that the manufacturer's date is not the expiration date, and that the GM 1 wasn't sure what the expiration date is for the aforementioned items, and that it wasn't displayed on the aforementioned containers.

Interview with Nursing Home Administrator on July 25, 2019, at approximately 9:36 AM revealed that when food items are opened they should be dated with an open or use by date. It was also revealed that if the refrigerator and or shelves become dirty between the scheduled cleaning time they should be wiped down or cleaned as needed.

Observation on July 25, 2019, at approximately 11:03 AM revealed the accumulation of dust and food residue was removed, the reddish-brown substance remained on the front trim and side poles of the shelves.

During an interview with the GM 1 on July 25, 2019, at approximately 11:03 AM revealed that the shelves were cleaned, however the shelves the reddish-brown substance didn't come off. It was revealed that the per the manufacture's guideline the salad dressing is good for 14 days once opened

Observation on July 22, 2019, at approximately 9:55 AM in nursing unit nourishment pantry refrigerator the following supplement, and juice containers were open, and didn't contain an open and/or a use by date: Three containers of nutritional supplement 2.0 (a liquid nutritional supplement use to provide added calories and nutritive value); One container of honey thickened water; Two containers of nectar thickened orange juice; One container nectar thickened cranberry juice; One container honey thickened cranberry juice; and 1 container honey thickened orange juice.

During an interview with the GM 1 on July 22, 2019, at approximately 9:57 AM it was revealed when a container is opened it should be dated with an open date, and that it is good for 7 days.

During an interview with the Nursing Home Administrator on July 25, 2019, at approximately 9:36 AM it was revealed that when beverages are opened they should be dated with an open or use by date.

During an observation of trayline service in the kitchen on July 22, 2019, at approximately 11:30 AM it was revealed that Assistant General Manager 1 was in the food preparation area and behind the steam table, and he had a short beard and mustache, and wasn't wearing a beard net. Further observation made at 11:35 AM in the same area revealed GM 1 with a short beard and mustache, and wasn't wearing a beard net.

During an interview with the Nursing Home Administrator on July 25, 2019, at approximately 9:36 AM it was revealed that a beard restraint should be worn by any staff member with a beard or mustache in the food production area.

During an interview with GM on July 25, 2019, at approximately 11:06 AM it was revealed that beard nets should have been worn by staff members with a beard and/or mustache while in the food production area.

28 Pa Code 211.6(b)(d) Dietary Services






 Plan of Correction - To be completed: 09/09/2019

At the time of the survey GM/district manager audited refrigerators and removed any products that did not have dating and labeling according to (standard).

At the time of the survey on July 22, 2019 the dining assistant was in the middle of completing the cleaning schedule in the main refrigerator when the surveyor noticed the black and red and orange substance. The dining assistant immediately wiped down the shelves and removed the white, brown and black substance.

At the time of the survey GM and dining team members immediately wore beard nets when in the food production or kitchen areas.

At the time of the survey GM/district manager audited refrigerators and removed any products that did not have labels.

A deep clean of the walk in refrigerator and cleaning of shelving and floors will be completed. The shelving that had the brown-reddish substance or could not be wiped off will be replaced.

Dining team members will be re-educated to wear beard nets immediately.


Re-education to dining and nursing team members on the dating and labeling process.

New stickers will be utilized to include open and used by date.

Food and sanitation audit will include proper label and dating.

Re-education to dining team members of the cleaning schedule which includes shelves, floor, and post. Dining team members will be re-educated that in between the cleaning schedules if refrigerator, floor or equipment appears dirty it must be cleaned.

Re-education to dining team members on Use of Hair Restraints Policy.

GM/designee will audit the refrigerators weekly times 3 and weekly x 8 to ensure cleanliness, and dating and labeling process is being followed. Findings of the audits will be brought to QAPI for further recommendation.

GM/designee will audit team members 3 times a week x four weeks and then weekly times 8 to ensure beard nets are being worn. Findings of the audits will be brought to QAPI for further recommendations.



483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:


Based on clinical record review, facility document review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed hold policy to one of two residents reviewed for hospitalizations (Resident 54).

Findings include:

Review of facility policy titled, "Bed Hold Notice Standard," revealed it stated, "The skilled care centers of SpiriTrust Lutheran [will] provide to residents/responsible parties at the time of admission and at the time of transfer to a hospital or therapeutic leave written notice which specifies the duration of the bed hold policy." Section 3 under "Procedures," stated, "The Social Service Designee will call the responsibly party after the resident is determined to be admitted to the hospital or under observation status to inquire about the decision to hold the bed and follow up with sending the bed hold letter to the resident/responsible party to obtain written verification of a decision to hold the bed which will include; a copy of the bed hold notice standard of practice, two copies of the bed hold letter, and a self-addressed stamped envelope. The Social Service Designee should explain the information that will be sent and that one copy of the signature form with the decision regarding bed hold needs to be returned to the skilled care center."

Review of Resident 54's clinical record on July 23, 2019, at approximately 10:15 AM revealed diagnoses including vascular dementia (progressive, irreversible degenerative disease of the brain that results in decreased reality contact and daily functioning ability) and anemia (decreased red blood cells).

Review of Resident 54's clinical record revealed that Resident 54 was transferred to the hospital on May 20, 2019. Review of Resident 54's clinical progress notes revealed that Resident Resident 54's representative party was notified of the transfer and verbally notified of the bed hold on May 20, 2019.

On July 23, 2019, at approximately 2:00 PM the facility was requested to provide documentation that a written notice of the facility's bed hold policy was provided to the representative part of Resident 54.

During a staff interview on July 25, 2019, at approximately 2:15 PM the Nursing Home Administrator revealed that there was no written bed hold policy sent to Resident 54's representative and that it was the facility's expectation that written bed hold policies are sent to resident/resident representatives.


28 Pa. Code 201.14(a) Responsibility of Licensee







 Plan of Correction - To be completed: 09/09/2019

Resident 54 responsible party was notified at the time of the transfer via phone. The letter will be given to the resident.

Facility will complete a 30 day look back of residents transferred to the hospital.
Resident without a bed hold letter will receive one or responsible party.

Re-education to social services and Guest Service department on the Bed hold policy.
Guest Service Coordinator will track transfers to ensure bed hold notification is completed.

NHA/designee will audit transfer letters X 4 for bed hold letters to ensure distribution. Findings and results of the audits will be brought to QAPI for further recommendation.
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on observation, clinical record review, and staff interviews it was determined that the facility failed to review and revise the resident plan of care for two of 41 residents reviewed (Residents 15 and 60).

Findings include:

Review of Resident 15's clinical record revealed diagnoses that included Muscle Weakness, History of Falling, anxiety disorder (mental disorder characterized by significant feelings of anxiety and fear; anxiety is a worry about future events, and fear is a reaction to current events), Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and Alzheimer's Disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain).

Observation in Resident 15's room on July 22, 2019, revealed that resident was asleep in bed and a fall mat was observed on the left side of her bed.

Review of a facility Fall report dated for April 29, 2019, revealed that an Interdisciplinary Review was completed and that "fall mat already in place, will place perimeter mattress" were included as interventions to be put in place.

Review of Resident 15's current/active Care Plan provided on July 24, 2019, failed to reveal a fall mat as an intervention for the care Focus area of Falls.

During an interview on July 25, 2019, at 10:45 AM with Director of Nursing (DON) and Nursing Home Administrator (NHA), the NHA revealed the expectation that Resident 15's care plan should have been updated to reflect the fall mat as a fall intervention.

Review of Resident 60's clinical record revealed diagnoses that included Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain; It is the most common cause of premature senility), osteoarthritis (degeneration of joint cartilage and the underlying bone, causing pain and stiffness especially in the hip, knee, and thumb joints), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue) of a joint.

Review of Resident 60's care plan revealed a focus area for Activities of Daily Living function with an intervention for right palm splinting with finger separated, to be applied in the AM and off during the PM, with skin checks, Date Initiated: 08/01/2018. Further review of Resident 60's care plan revealed a focus area for a restorative program with an intervention for "Right hand orthotic splint 3-5 hours daily, observe for pain, discomfort and/or redness, Date Initiated: 11/29/17 .

During an interview with the Director of Nursing on July 24, 2019, at approximately 2:50 PM revealed that the splint to right hand is utilized as part of the restorative program and is to be worn 3-5 hours a day. It was also revealed that the care plan was updated, and removed the right palm splinting with finger separated, to be applied in the AM and off during the PM intervention.

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

28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.

















 Plan of Correction - To be completed: 09/09/2019

Resident 15 and 60's care plans were reviewed and updated at the time of the survey.

Audits of current residents who have had a fall in the last 3 months and resident who currently have a splinting program will be conducted for care plan accuracy. Modifications will occur if necessary.

Re-education of IDT and licensed staff regarding revision of care plans at each assessment, including comprehensive and quarterly reviews.

RNAC/designee will audit 3 fall care plans/splinting care plans care plans weekly x 12 weeks. Findings and results of the audits will be brought to QAPI for further recommendation.


483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:


Based on clinical record review and staff interview it was determined that the facility failed to ensure each resident with an anticipated discharge receives a discharge summary including a recapitulation of the resident's stay, a final summary of the resident's status, a reconciliation of pre-discharge medications and a post-discharge plan of care developed with the participation of the resident and/or resident representative, for one of 41 residents reviewed (Resident 90).

Findings Include:

Review of Resident 90's physician orders revealed diagnoses that included chronic back pain and hypertension (elevated blood pressure).

Review of Resident 90's clinical record revealed an admission to the facility on April 25, 2019, with a discharge date of April 29, 2019. According to the facility's interdisciplinary progress notes, Resident 90's goal was to receive nursing and rehabilitation services.

Additional review of the clinical record revealed Resident 90 was discharged from the facility, per preference, on April 29, 2019, with a transfer to another facility for continued services.

Further review of the clinical record revealed no discharge summary completed after Resident 90's discharge from the facility.

An interview with the Medical Director (MDS) 1, on July 25, 2019, at 12:26 PM confirmed Resident 90 was transferred and the discharge was anticipated.

28 Pa. Code 211.5(f) Clinical records
















 Plan of Correction - To be completed: 09/09/2019

Resident 90 was transferred to another facility in our organization.

A look back of discharges from the last month was completed to ensure discharge summary was completed.

Re-education to current physicians and nurse extenders on the regulatory requirement for a discharge summary on anticipated discharges.

Medical records/ designee will audit 2 charts weekly for discharge summaries on anticipated discharges for four weeks and 1 chart weekly times 8. Findings and results of the audits will be brought to QAPI for further recommendation.
483.25 REQUIREMENT Quality of Care: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.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on observation, review of the clinical record and staff interview, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 41 residents reviewed (Resident 15).

Findings include:

Review of facility policy regarding Neurological Evaluation Standard (last reviewed April 27, 2017) revealed under PROCEDURE 1, that "Neurological evaluations are initiated when it is known or suspected that a resident has hit his/her head" and for "incidents of unwitnessed falls." Further review of the PROCEDURE revealed "5. Nursing team members completing the form will document Level of consciousness, pupil response, motor functions, pain response and vital signs as indicated on the form [Neurological Evaluation Flow Sheet] within the delineated time frames for the evaluation.)

Review of Resident 15's clinical record revealed diagnoses that included Muscle Weakness, History of Falling, anxiety disorder (mental disorder characterized by significant feelings of anxiety and fear; anxiety is a worry about future events, and fear is a reaction to current events), Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and Alzheimer's Disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain).

Review of Resident 15's clinical record revealed that she was admitted to facility on April, 26, 2019. Review of Resident's Admission Minimum Date Set (MDS- assessment tool used to determine residents' care and service needs) dated for May 3, 2019, revealed that she was not cognitively intact.

Review of Resident 15's clinical record revealed that she had falls in the facility on April 29, 2019, and April 30, 2019. Review of facility fall reports revealed that both falls were unwitnessed, occurred in her room, and that neurochecks (used to assess an individuals neurological functions and level of consciousness in order to determine whether or not individual is functioning properly and reacting appropriately to the tests being performed) were initiated.

Resident 15's Flow Sheet was initiated on April 29, 2019, following her fall with start time of 9:35 PM. Further review of the Flow Sheet revealed that her initial four checks (every 15 minutes) were completed, that her next two checks (every 30 minutes) were completed, and that the next two checks (every hour) were completed. The Flow sheet then revealed that the next check was to be a four hour check at 5:20 AM. Review of the documentation for this check revealed that the evaluation test for Level of Consciousness, Pupil Response, and Hand Grasp were not completed and it was also revealed that "sleeping" was written across these sections.

Resident 15 had an additional unwitnessed fall on April 30, 2019, prior to the completion of the required 72 hours of neurological evaluation for the April 29, 2019, fall, a new Flow Sheet was started beginning April 30, 2019, at 4:45 PM with completion of the four checks every 15 minutes, the two checks every 30 minutes, and the two checks every hour. Review of the documentation revealed that on May 1, 2019, the Flow Sheet then revealed that the next check was to be a four hour check at 12:30 AM. Review of the documentation for this check revealed that the evaluation test for Level of Consciousness and Pupil Response were not completed and that the section for Motor Function was coded as "U [Unable to follow commands]," this documentation also revealed that "sleeping" was written across the incomplete sections.

During an interview with Director of Nursing (DON) and Nursing Home Administrator (NHA) on July 25, 2019, at approximately 10:45 AM the NHA revealed that the Neurological Evaluations should have been completed.

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

























 Plan of Correction - To be completed: 09/09/2019

Resident 15 was reassessed and had a MD evaluation with no change to resident prognosis.


Audit of neurological checks per facility standard will be completed for current residents for the last month to determine if there are other residents at risk for cited concern.

Re-education to Licensed staff on neurological evaluation standard. Completed neurological flow sheets will be submitted to DON/designee for review prior to filing in resident chart.

DON/Designee will audit neurological evaluations per the facility policy weekly x 4 to ensure accuracy and then audit 4 neurological evaluations monthly times 2. Findings and results of the audits will be brought to QAPI for further recommendation.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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.
483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on observation and interview, it was determined that the facility failed to maintain oxygen for an in use portable oxygen tank for one of 41 residents reviewed (Resident 69).

Findings include:

Review of the clinical record for Resident 69 on July 22, 2019, revealed diagnoses that included Morbid obesity (over weight) and Diabetes Mellitus (DM-failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Observation on July 22, 2019, at 10:38 AM revealed Resident 69 sitting out of bed in her wheel chair with oxygen tubing via nasal cannula in place. Observation of the portable oxygen tank attached to the rear of her wheel chair revealed the level of oxygen was in the red area at its lowest point, indicating the tank was empty. Staff were notified and the oxygen tank was replaced.

During an interview with the Nursing Home Administrator and the Director of Nursing on July 24, 2019, at 11:30 AM they revealed that oxygen supply should be maintained at all times.

28 Pa Code 211.12(a)(c)(d)(3)(5) Nursing services
Previously cited 8/5/16
















 Plan of Correction - To be completed: 09/09/2019

Resident 69 was provided with a new oxygen tank at the time of the incident. No negative outcomes related to the noted concern.

Full house audit will be completed on residents that utilize portable oxygen. Order template created for portable oxygen for checks.

Re-education to licensed staff on oxygen administration procedure. Order template created for portable oxygen for checks.

DON/designee will do audits for residents using portable oxygen weekly x 4 weeks to ensure portable oxygen in place then 4 audits monthly x 2. Findings and results of the audits will be brought to QAPI for further recommendation.

483.90(e)(1)(ii) REQUIREMENT Bedrooms Measure at Least 80 Sq Ft/Resident: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.
483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms;
Observations:


Based on observations and documentation provided by the facility, it was determined that the facility failed to provide the regulatory required minimum square footage in one of 51 resident rooms.

Findings include:

Review of the facility documentation and observation revealed that room 319 has two beds and measures 160 square feet. Room 319 multi-bed room failed to provide the minimum square footage requirement of 80 square feet per bed.

42 CFR 483.70(d)(1)(ii)
Previously cited 9/24/2012, 9/12/2013, 8/7/2014, 9/3/2015, 8/5/2016, 7/27/2017, 8/2/18

28 Pa. Code 2015.20 Euro(f) Resident Bedrooms
Previously cited 9/24/2012, 9/12/2013, 8/7/2014, 9/3/2015, 8/5/2016, 7/27/2017, 8/2/18







 Plan of Correction - To be completed: 09/09/2019

The residents who reside in this room are aware that the square footage is less than other resident rooms and do not express any concerns with comfort of the room.

This room is the only room in the facility that doesn't meet square footage requirements. Anyone new moving into the room is made aware of the square footage variance and is permitted to choose not to accept the room.

The facility will re-apply annually for the federal waiver for the room that does not meet the federal requirement for square footage. A waiver has been in place for PA.

The application process will be reviewed with the facilities Quality Assurance and Improvement Program, and reported at the meeting.

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