Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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GARDENS AT WYOMING VALLEY, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit and abbreviated complaint survey completed on December 27, 2019, it was determined The Gardens at Wyoming Valley corrected the federal deficiencies cited during the survey of October 31, 2019, but 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 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.
483.25(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.

Based on resident and staff interviews and a review of clinical records, information submitted by the facility and select facility investigation it was determined that the facility failed to provide necessary safety devices during transport to prevent a fall, which caused a fractured arm for one resident out of eight sampled (Resident 39).

Findings include:

A review of the clinical record of Resident 39 revealed admission to the facility on June 27, 2017, with diagnoses to include Spina Bifida (individual born with a defect of the spine which often causes paralysis of the lower limbs), cellulitis (inflammation of subcutaneous connective tissue) and chronic kidney disease.

A review of a 14-day Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 15, 2019, revealed that the resident was cognitively intact, with a BIMS score of 15 (brief interview for mental status - a tool to assess cognitive function; a score of 13 to 15 indicates no cognitive impairment). The resident required supervision and staff assistance for transfers, utilized a wheelchair for mobility and did not ambulate.

A review of information dated November 15, 2019, submitted by the facility Resident 39 "had a fall from motorized wheel chair during transport in facility van to appointment. When the driver applied brakes resident felt that catheter pulled, leaned forward and fell from chair. Van driver pulled vehicle off road and called 911. Paramedics responded and transported resident to hospital emergency room for assessment and treatment. Follow Up - Resident was treated for left humerus fracture at the ER and returned to facility. Resident will attend future appointments via wheel chair with clip belt in place on wheel chair. Upon further investigation it has been determined that the employee failed to follow facility transport policy (which states that each driver must be competent in "securing resident with wheelchair belt correctly [immediately before and after the resident is on the vehicle wheelchair belt should be palced and removed] and PA state law by not securing the resident with a seatbelt."

A review of a facility incident investigation dated November 15, 2019, at 12:35 p.m., revealed that Resident 39 was being transported to an appointment outside of the facility in the facility owned transport van. The driver of the van, Employee 1, van driver, stated that she came to a complete stop at the end of the off ramp at which time Resident 39 fell out of his wheelchair. Employee 1 then pulled the van over and called 911. Resident 39 was transported to the emergency room for an evaluation. Further review of the statement made by Employee 1, revealed that she had secured the resident's wheelchair in the van prior to leaving the facility, but failed to place the wheelchair seat belt on the resident for transport.

A review of documentation in Resident 39's clinical record dated November 15, 2019, at 7:05 p.m. revealed that the resident returned from the hospital with a left arm immobilizer in place. The resident had been diagnosed with a "closed 2-part non-displaced (broken bones remain in their correct position) fracture of \ surgical neck of left humerus (upper left arm)."

Interview with Resident 39 on December 27, 2019, at approximately 10:00 a.m., revealed that the resident was on his way to an appointment on November 15, 2019, in the facility van. The resident explained that he a wound vac (type of wound healing therapy that is vacuum-assisted) canister positioned between his feet on the foot rest of his electric wheelchair. Resident 39 further stated that he was leaning forward to hold the canister in place when the van came to a sudden stop and he fell forward out of his wheelchair and hit his head and "broke" his arm. The resident confirmed that the seat belt was not applied on his wheelchair and that the shoulder strap from the van had also not been applied to secure the resident in the chair.

Interview with the Nursing Home Administrator and the Director of Nursing on December 27, 2019, at approximately 1:00 p.m. confirmed that Employee 1 had failed to apply the wheelchair seatbelt and van shoulder strap to secure the resident during transport and the resident fell from the wheelchair and fractured his arm.

28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Previously cited: 10/31/19, 10/1/19, 6/21/19, 4/26/19

 Plan of Correction - To be completed: 01/10/2020

This was a self-reported event wherein a staff member failed to apply the provided safety device during resident #39's transport.

1. Employee 1 was immediately suspended pending investigation into the incident and subsequently discharged from employment.

2. Following this incident on 11/16/2019, facility transport staff completed driver competencies to insure the proper use of safety devices during transportation.

3. The facility implemented a safety checklist prior to transportation departures.

4. The transport Coordinator/designee will perform random audits to insure proper safety devices are in use on transports weekly for 4 weeks, then monthly for 2 months.

5. The results of the audit will be presented to the Quality Assurance Committee for review and recommendation.

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