Nursing Investigation Results -

Pennsylvania Department of Health
WILLOWBROOKE COURT AT SPRING HOUSE ESTATES
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WILLOWBROOKE COURT AT SPRING HOUSE ESTATES
Inspection Results For:

There are  28 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.
WILLOWBROOKE COURT AT SPRING HOUSE ESTATES - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on Medicare Recertification Survey, Civil Rights Compliance Survey and State Licensure Survey, completed on September 20, 2019, it was determined that Willow Brooke Court at Spring House Estates, was not in compliance with the 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:


483.25(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.
Observations:

Based on review of facility policy, clinical records and facility documentation and interviews with staff, it was determined, that the facility failed to provide an environment free of accident hazards which resulted in actual harm to one of 20 resident reviewed (Resident R16) who attempted to cut both his wrists with his own razor, requiring transfer and admission to the hospital via emergency services. Additionally, the facility failed to properly and safely provide transfer assistance from one surface to another for two of 20 residents reviewed (Resident R235 and Resident R62).

Findings include:

Review of Resident R16's clinical record revealed an admission diagnosis, including but not limited to, Alzheimers' disease with dementia, (progressive brain disorder characterized by confusion and impaired memory, judgement and reasoning ability) and obsessive compulsive behavior (mental health disorder characterized by repetitive actions that seem impossible to stop).

Continue review of Resident R16's clinical record revealed a "person center behavioral support plan" initiated August 5, 2019 addressing the resident compulsive behaviors through the day which continue through the night. The behavior plan indicated that Resident R16 was very particular about his appearance and fixates on the feel and look of clothing and space.

Review of Resident R16's psychotherapy progress note dated August 14, 2019, indicated that Resident R16's mood was anxious and depressed. Continued review of the psychotherapy note revealed Resident R16's insight was lacking and judgement was poor. Additionally, Resident R16's obsessive compulsive disorder signs and symptoms were getting worse and the resident was severely depressed. The treatment plan include to increase the antidepressant Lexapro.

Further review of Resident R16's clinical record revealed a nursing progress note dated August 19, 2019, at 6:25 p.m. which indicated that at approximately 5:15 p.m. resident approached two nurse " Resident ambulating with his walker, entered the nurses station to show us his bloody wrists... This nurse asked resident what happened" and the resident stated, "I tried to commit suicide". Resident indicated to Employee E13, Licensed nurse, "Frustrated and fed up". Employee E13 asked R16, "What he used to cut his skin", he replied, "My shaving razor. Both wrists were cleaned and dressed, wound were superficial in nature. Right wrist measured a cut of 2 center meters, (cm), x 3 cm x 0.1 cm and left wrist measured a cut area of 2 cm x 1 cm x 0.1 cm. No acute distress noted, resident sat calmly in the chair while being supervised 1:1 by nursing staff. Spoke with CRNP who gave order to send resident to [hospital] for evaluation and treatment... spoke with resident's daughter.. who was in agreement with plan of evaluation in the hospital... The resident remained in the nursing office with 1:1 nursing while room was searched and several razors were removed immediately as well as any other objects that could be potential harmful. 911 was called... Resident departed the facility at 6:25 p.m.

Review of hospital history and physical dated August 28, 2019 revealed that the resident "had been thinking about it for about an hour before he took a razor blade to his wrist. States he reported to the staff that he had tried to cut himself. Did not required sutures. Denies any suicidal ideation at present." Further review of the history and physical noted that the resident "states had passive wish to die before attempting to cut himself."

Review of the discharged instruction from the hospital confirmed that the resident came to the hospital for a suicidal gesture by attempting to cut wrist "superficially with a safety razor."

Interview with the Assistant Director of Nursing on September 19, 2019, at 11:30 a.m. confirmed review of Psychotherapy progress note dated August 14, 2019, indicated that Resident R16, was anxious, lacked insight, was with poor judgement and was severly depressed. Assistant Director of Nursing further confirmed five days after Resident R16 was seen by psychotherapy, he cut the anterior sides of his right and left wrists.

The facility failed to ensure that Resident R16's environment remained free from accident hazards, resulting in actual harm to Resident R16 who attempted to cut both his wrists with his own razor, requiring transfer and admission to the hospital via emergency services.

A review of Resident R235's clinical record revealed that the resident was admitted to the facility on September 5, 2019, with a diagnosis of status post left hip fracture, history of falling, pain, and difficulty in walking. A review of Resident R 235's fall risk assessment evaluation dated September 5, 2019, revealed that the resident was at a high risk for falls.

A review of the resident's care plan titled "I am a fall risk. I have impaired vision, I am on antidepressants and I have a decrease in my mobility" dated September 7, 2019, revealed that the resident should have appropriate footwear on when ambulating or in the wheelchair. A review of the resident care plan titled "I have potential for impairment to skin integrity", dated September 7, 2019, revealed "use caution when you are transferring and moving me to prevent striking my arms, legs and hands against any sharp or hard surfaces.

A review of Resident R235's admission Minimum Data Set (MDS- a periodic review of resident care needs) dated September 12, 2019, revealed that the resident was independent in decision making skills. Further review of the MDS revealed that the resident needed extensive assistance with bed mobility, transfers, dressing, and toilet use. Additionally, the MDS indicated that the resident needed the physical assistance of two staff persons for bed mobility, transfers, dressing and toilet use.

A review of nurse's notes dated September 13, 2019, revealed that Resident R235 was an "attempted transfer from the bed to the wheelchair for toileting by CNA (nursing assistant) care giver without assistance of another CNA. The resident's feet were bare. Upon transfer, the resident's left foot which was recently surgically repaired, came into contact with the wheelchair wheel and or castor frame causing a laceration between the fourth and fifth toes. First aid provided. CRNP made aware."

Review of the facility investigation of the incident sustained by Resident R235 determined that there was improper procedure and staff handling as predisposing environmental factors to the incident. Further review of the investigation noted that the resident had improper foot wear during transfer.

Interview with Employee E7, a nurse, on September 20, 2019, at 10:00 a.m. confirmed that he had written the nurse's note on September 13, 2019, and that the resident required the assistance of two staff persons for transfers.

Interview with the Employee E8, the registered nurse assessment coordinator (RNAC), on September 20, 2019, at 12:00 p.m. confirmed that Resident R235 needed the physical assistance of two staff members for transfers and that this was documented on the admission MDS dated September 12, 2019.

The facility failed to ensure that Resident 235 received the physical assistance of two staff persons during transfer from bed to wheelchair and was provided with the proper footwear which resulted in Resident 235 sustaining a laceration between her fourth and fifth toe on her left foot.

Review of Resident R62's comprehensive Minimum Data Set (MDS-an assessment of care needs) dated May 17, 2019, indicated that the resident was cognitively intact. The assessment further indicated that Resident R62 required extensive physical assistance from two staff persons for transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position).

Review of the comprehensive care plan for Resident R62 dated May 2019, through September 2019, revealed that Resident R62 was care planned to receive physical assistance from two staff with transfers. The care plan also indicated that the resident was to be transferred via a mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair by the use of electrical or hydraulic power).

A review of a nursing progress note dated June 13, 2019, indicated that Resident R62 reported being improperly transferred by a nursing assistant. Resident R62 indicated that a nursing assistant lost their balance during the transfer, falling onto the resident's bed and landing on Resident R62's foot. Resident R62 reported being in pain after the incident and that it felt as though his ankle was broken.

On June 13, 2019, nursing documentation indicated that an examination of the resident R62's left foot was done. As the nurse removed the sock from the resident's foot the resident yelled out in pain. The nurse indicated that Resident R62 continued to yell out in pain when the nurse attempted gentle range of motion. The physican was notified and ordered that Resident R62 be administered Tylenol (acetaminophen- pain reliever) 500 milligrams (mg), two tablets every four hours, as needed for pain management. The physician also ordered that ice be applied to the left ankle.

A review of facility documentation dated June 13 and 14, 2019, revealed that Employee E12, nursing assistant, assigned to provide care and services for Resident R62 failed to follow the comprehensive care plan for Resident R62's transfer. Review of a statement obtained from the resident revealed that Resident R62 reported that he was supposed to be transferred with two persons and a mechanical lift; however, on June 13, 2019, the nursing assistant performed a "one person transfer" and subsequently fell on top of the resident's foot. He clarified that he was not dropped but that the staff member fell on top of his foot during the one person transfer.

Interview with the Director of Nursing, Employee E2, on September 19, 2019, at 10:00 a.m., confirmed that Employee E12 Resident R62's was not transfer via mechanical lift as established on the resident's care plan on June 13, 2019.

The facility failed to properly transfer Resident R62 from the wheelchair to bed.

42 CFR 483(h) Free of Accident Hazards/Supervision/Devices.

28 Pa Code 201.14(a) Responsibility of Licensee.

28 Pa Code 201.18(b)(1)(3) Management.

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

28 Pa Code 211.10(d) Resident care policies.

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

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














 Plan of Correction - To be completed: 10/18/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared solely as a matter of compliance with federal and state law.

R16: Resident's room was immediately checked for razors and were removed. The resident's superficial wrist wounds were cleansed and treatment was provided. The resident was transferred to the ER for mental health evaluation.

Residents with a dementia diagnosis had their rooms checked for razors.
Staff education was provided to staff members to check rooms of dementia residents for razors. The policy for the shaving of residents was reviewed with staff to re-educate regarding disposable razor use. Family members have been notified via mail, requesting that disposable razors are not left in their loved ones' room. Razors should be given to the nursing staff to secure. This letter has also been placed in the Admission Packet for new residents.

Director of Nursing or designee will conduct weekly audits for three months, then bi-weekly audits for 6 months, then monthly audits for 12 months to check for the presence of razors in resident rooms. The results of the audits will be reported to QAPI for one year.

R235: Resident immediately received first aid treatment to her left 4th/5th toes. Nursing updated her special instructions and care plan to reflect her new transfer status of 2 person assist.
Staff education provided to nursing staff that residents must wear the proper footwear before transfers (i.e., non-skid socks or footwear of the residents' choice).
Director of Nursing or designee will conduct weekly audits for 4 weeks, then monthly audits for six months to check that residents are wearing appropriate footwear before transfers. The results of the audits will be reported to QAPI for one year.

R62: Resident was immediately assessed and evaluated for injury. No outward signs of injury were noted. Diagnostic testing was completed and showed an old-healing fracture of his left ankle. Resident received Alleve for pain relief and his ankle was wrapped for comfort purposes only.
Staff education immediately provided to nursing staff on the Transfer/Ambulation Policy and Procedure. Staff competencies were completed on the use of a mechanical lift transfer.
Director of Nursing or designee will conduct weekly audits for 4 weeks, then monthly for six months to check that staff are performing proper transfer techniques as per the residents' plan of care. The results of the audits will be reported to QAPI for one year.


483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on review of clinical records, review of facility documentation, and review of facility policy and resident and staff interviews, it was determined that the facility failed to provide restorative nursing services for ambulation and range of motion for one of 20 residents reviewed (Resident R17).

Findings include:

Review of facility policy, "Restorative Nursing", dated, April 2014, indicated, "The restorative process is based on the premise that basic human needs are universal and fulfillment of those needs is imperative to the resident's well-being."

During an interview with Resident R17 on September 17, 2019, at 10:30 a.m. it was stated by the resident the desire to walk more often. The resident additionally indicated that "staff are so busy or not enough staff to help me walk."

Clinical record review revealed a quarterly MDS, (Minimum Data Set -periodic assessment of needs), dated June 21, 2019, which indicated Resident R21 required extensive assistance, (resident involved in activity, staff provide weight bearing support) with one person physical assist.

Review of therapy progress notes revealed Resident R17, was discharged from therapy services on March 4, 2019. Interview with Physical/Occupational Therapy (PT/OT) Director, Employee E11 on September 20, 2019, at 1:00 p.m. indicated that Resident R17 was to receive a Restorative Nursing Program (RNP- a daily program, with oversite by a staff person to assist a resident in maintaining functional status that improved, as a result of receiving therapy services, such as daily walking) on an ongoing basis after discharge from therapy services.

Further review of therapy progress notes revealed a RNP - Recommendations, dated, March 25, 2019, which indicated, Resident R17 would facilitate daily functional ambulation on the unit hallway, (10-20 feet), using a rolling waker and facilitate daily active range of motion of lower extremities, by all major planes of motion in seated position.

A follow up interview with Employee E11, PT/OT Director, on September 20, 2019, 9:15 a.m. indicated that RNP for Resident R17, would have maintained daily living skills such as walking and range of motion.

An interview with the Director of Nursing on September 20, 2019, at 11:15 a.m. revealed that the facility had not had a designated staff person to fulfill Restorative Nursing Program duties for residents including, Resident R17, during the time period of November 17, 2018 to May 12, 2019 and May 30, 2019 to the time of the interview with the Director of Nursing, (September 20, 2019, at 11:15 a.m.).

The facility failed to provide restorative nursing services for ambulation and range of motion to Resident R17.


28 Pa. Code 201.18(b)(2) Management

28 Pa. Code 211.10(d) Resident care policies

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









 Plan of Correction - To be completed: 10/18/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared solely as a matter of compliance with federal and state law.

The resident (R17) was screened on 10/4/19. Resident agreeable to work with physical therapy with goal to develop an RNP for ambulation.
Residents are screened by the care team on a quarterly basis to monitor for changes in functional performance and are referred for therapy when appropriate. When a resident is discharged from rehabilitation therapy services and requires restorative services, the rehabilitation department will communicate the specific needs/plan of the resident to the restorative nurse and aides via the restorative nursing program recommendations form. This plan will then be implemented per therapy communicated instructions. The resident's plan of care will be updated to reflect all new approaches/interventions.

Residents who are being discharged from therapy services will be discussed in the daily morning meeting. Those residents who have been discharged with a recommendation for an RNP will be reviewed by the care team and will have a plan of care developed.

The RNACs will monitor the program on a monthly basis thereafter and will report to QAPI for 6 months. Director of Nursing or designee will conduct weekly audits for 4 weeks, then monthly for six months to check that proper documentation regarding a resident's participation and progress in a restorative nursing program is maintained. The results of the audits will be reported to QAPI for six months.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on observation, staff and resident interviews and a review of facility documentation, it was determined that the facility failed to serve food at a safe temperature.

Findings include:

A review of facility policy " Food Temperatures," date revised January 2013, stated to strive to ensure proper serving temperatures, food temperatures will be obtained and recorded prior to meal service and any inappropriate temperatures will be corrected. Procedure: using a sanitized calibrated food thermometer, obtain final temperatures for all menu items, hot or cold, prior to serving.

Further review of the facility policy "Service of hot beverage, soup and cereal in the skilled care center," date revised April 2010, stated to strive to ensure that residents in the skilled care center are served hot beverages, soup, and cereal at a safe and palatable temperature.

Holding temperatures of hot beverages, soup, and cereal will be recorded on the meal record log by the cook or medical diet aide. Each community will establish serving temperatures controls to maintain food at the desired temperature. Hot beverages, soup, and cereal will be served to the residents at temperatures not exceeding 155 degrees fahrenheit at point of service ( when the resident receives the food item). If the hot beverage, soup or cereal is above 155 degrees fahrenheit at point of service, the item will be held for several minutes to allow to cool until the temperature of the item falls to 155 degrees fahrenheit. To expedite the cooling process, the item may be stirred or be placed into bowls or mugs, and the temperature re-checked prior to serving.

An observation of the lunch meal on Willow Spring dinning room, on September 17, 2019, at 12:10 p.m. revealed that Resident R55 received her soup and stated "oh this soup is hot." When asked at what temperature the soup was being served, Employee E3, a dietary aide stated "I am new I will get another employee to help you. Employee E5, dietary aide, got a thermometer and took the temperature of the soup that was on the cart about to be served, the soup temperature was 163 degrees fahrenheit. When Employee E3 was asked what is done when soup is hot, he stated that " I will hold it for a few minutes and let the soup cool."

Employee E4, the nutritional service manager, was interviewed on September 17, 2019, at 2:00 p.m. and confirmed that the soup should have been served below 163 degrees fahrenheit. When asked when the soup temperature was taken and what is was, Employee E4 stated that the soup temperature was taken at the steam table and it was 176 degrees fahrenheit. When asked if the soup temperature was taken right before being served to the resident. Employee E4 stated "no."

A review of food temperature control logs for the month of September 2019, on the Willow Springs dining room revealed that food temperatures were recorded at the steam table but on the following days there were no serving temperatures recorded at the point of service: September 2, 2019, September 3, 2019, September 5, 2019, September 6, 2019 September 7, 2019, September 8, 2019, September 13, 2019, September 16, 2019,September 17, 2019. On the following days food temperatures were not recorded for all three meals: September 2, 2019, September 8, 2019, September 14, 2019 . And on the following days food temperatures were not recorded for certain meals: September 6, 2019-dinner food temperatures were not recorded, September 13, 2019- breakfast and lunch food temperatures were not recorded and September 18, 2019- dinner food temperatures were not recorded.

The facility failed to ensure that soup was served at a safe temperature.

28 Pa Code 201.14(a) Responsibility of licensee.

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









 Plan of Correction - To be completed: 10/18/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared solely as a matter of compliance with federal and state law.

Resident 55 had her soup removed immediately. The temperature was rechecked after several minutes and was within a safe range. The soup was returned to her.

The remaining soups were all temperature checked and provided to the residents.

Staff not demonstrating proficiency at the time of survey were in-serviced on proper practices and procedures for the service of hot beverages, soups and hot cereals. The culinary staff will be educated by the Director of Culinary and Nutrition Services or designee on the policies and procedures for Food Temperatures and Service of Hot Beverages, Soups and Cereal including appropriate logs and documentation of service temperatures as per Acts policy. Trainees will demonstrate competency to perform tasks as instructed.

Director of Culinary and Nutrition Services or designee will conduct weekly audits across all meals x 4 for one month then monthly x 2 and thereafter on a random basis. Results of the audits and observations will be reported to QAPI by the Culinary Director or designee quarterly for further recommendations.

483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.
Observations:

Based on observation and staff interviews, it was determined that the facility failed to post survey results on three of four nursing units. (Apple, Maple and Pine Nursing Units)

Findings include:

Observations on September 19, 2019, at 12:00 p.m. of the Apple, Maple, Pine Nursing Units revealed that there were no survey results posted in a prominent location with easy access for residents and visitors.

Interview with the Administrator on September 19, 2019, at 12:30 p.m., confirmed that there were no survey results posted in a prominent location with easy access for resident and visitors.

The facility failed to provide survey results and easy access for survey results to resident.

28 Pa. Code 201.29(b) Resident rights















 Plan of Correction - To be completed: 10/18/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the providers of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. This plan of correction is prepared solely as a matter of compliance with federal and state law.

The missing "Survey Results" book was found and placed in a prominent area with easy access for residents and visitors.
Facility to post a sign in two prominent areas indicating where to find the "Survey Results" book. In addition, another copy will be kept at the main nurse's station. Residents are also made aware of the availability of the survey results in resident council meeting.
Administrator or designee will conduct weekly audits for 4 weeks, then monthly thereafter for six months, to check that the "Survey Results" book is accessible. Results of these audits shall be reported to our quarterly QAPI meeting.


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