Pennsylvania Department of Health
EMBASSY OF SAXONBURG
Patient Care Inspection Results

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EMBASSY OF SAXONBURG
Inspection Results For:

There are  100 surveys for this facility. Please select a date to view the survey results.

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EMBASSY OF SAXONBURG - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated survey in response to three complaints completed on January 19, 2024, it was determined that Embassy of Saxonburg 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:


483.21(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 review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of three residents (Resident R23) to accurately reflect the current status of the resident after an elopement event.

Findings include:

Review of facility policy "Comprehensive Care Plan" dated 2/15/23, indicated the facility will develop and implement a comprehensive care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the residents progress. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (a periodic assessment of care needs). Alternative interventions will be documented, as needed.

Review of the facility policy "Elopements and Wandering Residents" dated 2/15/23, indicated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement.

Review of Admission Record indicated that Resident R23 was admitted to facility 12/19/23.

Review of Resident R23's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/23, indicated diagnoses Alzheimer's disease (a degenerative brain disorder resulting in progressive memory loss, impaired thinking, disorientation, and changes in personality and mood), anxiety disorder (a group of mental illnesses that cause constant fear and worry, characterized by sudden feeling of worry, fear and restlessness), and high blood pressure.

Review of Resident R23's Admission Assessment dated 12/20/23, indicated that resident does not have the cognitive ability to be orientated to room/surroundings, and that resident is currently receiving hospice services. Further review identified that has she has impaired cognition and/or decision making skills, and is independent with indoor mobility (ambulation).

Review of Resident R23's Wander/Elopement Assessment dated 12/20/23, indicated that she is at risk for elopement. Further review indicated that "Rationale for Risk Decision: Resident has been diagnosed with Alzheimer's disease. She has gathered her belongings in a blanket and stated "I am going home" as she came out of her room to hallway." Further review indicated that appropriate interventions have been initiated.

Review of Resident R23's clinical progress note dated 1/13/24, at 11:30 a.m., indicated that resident was seen walking back into facility by another resident's family; it appears that walked out of facility without her wanderguard going off and within 2 minutes was walking back into building at which time wanderguard did go off; Resident was brought to desk by staff with no apparent injuries noted; Resident is not in any apparent distress or have any issues notes at this time.

Review of Resident R23's Wander/Elopement Assessment dated 1/14/24, at 7:34 a.m., indicated that she is at risk for elopement. Further review indicated that "Rationale for Risk Decision: eloped from facility 1/13/24." Further review indicated that appropriate interventions have been reviewed.

Review of Resident R23's current care plan, initiated 12/20/23, updated 1/12/24, failed to indicate any revisions or implementation of new interventions to address elopement event on 1/13/24.

During an interview conducted on 1/19/24, at 3:45 p.m., the Nursing Home Administrator confirmed the facility failed to update a care plan for one of three residents (Resident R23) to accurately reflect the current status of the resident after an elopement event.

28 Pa. Code: 211.10(c) Resident care policies.

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



 Plan of Correction - To be completed: 02/15/2024

- Affected resident's care plan was immediately updated while surveyor was present to reflect the date of elopement event and interventions

- An audit was completed of all like residents to ensure care plans were up to date with any applicable revisions.

- Licensed nurses and Interdisciplinary team will be re-educated by DON or designee on the comprehensive care planning process specifically as it relates to revisions and interventions to address individualized care plans for elopement risk residents.

- All new admissions will be audited twice weekly for 2 weeks then weekly going forward, for proper individualized care planning as it pertains to elopement risk residents. Any resident that has a change in status or change in wandering risk, will be re-assessed and re-care planned to reflect the changes and ensure proper interventions are in place. All audits will be reviewed through facility QAPI process.

51.3 (f) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Observations:

Based on review of facility policy, facility documents, and staff interview, it was determined that the facility failed to notify the State Survey Agency of a significant gastrointestinal outbreak for 22 of 53 residents (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22).

Findings include:

A review of facility policy "Infection Prevention and Control Program", dated 2/15/23, indicated that the facility will establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

A review of facility "Outbreak Case - Patient Line List", indicated the following:

12/27/23 Resident R1 - onset symptoms of Nausea (N), Vomiting (V), and diarrhea (D)

12/28/23 Resident R2, R3, R4, R17, R21 - onset symptoms of N, V, and D
Resident R11 - onset symptoms of N and V
Resident R5, R12, R13, R14, R15 - onset symptom of D

12/29/23 Resident R6 - onset symptom of V

12/30/23 Resident R9, R16, R18 - onset symptoms of N, V, and D
Resident R19 - onset symptoms of D
Resident R20 - onset symptoms of N and fever (F)

1/1/24 Resident R7 - onset symptoms of N, V, and D

1/3/24 Resident R22 - onset symptoms of D

1/4/24 Resident R10 - onset symptoms of N, V, and D

During an interview on 1/19/24, at 3:45 p.m., the Nursing Home Administrator confirmed that the facility failed to notify the State Survey Agency of a gastrointestinal outbreak that occurred in the facility between 12/27/23 - 1/4/24.




 Plan of Correction - To be completed: 02/15/2024

- Reportable ERS being completed to notify of the Norovirus outbreak that occurred

- No other residents were affected by this except the residents identified in the line listing kept during outbreak

- DON and Infection Preventionist will be educated by NHA or designee on proper reporting of health department reportable diseases through the DOH ERS site

- Any further DOH reportable health diseases will be audited to ensure proper reporting is completed. Any findings will be reviewed through facility QAPI process.


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