Pennsylvania Department of Health
LUTHERAN HOME AT KANE
Patient Care Inspection Results

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LUTHERAN HOME AT KANE
Inspection Results For:

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LUTHERAN HOME AT KANE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance Survey completed on January 31, 2024, it was determined that The Lutheran Home at Kane was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.








 Plan of Correction:


483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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.
§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:


Based on review of facility policy and Resident Council minutes, and resident and staff interviews, it was determined that the facility failed to ensure that residents were updated in a timely manner regarding Resident Council concerns, and the facility failed to correct Resident Council concerns for a period of three months (November 2023 through January 2024).

Findings include:

Review of facility policy entitled, "Resident Council," dated 1/2/24, revealed "Resident Council is a social forum where residents are encouraged to discuss and make decisions about the environment in which they live. Residents are free to make grievances and recommendations to benefit all residents living in the nursing home." Procedure of Resident Council meeting indicated, "Activity Director or designated staff will conduct the meeting (as per Resident vote). It is the department's director's responsibility to fully investigate and answer concerns. If any department fails to address/investigate concerns, necessary actions will be taken."

Review of the Resident Council minutes and Grievances over the past three months, for November 2023 through January 2024, revealed a pattern/trend with issues regarding lengthy waiting times to go to the bathroom.

During a Resident Council meeting on 1/29/24, at 10:00 a.m. interviews with Resident R22, Resident R44, and Resident R58, who all attend Resident Council meetings regularly, indicated that concerns of wait times for toileting have been voiced in several past monthly meetings with no resident update or resolution.

An interview with the Activity Director on 1/30/24, at approximately 10:00 a.m. confirmed that he/she attends Resident Council meetings and reviews past monthly concerns in "new business and old business" with residents; and the concerns of lengthy wait times have been voiced by residents during the meetings in November 2023, December 2023, and January 2024 with no resolution.

An interview with the Director of Nursing on 1/30/24, at 12:25 p.m. confirmed that the facility had not corrected the Resident Council concerns regarding lengthy waiting times to go to the bathroom from the November 2023, December 2023, and January 2024 Resident Council meetings.

No evidence was provided to ensure the residents' concerns verbalized and further stated in the Resident Council minutes for the past three months reviewed was noted of timely corrective actions, in addition to no evidence of the residents being updated in a timely manner of those actions.

28 Pa. Code 201.14 (a) Responsibility of licensee

28 Pa. Code 201.18 (e)(1)(4) Management

28 Pa. Code 201.29(a) Resident rights





 Plan of Correction - To be completed: 03/12/2024

ADON followed up on the concerns identified in the deficiency at the resident council meeting.

The Lutheran Home at Kane has updated its process of handling concerns brought up during Resident Council meetings.
We have created a response form to be completed at each resident council meeting for any concerns/recommendations.
We have also created a concern tracking spreadsheet that will be maintained by the Activities Director. She will log the date of each concern, date it was sent to the Department Director, and the date the findings/solutions were communicated with the resident council President and resident who voiced the concern.
The Activities Director/designee will educate all alert and oriented residents of this new process for addressing concerns/suggestions.
The Activities Director will educate all Directors/Assistants on this new process.
The Activities Director or designee will present the response form to the Department Director/designee who oversees the specific area of concern for investigation/response. The Department Director/designee will have 7 days to investigate and communicate their findings by completing and returning the response form to the Activities Director.
The Activities Director/designee will meet with the Resident Council President and the Resident who voiced the concern to discuss the findings/solutions within 3 days of receiving the results/solutions.
The Activities Director/designee will review the concerns as well as the findings/solutions at the next regularly scheduled monthly resident council meeting to ensure all residents in attendance are updated.
The CEO/Administrator will conduct monthly audits for 3 months then quarterly for 6 months to ensure concerns are being addressed and feedback is provided to the residents.
The concerns/suggestions will also be discussed during the QAPI meetings.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on review of facility policy, resident and staff interviews, it was determined the facility failed to ensure the provision of a substantial evening snack when up to 14 hours and 45 minutes elapsed from the supper meal to breakfast the next day.

Findings include:

A review of facility's policy entitled "Meal times and frequency" with a policy review date of 1/2/2024, revealed meals and evening snack will be served at the following times: Breakfast 7:30 a.m., Lunch 11:00 a.m., Dinner 4:45 p.m., Evening snack 7:00 p.m. In nursing facilities, there will be no more than 14 hours between a substantial evening meal (dinner) and breakfast the following day. All residents will be offered a bedtime snack. If a nourishing snack is served at bedtime, then up to 16 hours may elapse between a substantial evening meal (dinner) and breakfast the next day.

Interviews conducted with residents during Resident Council meeting on 1/29/2024, revealed that three of three residents in the meeting indicated that a nourishing evening snack is not consistently served.

During an interview on 1/29/2024, at 1:00 p.m. the Dietary Manager and Registered Dietitian confirmed that there was no evidence that dietary staff or nursing staff provided residents with a nourishing evening snack. The Dietary Manager and Registered Dietitian also confirmed that there was more than 14 hours from the evening meal until breakfast the next day.

28 Pa. Code 211.6(a)(b) Dietary services




 Plan of Correction - To be completed: 03/12/2024

1. The Director of Nursing/designee will provide education to nursing staff on the appropriate times for residents to have a snack and will monitor that all residents are offered a snack in a timely manner.
2. One to two CNAs will be assigned to snack duty during the evening shift. The RN supervisor will monitor the completion of handing out snacks by checking the CNA's documentation in POC and have them sign a snack sheet. The dietary team will supply a variety of nourishing snacks daily such as sandwiches, yogurt, and fruit cups for the residents to choose from and ensure snack supplies are fully stocked.
3. RN night supervisor will run an audit to monitor that all residents have been offered a snack.
4. The RN night supervisor will complete an audit daily for two weeks, then three times a week for two weeks, and then weekly until significant compliance is met. This information will be discussed at the Resident Council meeting monthly and at QAPI quarterly.
5. Corrective action will be completed by March 12, 2024.


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