Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT BLUE RIDGE, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT BLUE RIDGE, THE
Inspection Results For:

There are  202 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.
GARDENS AT BLUE RIDGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Findings of an Abbreviated complaint survey, in response to four complaints, completed on February 25, 2020, at The Gardens at Blue Ridge identified that the facility 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:


483.25 REQUIREMENT Quality of Care: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.
483.25 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 clinical record review 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 two of seven Residents reviewed (Residents 6 and 7).

Findings Include:

Review of Resident 6's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar) and gastro-esophageal reflux disease (GERD- acid reflux). Review of Resident 6's physician orders revealed an order for Lantus SoloStar Solution (insulin) inject 5 units subcutaneously one time a day and 20 units subcutaneously at bedtime, and an order for Insulin Aspart Solution, inject 10 units subcutaneously three times a day. There were no blood glucose parameters written in the order.

Review of Resident 6's Medication Administration Records (MAR) dated January 2020 and February 2020 revealed the Lantus was held on the following dates and times:
January 7 at 9:00 PM- blood glucose (BG) 81, physician made aware
January 14 at 9:00 AM- BG 69, physician made aware
January 16 at 9:00 AM- BG 98, no evidence the physician was made aware
January 22 at 9:00 PM- BG 54, glucose gel given, physician was made aware.
February 3 at 9:00 PM- BG 101, no evidence the physician was made aware
February 5 at 9:00 AM- MAR was marked "blood sugar level below parameters", there were no parameters ordered, no corresponding nursing note, no documentation of BG level and no evidence the physician was made aware
February 6 at 9:00 AM- BG 94, no evidence the physician was made aware
February 10 at 9:00 AM- BG 90, no evidence the physician was made aware
February 10 at 9:00 PM- BG 73, physician made aware.

Further review of the MAR revealed that the Lantus was given on the following dates and times with the following blood glucose levels:
January 13 at 9:00 AM- BG 72
January 19 at 9:00 AM- BG 78
January 21 at 9:00 AM- BG 86
January 22 at 9:00 AM- BG 73

Review of Resident 6's MAR revealed that on January 15, 2020, at 9:00 AM it is documented that Resident 6's BG was 71 and 5 units of Lantus was administered. Review of corresponding progress note dated January 15, 2020, at 9:30 AM revealed "orange juice administered. BS [blood sugar] re-assessed. BS: 78." There is no documented evidence that the physician was made aware.

Review of Resident 6's MAR dated January 2020 and February 2020, revealed the Insulin Aspart was held on the following dates and times:
January 2 at 8:00 AM- BG 95, physician was made aware
January 4 at 8:00 AM- BG 73, physician was made aware
January 7 at 8:00 AM- BG 97, no evidence that the physician was made aware
January 14 at 8:00 AM- BG 69, physician made aware
January 15 at 5:00 PM- BG 68, offered orange juice and candy bar, no evidence that the physician was made aware
January 16 at 8:00 AM- BG 98, no evidence the physician was made aware
January 31 at 5:00 PM- BG 58, glucose gel given, physician made aware.
February 5 at 5:00 PM- BG 91, Resident refused to eat, physician made aware
February 6 at 8:00 AM- BG 94, no evidence the physician was made aware
February 7 at 8:00 AM- BG 73, Resident refused x 3, physician made aware
February 10 at 8:00 AM- BG 90, MAR is signed off "blood sugar level below parameters"; No parameters written, no evidence the physician was made aware
February 15 at 5:00 PM- BG 80, physician aware
February 17 at 12:00 PM- BG 78, no evidence physician was made aware
February 17 at 5:00 PM- BG 92, no evidence physician was made aware.

Further review of the MAR revealed that the Insulin Aspart was given on the following dates and times with the following blood glucose levels:
January 3 at 12:00 PM- BG 78
January 10 at 5:00 PM- BG 75
January 13 at 8:00 AM- BG 72
January 15 at 8:00 AM- BG 71
January 19 at 8:00 AM- BG 78
January 19 at 12:00 PM- BG 78
January 20 at 5:00 PM- BG 78
January 21 at 8:00 AM- BG 86
January 22 at 8:00 AM- BG 73
January 31 at 12:00 PM- BG 78
February 3 at 12:00 PM- BG 80
February 3 at 5:00 PM- BG 71.

During an interview with the Regional Director of Nursing, on February 24, 2020, at 3:25 PM she stated that the physician should have been looking at the blood glucose more closely and that when the insulin was being given, nursing was following the order because there were no parameters written. No additional information was provided.

There was no evidence that the facility clarified the medication orders with the physician or consistently communicated to the physician when the ordered medication was held.

Review of Resident 7's clinical record revealed diagnoses that included hypertension (elevated blood pressure) and Type 2 Diabetes Mellitus. Review of Resident 7's physician orders revealed an order dated January 25, 2020, for Insulin Aspart Solution, inject 20 units subcutaneously with meals, hold if not eating or if blood glucose prior to meal is less than 120.

Review of Resident 7's medication administration record (MAR) dated January 2020, revealed that on January 27, 2020, at 8:00 AM, Resident 7's blood glucose was 114 and the nurse documented that insulin was given.

On February 24, 2020, at 2:30 PM the Director of Nursing was made aware of the above findings. He had no additional information or comment to provide to the surveyor at that time.

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




 Plan of Correction - To be completed: 03/11/2020

- Resident #6 no longer resides at facility.
- Resident #7 no longer resides at facility.
- Residents receiving insulin are at risk for this alleged deficient practice. These residents will have hold parameters established as per the MD. A house-wide audit of residents with insulin orders has been completed to ensure hold parameters have been written as per MD order.
- Licensed staff will be in-serviced on ensuring that residents that have insulin orders have hold parameters established as per the MD
- The DNS/designee will conduct 5 random audits of residents that have Insulin orders weekly x 4 and then monthly x2 or until substantial compliance has been achieved to ensure these orders have hold parameters written per MD order. Results of audits will be submitted to the Quality Assurance Committee for further recommendations.


483.30(b)(1)-(3) REQUIREMENT Physician Visits - Review Care/Notes/Order: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.
483.30(b) Physician Visits
The physician must-

483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;

483.30(b)(2) Write, sign, and date progress notes at each visit; and

483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
Observations:

Based on clinical record review and staff interview it was determined that the facility failed to ensure the physcian reviews the resident's total program of care, including medications, at each visit with the resident for one of seven residents reviewed (Resident 6).

Findings Include:

Review of Resident 6's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar) and gastro-esophageal reflux disease (GERD- acid reflux).

Review of Resident 6's physician orders revealed an order, dated November 4, 2019, for Glucose Gel 40 % (used for treating dangerously low blood glucose levels) give 1 application by mouth as needed for constipation.

The surveyor requested the original physician order for the glucose gel on February 24, 2020, at approximately 3:30 PM, again on February 25, 2020, at 9:16 AM and at 1:56 PM.

As of February 26, 2020, at 8:00 AM the facility has not provided the original, signed physician order for the glucose gel. No additional information has been provided by the facility.

The physician failed to ensure that the indication for use of the glucose gel was reviewed, as glucose gel is not used to treat constipation.


28 Pa. Code 211.2 (a) Physican's services



 Plan of Correction - To be completed: 03/11/2020

- Resident #6 no longer resides at facility.

- Residents with Diabetic orders are at risk for this alleged deficient practice. A house wide audit of Residents with Glucose Gel Orders will be reviewed to ensure the orders are within parameters.

- Nursing staff will be in-serviced on ensuring that residents orders are reviewed for accuracy.

- The DNS/designee will conduct 5 random audits of residents Orders, weekly x 4 and then monthly x2 or until substantial compliance. Results of audits will be reported to QAPI.



483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure the prevention of a significant medication error for one of seven residents reviewed (Resident 6).

Findings Include:

Review of facility policy titled "Nursing Care of the Resident with Diabetes Mellitus" with a revision date of December 2015, revealed "a. The reference ranges for normal blood glucose vary with different laboratories. b. Normal ranges are defined as 80-130 mg/dL [milligrams per deciliter] before meals and <180 mg/dL after meals."

Review of Resident 6's clinical record revealed diagnoses that included Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar) and gastro-esophageal reflux disease (GERD- acid reflux). Review of Resident 6's physician orders revealed an order dated November 20, 2019, for Insulin Aspart Solution, inject 10 units subcutaneously three times a day, an order dated December 9, 2019, for Lantus SoloStar Solution (insulin), inject 5 units subcutaneously one time a day, and an order dated December 11, 2019 for Lantus SoloStar Solution, inject 20 units subcutaneously at bedtime.

Review of the manufacturer's guidelines for insulin aspart revealed that it "should generally be given immediately (within 5-10 minutes) prior to the start of a meal."

Review of Resident 6's Medication Administration Record, dated February 2020, revealed that on February 3 at 12:00 PM her blood sugar was 80 and 10 units of insulin aspart was administered. On February 3, at 5:00 PM her blood sugar level was 71 and the insulin aspart, 10 units, is signed off as being administered at that time. Review of Resident 6's meal intake percentage on February 3, 2020, at 6:11 PM revealed that Resident 6 refused her meal.

Review of Resident 6's late entry nursing progress note, dated February 3, 2020 at 8:40 PM revealed that the nurse was called to Resident 6's room, "observed resident in bed unresponsive with eyes open and her tongue protruded out like beefy tongue, and skin sweaty. Blood sugar taken immediately was 27." Resident was given Glucagon (used to treat low blood sugar) 1 mg (milligram) IM (intramuscular), per order. Physician was notified and order was received to send resident to the hospital. Resident 6's blood sugar was checked after 15 minutes and it was 37, then 47. By the time EMS arrived to take Resident to the hospital, her blood sugar was 61 and Resident 6 refused to go to the hospital, stating she was feeling better. Food and juice was given and blood sugar reading was then 107.

Review of Resident 6's clinical record revealed no evidence that Resident 6 was educated to eat or drink anything or was being more closely monitored after she was given her 5:00 PM insulin and refused her supper.

During a staff interview on February 24, 2020, at 3:25 PM the Regional Director of Nursing stated that nursing was following the physician order for the insulin because there were no parameters written.

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





 Plan of Correction - To be completed: 03/11/2020

Resident #6 no longer resides at facility.
Residents currently receiving medications are at risk for this alleged deficient practice. A 14 day look back of medication administration records will be reviewed to determine that insulin is administered in a timely manner as directed by the provider.
Director of Nursing/designee will educate license staff on insulin administration ensuring they are within parameters, to include dietary intake and refusal.
The DNS/designee will conduct 5 random Medication Administration Record Audits of residents receiving insulin weekly x 4 and the monthly x2 or until substantial compliance has been achieved to ensure these orders are followed and written per MD. Results of audits will be submitted to the Quality Assurance Committee for further recommendations.

483.70 REQUIREMENT Administration: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.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:

Based on facility policy review, clinical record review, and interviews it was determined that the facility failed to be administered in an effective manner regarding the implementation of the policies and procedures for fall investigations by failing to thoroughly investigate a fall in a timely manner, that involved a major injury, hospitalization, and surgery, for one of four residents who sustained a fall within the past month (Resident 2).

Findings include:

Review of facility policy Falls Management System, revised 2016, revealed "When a resident sustains a fall, an evaluation may include investigation to determine probable causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall. The investigation and appropriate interventions will be evaluated at the time of the fall and reviewed by Nursing Management or IDT (interdisciplinary team)."

Review of Resident 2's clinical record revealed diagnoses that included; history of falling, muscle weakness, dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning), seizures (a sudden attack of illness, especially a stroke or epileptic fit), polyneuropathy (disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain).

Review of Resident 2's plan of care revealed Resident 2 requires the following: bed in a lower position, assistance of 2 staff members for bed mobility, assistance of 2 staff members while transferring with a mechanical lift, assistance of 2 staff members when care is provided in bed, and assistance of 1 staff member when providing personal hygiene, assistance of 1 staff member when dressing.

Surveyor asked the Director of Nursing on February 24, 2020, at approximately 10:00 AM for documentation that included a fall report for Resident 2 to include vital signs. The aforementioned documentation was received at approximately 1:00 PM, and did not include documentation of vital signs or witness statements to verify what was occurring when Resident 2 fell out of bed. The fall investigation was limited to: a nursing description of the event post fall; Resident 2's statement; immediate action taken; the statement "no injuries observed at time of incident;" the mental status of the resident; predisposed psychological factors that included a recent increase in behavior of yelling out for help and attention seeking. The aforementioned investigation failed to include witness statements from both Nursing Assistants who attempted to provide care, and the Housekeeper.

Review of the fall report dated February 13, 2020, at approximately 10:00 AM, with a revision date of February 24, 2020, at approximately 10:57 AM, revealed in the notes section that Licensed Practical Nurse 1 was made aware that Resident 2 had fallen out of bed. Resident 2 was found on her left side on the floor at the window side of the bed, the bed was in the low position, vital signs obtained, and Resident 2 complained of left hip pain. The Director of Nursing assessment of Resident 2 revealed she was on the floor next to the bed on her left side in a parallel position, no lateral or medial rotation, pedal pulses present, no obvious injuries noted, Resident 2 is alert and oriented, complained of left leg pain, medication was given, physician was notified, and x-ray of left leg advised.

Review of a facsimile from the contracted portable x-ray company dated February 13, 2020, at approximately 2:31 PM revealed the findings of the left hip with pelvis unilateral two to three view ray; acute fracture of the left femur proximally (a broken bone in the hip region, usually the result of a lower impact trauma.

Progress noted dated February 13, 2020, at 6:10 PM revealed the aforementioned x-ray results, physician notified, order provided to send Resident 2 to the hospital, Resident 2's daughter/power of attorney was notified of the transfer, and Resident 2 left the facility at approximately 6:00 PM.

Review of the hospital discharge summary dated February 16, 2020, revealed that Resident 2 was admitted on February 13, 2020, with a left hip fracture sustained from a fall, received surgery to repair her hip, and was discharged back to the facility on February 16, 2020.


On February 24, 2020, at approximately 3:10 PM surveyor was provided a copy of an occurrence/event witness statement signed by Nursing Assistant 1. The aforementioned form lacked documentation of the date of occurrence/event, and the date the form was signed by Nursing Assistant 1; the aforementioned dates were left blank. During an interview with the Director of Nursing on February 24, 2020, at approximately 3:11 PM it was questioned as to when the aforementioned statement was obtained, and the Director of Nursing stated "February 13th" and he proceeded to write in pen on the signature date line "2/13/20." Review of the aforementioned witness statement revealed that Nursing Assistant 1 and another Nursing Assistant, who was not named, were assisting Resident 2 with her activities of daily living. Resident 2 was being toileted while in bed, therefore Nursing Assistant 1 stood at the door to Resident 2's room to provide privacy, and the other Nursing Assistant exited the room to assist another resident. It was at that time Nursing Assistant 1 heard a noise, turned around to find Resident 2 on the floor. The housekeeper, who is not named, told Nursing Assistant 1 that she thought Resident 2 was reaching for a baby. Nursing Assistant 1 statement revealed that prior to leaving Resident 2's bedside they were talking about the birds having babies, and that the birds weren't real.

During an interview with the Assistant Director of Nursing on February 24, 2020, at approximately 3:17 PM it was revealed that the signature on the aforementioned witness statement belonged to Nursing Assistant 1. When the Assistant Director of Nursing was questioned as to whether Nursing Assistant 1 was still in the building, she replied "I'm not sure if she left."

During an interview on February 24, 2020, at approximately 3:18 PM with Nursing Assistant 2 it was revealed that Nursing Assistant 1 was no longer in the facility, that she left after she wrote the witness statement.

The facility failed to ensure a sincere attempt was made to determine the cause of the aforementioned fall, by obtaining witness statements from all staff members involved, prior to eleven days after the fall.

During an interview with the Regional Director of Nursing on February 24, 2020, at approximately 3:30 PM it was revealed that fall reports usually include witness statements, and that the statements may not be obtained the date of the incident, as it is dependent on the ability to communicate with the necessary staff members; which may take several days.


28 Pa code 201.18(3) Management
28 Pa code 211.12(5) Nursing Services








 Plan of Correction - To be completed: 03/11/2020

- Resident #2 had their fall on 2/13/2020 investigation completed.

- A house wide audit will be done to ensure the investigations are completed.

- Administration will be in-serviced on ensuring an investigation is completed with statements.

- The DNS/designee will conduct 5 random audits of residents that have sustained a fall, weekly x 4 and then monthly x2 or until substantial compliance has been achieved to ensure that appropriate investigation processes have been completed post fall. Results of audits will be reported to QAPI.




Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port