Pennsylvania Department of Health
GARDEN SPOT VILLAGE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDEN SPOT VILLAGE
Inspection Results For:

There are  44 surveys for this facility. Please select a date to view the survey results.

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GARDEN SPOT VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on January 5, 2024, at Garden Spot Village, it was determined the facility was not in compliance under 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 as they relate to the Health portion of the survey process.


 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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 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 review of facility policy and clinical record review, it was determined that the facility failed to follow physician's orders and timely notify the physician of a significant change in condition for one of 18 residents reviewed, resulting in actual harm of Hypoxia (the body is deprived of adequate oxygen supply at the tissue level) for Resident 8.

Findings include:

Review of facility policy, "Notification of Condition Changes," last revised April 19, 2023, revealed the facility would notify the resident's provider when there is a significant change in the resident's condition, abnormal test results, and/or a need to alter treatment significantly.

Review of Resident 8's physician's orders revealed an order dated November 20, 2023, for oxygen 3 liters (L) nasal cannula every shift for shortness of breath and hypoxia (low oxygen levels). The order further stated that nursing may titrate (adjust) oxygen to keep the resident's oxygen saturation above 90%.

Review of Resident 8's progress notes revealed a nursing note dated November 20, 2023, (6:00 p.m.) which indicated: "Resident's o2 [(oxygen)] read 78 [(normal is 95-100)] and resident refused to wear oxygen cannula. After dinner, resident's o2 read 57 and continue to refuse to wear cannula. Resident was convinced to wear it but stated she will remove it shortly."

Additional review of Resident 8's clinical record failed to reveal any documented evidence the physician was notified of the resident's low oxygen saturation levels or the resident refusing to wear the oxygen cannula. There was no documented evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%.

Further review of Resident 8' progress notes revealed a nurse's note dated November 21, 2023, at 5:03 a.m. which indicated: "Resident's [pulse oximetry] was 87% with o2 at 2L. Resident refused [head of bed] to be raised. Staff continues to educate resident about the [pulse oximetry] level she should be at and how to achieve that goal. Resident has audible wheezing and is [short of breath.] Will continue to follow plan of care."

Further review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels, wheezing, or shortness of breath. There was no documented evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%.

Review of Resident 8's clinical record revealed a nurse's note on November 22, 2023, at 5:46 a.m. which indicated: "Resident found sitting in recliner leaning to the left with eyes closed without o2 cannula. At this position resident [pulse oximetry] was 67%. Resident difficult to arouse. When applying o2 cannula, [pulse oximetry] increased to 87% on 2L o2. A few minutes later resident woke up gasping with [shortness of breath,] frantic, and confused. Gave resident education about leaving o2 cannula on and explanation. Resident agreed to leave it on. Will continue to follow plan of care."

Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%.

Further review of Resident 8's progress notes revealed a nurse's note on November 23, 2023, at 5:27 a.m. which stated: "Resident lying in bed [pulse oximetry] was 65%. When [Resident 8] sat on the side of bed [pulse oximetry] increased to 83%. Resident was encouraged to take deep breaths and cough but no further improvement."

Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%.

Further review of Resident 8's progress notes revealed a nurse's note on November 23, 2023, at 11:25 a.m. which stated: "Resident away from home with family for thanksgiving dinner and left facility at 11:25. Resident's pulse ox was 83% on 3L of o2 via [nasal cannula.]"

Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%.

Further review of Resident 8's progress notes revealed a nurse's note date November 23, 2023, at 10:20 p.m. which indicated: "Resident's o2 fluctuated throughout the shift. At one time it read 49% when returning from an outing with family. After o2 cannula placed on resident, [his/her] o2 raised to 84%. When checked at [bedtime,] resident's o2 read at 72%. Resident appears to only be mouth breathing and cannula is not being used correctly. Resident removes cannula periodically when left alone. Resident is reminded to breathe through nose."

Review of Resident 8's clinical record failed to reveal documented evidence the physician was notified of the resident's low oxygen saturation levels or shortness of breath. There was no evidence that the facility attempted to titrate the resident's oxygen to maintain a level above 90%.

Further review of Resident 8's progress notes revealed a nursing note dated November 24, 2023, at 5:00 a.m. which indicated: "Resident noted using abdominal muscles for breathing and experiencing air hunger (difficulty breathing). Unable to raise oxygen saturation more than 83% @3L. The on-call [physician] gave orders to send the resident to [emergency room] for eval."

Review of Resident 8's hospital discharge summary revealed the resident was hospitalized in the intensive care unit (ICU) from November 24, 2023 until December 3, 2023, with a diagnosis of acute respiratory failure with hypoxia and hypercapnia (high levels of carbon dioxide) and required BiPAP (machine that normalizes breathing by delivering pressurized air via face mask into the upper airway that leads to the lungs. Its bilevel design means that a BiPAP device provides two different levels of air pressure: one for breathing in and one for breathing out.)

The facility's failure to follow Resident 8's physician's orders for oxygen at 3 liters and titrating to maintain oxygen levels above 90% as well as the failure to timely notify the physician of Resident 8's change in condition was discussed with the Nursing Home Administrator and Director of Nursing on January 5, 2023, at approximately 10:40 a.m.

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

28 Pa Code 211.5(f) Clinical Records

28 PA Code 211.10(a) Resident care policies



 Plan of Correction - To be completed: 02/01/2024

Resident 8 titration order discontinued on 1/10/24 due to unsuccessful attempts to wean oxygen. Updated order for continuous O2 2L/min via NC in place. Pulse Oximetry scheduled for BID. Resident's most recent Pulmonology appointment scheduled 1/5/24.

The resident continues to be re-educated on the importance of O2 compliance and care plan updated to reflect changes.

An audit performed by DON and/or designee of all current residents using O2 will occur to determine care plan adherence, documentation, appropriate O2 orders and timely notification to Provider if indicated. Corrections and notifications will occur if areas of concern are found.

Initiated EMR 24-hour summary report & other EMR reports to identify changes in condition and to ensure physician notification. Notification of Conditions Changes policy will be reviewed to ensure up to date.

DON met with Medical Director and identified a standard for elimination of titration orders. When Provider is notified of a change in resident's condition related to O2 orders, Provider will determine if there is a need for a new order.

All LPNs and RNs will be re-educated on Notification of Conditions Changes policy related to significant change in resident condition by Staff Educator.

A weekly audit by DON and/or designee will occur for all residents using O2 to ensure care plan adherence, documentation, appropriate O2 orders and timely notification to Provider if indicated. After audits, corrections will be resolved, and individual re-education will occur as needed. Additionally, the monthly audit report will be reviewed at QAPI.

483.20(g) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview it was determined the facility failed to complete accurate assessments for one of 24 residents reviewed. (Resident 70)

Findings Include:

Review of Resident 70's clinical record inclusding progress notes revealed a nursing entry dated October 27, 2023 indicating Resident 70 went home with all of his belongings and medications.

Review of Resident 70's discharge Minimum Data Set (MDS- periodic assessment of resident needs) dated October 27, 2023 revealed the assessment was coded as Resident 70 being discharged to a hospital.

Interview with Licensed Nursing Employee E3 on January 5, 2023 at 10:00 a.m. confirmed Resident 70's discharge MDS of October 27, 2023 should have been coded as the resident being discharged to home not to a hospital.

28 Pa. Code 211.5(f) Clinical records

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


 Plan of Correction - To be completed: 02/01/2024

Resident 70's MDS was updated to reflect the appropriate discharge identification on 1/5/24 and was resubmitted on 1/8/24.

An audit by Social Services and/or designee for all closed charts from October 1st, 2023 (when MDS changes occurred) will occur to ensure appropriate discharge identification After audits, corrections will be resolved, and individual re-education will occur as needed. Additionally, the audit report will be reviewed at QAPI.

All RNAC staff will be re-educated on the importance of accurate and timely MDS coding provided by staff educator.

Going forward, until QAPI team determines otherwise, a second RNAC will confirm all discharge identification to ensure accuracy. Any inaccuracies found will be resolved and individual re-education will occur as needed. Additionally, this information will be reviewed at QAPI.


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