395090
11/05/2024
Windber Woods Senior Living & Rehabilitation Ctr
277 Hoffman Avenue Windber, PA 15963
F 0580
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of five residents reviewed (Resident 1). The facility's policy regarding changes in condition, dated December 14, 2023, indicated that the nurse would notify the resident's physician when there was a change in the resident's condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 19, 2024, revealed that the resident was severely cognitively impaired and had diagnoses that included dementia, depression, and Alzheimer's disease. A health status note for Resident 1, dated September 13, 2024, at 9:30 p.m., revealed that the nurse aide updated the licensed practical nurse, who in turn updated the registered nurse supervisor, that the resident was more confused than usual and that the resident's daughter was in to visit earlier in the evening and left early due to the resident swearing and yelling at her. Staff reported similar conduct when providing evening care and stated that this was not the resident's normal behavior. The nurse also reported that the resident had dark-colored, foul-smelling urine. The resident was reported to be afebrile at this time. A health status note for Resident 1, dated September 14, 2024, at 5:24 p.m., revealed that the resident's daughter was visiting and stated that her mother seemed different and more confused. The daughter commented that she felt her mother may have a urinary tract infection. The physician was then notified and a urine culture was ordered. There was no documented evidence that the physician was notified on September 13, 2024, at 9:30 p.m. regarding the resident's change in mental status and of the dark-colored, foul-smelling urine. The physician was not notified until the next day, September 14, 2024, at 5:24 p.m., approximately twenty hours later. Interview with the Nursing Home Administrator on November 5, 2024, at 3:31 p.m. confirmed that the physician was not notified in a timely manner of Resident 1's change in mental and physical condition, and he should have been. 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
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395090
395090
11/05/2024
Windber Woods Senior Living & Rehabilitation Ctr
277 Hoffman Avenue Windber, PA 15963
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm or potential for actual harm
Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse after a change in condition occurred for one of five residents reviewed (Resident 1).
Residents Affected - Few
Findings include: The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals. The facility's policy for change in condition, dated December 14, 2024, indicated that if a resident has a change in condition, it is the registered nurse's responsibility to assess, chart on, and update the physician regarding that resident's altered condition. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 19, 2024, revealed that the resident was severely cognitively impaired and had diagnoses that included dementia, depression, and Alzheimer's disease. A health status note for Resident 1, dated September 13, 2024, at 9:30 p.m., revealed that the nurse aide updated the licensed practical nurse, who in turn updated the registered nurse supervisor, that the resident was more confused than usual and that the resident's daughter was in to visit earlier in the evening and left early due to the resident swearing and yelling at her. Staff reported similar conduct when providing evening care and stated that this was not the resident's normal behavior. The nurse also reported that the resident had dark-colored, foul-smelling urine. The resident was reported to be afebrile at this time. There was no documented evidence in Resident 1's clinical record to indicate that she was assessed by a registered nurse regarding the resident's change in demeanor, mental status, and dark-colored, foul-smelling urine. A health status note for Resident 1, dated September 14, 2024, at 5:24 p.m., revealed that the resident's daughter was visiting and stated that her mother seemed different and more confused. The daughter commented that she felt her mother may have a urinary tract infection. The physician was notified and a urine culture was ordered. Interview with the Nursing Home Administrator on November 5, 2024, at 3:31 p.m. confirmed that there was no documented registered nurse assessment regarding Resident 1's change in mental and physical condition on September 13, 2024, at 9:30 p.m., and there should have been. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
395090
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