Wesley Enhanced Living At Stapeley (October)

Based on review of clinical record, facility policy, observations and interviews with staff, it was determined that the nursing home failed to check the feeding tube placement prior to giving a water flush for one of four residents with a feeding tube reviewed. The findings included the following: In a review of Resident R31’s clinical record revealed an undisclosed diagnosis. In further review it was revealed in the physician’s orders that a unspecified treatment was to be given three times a day. In observation of administration of a 250cc water flush into the feeding tube on September 30, 2013 at 11:00 a.m. revealed that Employee E3 failed to check the feeding tube placement prior to the water being instilled. In review of the facility’s home’s policy for tube feeding, dated January 1, 2013, revealed that the nurse should place a stethoscope over the stomach and instill a small amount of air into a feeding tube, and listen for air to enter the stomach. In an interview with Employee E3 on September 30, 2013 at 11:15 a.m. confirmed that the feeding tube placement was not checked prior to giving the water flush. The facility failed to follow physician’s orders.

Based on facility policies and procedures, a review of clinical records, a review of the Event Reporting System and interviews with staff, it was determined that the facility failed to notify the Pennsylvania Board of Health, Division of Nursing Care Facilities, of an allegation of abuse for one of 22 residents reviewed. The findings included the following: The 28 PA Code indicated that the nursing home shall report to the appropriate Division of Nursing Care Facilities field office serious events involving residents as set forth in the 28 PA Code.For purposes of this report, references to patients include references to residents. The 28 PA Code revealed serious events included complaints of patient abuse, whether or not confirmed by the facility. Review of facility policy titled Abuse: Zero Tolerance, dated February 2009, revealed that the facility will immediately notify the Department of Health via the electronic Event Reporting System, of an allegation of abuse. Clinical record review of Resident R33 revealed a minimum data set dated March 17, 2013, indicating the resident was cognitively intact. In review of nursing progress notes dated May 30, 2013, it was revealed that Resident R33 reported to facility staff that a certified nursing assistant made several comments to the resident over a one-to-two week period that the CNA was picking on me, and that the CNA was just being smart. The review of the Electronic Reporting System revealed that the incident was reported electronically as required by state regulations. In an interview with the Administrator on September 27, 2013 at 2:30 p.m. confirmed that this occurrence had not been reported to the Pennsylvania Department of Health as required.