CHESTNUT HILL LODGE HEALTH AND REHAB CENTER
LOCATED: 8833 STENTON AVENUE, WYNDMOOR, PA 19038
CHESTNUT HILL LODGE HEALTH AND REHAB CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT
LEVEL OF HARM –ACTUAL HARM
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of clinical records, facility policies and procedures, facility documentation, the electronic Event Reporting System, manufacturer’s medication guidelines and interviews with staff, it was determined that the facility failed to provide adequate assessment and monitoring for a resident who sustained a fall, for one of four residents reviewed (Resident CL1), resulting in actual harm to that resident.
Review of a nurses’ note dated [DATE], at 12:30 a.m., revealed that Resident CL1 was found on the floor after the staff was notified by the resident’s roommate. The nurses’ note further revealed that Resident CL1 was found lying on the resident’s right side with a skin tear noted behind the right ear lobe and a possible closed head injury (a head injury in which the scalp and mucous membrane remain unbroken).
Review of the Neurological Assessment Flowsheet dated [DATE], for Resident CL1, revealed the resident’s vital signs were as follows: blood pressure, [DATE], pulse (heart rate) 82, respiration’s 16 at 12:45 a.m. (at the time of the fall); blood pressure, [DATE], pulse 96, respiration’s 20 at 1:00 a.m.; blood pressure, [DATE], pulse 110, respiration’s 22 at 1:15 a.m.; blood pressure, [DATE], pulse 76, respiration’s 24 at 1:30 a.m.; blood pressure, [DATE], pulse 80, respiration’s 26 at 1:45 a.m.; blood pressure ,[DATE], pulse 122, respiration’s 28 at 2:45 a.m.; and blood pressure ,[DATE], pulse 122, respiration’s 28 at 2:55 a.m.
Review of another nurses’ note dated [DATE], revealed Resident CL1’s condition was observed to get worse while checking the vital signs and neurological responses after the fall, the resident’s blood pressure, kept going down, and the resident’s pulse oximetry (measurement of percent of oxygen in the blood) level was recorded as 81 percent (100 percent is fully [MEDICATION NAME]) on room air and the resident required oxygen to be delivered via a non-rebreather mask (mask used to deliver oxygen). The note further indicated that the resident stated, I feel very weak. The note indicated the resident was sent to the hospital for evaluation via 911 emergency services at 2:55 a.m., and that the Registered Nurse Supervisor notified the resident’s physician.
Review of the Pennsylvania Department of Health Event Reporting System (electronic computer incident reporting system for long term care facilities) revealed that Resident CL1 was sent to a trauma center hospital for evaluation after the fall on [DATE], and while being evaluated in the hospital, the resident expired.
Review of the facility’s incident report dated [DATE], revealed that Resident CL1’s fall occurred on [DATE], at 12:30 a.m., the resident hit his head, and the resident’s physician was initially contacted at 12:51 a.m., on [DATE]. Further review of the incident report revealed that the resident’s physician responded to the facility on [DATE], at 2:30 a.m., approximately two hours after the resident fell.
Further review of the clinical record and the facility’s incident investigation report revealed no documentation that the nurse attempted to contact the resident’s physician when the resident experienced a significant change in the resident’s vital signs upon the second and third neurological checks which were documented at 1:00 a.m., and 1:15 a.m., on [DATE]. Additionally, the incident investigation report revealed no documentation that the facility’s Medical Director was contacted related to the lack of response by the resident’s attending physician upon the initial telephone contact after Resident CL1’s fall.
An interview with the Director of Nursing on [DATE], at 2:45 p.m., confirmed that Resident CL1 experienced an acute and significant decline in vital signs after sustaining a fall on [DATE], at approximately 12:30 a.m., confirmed the nurse did not ensure Resident CL1’s physician was notified of the resident’s ongoing change in status, and confirmed the nurse did not conduct complete, thorough and accurate assessment and monitoring of the resident after sustaining the fall. The facility failed to ensure that Resident CL1, a resident receiving blood thinning medication which is identified as a serious risk factor for bleeding, was adequately assessed and monitored by the facility staff after a fall which was unwitnessed by the staff and a questionable closed head injury occurred.
Personal Note from NHA-Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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