Nursing Investigation Results -

Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LITITZ
Patient Care Inspection Results

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KADIMA REHABILITATION & NURSING AT LITITZ
Inspection Results For:

There are  95 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT LITITZ - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure, Civil Rights survey completed on December 24, 2018, it was determined that Kadima Rehabilitation and Nursing at Lititz 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 for the Health portion of the survey process.









 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on observations and review of facility policy, it was determined that the facility failed to maintain and store food in a sanitary manner in the main kitchen.

Findings include:

Review of facility policy titled, " Personnel Standards",dated June 2014 under heading, Dining Services Department, revealed "covering of all hair must be worn at all times while on duty including a beard net for facial hair".

Additional review of facility policy titled, "Food Storage", dated June 2014 revealed all foods stored in refrigerators and freezers should be dated at time of receipt. Un-served food shall be labeled, dated, and stored for a period not to exceed 7 days.

Observation and tour of kitchen with dietary staff, Employee E5 on December 18, 2018 starting at approximately 12:15 p.m. revealed the following: two dietary staff, Employees E7, and E8, were observed with protective coverings to their beard and mustache.

Observations of the main kitchen on December 18, 2018 at approximately 112:30 p.m. revealed a shelf over sink by toaster oven with an open bag of powder (cheese sauce) unlabeled/undated, an open bag of brown sugar with no label or date, a container of white flakes (mashed potatoes) undated/unlabeled, a box of raisins opened with no date/label, a pasta bag opened with no date/label, and a container on prep table with no label or date which appears to be butter.

Continued observation revealed the refrigerator in dishwasher room contained 2 containers of yogurt and a can of soda. Dietary staff, Employee, E5 revealed it belonged to an employee and employee food should not be there, but rather in employee breakroom refrigerator.

Further observation of the freezer in the dishwasher room revealed items thrown on top of each other, no organization many items with no date or labels. Containers of food open so contents exposed, some items appeared to have freezer burn. The following were items left unwrapped and undated without a label: bag of tater tots, a bag of sausages unwrapped, a bag of turkey meat unsealed, pixie pies(dessert), garlic bread unwrapped, diced chicken meat unsealed, open bag of diced carrots, premade omelets opened, bag of sausage links unsealed, box of burgers unsealed, an open bag of sugar cookies and a bag of chicken nuggets sealed in bag with no date/label.

Additional observation of the freezer in basement revealed three large pieces of meat (pork loins) wrapped in thin plastic undated and unlabeled, 4 loaves of bread not dated with noted freezer burn.

These observations were confirmed with dieatry staff, Employee E# 5 who confirmed that above items should have been sealed, dated, and labeled.

Observation of December 19, 2018 at 2:00 p.m. of the freezer in the main kitchen revealed a box of sugar cookie dough and box of chocolate chip cookie dough both unsealed and opened in freezer. The date on box was not legible. These findings were confirmed with the Administrator on December 19, 2018 at approximately 2:25 p.m.


28 Pa. Code 201.18 (b) (1) Management
Previously cited on 09/22/17

28 Pa. Code 211.6 (c) Dietary Services
Previously cited on 09/22/17














 Plan of Correction - To be completed: 01/29/2019

1. All unlabeled food products/unsealed products were discarded at time of survey
2. The Nursing Home Administrator or designee is inspecting all kitchen refrigerators/freezers for unmarked/open product and proper labeling
3. Dietary manager and dietary staff have been reeducated regarding dating and labeling sealing product and storing personal food.
4. The Nursing Home Administrator or designee will conduct audits of kitchen refrigerators/freezers for proper dating labeling, sealing product and storing personal food. Weekly x 4 and then monthly x2 or until substantial compliance has been achieved. Results of Nursing Home Administrator or designee audit will be reported to the Quality Assurance Committee. Any findings or corrective actions will be followed up on by IDT team.
5. Date of compliance 1/29/19

483.10(j)(1)-(4) REQUIREMENT Grievances: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.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:



Based on a review of resident group interview, and staff interview it was determined, that the facility failed to make certain residents were notified of a procedure for filing grievances anonymously on three of three nursing units (North Hall, East Hall and South Hall Units).

Findings included:

Federal regulation states, "The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the resident's rights. The resident has the right to file grievances anonymously."

During a resident group meeting conducted on December 19, 2018 at 2:30 p.m. with ten alert and oriented residents residing on the North Hall, East Hall and South Hall Units, revealed that these residents were asked if they knew how to file a grievance or concern and how they would file anonymously. All ten residents were unclear how to file anonymously and they were unaware of the location of Grievance/Concern forms.

During an observation on the North Hall Unit on December 18, 2018 at approximately 12:45 p.m. revealed a clear bin observed hanging approximately six feet high, on the wall located above the nurses' station desk containing a manilla file folder which was labeled "Grievances" with three grievance forms inside. The grievance forms were not readily accessible to residents.

During an observation on the South Hall Unit on December 18, 2018 at approximately 12:55 p.m. revealed a clear bin observed hanging approximately six feet high, on the wall located above the nurses' station desk containing a manilla file folder which was labeled "Grievances" placed behind another file folder that no one would be able to find. The file folder had no grievance forms inside. The grievance forms were not readily accessible to residents.

During an observation on the East Hall Unit on December 18, 2018 at approximately 1:15 p.m. revealed a bulletin board located in the back entrance hallway of the facility had no posting of a "Resident Grievance Policy". The process of how to file a grievance anonymously was not displayed and no Grievance/Concern Forms visible on the unit.

During an interview on December 20, 2018 at approximately 1:45 p.m. the Nursing Home Administrator confirmed that there was no grievance policy displayed on bulletin board near the back entrance hallway explaining the grievance process, there was no way for a resident or family to file an anonymous grievance and grievance/concern forms are not accessible to resident or families without asking a staff member.

The facility failed to establish a grievance policy informing residents and families on how to file a grievance or complaint orally, written, or the right to file a grievance anonymously.

28 Pa. Code 201.29 (a)(i) Resident Rights
Previously cited 11/14/18

28 Pa. Code 201.18 (e)(4) Management




 Plan of Correction - To be completed: 01/29/2019

1. Residents have been notified of the location of the grievance forms and how to file a grievance anonymously.
2. Grievance forms have been moved to a central location, that is readily accessible to residents. A letter was added to the admission packet with the location and how to file a grievance anonymously.
3. The Nursing Home Administrator will educate Social Services on the policy for informing residents and families on how to file a grievance or compliant orally, written, or the anonymously.
4. The Nursing Home Administrator or designee will conduct audits of resident council minutes to ensure it was reviewed were the grievance forms are located, and the process to fill the forms out. Theses audits will be completed monthly X3 or until substantial compliance has been achieved. Results of Nursing Home Administrator or designee audit will be reported to the Quality Assurance Committee. Any findings or corrective actions will be followed up on by IDT team.
5. Date of compliance 1/29/19

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of facility policy, clinical record review and staff interviews, it was determined the facility failed to ensure a comprehensive person-centered care plans were developed. The facility failed to ensure that each person-centered care plans were reviewed and revised by the interdisciplinary team after each assessment for eight of 12 residents reviewed (Residents #12, #18, #19, #23, #24, #27, #31 and #32).

Findings include:

Review of facility policy titled "Care Planning - Interdisciplinary Team" revised November 28, 2017, revealed "Our facility's Care Planning/Interdisciplinary Team is responsible for the development of a preliminary care plan for each resident upon admission, and an individualized comprehensive care plan for each resident. The resident has the right to participate in planning of his or her person-centered care and treatment or changes in care or treatment. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: When there has been a significant change in the resident's condition; When the desired outcome is not met; When the resident has been readmitted to the facility from a hospital stay; and At least quarterly. The mechanics of how the Interdisciplinary Team meets its responsibilities in the development of the interdisciplinary care plan (e.g., face-to-face, teleconference, written communication, etc.) is at the discretion of the Care Planning Committee."

Review of Resident #12's clinical record revealed a quarterly interdisciplinary care conference held on September 26, 2017. Further review of the resident's clinical record revealed the next documented quarterly interdisciplinary care conference was not held until September 18, 2018, which was twelve (12) months later.

Review of Resident #18's clinical record revealed a quarterly interdisciplinary care conference held on August 1, 2017. Further review of the resident's clinical record revealed the next documented quarterly interdisciplinary care conference was not held until September 27, 2018, which was thirteen (13) months later.

Review of Resident #19's clinical record revealed a quarterly interdisciplinary care conference was held on October 20, 2017, which was still in progress and never signed off as completed by the interdisciplinary team. Further review of the resident's clinical record revealed the next documented quarterly multidisciplinary care conference was not held until September 25, 2018, which was eleven (11) months later.

Review of Resident #23's clinical record revealed a quarterly interdisciplinary care conference held on August 29, 2017. Further review of the resident's clinical record revealed the next documented quarterly interdisciplinary care conference was not held until September 20, 2018, which was thirteen (13) months later.

Review of Resident #24's clinical record revealed a quarterly interdisciplinary care conference held on November 17, 2017. Further review of the resident's clinical record revealed the next documented quarterly interdisciplinary care conference was not held until October 2, 2018, which was eleven (11) months later.

Review of Resident #27's clinical record revealed a quarterly interdisciplinary care conference was held on September 18, 2017. Further review of the resident's clinical record revealed the next documented quarterly interdisciplinary care conference was not held until September 27, 2018, which was twelve (12) months later.

Review of Resident #31's clinical record revealed a quarterly interdisciplinary care conference was held on December 26, 2017. Further review of the resident's clinical record revealed the next documented quarterly interdisciplinary care conference was not held until October 2, 2018, which was ten (10) months later.

Review of Resident #32's clinical record revealed a quarterly interdisciplinary care conference was held on September 26, 2017. Further review of the resident's clinical record revealed the next documented quarterly interdisciplinary care conference was not held until October 9, 2018, which was twelve (12) months later.

Interview with Nursing Home Administrator on December 21, 2018 at 12:30 p.m. confirmed the interdisciplinary care conferences were not being held as often as they should be.

Interview with licensed nurse, Employee E3 on December 24, 2018 at 9:00 a.m. confirmed awareness that residents interdisciplinary care conferences were not being done quarterly and it was after October 2018 that residents care conference began to be held quaterly.

The facility failed to ensure Multidisciplinary Care Conference were being held on at least a quarterly basis.

28 Pa. Code 211.11 (d) Resident care plan

28 Pa. Code 211.12 (d)(5) Nursing services
Previously cited 11/14/17




 Plan of Correction - To be completed: 01/29/2019

1. Resident's #12, #18, #19, #23, #24, #27, #31 and #32 all have quarterly multidisciplinary care conference that have been scheduled and completed.
2. All multidisciplinary care conference have been scheduled for all residents
3. The Nursing Home Administrator will educate E3 to ensure multidisciplinary care conference are being held on at least a quarterly basis.
4. The Nursing Home Administrator or designee will conduct audits of multidisciplinary care conference to ensure timely scheduling and forms being completed. Theses audits will be completed weekly X4 and then monthly X2 or until substantial compliance has been achieved. Results of Nursing Home Administrator or designee audit will be reported to the Quality Assurance Committee. Any findings or corrective actions will be followed up on by IDT team.
5. Date of Compliance 1/29/19

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review, it was determined that the facility failed to notify the State Ombudsman's office of residents transferred to acute care facilities for 8 of 12 residents reviewed (Resident #16, Resident #18, Resident #19, Resident #23, Resident #24, Resident #25, Resident #34, and Resident #235).

Findings include:

Review of Resident #16's nursing progress note dated September 15, 2018, indicated that the physician ordered the resident to be sent to the emergency room (ER) for evaluation of abnormal vital signs and possible dehydration. Further review of Resident #16's clinical record revealed no documented evidence that the State Ombudsman's office was notified of the transfer to the hospital.

Review of Resident #18's clinical record revealed resident was transferred to hospital for evaluation of possible pneumonia on September 4, 2018. Further review of Resident #18's clinical record failed to reveal documented evidence that the State Ombudsman's office was notified of Resident #18's transfer from the facility to the hospital.

Review of Resident #19's clinical record revealed resident was admitted to the hospital on August 20, 2018 due to fall from wheelchair sustaining a laceration to forehead. Additional review of Resident #19's clinical record revealed the facility failed to contact Ombudsman's office to notify them of Resident #19's transfer to the acute care facility.

Review of Resident #23's clinical record revealed resident was sent to hospital for evaluation of chest pain and change in mental status on November 6, 2018. Further review of Resident #23's clinical record failed to reveal evidence that the State Ombudsman's office was notified of Resident #23's transfer from the facility to the hospital.

Review of Resident #24's clinical record revealed resident was sent to hospital on November 14, 2018 for a fall in which they sustained a laceration to forehead. Additional review of Resident # 24's clinical record failed to reveal evidence that the State Ombudsman's office was notified of Resident #24's transfer from the facility to the hospital.

Review of Resident #25's clinical record revealed resident sent to hospital on December 2, 2018 for complaints of pain in left leg for possible DVT (Deep Vein Thrombosis). Further review of Resident #25's clinical record failed to reveal evidence that the State Ombudsman's office was notified of Resident #25's transfer from the facility to the hospital.

Review of Resident #34's clinical closed record revealed resident was sent to emergency room on September 20, 2018 for respiratory distress. Additional review of Resident # 34's clinical closed record failed to reveal evidence that the State Ombudsman's office was notified of Resident #34's transfer from the facility to the hospital.

Review of Resident #235's clinical record revealed resident sent to hospital on December 17, 2018 for evaluation from a fall and possible seizures. Additional review of Resident # 235's clinical record failed to reveal evidence that the State Ombudsman's office was notified of Resident #235's transfer from the facility to the hospital.

Interview with Director of Nursing on December 21, 2018 at approximately 12:30 p.m. revealed that the facility did not typically notify the Ombudsman for transfers to acute care facilities.


28 PA Code 201.18(b)(1)(2) Management
Previously cited 11/14/17, 4/10/2018










 Plan of Correction - To be completed: 01/29/2019

1. The Ombudsman's office was made aware of the transfer of Residents #16, #18, #19, #23, #24, #25 #34, and #235.
2. The ombudsman will be notified of Residents who are transferred out of facility on a monthly basis.
3. The Director of Nursing and Social Services Director will be reeducated by the NHA or designee on the process for sending monthly notification to the Ombudsman's office of all residents transferred out of the facility.
4. The Nursing Home Administrator or Designee will audit the monthly communication to the Ombudsman to ensure notification of all residents that have been transferred out of the facility. Audits will be completed monthly X4. Results of Nursing Home Administrator or designee audits will be reported to the Quality Assurance Committee. Any findings or corrective actions will be followed up on by IDT team.
5. Date of Compliance 1/29/18

483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
483.15(c) Transfer and discharge-
483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with 483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:


Based on clinical record review, it was determined that the facility failed to send all appropriate clinical documentation for residents transferred to acute care facilities for 7 of 12 residents reviewed (Resident #16, Resident #18, Resident #19, Resident #23, Resident #24, Resident #34, and Resident #235).

Findings include:

Review of Resident #16's progress nursing note dated September 15, 2018, indicated that the physician ordered the resident to be sent to the emergency room (ER) for evaluation of abnormal vital signs and possible dehydration.
Further review of Resident #16's record revealed no evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #18's nursing documentation dated September 4, 2018 revealed that the resident was transferred to hospital for evaluation of possible pneumonia on September 4, 2018. Further review of Resident #18's clinical record revealed no evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #19's clinical record revealed resident was admitted to the hospital on August 20, 2018 due to fall from wheelchair sustaining a laceration to forehead. Further review of Resident #19's record revealed no evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #23's clinical record revealed resident was sent to hospital for evaluation of chest pain and change in mental status on November 6, 2018. Additional review of Resident #23's clinical record revealed the facility failed to send appropriate documentation to the acute care facility Resident #23 was transferred to.

Review of Resident #24's clinical record revealed resident was sent to hospital on November 14, 2018 for a fall in which the resident sustained a laceration to forehead. Further review of Resident #24's clinical record revealed no documented evidence that all appropriate documentation was sent to the acute care facility.

Review of Resident #34's closed clinical record revealed resident was sent to emergency room on September 20, 2018 for respiratory distress. Additional review of Resident #34's closed clinical record revealed no documented evidence that the the facility send appropriate documentation to the acute care facility Resident #34 was transferred to.

Review of Resident #235's clinical record revealed resident was sent to hospital on December 17, 2018 for evaluation from a fall and possible seizures. Further review of Resident #235's clinical record revealed no documented evidence that all appropriate documentation was sent to the acute care facility.

Interview with Director of Nursing on December 21, 2018 at approximately 12:30p.m. revealed that the facility did not typically send the nursing care plan with resident when transferred to acute care facility.


28 PA Code 201.18(b)(1)(2) Management
Previously cited 11/14/2017, 4/10/2018








 Plan of Correction - To be completed: 01/29/2019

1. The facility cannot retroactively correct the deficiency as it relates to Residents #16, #18, #19, #23, #24, #34, and #235 as all residents have since returned from the hospital.
2. Residents who require transfer to an acute care facility will have all appropriate clinical documentation, including care plan sent to the acute care facility.
3. All Licensed nursing staff will be reeducated by the Director of Nursing or designee on the process for sending all appropriate clinical documentation with any resident being transferred to an acute care facility.
4. The Director of Nursing or Designee will audit any residents that have been transferred to an acute care facility daily. Theses audits will be completed weekly X4 and then monthly X2 or until substantial compliance has been achieved. Results of Nursing Home Administrator or designee audit will be reported to the Quality Assurance Committee. Any findings or corrective actions will follow up on by IDT team.
5. Date of Compliance 1/29/19

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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.
483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:

Based on observations, facility policy, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure a resident was safely self-administered medications for one of 12 residents reviewed (Resident #12).

Findings include:

Review of facility policy titled " Self-administration of Medications," implemented in September 2014, revealed that the patient can only self-administer medication after the evaluation has been completed and it is determined that the patient is granted approval to fully self-administer medications. Storage of medications in the resident's room must be such that it will prevent access by other residents.

Observation on December 18, 2018 at approximately 4:10 p.m. during observation of medication pass, licensed nurse, Employee, E6 went to administer medications to Resident #12. Resident #12 was sitting in her room. Licensed nurse, Employee, E6 proceeded to look for resident's eye drops which were not on the medication cart. Licensed nurse, Employee, E6 asked resident if she knew where the eye drops where and Resident #12 stated that she had them in the pocket of her dress. Resident #12 proceeded to take the eye drops out of dress pocket and hand them to licensed nurse, Employee E6. Resident #12 explained to licensed nurse, Employee, E6 " I keep them so I can give them to myself when I need them". Licensed nurse, Employee E6 assisted Resident #12 with drop administration and left them with resident., who placed drops back in her dress pocket.

Interview conducted on December 19, 2018 at approximately 10:00 a.m. with Resident #12 in relation to her eye drops confirmed that Resident #12 always kept the eye drops in the pocket of her dress and at night she kept them on her nightstand. Resident #12 stated that she sometimes takes an extra few drops at night if her eyes are very dry due to heat in the winter.

Review of Resident #12's physician's orders dated December 2018 revealed, Artificial Tears Solution 0.4%, instill 1 drop in both eyes four times a day related to dry eye syndrome. May keep drops at bedside.

Further review of Resident #12's clinical record revealed that no assessment had been completed by the facility to determine that Resident #12 could safely and properly administer her own medications.

Additional review of Resident #12's clinical record revealed no nursing care plan interventions were available for self administration of medications and safe storage of medications.

Interview with the Director of Nursing and the Administrator on December 20, 2018, at 3:30 p.m. confirmed that the resident had no assessment done for the self-administration of eye drop medication or a nursing care plan developed for safe, self administration of eye drops.

The facility failed to ensure that Resident #12 was safely self-administering medications.

28 Pa. Code 201.29 (a) Resident Rights
Previously cited 2/13/2018

28 Pa. Code 211.10(a) (c) (d) Resident Care Policies
Previously cited 2/13/2018

28 Pa. Code 211.12(c) (d) (3) (5) Nursing Services
Previously cited 9/22/2017, 2/13/2018


















 Plan of Correction - To be completed: 01/29/2019

1. Resident #12 was assessed, and care planned will document interventions to support for safe self-administration of medication and storage and as per policy.
2. Residents who self-administer medications were verified to have an assessment for safe self-administration.
3. Employee E6 and all Licensed nursing staff, will be reeducated by the Director of Nursing or designee on the process for assessing a resident's ability to safely administer medication prior to allowing self-administration
4. Director of Nursing or Designee will audit residents that are care planned for self-administration of medication Theses audits will be completed weekly X4 and then monthly X2 or until substantial compliance has been achieved. Results of NHA or designee audit will be reported to the Quality Assurance Committee. Any findings or corrective actions will be followed up on by IDT team.
5. Date of Compliance 1/29/19

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on documentation submitted by the facility, and staff interviews, it was determined that the facility failed to report allegations of sexual abuse to the Department of Aging for one of 12 residents reviewed. (Resident #13)

Findings include:

Review of the Older Adults Protective Services Act (OAPSA), mandates reporting requirements on suspected abuse. Any employee or administrator of a facility who suspects abuse is mandated to report the abuse. All reports of abuse should be reported to the local Area Agency on Aging and licensing agencies. If the suspected abuse is sexual abuse, serious physical injury, serious bodily injury, or suspicious death as defined under OAPSA, the law requires additional reporting to the Department of Aging and local law enforcement.

Review of documentation submitted by the facility to the State Agency revealed Resident #13 made an allegation of sexual abuse on December 18, 2018. Further review of this documentation revealed that the facility did not notify Pennsylvania Department of Aging until December 20, 2018.

Interview with the Nursing Home Administrator on December 20, 2018 at 11:30 a.m. confirmed that the Pennsylvania Department of Aging was not notified in a timely manner of the sexual abuse allegations made by Resident #13.

28 Pa. Code: 201.14 (a)(c) Responsibility of licensee.
Previously cited 4/3/2017, 09/21/2017

28 Pa. Code: 201.18 (b)(1)(d) Management.
Previously cited 4/3/2017, 09/21/2017










 Plan of Correction - To be completed: 01/29/2019

1. Resident #13 still resides in the facility. The Pennsylvania Department of Aging has been updated and report was filed
2. Residents with an allegation of abuse will be reported to Pennsylvania Department of Aging as per Older Adults Protective Services Act.
3. The Nursing Home Administrator and Director of Nursing were in serviced on the requirement of reporting to Pennsylvania Department of Aging on any allegation of abuse.
4. The Nursing Home Administrator or designee will conduct audits of resident's allegation of abuse reported to Pennsylvania Department of Aging per Older Adults Protective Services Act requirement. Theses audits will be completed weekly X4 and then monthly X2 or until substantial compliance has been achieved. Results of Nursing Home Administrator or designee audit will be reported to the Quality Assurance Committee. Any findings or corrective actions will follow up on by IDT team.
5. Date of Compliance 1/29/19


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