Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT EAST MOUNTAIN, THE
Patient Care Inspection Results

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GARDENS AT EAST MOUNTAIN, THE
Inspection Results For:

There are  72 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GARDENS AT EAST MOUNTAIN, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on February 16, 2019, it was determined that The Gardens at East Mountain 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.



 Plan of Correction:


483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record review, resident and staff interview, it was determined that the facility failed to provide restorative nursing services for five of 15 sampled residents (Resident 2, 36, 83, 89, and 98).

Findings include:

A review of Resident 2's clinical record revealed that since December 2018, the resident had physician orders for restorative nursing services. The resident's restorative program was to include BUE (bilateral upper extremities) AROM (active range of motion) at least 15 minutes per day; BLE (bilateral lower extremities) AROM at least 15 minutes per day; dressing/grooming with set up and monitoring at least 15 minutes per day; transfers with stand by assistance for wheelchair to commode transfers and moderate to maximum assists sit to stand when getting up out of the wheelchair and walking with rollator walker and minimal assistance for 40-50 feet at least 15 minutes per day.

Interview with Resident 2 on February 16, 2019 at 1:45 p.m. revealed that the only exercises she gets is when she goes to an activity program in the chapel conducted by the facility's activities staff during which exercises are performed. The resident stated that nursing staff does not exercise her or walk her. The resident stated that staff will assist her with transfers from the wheelchair to commode and with sit to stand when getting up out of the wheelchair, but only when she requests these services. The resident stated staff does set her up for dressing and grooming, but do not monitor her activities to ensure that she receives 15 minutes of restorative services fore dressing and grooming.

A review of Resident 36's clinical record revealed that since December 2018, the resident had physician orders for restorative nursing services. The residents' restorative program was to include ambulation at least 15 minutes per day, resident is to utilize rollator walker and minimal assistance for 75 feet in hallway with the wheelchair following; BUE and BLE AROM in all planes of motion 15 reps (repetitions) times 2 and wheelchair pushups 15 times every other day; dressing/grooming and the resident will complete daily ADLs (activities of daily living) with maximal assist at least 90% of the time and the resident is to maintain safe transfers with moderate assistance 15 minutes per day.

Interview with Resident 36 on February 16, 2019 at 1:15 p.m. revealed that the resident stated that nursing staff does not provide restorative nursing services to him on a daily basis. The resident stated that he does his BUE and BLE AROM and wheelchair pushups every other day by himself with no help from staff.

A review of Resident 83's clinical record revealed that since December 2018, the resident had physician orders for restorative nursing services. The resident's restorative program was to include ambulation at least 15 minutes per day, staff to encourage increased ambulation with rollator walker and contact guard assistance for 100 feet; BUE AROM at least 15 minutes per day, for self care at least 15 minutes a day and staff to encourage AROM exercises to both upper extremities in all planes of motion 10 reps assisting with completion; assist with upper and lower body bathing with moderate assistance and upper and lower body dressing with maximum assistance and transfers at least 15 minutes per day, staff to encourage participation in all transfers with contact guard assistance.

During interview with Resident 83 on February 16, 2019, at 1:25 p.m. she stated that the nursing staff does not provide her restorative nursing services on a daily basis. The resident stated that staff does help her with her dressing and bathing, but not in the manner specified in the resident's restorative nursing program. The resident stated that staff does not walk her on a daily basis nor does she receive BUE AROM at least 15 minutes per day on a daily basis. She stated that staff does help her with transfers, but for a total of 15 minutes daily.

A review of Resident 89's clinical record revealed that from December 2018, the resident had physician orders for restorative nursing services. Resident 89 has nursing rehab program for
RUE (right upper extremity) stretching at least 15 minutes per day, and staff are to encourage trapeze stretching with position of arm and neck to maintain decreased pain and stiffness in the right shoulder.

Interview with Resident 89 on February 16, 2019, at 1:35 p.m. revealed that the resident stated that she performs the exercises by herself without staff help. The resident stated that "staff are busy with other things usually" and she has to do the exercises by herself.

A review of Resident 98's clinical record revealed that since December 2018, the resident had physician orders for restorative nursing services. Resident 98 restorative program was to include ambulation at least 15 minutes per day, staff to encourage resident to walk 250 feet (walk from residents room to nurses station and back) with rollator walker and stand by assistance and BUE AROM at least 15 minutes per day, staff to assist resident with BUE AROM in all planes of motion 15 reps.

During interview with Resident 98 on February 16, 2019, at 2:00 p.m. the resident stated she does walk from her bed to the bathroom, but staff does not walk her in the hallway and staff does not provide BUE AROM exercises on a regular or daily basis.

A review of restorative nursing documentation for the months of December 2018, January 2019, through the date of the survey February 16, 2019, revealed staff documentation indicating the above residents were receiving the restorative nursing programs as prescribed and at the prescribed frequency.

The Director of Nursing, during interview on February 16, 2019 at 2:30 p.m., was unable to explain why staff documentation indicated that these residents were receiving their restorative nursing services, but Residents 2, 36, 83, 89, and 98 stated that nursing staff was not consistently providing the services as planned for each resident.


28 Pa. Code: 211.5(f) Clinical records
Previously cited 7/20/18

28 Pa Code 211.12 (a)(c)(d)(5) Nursing services
Previously cited 7/20/18









 Plan of Correction - To be completed: 04/02/2019

Those residents identified had documentation present that restorative nursing programs were completed.

Residents currently receiving restorative programs will have their programs reviewed with them to ensure they understand the purpose and meaning of a restorative program. Resident education will be completed by utilizing The Brief Interview for Mental Status or BIMS of 13-15 indicating cognitively intact and a BIMS of 08-12 indicating moderately impaired.

Nursing assistants will be educated on the importance of explaining to the resident when they will be performing their restorative program which will assist the residents to understand the difference between personal care and restorative care.

DON/designees will complete audits on residents with a restorative nursing program and a BIMS between 8 and 15 to assure they have an understanding of their restorative program. The results of the audits will be reviewed with the QAPI committee to determine if additional audits or education is needed.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on review of clinical records and select facility reports and staff interview, it was determined that the facility failed to maintain complete and accurate records for one of 15 residents sampled (Resident CR1).

Findings include:

A review of the clinical record of Resident CR1 revealed admision to the facility on November 13, 2018, with diagnoses that included anxiety, and hypertension. The resident was hospitalized on January 4, 2019, and discharged from the facility that same date.

Review of Resident CR1's clinical record revealed physician progress notes for November 2018. Interview with the Director of Nursing on February 16, 2019, revealed that the resident was seen by the CRNP (Certified Registered Nurse Practitioner) in November 2018, December 2018, and January 2019, but there was no documentation in Resident CR1's clinical record to support these visits. Following surveyor inquiry, the facility printed out notes from an electronic system (EPIC) used by the CRNP (not a part of the resident's clinical record) to provide evidence that Resident CR1 was seen every month for the first 90 days. There was no documentated evidence of these physician/physician extender visits in Resident CR1's clinical record.

A review of nurses notes in Resident CR1's clinical record revealed that that the resident had a fall at 12:15 a.m. on January 3, 2019. The nurses note indicated that there were no obvious signs of injury. From the time of the fall at 12:15 a.m. on January 3, 2019, until a nurses note on January 4, 2019, at 1:50 p.m. there was no indication that the resident displayed signs of injury or pain. However, a nurses note dated January 4, 2019, at 1:50 p.m. indicated a drug interaction between Tramadol and Sertraline. The resident was receiving Sertraline prior to the fall, but not Tramadol. There was no documentation of the resident's pain or that the physician or CRNP had been notified and nursing had received an order for Tramadol.

Nurses note on January 4, 2019, at 1:51 p.m. indicated that the CRNP was made aware of the drug interaction. A nurses note dated January 4, 2019, at 1:54 p.m. noted that the CRNP ordered Tramadol for pain and that the resident's responsible party was aware.

A nurses note dated January 4, 2019 at 5:54 p.m. indicated that the x-ray results revealed that the resident had a left hip femur fracture.

There was no indication in Resident CR1's clinical record that the resident had complained of pain, signs or symptoms of a fractured hip or that an x-ray had been ordered.

Interview with the Director of Nursing on February 16, 2019 at 2:00 p.m. confirmed that the resident's clinical record was incomplete and lacked necessary documentation of physician visits, nursing assessment and monitoring of the resident after a fall, signs and symptoms of injury and the care and services provided to the resident in response to these clinical findings and identified injury.



28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
Previously cited: 7/20/18

28 Pa. Code 211.5 (f) Clinical records.
Previously cited: 7/20/18




 Plan of Correction - To be completed: 04/02/2019

Cannot correct clinical record for CR1 record is closed, resident had been discharged from the facility.

Current resident clinical records will be reviewed and updated with current CRNP documentation of visits. With the occurrence of an Incident/Accident nursing documentation will be reviewed to ensure a comprehensive assessment and corresponding documentation is present in resident's clinical record.

Medical Records staff will be educated on the importance and responsibility of ensuring Physician/CRNP progress notes will be placed in the resident's chart or downloaded into the clinical record. Licensed nursing staff will be educated on their responsibility for proper documentation that shows consistency and follow through to clearly explain the condition and outcome of resident's condition in their documentation. Re-education will be provided for failure of adequate documentation.

DON/designee will randomly audit nursing documentation to identify and ensure Licensed staff are completing documentation and outcomes in a clear consistent manner. The results of the audits will be reviewed with the QAPI committee to determine if additional audits or education is needed.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to timely notify residents' representatives of accidents involving the residents for three of 15 sampled residents (Residents 26, 105, and CR1).

Findings include:x

A review of the clinical record revealed that Resident 26 was admitted to the facility on January 18, 2019, and had diagnoses that included hypertension, and dementia.

Review of Resident 26's clinical record revealed that resident had a fall on January 29, 2019, at 2:40 p.m.

Nurses notes dated January 29, 2019 at 3:02 p.m. indicated that a call was placed to the resident's responsible party, but the phone kept ringing. There was no documented evidence of facility follow-up or that the facility had made contact with the resident's representative to inform them of the resident's fall.

A review of the clinical record revealed that Resident 105 was admitted to the facility on December 16, 2013, and had diagnoses that included diabetes, and dementia.

Review of Resident 105's clinical record revealed that the resident had a fall on January 21, 2019, at 10:00 p.m. Nurses notes dated January 21, 2019 at 10:25 p.m. indicated that a call was placed to the resident's representative, but there was no answer. There was no documented evidence that the facility had made contact with the resident's representative to inform them of the resident's fall.

A review of the clinical record revealed that Resident CR1 was admitted to the facility on November 13, 2018, and had diagnoses that included anxiety, and hypertension.

Review of Resident CR1's clinical record indicated that the resident had a fall on January 3, 2019, at 12:15 a.m. There was no indication in this resident's clinical record that the responsible party was notified of the resident's fall.

Interview with the Director of Nursing on February 16, 2019 at 2:15 p.m. confirmed that there was no documented evidence that the facility had notified the residents' representatives of the above falls.



28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services
Previously cited 7/20/18





 Plan of Correction - To be completed: 04/02/2019

Corrections does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

Resident 26 and 105 representatives were notified of their incidents. Resident CR1 was discharged from facility.

Resident's responsible representatives will be notified when the resident experiences an Accident/Incident with corresponding documentation reflected in the clinical documentation. I & A reports for the past 30 days will be reviewed to verify documentation of RP notification is present in both the clinical record and not solely on the Incident report.

I & A will be reviewed at the morning clinical meeting to verify that notification of RP is documented in the clinical record. Licensed nursing staff will be educated on their responsibility and importance of documentation of RP notification in the clinical record and not only on the Incident report.

DON /designee will audit resident's I & A reports to assure documentation of notification is present in the clinical record. The results of the audits will be reviewed with the QAPI committee to determine if additional audits or education is needed.


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