Nursing Investigation Results -

Pennsylvania Department of Health
HAMILTON ARMS CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HAMILTON ARMS CENTER
Inspection Results For:

There are  53 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.
HAMILTON ARMS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Complaince survey and two complaints completed on April 26, 2019, it was determined that Hamilton Arms Center 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:


483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the attending physician was notified of a resident's weight loss, and that medications were administered according to physician's order for five of 20 residents reviewed (Residents #6, Resident #34, Resident #62, Resident #63 and Resident #75).

Findings include:

Review of Resident #6's clinical record revealed a diagnosis of chronic diastolic (congestive) heart failure and chronic obstructive pulmonary disease.

Further review of Resident #6's clinical record revealed a physician's order dated July 17, 2018 for the resident to be weight daily and call (heart specialist office) for weight gain of two pounds in one day or three pounds in three days, every day shift related to chronic diastolic (congestive) heart failure (excessive body/lung fluid caused by a weakened heart muscle).

Review of Resident #6's clinical record revealed an increase in weight from August 14, 2018 of 190 lbs. to August 15, 2018 to 192.4 lbs.; an increase of 2.4 pounds; on August 20, 2018 -188 lbs. to August 21, 2018 - 192lbs. an increase of 4 pounds; August 26, 2018 -187lbs. to August 27, 2018-190.4lbs. an increase of 3.4 pounds; August 28, 2018- 185lbs. to August 29, 2018 -190lbs. an increase of 5 pounds, with no documented evidence that the physcian was notified of the resident increase in weight.

Further review of Resident #6's clinical record revealed weights for September 5, 2018 -189.4 lbs. to September 6, 2018 194lbs. an increase of 4.6 pounds; September 9, 2018- 186lbs. to September 10, 2018 -188lbs. an increase of 2 pounds; September 12, 2018 -186.7lbs. to September 13, 2018 -189lbs. an increase of 2.7 pounds; September 19, 2018 -178.1lbs. to September 20, 2018- 182.8 lbs. an increase of 4.7 pounds; September 25, 2018 178lbs. to September 26, 2018 -181.4lbs. an increase of 3.4 pounds; September 27, 2018- 180lbs. to September 28, 2018- 183.6lbs. an increase of 3.6 pounds, with no notification documented.

An interview was conducted with the Nursing Home Administrator on April 26, 2019, at approximately 11:00 a.m. revealed that there was no further documentation.

Review of Resident #34's April 2019 physician's orders revealed that the resident was order Gabapentin Solution 50mg/5ml (milligrams per milliliter) 10 ml by mouth three times a day for muscle pain."

Observation of the medication pass on April 26, 2019 at approximately 9:18 a.m. revealed Resident #34 was not administered pain medication Gabapentin Solution 50mg/5ml (milligrams per milliliter). Interview on April 26, 2019 at approximately 9:18 a.m. with licensed nursing staff, Employee E3 revealed Gabapentin Solution was not administered to resident as the medication had not been received from the pharmacy.

Review of Resident #34's clinical record revealed notes dated April 23, 2019 and April 24, 2019 indicating, "Gabapentin Solution 250 mg/5ml give 10 ml by mouth three times a day for muscle pain, n/a awaiting from pharmacy." Review of Resident #34's April 2019 Medication Administration Record (MAR) revealed that resident missed five doses of Gabapentin 250 mg/5ml in April 2019 due to awaiting delivery from the pharmacy. The missed doses occurred on April 23, 2019 at 2:00 p.m. and 10:00 p.m. and then on April 24, 2019 at 10:00 a.m., 2:00 p.m. and 10:00 p.m.

Further review of Resident #34's clinical record revealed a physician's order for Gabapentin solution 250mg/5ml (Give 5 ml by mouth two times a day for nerve pain). Review of Resident #34's clinical record revealed the resident missed one dose on January 1, 2019, two doses on January 2, 2019, and one dose on January 3, 2019 due to "Not in stock. Awaiting arrival from pharmacy." Continued review of Resident #34's clinical record revealed resident missed doses of Gabapentin on January 28, 2019 (2 doses missed) and January 29, 2019 (2 doses missed).

Review of Resident #34's physician orders revealed an order for Biofreeze Gel 4% (Menthol Topical Analgesic) with instructions "Apply bilateral knees topically every day and evening shift for pain." Review of Resident #34's Medication Administration Record progress note indicated "Biofreeze Gel 4% apply to bilateral knees topically every day and night shift for pain. Awaiting arrival from pharmacy."

Further review of Resident #34's April MAR revealed that resident missed two doses of Biofreeze on the evening shift of April 23, 2019 and April 24, 2019.

Review of Resident #34's clinical record failed to reveal that attending physician was notified of the missed medications due to awaiting pharmacy delivery.

Review of Resident #62's clinical record revealed diagnoses including but not limited to following: Hypertension (High blood pressure); Muscle weakness; abnormalities of gait; Charcot's joint (progressive, degenerative condition which results in weakening of bones of the foot); pain in left knee; Achalasia of Cardia (failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed); Diabetes Mellitus (Failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment); Hyperlipidemia (abnormally elevated levels of any or all lipids or lipoproteins in the blood); and Obstructive sleep apnea (throat muscles intermittently relax and block your airway during sleep).

Review of Resident #62's clinical record revealed a physician's order for Preser/Vision/Lutein with administration instructions of "Give 1 capsule by mouth two times a day for supplement."

Review of Resident #62's April 2019 Medication Administration Record (MAR) revealed, Resident #62 did not receive the medication on April 22, 2019 (1 dose); April 23, 2019 (2 doses); and April 24, 2019 (2 doses).

Review of Resident #62's interdisciplinary progress notes revealed an MAR note dated April 22, 2019 at 8:57 p.m. indicating, "PreserVision/Lutein Capsule Give 1 capsule by mouth two times a day for supplement. awaiting from pharmacy." Progress note dated April 24, 2019 indicating, "Medication not available from pharmacy at this time."

Review of Resident's #62's clinical record revealed a physician's order for Pravachol (used to lower blood cholesterol and reduce the risk of heart attack, stroke and death) 20mg with administration instructions to give 20mg by mouth at bedtime for hyperlipidemia.

Review of Resident #62's March 2019 MARs revealed that on March 11, 13, and 14; resident did not receive medication.

Review of Resident #62's March 2019 physician's order revealed an order for Breo Ellipta Aerosol Powder 100-25 mcg/inh (micrograms per inhalation) to be administered as 1 inhalation orally one time a day.

Review of Resident #62's interdisciplinary progress notes revealed an MAR progress note dated March 4, 2019 at 9:22 a.m. indicating "Breo Ellipta Aerosol Powder Breath Activated 100-25 mcg/inh 1 inhalation inhale orally one time a day ..... N/A (not available) awaiting from Rx (pharmacy)."

Review of Resident #62's physician's March 2019 physician's orders revealed an order for Oxybutynin Chloride ER (antispasmodic and anticholinergic agent used to treat symptoms of overactive bladder, such as frequent or urgent urination, incontinence (urine leakage), and increased night-time urination) 5 mg with administration instructions of "Give 1 tablet by mouth at bedtime for overactive bladder."

Review of Resident #62's interdisciplinary progress notes revealed an MAR progress note date January 29, 2019 at 9:32 p.m. "Oxybutynin Chloride ER Tablet Extended Release 24 Hour 5 MG Give 1 tablet by mouth at bedtime for overactive bladder. medication not available from pharmacy at this time." A progress note dated March 1, 2019 at 8:36 p.m. indicated "Oxybutynin Chloride ER Tablet Extended Release 24 Hour 5 mg. Give 1 tablet by mouth at bedtime for overactive bladder. awaiting from pharmacy."

Review of Resident #62's clinical record revealed a physician's order for Klor-Con (Potassium Chloride - to treat low levels of potassium in the blood) to be administered "give 50 mg by mouth two times a day." Review of Resident #62's clinical record revealed progress notes dated January 13, 2019 February 12, 2019 and February 28, 2019 indicating the medication was not available due to awaiting pharmacy delivery.

Review of Resident #62's revealed an order for Toprol XL (used to treat Hypertension) 50 mg to be administered as "give 50 mg by mouth two times a day." Review of Resident #62's MAR progress note dated January 25, 2019 at 8:36 p.m. indicating, "medication not available from pharmacy at this time."

Continued review of Resident #62's clinical record failed to reveal physician notification of the missed medications.

Interview on April 26, 2019 at approximately at 8:55 a.m. with the Nursing Home Administrator confirmed that Resident #32 and #62 did not receive their scheduled medications and the physician was not notified of missed medications.

Review of Resident #63's clinical record revealed a diagnosis of hypertension (elevated blood pressure) and chronic combined systolic and diastolic heart failure (excessive body/lung fluid caused by a weakened heart muscle and decline in performance of one or both ventricles of heart during).

Review of Resident #63 physician's order revealed an order for the blood pressure medication Metoprolol Succinate Extended Release 24 HR (hour) 25 milligram, give one tablet by mouth one time a day related to hypertension and chronic combined systolic and diastolic heart failure: hold for SBP (systolic blood pressure) < 105 or HR (heart rate) < 55.

Review of Resident #63's March 2019 Medication Administration Records (MAR) revealed that the resident received medication on March 3, 2019 with a blood pressure of 102/62; March 5, 2019 with a blood pressure of 97/64; March 15, 2019 with a blood pressure of 96/80; and April 21, 2019 with a blood pressure of 96/50.

An interview was conducted with the Nursing Home Administrator on April 26, 2019, at approximately 11:15 a.m. that confirmed that Resident #63 should not have received the medication on the above dates and the facility failed to follow the physician's orders.

Review of Resident #75's January 2019 physician's orders revealed an order for Plavix (blood thinning medication) 75 milligrams (mg) 8 tablets (600 mg total) to be administered one time prior to heart catheterization.

Review of Resident #75's January 2019 Medication Administration Record (MAR) revealed that Resident #75 received Plavix 600 mg on January 3, 2019 at 9:00 p.m. and an additonal dose on January 4, 2019 at 9:00 p.m. which was not according to physician's order.

Further review of Resident #75's January 2019 MAR revealed Resident #75 also received Plavix 75 mg on January 4, 2019 at 6:00 a.m. which was the date the resdient was scheduled for heart catheterization.

Interview with the Nursing Home Administrator and Director of Nursing on April 26, 2019 at approximately 11:30 a.m. confirmed that the facility did not follow physician's orders for the administration of Plavix to Resident #75 in January 2019.



28 Pa. Code 211.12(c) Nursing Services
Previously cited on 02/14/18

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited on 02/14/18





 Plan of Correction - To be completed: 06/21/2019

1. The physician(s)/medical director were notified of the medications missed and/or weight notifications for Residents #6, #34, #62, #63 and #75. The cited residents did not experience ill effects from this occurrence.

2. The Unit Manager/ designee will complete an initial audit with lookback of 7 days to ensure that the weights obtained for current residents are reported to the physician and responsible party when there is a weight loss/gain noted within ordered parameters.

The Unit Manager/ designee will complete an initial audit with lookback of 7 days to ensure that medications are administered according to physician orders.

3. The Unit Manager/ designee will complete a weekly audit to ensure that the weights obtained for current residents are reported to the physician and responsible party when there is a weight loss/gain noted within ordered parameters.

The Unit Manager/ designee will complete a weekly audit to ensure that medications are administered according to physician orders.

4. The Product Development Specialist (PDS)/ designee will educate licensed staff on the weight reporting parameters and notification to the physician and responsible party.

The Product Development Specialist (PDS)/ designee will re-inservice licensed staff on administering medications according to physician orders. Re-education will also including notification of physician and pharmacy if a medication is not available as well as procedures if medication is not immediately available.

5. The Center Executive Director/ designee will review the results of the audits at the Facility's Monthly Quality Improvement Meeting x3 months.



483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure that medications were available from pharmacy for three out of 20 residents reviewed (Resident #34, Resident #62 and Resident #72).

Findings include:

Review of Resident #34 clinical record revealed diagnoses including but not limited to following: Chronic Inflammatory Demyelinating Polyneuritis (acquired immune-mediated inflammatory disorder of the peripheral nervous system); Epigastric pain; Lower back pain; Osteoarthritis (pain and stiffness in the hip, knee, and thumb joints); Idiopathic peripheral autonomic Neuropathy (pain and numbness, muscle problems and problems with body organs); Intervertebral Disc Degeneration Lumbar region (damaged discs in the lumbar spine cause symptoms of pain).

Observation of Medication pass on April 26, 2019 at approximately 9:18 a.m. revealed Resident #34 was not administered pain medication Gabapentin Solution 50mg (milligrams) /5ML (milliliters). Current physician order indicates the medication is to be administered as follows: "Give 10 ml by mouth three times a day for muscle pain."

Interview on April 26, 2019 at approximately 9:18 a.m. with licensed employee E3 revealed Gabapentin Solution was not administered to resident as the medication had not been received from the pharmacy.

Review of Resident #34's clinical record revealed notes dated April 23, 2019 and April 24, 2019 indicating, "Gabapentin Solution 250 mg/5ML give 10ml by mouth three times a day for muscle pain, n/a awaiting from pharmacy." Review of Resident #34's clinical record revealed that resident missed five doses of Gabapentin 250 mg/5ml in April 2019 due to awaiting delivery from the pharmacy. The missed doses occurred on April 23, 2019 at 2 p.m. and 10 p.m. and then on April 24, 2019 at 10 a.m., 2 p.m. and 10 p.m.

Further review of Resident #34's clinical record revealed a physician's order for Gabapentin solution 250mg/5ml (Give 5 ml by mouth two times a day for nerve pain). Review of Resident #34's clinical record revealed the resident missed one dose on January 1, 2019, two doses on January 2, 2019, and one dose on January 3, 2019 due to "Not in stock. Awaiting arrival from pharmacy."

Continued review of Resident #34's clinical record revealed resident missed doses of Gabapentin on January 28, 2019 (2 doses missed) and January 29, 2019 (2 doses missed).

Review of Resident #34's physician orders revealed an order for Biofreeze Gel 4% (Menthol Topical Analgesic) with instructions "Apply bilateral knees topically every day and evening shift for pain." Continued review of Resident #34's clinical record revealed a MAR (electronic Medication Administration record) progress note indicated "Biofreeze Gel 4% apply to bilateral knees topically every day and night shift for pain. Awaiting arrival from pharmacy."

Further review of Resident #34's April MAR (Medication Administration Record) revealed that resident missed two doses of Biofreeze on the evening shift of April 23, 2019 and April 24, 2019.


Review of Resident #62's clinical record revealed diagnoses including but not limited to following: Hypertension (High blood pressure); Muscle weakness; abnormalities of gait; Charcot's joint (progressive, degenerative condition which results in weakening of bones of the foot); pain in left knee; Achalasia of Cardia (failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed); Diabetes Mellitus (Failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment); Hyperlipidemia (abnormally elevated levels of any or all lipids or lipoproteins in the blood); and Obstructive sleep apnea (throat muscles intermittently relax and block your airway during sleep).

Review of Resident #62's clinical record revealed a physician's order for Preser/Vision/Lutein with administration instructions of "Give 1 capsule by mouth two times a day for supplement."

Review of Resident #62's April 2019 MAR (Medication Administration Record) revealed, Resident #62 did not receive the medication on April 22, 2019 (1 dose); April 23 (2 doses); and April 24 (2 doses).

Review of Resident #62's interdisciplinary progress notes revealed a MAR note dated April 22, 2019 at 8:57 p.m. indicating, "PreserVision/Lutein Capsule Give 1 capsule by mouth two times a day for supplement. awaiting from pharmacy." Progress note dated April 24, 2019 indicating, "Medication not available from pharmacy at this time."

Review of Resident's #62's clinical record revealed a physician's order for Pravachol 20mg (used to lower blood cholesterol and reduce the risk of heart attack, stroke and death) with administration instructions to give 20mg by mouth at bedtime for hyperlipidemia.

Review of Resident #62's March 2019 MAR's revealed that on March 11, 13, and 14, 2019 the resident did not receive the medication.

Review of Resident #62's March 2019 physician's order revealed an order for Breo Ellipta Aerosol Powder 100-25 MCG/INH (inhalation) to be administered as 1 inhalation orally one time a day.

Review of Resident #62's interdisciplinary progress notes revealed a MAR progress note dated March 4, 2019 at 9:22 a.m. indicating "Breo Ellipta Aerosol Powder Breath Activated 100-25 MCG/INH 1 inhalation inhale orally one time a day ..... N/A (not available) awaiting from Rx (pharmacy)."

Review of Resident #62'sMarch 2019 physician's orders revealed an order for Oxybutynin Chloride ER 5mg (antispasmodic and anticholinergic agent used to treat symptoms of overactive bladder, such as frequent or urgent urination, incontinence (urine leakage), and increased night-time urination) with administration instructions of "Give 1 tablet by mouth at bedtime for overactive bladder."

Review of Resident #62's interdisciplinary progress notes revealed a MAR progress note date January 29, 2019 (9:32 p.m.) "Oxybutynin Chloride ER Tablet Extended Release 24 Hour 5 MG Give 1 tablet by mouth at bedtime for overactive bladder. medication not available from pharmacy at this time." A progress note dated March 1, 2019 at 8:36 p.m. indicated "Oxybutynin Chloride ER Tablet Extended Release 24 Hour 5 MG (millifram). Give 1 tablet by mouth at bedtime for overactive bladder. awaiting from pharmacy."

Review of Resident #62's clinical record revealed a physician's order for Klor-Con (Potassium Chloride - to treat low levels of potassium in the blood) to be administered "give 50 mg by mouth two times a day."

Review of Resident #62's clinical record revealed progress notes dated January 13, February 12, and February 28, 2019 indicating the medication was not available due to awaiting pharmacy delivery.

Review of Resident #62's revealed an order for Toprol XL 50mg (used to treat Hypertension) to be administered as "give 50 mg by mouth two times a day."

Review of Resident #62's eMAR progress note dated January 25, 2019 at 8:36 p.m. indicating, "medication not available from pharmacy at this time."

Review of Resident #72's clinical record revealed the following diagnoses: Hypothyroidism (a common condition resulting from decreased production of thyroid hormones from the thyroid gland), anxiety, neuropathy (a nerve problem that affects the nerves outside of the brain and spinal cord causing tingling and pain in the fingers and toes), gastroparesis (a condition that affects the normal spontaneous movement of the muscles in your stomach slowed down, preventing your stomach from emptying properly) and constipation.

Further review of Resident #72's clinical record revealed physician's orders for the following medication; Levothyroxine Sodium Tablet 75 MCG Give 1 tablet by mouth in the morning for hypothyroidism; Lorazepam Tablet 1 MG Give one tablet by mouth every six hours for anxiety; Lyrica Capsule 75 MG Give one tablet by mouth three times a day for Neuropathy; Reglan Tablet 5 MG Give one tablet by mouth four times a day for gastroparesis; and Senna Tablet 8.6 MG Give two tablet by mouth three times a day for constipation.

Further review of Resident #72's clinical record revealed February's 2019 Medication Administration Record (MAR) stating that on February 14, 2019, Levothyroxine Sodium, Lorazepam, Lyrica, and Reglan were unavailable and the pharmacy was notified.

Review of the March 2019 MAR's revealed that on March 19, 2019, Levothyroxine Sodium, Lyrica, Reglan and Senna were unavailable and the pharmacy was notified.

Review of the April 2019 MAR's revealed that on April 5, 2019, Levothyroxine Sodium, Lorazepam, Lyrica, Reglan and Senna were unavailable and the pharmacy was notified.


The facility failed to ensure the timely delivery of all medication from pharmacy for Resident #34, Resident #62 and Resident #72.

28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services
Previously cited on 02/14/18

28 Pa. Code 211.9(a)(1) Pharmacy Services





 Plan of Correction - To be completed: 06/21/2019

1. Medical director/ physician have been notified of the missed medication identified for Resident #34, #62 and #72. Residents experienced no ill effects from the occurrence.

2. The Center Nurse Executive/ designee will conduct an initial audit with lookback of 7 days of medicine reconciliation for new orders of all residents residing in the facility. This will be completed to ensure all medications were available and administered.

3. The Center Nurse Executive/ designee will conduct a weekly audit of current/new residents' medication orders to ensure all medications were available and administered.

4. The Product Development Specialist (PDS)/ designee will re-educate licensed staff on the need for prescribed medications to be given per physician order and their role in notifying if the medication cannot be located. Licensed staff will be re-educated that when a medication is unavailable from the pharmacy, licensed staff will A. Determine if it is available in the facility emergency medication supply, B. Arrange to have the missing medication delivered on the next scheduled pharmacy delivery and/ or C. Facility staff will notify the physician/prescriber when a resident misses a dose of medication and ask for new orders or further instructions.

5. Compliance will be monitored by performing weekly audits of physician orders to ensure medications are available as ordered. Results of the audits will be reviewed by the DON/ designee at the Facility's Quality Assurance meeting monthly x 3.
483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(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 reviews and staff interviews, it was determined that the facility failed to ensure that written notices of emergency transfers to the hospital were provided to the Office of the State Long Term Care Ombudsman for three of five residents reviewed (Residents #34, Resident #76, and Resident #87).

Findings include:

Review of Resident #34's nursing notes revealed a nurse entry dated March 5, 2019, indicating that the resident was admitted to the hospital with a diagnosis of bowel obstruction.

Review of Resident's #76's nursing notes revealed a note dated April 25, 2019, indicating that the resident was admitted to the hospital for possible Cerebral Vascular Accident (brain hemorrhage/stroke).

Review of Resident #87's nursing notes dated April 18, 2019, indicated that the resident was admitted to the hospital for unrelieved pain and possible infection.

Interview with Nursing Home Administrator on April 26, 2019 at approximately 8:15 a.m. revealed that the facility did not notified the State Ombudsman's office when Resident #34, #76 and Resident #87 were transferred to the hospital.

28 Pa Code 201.14(a) Responsibility of Licensee

28 Pa Code 201.18(e)(1) Management









 Plan of Correction - To be completed: 06/21/2019

1. Residents #34, #76 and #87 were reported on the May 2019 monthly report to the Office of the State Long-Term Care Ombudsman.

2. An audit will be done of all residents transferred to the hospital in April 2019 to ensure that all transfers have been reported.

3. The Administrator will conduct an audit monthly x3, and then quarterly, to ensure that transfers and discharged residents are reported timely to the Office of the State Long-Term Care Ombudsman per the reporting algorithm.

4. The Regional Vice President will re-educate the Center Executive Director on reporting transfers and discharges timely to the Office of the State Long-Term Care Ombudsman per the reporting algorithm. The Center Executive Director/designee is responsible for reporting.

5. The Administrator/ designee will review the results of the audits at the Facility's Quality Improvement Meeting x3 months.


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(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 clinical record review and interviews with staff, it was determined that the facility failed to develop and revise comprehensive care plans for two of 20 residents reviewed (Resident #49 and Resident #75).

Findings include:

Resident #49's clinical record revealed a care plan that dated October 4, 2018 which identified the resident with impaired swallowing related to pocketing his foods; with an intervention to provide dysphagia advanced texture consistency diet as ordered.

Further review of Resident #49's clinical record revealed a dietary note dated January 7, 2019 which stated that the resident was identified for weight loss and the diet was down graded on December 3, 2018 to dysphagia pureed texture.

The facility failed to revised the resident's plan of care dated October 4, 2018 related to the resident diet to reflect the diet of dysphagia pureed texture ordered on December 3, 2018.


Review of Resident #75's active plan of care dated November 14, 2018 revealed "resident has a living will on medical record which reflects DNR [do not resuscitate] status." Further review of Resident #75's active plan of care revealed an intervention for the above mentioned focus which stated "Full Code." Further review of Resident #75's clinical record failed to provide evidence that Resident #75's active plan of care was updated and revised.

An interview was conducted with the Nursing Home Administrator on April 26, 2019 at approximately 11:30 a.m. revealed that the dysphagia advanced texture consistency diet, is not the same as a dysphagia pureed texture diet and the care plan was not updated accordingly. This interview further confirmed that Resident #75's active plan of care was not revised to reflect Resident #75's current code status.


28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.10(c) Resident care policies

28 Pa Code 211.11(a)(d) Resident care plan

28 Pa Code 211.(d)(1)(5) Nursing services
Previously cited on 02/14/18








 Plan of Correction - To be completed: 06/21/2019

1. Resident #49: Resident's careplan has been updated and is current. Resident #75: Resident's careplan has been updated and is current.

2. The Unit Manager/ designee will complete an initial audit with lookback of 7 days of current residents to ensure that a care plan is in place and reflects the current code status.

The Unit Manager/ designee will complete an initial audit of current residents with lookback of 7 days to ensure that a care plan is in place and reflects the current diet order.

3. The Unit Manager/ designee will complete weekly audit of current residents to ensure that any changes to the plan of care reflects the current code status and any new admissions have a baseline care plan to reflect Advanced Directives, Living Will or POLST.

The Unit Manager/ designee will complete a weekly audit of current residents and new admissions to ensure that a care plan is in place and reflects the current diet order.

4. The Product Development Specialist/ designee will re-inservice the interdisciplinary team on the Resident Centered Care Plan policy.

5. The Center Executive Director/ designee will review the results of the audits at the Facility's Monthly Quality Improvement Meeting x3 months.


483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on review of facility policy, review of clinical records and staff interviews, it was determined that the facility failed to document the rationale for continuing a as needed psychotropic medication for one of five residents reviewed (Resident #64).

Findings include:

Review of facility policy "Psychotropic Medication Use" revised November 28, 2016, revealed that prn (as needed) orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the prn order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the prn order.

Review of Resident #64's clinical record revealed the following (but not limited to) diagnoses: major depressive disorder (loss of interest in pleasurable activities), anxiety disorder, and bipolar disorder (is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks).

Review of Resident #63's January 2019 physician's orders revealed an ordered dated January 19, 2019 for the seizure medication Klonopin .5 milligrams (mg) by mouth every 12 hours as needed for delirium BID (twice a day) without a stop date.

Review of January, February and March 2019 Medication Administration Records (MAR) revealed that in January 2019 the resident received Klonopin .5 mg on January 20 (x2), 22, 23(x2), 24, 25 (x2) and 27, 2019; on February 2019 the medication was given on the 2, 7, and the 16, 2019 and in March 2019 the medication was given on March 3, 2019. Review of January, February and March 2019's physician's notes revealed that at no time did the physician stated their rationale and indicate the duration for the prn order.

An interview was conducted with the Nursing Home Administrator on April 26, 2019 at approximately 9:40 a.m. confirming that there was no further documentation explaining the rationale for the prn medication to be used more than 14 days.

28 PA Code 211.5(f) Clinical records

28 PA Code 211.10(a) Resident care policies

28 PA Code 211.12(d)(1)(5) Nursing services







 Plan of Correction - To be completed: 06/16/2019

Resident #64 had her PRN psychotropic medication D/Ced 3/19/19.
All current orders will be reviewed to identify residents who have PRN psychotropic drug orders.
14 day "STOP" dates will be requested from physicians for these orders or a documented rationale for continued use.
All professional nursing staff will be inserviced.
A weekly audit will be done to ensure that PRN psychotropics are monitored for a 14 day "STOP" date or well documented rationale for usage.
The results of these audits will be presented to the QI Committee monthly for 3 months and then quarterly.
Monitoring will be done by Nursing Administration and Pharmacist.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(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 observation and staff interview, it was determined that the facility failed to serve food in accordance with professional standards for food service safety for one of two units observed. (1st floor).

Findings include:

Observations of meal service on April 23, 2019 at approximately 5:12 p.m. revealed non-licensed Employee E4 with disposable gloves serving the evening meal.

Continued observation revealed Employee E4 then grabbed the mobile warming cart using gloved hands then proceeded to touch wall and cart cord, removing it from the wall outlet. Employee E4 moved the mobile warming cart next grouping of resident rooms. Employee E4 grabbed cart cord and inserted into wall plug using gloved hands. Employee E4 braced self by using left gloved hand placed on the wall. Employee E4 then proceeded to serve residents including handling dinner rolls and garlic bread without changing gloves.

Observation of noon time meal service on April 24, 2019 at approximately 12:22 p.m. revealed Employee E5 with disposable gloves serving the meal. Employee E5 then grabbed the mobile warming cart using gloved hands then proceeded to touch wall and remove cart cord from wall outlet. Employee E5 moved the mobile warming cart next grouping of resident rooms. Employee E5 grabbed cart cord and inserted into wall plug using gloved hands. Employee E5 then proceeded to serve residents including handling chicken pieces, dinner rolls and bread slices without changing gloves.

Interview on April 26, 2019 at approximately 11:10 a.m. with Nursing Home Administrator confirmed that staff did not practice professional standards when handling food and serving residents during the two meal observations.

28 Pa. code 211.6(f) Dietary services









 Plan of Correction - To be completed: 06/16/2019

Dietary staff has been re-inserviced regarding glove usage.
Dietary staff will remove gloves after moving the cart and sanitize their hands via the wall sanitizers prior to putting on new gloves for food serving.
This will be monitored by the FSD and Regional District Manager. Weekly random audits will be conducted for meals. The results of these audits will be presented to the QI committee monthly for three months and then quarterly thereafter.

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