Nursing Investigation Results -

Pennsylvania Department of Health
MORAVIAN VILLAGE OF BETHLEHEM
Patient Care Inspection Results

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MORAVIAN VILLAGE OF BETHLEHEM
Inspection Results For:

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

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MORAVIAN VILLAGE OF BETHLEHEM - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification survey, State Licensure survey and Civil Rights Compliance survey completed on January 25, 2018, it was determined that Moravian Village of Bethlehem, 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:


483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide a skilled nursing facility advanced beneficiary notice (SNF-ABN) to the resident or the resident's representative following the end of their Medicare coverage for one sampled residents who was discontinued from Medicare Part A with benefit days remaining out of 24 sampled residents. (Resident 14)

Findings include:

Clinical record review revealed that Resident 14 received Medicare Part A services from October 13, 2018, through November 4, 2018. According to the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by the facility, Resident 14 was discontinued from Medicare Part A with benefit days remaining and that the termination of skilled services was initiated by the facility. There was no documented evidence that the resident or representative was provided the required SNF-ABN form (a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case).

In an interview on January 25, 2019, at 9:05 a.m., the Director of Nursing confirmed that the SNF-ABN notice was not issued to the resident or her representative.

28 Pa. Code 201.18(e)(1) Management.




 Plan of Correction - To be completed: 03/11/2019

- Resident 14 no longer resides in the facility.

- All residents remaining in the facility after being discontinued from Medicare Part A services with benefits days remaining shall receive notice through the SNF-ABN form that Medicare is not likely to provide continued coverage.

- The policy and procedures for issuing Medicare Beneficiary Notices shall be reviewed with the staff involved in discharging residents from Medicare Part A.

- Nursing management will monitor compliance with issuing SNF-ABN notices by verifying the notice is signed by the resident. Audits will be done weekly x 4 and then monthly x2. Results will be reported to the Quality Assurance Committee. Compliance will be evaluated and the process revised if necessary.

- Completion date: March 11, 2019.

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 review and staff interview, it was determined that the facility failed to notify the residents and residents' representative(s) of the transfers and the reasons for the moves in writing upon transfer from the facility for three of 24 sampled residents. (Residents 35, 42, 71)

Findings include:

Clinical record review revealed that Resident 35 was transferred and admitted to the hospital on August 25, 2018, after a change in condition. There was no documented evidence that the resident and resident's responsible party was provided with written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 42 was transferred and admitted to the hospital on November 13, 2018, November 30, 2018, and December 13, 2018, after a changes in condition. There was no documented evidence that the resident and resident's responsible party was provided with written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 71 was transferred and admitted to the hospital on January 8, 2019, after a change in condition. There was no documented evidence that the resident and resident's responsible party was provided with written information regarding the resident's transfer to the hospital.

In an interview on January 24, 2019, at 9:13 a.m., the Director of Nursing confirmed that the above mentioned residents' and their responsible parties were not provided written information regarding the transfers to the hospital.

28 Pa. Code 201.29(f) Resident rights



 Plan of Correction - To be completed: 03/11/2019

- Residents 35, 42 and 71 all returned to the facility.

- A Transfer and Discharge Notice shall be given to any facility initiated discharge of a resident, including residents emergently sent to the hospital. A copy of the notice shall be sent to the resident's representative party and the ombudsman.

- The policy and procedures for issuing Transfer and Discharge Notices shall be reviewed and the staff involved in discharging residents to the hospital shall be educated.

- Nursing management will monitor compliance with issuing the Transfer and Discharge Notices by verifying the mailed receipts. Audits will be done weekly x 4 and then monthly x2. Results will be reported to the Quality Assurance Committee. Compliance will be evaluated and the process revised if necessary.

- Completion date: March 11, 2019.

483.25(n)(1)-(4) REQUIREMENT Bedrails: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.
483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to attempt to use alternatives prior to the use of a side or bed rail and failed to review the risks and benefits related to the use of bed rails with the residents and obtain informed consent for utilization of bed rails for three of 24 sampled residents (Resident 34, 35, 42).

Findings include:

Review of the facility policy entitled, "Proper Use of Side Rails Level II", dated January 31, 2018, revealed that prior to the use of side rails, less restrictive interventions were to be attempted and documented if these approaches were not successful. Further, informed consent was to be obtained from the resident or legal representative after presenting potential benefits and risks.

Clinical record review revealed that Resident 34 was admitted to the facility on September 8, 2017, with diagnoses that included muscle weakness and Parkinson's disease. A Minimum Data Set (MDS) assessment completed December 12, 2018, revealed that the resident had no memory impairment and required extensive assistance of two staff members for bed mobility. On January 22, 2019, at 12:17 p.m., and at 2:07 p.m., the resident was observed in bed with two side rails in the up position at the top of the bed. Resident 34 was observed in bed on January 23, 2019, at 9:48 a.m., and on January 24, 2019, at 10:00 a.m., in bed with two side rails in the up position. There was no documented evidence that alternatives had been attempted prior to side rail use. There was no documented evidence that the risks and benefits of side rail use was discussed with the resident or that informed consent was obtained.

Clinical record review revealed that Resident 35 was admitted to the facility on July 16, 2015, with diagnoses that included muscle weakness and anemia. A MDS assessment completed November 15, 2018, revealed that the resident had no memory impairment and required extensive assistance of two staff members for bed mobility. On January 22, 2019, at 11:50 a.m., and at 2:20 p.m., and on January 23, 2019 at 8:25 a.m., the resident was observed in bed with two side rails in the up position at the top of the bed. There was no documented evidence that alternatives had been attempted prior to side rail use. There was no documented evidence that the risks and benefits of side rail use was discussed with the resident or that informed consent was obtained.

Clinical record review revealed that Resident 42 was admitted to the facility on October 18, 2018, with diagnoses that included muscle weakness, depressive disorder and gastrostomy. A MDS assessment completed January 11, 2019, revealed that the resident had no memory impairment and required extensive assistance of two staff members for bed mobility. On January 22, 2019, at 2:05 p.m., and on January 23, 2019, at 9:46 a.m., the resident was observed in bed with two side rails in the up position at the top of the bed. There was no documented evidence that alternatives had been attempted prior to side rail use. There was no documented evidence that the risks and benefits of side rail use was discussed with the resident or that informed consent was obtained.

In an interview on January 24, 2019, at 9:20 a.m., the Director of Nursing confirmed there was no documented evidence to support that risks and benefits of bed rail use was discussed with the resident, no attempt to use alternative bed mobility methods and informed consent was not obtained from the resident prior to bed rail use.

28 Pa 211.12(d)(5) Nursing services.




 Plan of Correction - To be completed: 03/11/2019

- Residents 34, 35 and 42 had no ill effects.

- Any resident requesting the use of side rails shall have alternatives interventions attempted, shall be informed of the risk/benefits of side rails and informed consent shall be obtained. All other residents will not use bedrails.

- The policy and procedures for the use of side rails shall be reviewed and updated as necessary. Nursing staff shall be educated on the use of bed rail policy.

- Nursing management will monitor compliance with the use of side rails by reviewing the side rail documentation and observing beds. Audits will be done weekly x 4 and then monthly x2. Results will be reported to the Quality Assurance Committee. Compliance will be evaluated and the process revised if necessary.

- Completion date: March 11, 2019.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 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 timely availability of prescribed medications for administration for one of 24 residents sampled (Resident 2).

Findings include:

Clinical record review revealed that Resident 2 was admitted to the facility on January 12, 2019, with diagnoses that included dysphagia and Parkinson's Disease. Review of nursing documentation reflected that the resident had become increasingly lethargic (sleepy and hard to arouse) and due to dysphagia (problems with swallowing), the resident often drooled medication out of her mouth. On January 17, 2019, the physician ordered Sinemet disintegrating tablets (a medication that helps to relieve Parkinson's Disease symptoms and makes the medication better absorbed into the body) three times daily. The facility sent the prescription to the pharmacy on January 17, 2019, at 5:14 p.m. The medication was not available for administration until January 22, 2019, five days after it was initially ordered.

In an interview on January 25, 2019, at 12:12 p.m., the Director of Nursing stated that the medication was to be available within 24 hours of initiating the request for the medication.

28 Pa. Code 211.9 (a)(1)(d)(k) Pharmacy Services.
Previously cited February 2, 2018.

28 Pa. Code 211.10(c) Resident Care Policies.

28 Pa. Code 211.12(d)(5) Nursing Services.




 Plan of Correction - To be completed: 03/11/2019

- Resident 2 no longer resides in the facility.

- The medication records for all residents will be reviewed to determine if all ordered medications are being administered.


- The policies relating to the ordering, delivery and receipt of medications and the medication administration policies will be reviewed for accuracy and completeness. The nurses will be educated on the procedures for medication ordering and administration. Medication administration records will be reviewed routinely for timely administration.

- The Medication administration records will be reviewed by nursing management. Audits will be conducted weekly x 4 and then monthly x 2. Audits will be reported monthly to the Quality Assurance Committee. Compliance will be evaluated and the process revised if necessary.

- Completion date: March 11, 2019.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to acknowledge a pharmacy recommendation for one of six residents sampled for unnecessary medications. (Resident 12)

Findings include:

Clinical record review revealed that Resident 12 was admitted on October 11, 2018, with diagnoses that included major depressive disorder. On October 16, 2018, a physician ordered for staff to administer an anti-psychotic medication (Seroquel) on a daily basis. Review of the admission Minimum Data Set assessment dated October 17, 2018, revealed that the resident was on an anti-psychotic medication for the last seven days of the assessment period. Review of the care plan identified that the resident was on psychotropic medications and there was an intervention for the physician to plan for a trial period of dose reduction. Review of a pharmacy recommendation dated November 19, 2018, revealed that the pharmacist recommended to discontinue the Seroquel while concurrently monitoring for re-emergence of target behaviors and/or withdrawal symptoms. There was no documented evidence that the physician acknowledged the pharmacists's recommendation until January 9, 2019, (over a month and a half later) and the physician did agree with the recommendation and discontinued the Seroquel.

In an interview on January 24, 2019, at 2:23 p.m., the Director of Nursing stated that there was a delay with the physician acknowledgement of the pharmacist's recommendation.

28 Pa Code 211.12(d)(1)(5) Nursing services.




 Plan of Correction - To be completed: 03/11/2019

- Resident 12 has shown no signs of ill effect. The physician responded to the Pharmacy recommendation.

- The latest pharmacy recommendations for the residents will be reviewed and the follow up actions by the physicians will be verified.

- The procedures for processing pharmacy recommendations were reviewed. Nurse supervisors will be educated on the procedures for processing pharmacy recommendation. Physicians will be notified of the procedures.

- Nursing management will monitor compliance with the Pharmacy Recommendation procedures. Audits will be done monthly x3 and then quarterly x2. Results will be reported to the Quality Assurance Committee.


- Completion date: March 11, 2019.

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 clinical record review and staff interview, it was determined the facility failed to clinically justify the use of an antipsychotic medication and failed to ensure a diagnosis to support the use of an antipsychotic for one out of six residents sampled for unnecessary medications (Resident 42).

Findings include:

Clinical record review revealed that Resident 42 was admitted to the facility on October 18, 2018, with diagnoses to include depressive episodes and anxiety disorder. A Minimum Data Set assessment completed January 11, 2019, refected that the resident had no memory impairment. A physician's order dated December 17, 2018, was for staff to administer Zyprexa (antipsychotic medication) by mouth one time daily for anxiety disorder. On December 24, 2018, the physician reevaluated the resident and changed the medication from once daily to as needed (PRN), however, at that time the physician failed to include the specific justification of the need to continue the medication and the duration. Review of the physician progress notes dated December 31, 2018, and January 15, 2019, revealed the physician had documented the need to continue the medication but, again, failed to include specific justification of the need to continue the medication and the duration.

In interview on January 25, 2019, at 9:05 a.m., the Director of Nursing confirmed that there was no justification or specified length of time for the use of the Zyprexa.

28 Pa Code 211.12(d)(1)(5) Nursing services.



 Plan of Correction - To be completed: 03/11/2019

- Resident 42 has shown no signs of ill effect. The physician has discontinued the order.

- All residents with psychotropic meds will be reviewed for clinical justification and supporting diagnosis.

- The policy and procedures for justifying the use of psychotropic medications shall be reviewed and updated. Nurses will be educated on the procedures for documenting the appropriate use of psychotropic medications. Physicians will be notified of the procedures.

- Nursing management will monitor compliance with psychotropic medication usage and documentation. Audits will be done monthly x3 and then quarterly x2. Results will be reported to the Quality Assurance Committee.


- Completion date: March 11, 2019.


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