Nursing Investigation Results -

Pennsylvania Department of Health
HEALTH CENTER AT THE HILL AT WHITEMARSH, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HEALTH CENTER AT THE HILL AT WHITEMARSH, THE
Inspection Results For:

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HEALTH CENTER AT THE HILL AT WHITEMARSH, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, and an abbreviated survey in response to a complaint, completed on April 15, 2019 at The Health Center at the Hill at Whitemarsh, it was determined that The Health Center at the Hill at Whitemarsh was not in compliance, related to the Health portion of the survey process, related to the following Requirements of 42 CFR Part 483, Subpart B, Requirements of Long Term Care Facilities and the 28 PA. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

























 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

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

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

Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

The "Food Receiving and Storage" Policy, Revised July 2014, states, "All food stored in the refrigerator or freezer will be covered, dated and labeled. Wrappers of frozen foods must stay intact until thawing."

An initial tour of the Food Service Department was conducted on April 11, 2019 at 9:20 a.m. with Employee E3, Food Service Director (FSD), and employee E4, Chef, which revealed the following:

Observations in the receiving area revealed a trash compacting dumpster which had bags of trash exposed.

Observations in the walk-in freezer revealed several clear plastic bags of breaded items of different shapes out of the master case and several bags of what appeared to be meatballs. Interview with chef confirmed that the breaded items were chicken tenders and chicken nuggets and the other items were cooked meatballs and should have been left in the master case or properly labeled.

Observations in the walk-in refrigerator revealed several plastic gallon jugs of salad dressings of various flavors, a gallon container BBQ sauce and a container of beef base all were open but were not marked with a date when open.

Observations in the dish room revealed a filter for the hood above the dish machine, was taken out of the hood and laying on top of the dish machine.

Interview with Employee E3 and Employee E4 on April 11, 2019 at 9:30 a.m. confirmed the above findings.

The facility failed to store, prepare and serve food in accordance with professional standards for food service safety.


28 Pa. Code: 2014(a) Responsibility of licensee
Previously cited 5/24/18

28 Pa. Code: 201.18(a)(b)(1)(2)(3) Management
Previously cited 5/24/18

28 PA. Code: 207.2(a) Administrator's responsibility
Previously cited 5/24/18



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

Trash compacting dumpster was emptied on the same day as observation.
Chicken tenders, chicken nuggets and meatballs from the walk-in freezer were disposed of on the same day as observation.
Salad dressings, BBQ sauce and beef base from walk-in refrigerator were disposed of on the same day as observation.
Vent was removed from laying on top of the dish machine on the same day as observation.
Dining team members will be re-educated regarding procedures for storing and labeling of foods, cleaning schedules and refuse policy.
Dining Supervisor or designee will perform weekly rounds of kitchen and compacter areas to ensure the facility is storing, preparing, distributing and serving foods in accordance with professional standards for food service safety.
Round results will be reported to QAPI meetings for review and further recommendation as indicated.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on review of clinical records, facility documentation, facility policy and procedure and interviews with residents and staff, it was determined that the facility failed to ensure that one of thirty residents reviewed received nursing care in an safe manner that resulted in a fall during transfer process. (Resident R36)


Findings:

Resident R36 was admitted to the facility on February 21, 2019. Diagnoses include but not limited to Parkinson disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), hypertension (elevated blood pressure) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).
Reviewed of the clinical record revealed in a nurse's note dated March 6, 2019 at 12:45 PM, that a nurse aide had lowered resident R36 to the floor. The nurse aide was transferring the resident from the recliner to the wheelchair with 2 person assistance when the resident became weak and was lowered to the floor.

Upon further review of the clinical record, the Minimum Data Set (MDS- periodic assessment of resident needs) dated February 28, 2019 revealed that the resident required extensive assistance with 2 person support for bed mobility, transfer, toilet use and full bath/shower. Physical Therapy evaluation of "Resident Transfer Status" on February 22, 2019 reads: Full weight bearing; Hoyer transfers. Under comments: Patient only to transfer in therapy. Resident care guide (details the care to be provided by the nurse aide) dated February 21, 2019, indicates for transfers and ambulation/mobility: Full weight bearing, transfers Hoyer lift assist x 2. The resident care plan stipulates transfer with Hoyer...Full Weight Bearing.

Interview with a Nurse Aide, Employee E7 on April 15, 2019 at approximately 9 AM revealed that the nurse aides receive a verbal report from the license nurse then they look at the resident care guide in the Kiosk.

Interview with a Registered Nurse, Employee E6 on April 15, 2019 at approximately 9 AM stated that the license nurse gives report to the nurse aide from their report sheet. How the resident is transfered not on the report sheet, the nurse aide are to review the information in the kiosk.

Interview with Nursing Home Administrator on April 15, 2019 at approximately 1:30 PM revealed that the nurse aide that provided care to resident R36 on March 6, 2019 at the time of the fall did not read the resident care guide.

The facility failed to ensure that the staff review resident's care information and to properly care for the resident in a safe manner.

28 Pa. Code 201.14 (a) responsibility of licensee

28 Pa. Code 201.18 (b) (1) (2) (3) (e) (1) Management

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




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

Resident R36 weight bearing status was clarified with Physical Therapy and the physician post incident.
Any resident with a physician's order to use a mechanical lift will be reassessed by Physical Therapy. If changes need to be made to the resident's status then the physician's orders will be clarified accordingly. Resident transfer information has been added to the nursing report sheet to be reviewed each shift as care information.
All nursing team members were reeducated regarding the policy and procedure for using mechanical lifts and reviewing resident's care information prior to providing assistance post incident in February 2019 and will be re-educated again to ensure compliance.
The Director of Nursing or designee will perform an audit weekly for four weeks then monthly to randomly assess a nursing team member's technique while using a mechanical lift and to assess their knowledge of how to review the resident's care information.
Audit results will be reported at QAPI meetings for review and further recommendation as indicated.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

483.20(b) Comprehensive Assessments
483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

483.20(b)(2) When required. Subject to the timeframes prescribed in 413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in 413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:

Based on clinical record review and employee interview, it was determinied that the facility failed to assess residents using the comprehensive review instrument specified by the State and approved by CMS (Centers for Medicaid and Medicare) called the Minimum Data Set (MDS), not less frequently than once every three months for one out of 30 residents reviewed (Resident R3).

Findings include:

A review of Resident R3's clinical record revealed that the resident had a MDS quarterly assessment done on December 7, 2018 and was due for a comprehensive assessment around March 1, 2019. However, no MDS was conducted at this time.

An interview with Employee E5, the Registered Nurse Assessment Coordinator, on April 15, 2019 at 11:00 a.m. confirmed that the comprehensive assessment had not been none in a timely manner.

The facility failed to do a comprehensive assessment in a timely manner.

28 Pa. Code: 211.12 (c)(d)(5) Nursing services.








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

Resident R3 comprehensive assessment was scheduled timely and completed timely but failed to be submitted due to a submission error. The comprehensive assessment that was completed then was submitted during the survey on April 15.
An initial audit was completed of the weekly MDS scheduled to ensure all other comprehensive assessments were submitted dating back to December 1, 2018. Audit revealed no other missed submissions.
The RNACs will be re-educated regarding timely submission of comprehensive assessments.
The Quality Measure Manager or designee will perform an audit weekly for four weeks then bi-weekly of submissions to ensure the comprehensive assessments have been submitted timely.
Audit results will be reported at QAPI meetings for review and further recommendation as indicated.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:

Based on clinical record review and employee interview, it was determinied that the facility failed to assess residents using the quarterly review instrument specified by State and approved by CMS (Centers for Medicaid and Medicare) called the Minimum Data Set (MDS), not less frequently than once every three months for one out of 30 residents reviewed. (Resident R2).

Findings include:

A review of Resident R2's clinical record revealed that the resident had a MDS quarterly assessment done on November 22, 2018, and was due for a quarterly assessment around February 16, 2019. However, no MDS was conducted at this time.

An interview with Employee E5, the Registered Nurse Assessment Coordinator, on April 15, 2019 at 11:00 a.m. confirmed that the quarterly assessment had not been none in a timely manner.

The facility failed to do a quarterly assessment in a timely manner.

28 Pa. Code: 211.12 (c)(d)(5) Nursing services.






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

Resident R2 quarterly assessment was scheduled timely and completed timely but failed to be submitted due to a submission error. The quarterly assessment that was completed then was submitted during the survey on April 15.
An initial audit was completed of the weekly MDS scheduled to ensure all other quarterly assessments were submitted dating back to December 1, 2018. Audit revealed no other missed submissions.
The RNACs will be re-educated regarding timely submission of quarterly assessments.
The Quality Measure Manager or designee will perform an audit weekly for four weeks then bi-weekly of submissions to ensure the quarterly assessments have been submitted timely.
Audit results will be reported at QAPI meetings for review and further recommendation as indicated.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on clinical record review, facility documentation review and staff interviews, it was determined that the facility failed to supervise one out 30 residents reviewed for an elopement. (Resident R299).
Findings include:
A review of the facility policy titled 11.0 Missing Resident "Code Yellow" date revised September 27, 2017, states to ensure a resident who has been determined "missing" or "eloped" without staff knowledge is found promptly without affecting their health well-being.
Procedure: should it be determined that a resident is missing or eloped call a Code Yellow over the radio system immediately and complete the "Elopment Notice." Notify the Emergency Director, the Emergency Director will assume control over the event.
A review of Resident R299's clinical record revealed that the resident was admitted to the health care center on April 7, 2019 due to bi-lateral lower extremity weakness.
A review of nurse's notes dated April 7, 2019, revealed that the resident has lower leg weakness and anxiety. The resident is alert with periods of forgetfulness and confusion, wheelchair used for locomotion. When the resident arrived at the health center she was walking with a walker but needed wheelchair because she stated she felt weak.
Further review of nurse's notes dated April 8, 2019, resident walks around unit with rolling walker , however is forgetful in remembering to walk around with it. Resident educated on importance of walker.
A review of nurse's note dated April 9, 2019, resident seen at 6:30 p.m. leaving the dinning room and heading to her room with rolling walker. Before dinner the resident asked several staff members to take her to her apartment, all stated they could not do it now but maybe tomorrow. This nurse was informed by supervisor that at 7:25 p.m. the residents pendant (a safety device worn around the neck that can be push and an alarm is sounded for emergency) was pushed and her whereabouts were unknown at this time. Security, nursing and nursing assistants were looking for the resident. The receptionist was asked if she had seen the resident leave, she stated no. This nurse was informed at 7:35 p.m. that the resident was found in her apartment and refused to come back to health care center.
A review of a nurse's note dated April 9, 2019 revealed that at 7:15 p.m. the resident's pendant was pressed. This writer called the front desk to see if the resident had been admitted to the health care center, this writer was told yes. Security will go and reset the pendent on the second floor. The resident was not there in health care center. Security asked that I accompany him to the residents apartment, when we arrived the resident was watching television and refused to come back to the health care center.
A review of facility documentation dated April 9, 2019 revealed that Resident R299 was last seen on the unit at 6:30 p.m. leaving the dinning room and walking with a walker to her room. At 7:15 p.m. the resident's pendant (a safety device worn around the neck that can be push and an alarm is sounded for emergency) alarmed.
The security guard and the nurse went to investigate the pendant alarm. They went to the residents apartment. When they got there, they found the resident in her cottage. She stated she pressed the pendant by accident. The receptionist was called and was asked had she seen the resident leave the health care center? she responded no. The resident was asked to come back to the health care center, she refused. The facility called the physician and the residents daughter. The daughter was agreeable to leave her mom at the cottage. The physician gave a verbal order to discharge the resident to home.
The resident walked with her walker to her cottage, a distance of 1,578 feet which is more than a quarter mile. No injuries noted. When found at the cottage, the resident was watching television.
An interview with the Nursing Home Administrator on April 15, 2019 at 10:15 a.m. confirmed that staff did not know she left the facility and that she was gone for about an hour.
The facility failed to monitor/supervise one resident who earlier requested to go to her apartment.
28 Pa. Code:201.18(b)(1)Management.
28 Pa. Code:211.12(d)(1)(2)(5) Nursing services.


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

Resident R299 was discharged from the facility per physician's orders back to her cottage in Independent Living.
All current residents have had a new elopement assessment completed to determine risk level. If necessary, per the assessment, new interventions will be placed immediately, per physician's orders.
All residents will continue to have an elopement assessment completed upon admission, quarterly and with any significant change.
All nursing team members, security and reception team members will be re-educated regarding elopement policies and procedures.
The Director of Nursing or designee will perform an audit weekly for three months to ensure all new admission elopement assessments are completed timely and interventions are placed appropriately.
Audit results will be reported at QAPI meetings for review and further recommendation as indicated.


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