Nursing Investigation Results -

Pennsylvania Department of Health
SOUTH HILLS REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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SOUTH HILLS REHABILITATION AND WELLNESS CENTER
Inspection Results For:

There are  79 surveys for this facility. Please select a date to view the survey results.

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SOUTH HILLS REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to five complaints completed on May 10, 2019, it was determined that South Hills Rehabilitation and Wellness Center, was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to 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 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 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 a review of facility policy and clinical records, and staff interview, it was determined that the facility failed to coordinate medication administration for one of four residents receiving hospice services (Resident R4).

Findings include:

A review of the facility policy "Hospice Care" dated 12/18/18, indicated all hospice assessments, plan of care, progress notes and services provided will be maintained on the medical record and integrated with the facility plan of care.

A review of a hospice progress note dated 4/10/19, indicated a recommendation to have morphine (narcotic pain reliever) and Ativan (anti-anxiety medication) ordered for PRN (as needed) usage.

A review of a hospice physican order dated 4/11/19, indicated a recommendation for Ativan 0.5 mg (milligrams) every four hours as needed for anxiety and morphine 0.25 ml (milliliter) every three hours for pain/shortness of breath.

The above hospice physician recommendations were signed by the facility physician on 4/12/19.

A review of the clinical record physician orders and medication administration record MAR for Resident R4 indicated the Ativan and morphine were not ordered and initiated until 4/23/19.

During an interview with the Nursing Home Administrator on 5/9/19, at 1:45 p.m. confirmed the above findings that the facility failed to coordinate medication administration for Resident R4.

28 Pa. Code 211.12(d)(3) Nursing services


 Plan of Correction - To be completed: 06/07/2019

1. Facility cannot retroactively address the medication administration related to Resident R4. Resident R4 was assessed for pain, her medication and care plan have been reviewed and orders address her current needs.
2. DON, or designee, will educate the professional staff regarding Hospice Care Policy, Coordination of Medication Administration and delivery of the medication and Physician Order review.
3. DON, or designee, will audit hospice orders and medication availability on all hospice orders 5x/week x 2 weeks, then weekly x 4 weeks, then monthly x 2.
4. DON, or designee, will report these audits monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:
Based on review of facility policies, clinical records and staff interviews, it was determined that the facility failed to obtain the required dental services for one of two residents (Resident R1).

Findings include:

A review of the facility policy "Dental Services" dated 12/18/18, indicated that residents with lost or damaged dentures will be promptly referred to a dentist, unless otherwise directed by the resident and/or responsible party.

A review of the clinical record progress notes dated 2/27/19, indicated "waiting for dental service to begin so the resident can be evaluated for replacement dentures."

A review of the clinical record on 5/9/19, did not include documentation that Resident R1 had been seen by a dentist as of that date.

During an interview on 5/9/19, at 10:35 a.m. p.m. Social Services Employee E1 confirmed that Resident R1's dentures were missing and the resident had not been evaluated for replacement dentures.

28 Pa. Code: 211.15(a) Dental services.




 Plan of Correction - To be completed: 06/07/2019

1. Facility cannot retroactively obtain the required dental services for Resident R1, however Resident R1 has been assessed and there were no negative outcomes related to the lack of a dental consult. Resident R1 will be seen by the dentist by June 20, 2019 for replacement denture evaluation.
2. NHA, or designee, will educate the nursing and social services staff on the importance of timely follow up with dental issues.
3. DON, or designee, will audit the 24 hour report daily looking for reported dental concerns The DON/designee will review the 24 hour report 5x a week x 2weeks the weekly x2 weeks, then monthly x 2 weeks
4. The DON, or designee, will report audit results to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.



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