Pennsylvania Department of Health
CEDAR HILL HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CEDAR HILL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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CEDAR HILL HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a complaint and an incident completed on February 28, 2024 at Moon Township Rehabilitation and Wellness Center, it was determined that no deficiencies were identified under the 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 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 review of facility policy and investigative documents, it was determined that the facility failed to provide quality of care with an unlicensed employee providing medications to six residents. This was identified as a past non-compliance for six of six residents (Resident R1, R2 R3, R4, R5 and R6).

Findings include:

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.

Review of the job description for NA (Nursing Assistant) indicated job functions to include: duties and responsibilities, administrative, committee, personnel, and specific job function, staff development, competency, safety, equipment & safety functions, financial responsibilities, customer service and resident rights. Giving medications to residents was not included on the nurse Assistant job description.

Review of the job description for LPN (Licensed Practical Nurse) indicated: Drug Administration Function: Prepare and administer medications as ordered by the physician. Ensure that direct nursing care is provided by a licensed nurse. Education: Must possess at a minimum a Nursing degree from an accredited college or university, or graduate from an approved LPN/LVN/RNM program.

Review of facility documentation submitted to the State Survey Agency indicated: It was reported to the DON (Director of Nursing ) on 8/14/23, by an agency nurse that over the weekend a co-worker, NA Employee E1, who has been function as an agency NA made the comment if there is a call-off they " are not taking a cart" . The DON initiated an investigation and discovered that NA Employee E1, had worked at the facility as an LPN on 7/24/23, and 8/8/23. The DON then contacted the agency and was told that NA Employee E1 was employed as a Nurse Aide through the agency. The agency confirmed that they were scheduled to work on 7/24/23, and 8/8/23.

During an on-site investigation 2/2/24, the following was documented on the facility investigation: Employee E2 LPN states that NA Employee E1 kept saying that they did not want to take a cart on the next shift as a nurse. Employee E2 LPN questioned about why NA Employee E1 would say that, and NA Employee E1 said "she had worked here before as a Nurse and that they are a LPN." After the conversation DON pulled staffing sheets for the past month and found out that NA Employee E1 was handwritten into the schedule as a nurse on 7/24/23, 3pm to 11pm and was also on the schedule 8/8/23, 11pm - 7am. Agency for NA Employee E1 was contacted and confirmed they had her as a Nurse Aide, but did not have her listed as an LPN.

Results of investigation failed to show that NA Employee E1 had a LPN current or expired.

On 8/18/23, the facility initiated a plan of correction that included:
Investigation determined that NA Employee E1 misinformed the scheduler that they were a nurse. Agency's providing staff to the facility were reduced from 7 to three staffing agencies.
Resident were assessed by Unit Manager and DON and no adverse effects noted. Reviewed with Medical Director.
Interim scheduler and unit managers educated that the schedule could not be changed without approval by DON/NHA.
All agency nursing personnel credentials have been audited to ensure the professional capacity in which they are working g matches the credentials in their file. No further issues were found.
All credentials are checked by scheduler and nursing prior to them working in facility.
The Moon Twp Police were notified and report was filed. The Board of Nursing was contacted via phone and email.
Audits were conducted for agency staff credentials 3x peer week for 4 weeks then weekly x 4 weeks to ensure the practice does not recur. Audits started on 8/22/23, and were completed on 10/30/23.

During an interview on 2/28/24, at approximately 10:30 a.m. The DON confirmed that the facility failed to provide quality of care with an unlicensed employee providing medications to six of six residents reviewed.

Plan of Correction - To be completed: 03/13/2024

Past noncompliance: no plan of correction required.

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