Nursing Investigation Results -

Pennsylvania Department of Health
PLEASANT ACRES REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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PLEASANT ACRES REHABILITATION AND NURSING CENTER
Inspection Results For:

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PLEASANT ACRES REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Findings of an abbreviated complaint survey in response to a complaint completed on February 27, 2019, at Pleasant Acres Rehabilitation and Nursing Center identified that the facility 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:


483.20(g) REQUIREMENT Accuracy of Assessments: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(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflects the residents' status for three of three resident records reviewed (Residents 1, 2 and 3).

Findings include:

Review of Resident 1's clinical record revealed diagnoses including Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and Cardiovascular Disease (a class of diseases that involve the heart or blood vessels).

Review of Resident 1's quarterly Minimum Data Set assessment (MDS-an assessment tool utilized to identify residents' physical, mental, and psychosocial needs) dated January 6, 2019, revealed that section C (Cognitive Patterns) subpart C0100 (Should Brief Interview for Mental Status be conducted?) was answered "No-resident is rarely/never understood-skip to and completed C0700-C1000, staff assessment for mental assessment." Subparts C0700 - C1000 (Staff Assessment for Mental Status) were not assessed and marked with dashes (-). In addition, Resident 1's same quarterly MDS assessment also revealed that section K0200 (Height and Weight) was coded as 62 inches in height and a dash (-) was entered for weight.

Review of Resident 2's clincal record revealed diagnoses that included Diabetes Mellitus (a disorder in which there are high blood sugar levels over a prolonged period) and chronic kidney disease.

Resident 2's quarterly MDS assessment dated January 3, 2019, revealed that section K0200 (Height and Weight) was coded as 62 inches in height and a dash (-) was entered for weight.

Review of Resident 3's clincal record revealed diagnoses including Dementia and Hypertension (high blood pressure.
Resident 3's quarterly MDS assessment dated December 26, 2018, revealed that section K0200 (Height and Weight) was coded as 62 inches in height and a dash (-) was entered for weight.

During an interview on February 27, 2019, at approximately 2:00 p.m. with the Director of Nursing revealed that it is the facility's expectation that MDS assessments should be completed accurately.

28 Pa. Code 211.5(g)(i) Clinical Records




 Plan of Correction - To be completed: 03/13/2019

This Plan of Correction is submitted under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long-term care. Preparation and evaluation of the enclosed Plan of Correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by federal and state provisions.
1. R1 no longer resides in the facility. R2 & R3 have been weighed and are routinely monitored by the dietitian.
2. Validation reports for February 2019 have been reviewed by the RNAC to identify any potential areas concern on the MDS. Any potential corrections have been submitted according to the RAI Manual guidance.
3. Communication of ARD dates to the Interdisciplinary Team will be done via email, and any updates to the dates will be coordinated through the lead RNAC. The facility process on obtaining routine weights has been revised as well. Monthly weights are now to be obtained with the first shower of the month. Education will be provided to disciplines that participate in the MDS process regarding the importance of accurate assessment completion and following the RAI guidelines.
4. Assessments will be audited weekly x 4 by the RNAC/designee, prior to locking, to ensure completeness. Additionally, audits will be completed by the RNAC/designee weekly x4 by reviewing the validation reports for any indication of "dashes" or inconsistencies. Results of audits will be submitted to the QAPI Committee for review and any recommendations.
5. Date of compliance 3/13/19.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on review of clinical records and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of three residents reviewed (Resident 2).

Findings include:

Review of Resident 2's clinical record revealed diagnoses that included revealed Diabetes Mellitus (a disorder in which there are high blood sugar levels over a prolonged period) and chronic kidney disease.

On February 27, 2019, at 11:32 a.m. review of Resident 2's electronic health record revealed that Resident 2's code status was "full code" ((full code would prompt immediate life-saving emergency procedure that involves breathing for the person and applying external chest compression to make the heart pump, and if needed to get a breathing tube inserted and hooked up to a ventilator)

Review of Resident 2' physician order dated February 19, 2019, revealed an order for "DNR" (Do Not Resuscitate, or allow natural death, is a legal order to withhold cardiopulmonary resuscitation or advanced cardiac life support in case their heart were to stop or they were to stop breathing). Review of Resident 2's POLST (Pennsylvania Orders for Life-Sustaining Treatment, which is a medical order that specifies the types of medical treatment the patient wishes to receive towards the end of life), dated February 18, 2019, which read "DNR"

An interview with the Director of Nursing on February 27, 2019, at approximately 2:30 p.m. revealed that the residents wishes were recently changed and that the electronic health record was not yet audited and updated.

28 Pa. Code 211.5(f) Clinical records









 Plan of Correction - To be completed: 03/13/2019

1. R2 medical record has been updated to accurately reflect her code status.
2. A facility-wide electronic health record update was completed, which updated all records.
3. An update in the electronic health record now automatically populates the code status to the dashboard from the physician's order. The manual "chart flag" has been disabled. Education will be provided to nursing staff regarding change in medical record process.
4. Facility-wide audits will be completed by the DON/designee monthly x 3 to ensure that physician's orders accurately reflect the resident preferences outlined on the POLST form. Results of audits will be submitted to the QAPI Committee for review and any recommendations.
5. Date of compliance 3/13/19.


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