Nursing Investigation Results -

Pennsylvania Department of Health
BRADFORD ECUMENICAL HOME INC
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BRADFORD ECUMENICAL HOME INC
Inspection Results For:

There are  58 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
BRADFORD ECUMENICAL HOME INC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and an abbreviated complaint survey completed on May 31, 2019, it was determined that Bradford Ecumenical Home, Inc. 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.





 Plan of Correction:


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 affects more than a limited 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. This deficiency was not found to be throughout this facility.
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 facility policy, clinical record review and staff interview, the facility failed to ensure recommendations made from the consultant pharmacist were acted upon for two of 21 residents reviewed (Residents R26 and R32).

Findings include:

The facility policy "Consultant Pharmacist Services Provider Requirements", dated 1/22/19, indicated that the Consultant Pharmacist would communicate recommendations for changes in medication therapy and the monitoring of medication therapy.

The Face Sheet for Resident R32 revealed an admission date of 1/22/18, with diagnoses to include but not limited to, dementia with behavioral disturbance, fractured right lower leg and insomnia.

The pharmacy medication regimen reviews dated 7/24/18, 8/28/18, 10/23/18, all were requesting review of Resident R32's Melatonin (medication to aid in sleeping) 9 milligram (mg) physician's order dated 3/1/18, to evaluate current dose and consider a gradual taper or discontinuing the medication due to duplicate therapies with other medications that Resident R32 was receiving. All pharmacy recommendations were not signed by the physician until 1/10/19, a period of almost six months from the original request dated 7/24/18, pharmacy review.

A pharmacy medication review dated 11/27/18, requested a gradual dose reduction on the antipsychotic medication Seroquel. This recommendation was not signed by the physician until 1/10/19, a period of 44 days.

During an interview on 5/31/19, at 8:30 a.m. the Director of Nursing confirmed that pharmacy recommendations for Resident R32 regarding duplicate drug therapies and antipsychotic medication review were not addressed by the physician until 1/10/19.

The Face Sheet for Resident R26 revealed an admission date of 11/29/18, with diagnoses including by not limited to cancer of the left ear, diabetes, high blood pressure, and heart disease.

The pharmacy medication regimen review dated 3/26/19, requested that Resident R26's uric acid level be drawn on the next day due to Resident R26 being on anti-gout medication. The physician signed the recommendation on 5/29/19, a period of 64 days from the 3/26/19, pharmacy review.

During an interview on 5/31/19, at 10:53 a.m. the Director of Nursing confirmed the pharmacy recommendation dated 3/26/19, was not addressed timely by the physician.

28 Pa. Code 211.9(i) Pharmacy services














 Plan of Correction - To be completed: 07/12/2019

Resident R32 and R26's clinical records were reviewed to determine that the referenced pharmacist recommendations were addressed. Resident R32's Melatonin was previously discontinued per the pharmacist recommendation but has been restarted at a lower dosage. Documentation was noted in resident R32's clinical record with the physician's rationale to continue the current dosage of Seroquel. The Uric acid level recommended for resident R26 was obtained on 05/31/19. The results were within normal limits and were reported to the attending physician with no new orders.

To identify other residents that have the potential to be affected, the consultant pharmacy reports from the previous 5 monthly visits will be audited by medical records/nursing secretary staff to determine any missed recommendations. Any missed recommendations will be reported to the DON and will be addressed with applicable attending physician. Documentation on the recommendations will be maintained in resident's clinical record.

To ensure that this practice doesn't recur the following actions will be taken. The urgent pharmacist recommendations/clinically significant pharmacist recommendations will be sent to the DON/ADON and the Administrator via e-mail to ensure that they are addressed timely. The non-urgent pharmacist physician recommendations will be printed and forwarded to the applicable physicians within one week of their receipt by the facility. The completed physician pharmacist recommendations will be reviewed by the DON to ensure that all recommendations were addressed appropriately. The DON/ADON and medical records/nursing secretary staff will utilize "The Medical Director Report" portion of the Pharmacy Report to monitor physician responses and ensure that all urgent/clinically significant recommendations are addressed timely and all non-urgent physician recommendations are addressed within 30 days. Any nursing recommendations made by the consultant pharmacist will be forwarded to nursing staff to be addressed within 30 days of receipt by the facility. Nursing staff will document any nursing recommendations made and actions taken in resident progress notes. The DON/ADON and medical records/nursing secretary staff will utilize "The Nursing Summary Report" to monitor nursing responses to ensure that pharmacy recommendations are addressed within 30 days. A mandatory nurse's meeting will be conducted on June 12, 2019 and nurses will be educated on F 0756, the need to ensure that all pharmacist recommendations are addressed, and the need to document any nursing recommendations made and actions taken in resident progress notes.

In order to ensure compliance, the DON/ADON will monitor physician and nursing responses to pharmacist recommendations on a weekly basis for 4 months and longer if compliance is not being met. The consultant pharmacist will continue to monitor physician and nursing responses to recommendations during monthly review. Any missing recommendations from the previous month will be reported to the DON/ADON. The results of the monitoring will be documented and reported to the QA committee on a monthly basis for at least 4 months.
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 review of the Minimum Data Set (MDS-a federally mandated periodic assessment of resident care needs) and clinical records and staff interview, it was determined that the facility failed to ensure that a Quarterly MDS was completed within the required time frame for two of 21 residents (Residents R1 and R2).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) Users-Manual 3.0, dated October 2017, which provides instructions and guidelines for completing MDS assessments, indicated that the Assessment Reference Date (ARD) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type.

Resident R1's clinical record revealed an admission date of 12/12/2013, with diagnoses including but not limited to fractured back, pelvis, ribs and hip, heart failure, and osteoporosis (condition where the bones become more porous and fragile increasing the risk of fractures).

Resident R1's assessment history revealed a Quarterly MDS Assessment completed with an ARD of 1/01/2019, followed by an Annual MDS Assessment completed with an ARD of 5/17/2019. The MDS Assessments were completed 136 days apart.

Resident R2's clinical record revealed an admission date of 7/09/18, with diagnoses including but not limited to Alzheimer's disease, diabetes, muscle wasting, heart disease and shingles (a viral infection that causes a painful rash).

Resident R2's clinical record revealed a Quarterly MDS Assessment completed with an ARD of 1/09/19, followed by a Quarterly MDS Assessment completed with an ARD of 5/15/19. The Quarterly MDS Assessments were completed 128 days apart.

During an interview on 5/30/19, at 12:14 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 and RNAC Employee E2 confirmed that Residents R1 and R2's Quarterly MDS Assessments were overdue and not completed in the required timeframe.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(d)(2)(3) Nursing services

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










 Plan of Correction - To be completed: 07/01/2019

Prior to survey, Resident R1 had an annual MDS assessment completed with an ARD of 5/17/2019 and was accepted by CMS on 5/24/2019. Resident R2 had a quarterly MDS Assessment completed with an ARD of 5/15/19 and was accepted by CMS on 5/24/2019. No necessary modifications to the submitted MDS assessments were necessary.

All current residents will have their MDS schedules reviewed for the past 3 months. If a missing MDS assessment is identified, immediate action will be taken based upon the guidance of the RAI, which will include completing and submitting the assessment to CMS.

Additional education and review of RAI practices will be provided to RNACs by the Director of Facility Development with a focus on the requirement for timely completion of quarterly OBRA MDS Assessments as outlined in the RAI manual.

An audit will be developed to monitor the MDS schedule for compliance with OBRA assessments. The audit will be completed by the Director of Facility Development, or designee, and will monitor the MDS schedule weekly x 4 weeks, then monthly x 3 months. In addition to internal audit, a "Missing Assessment Report" provided by the Casper Reporting System will be reviewed bi-weekly. A summary report will be provided to the monthly Quality Assurance Committee for the next four months for monitoring and further recommendations to ensure compliance.



483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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 review of clinical records and staff interviews, it was determined that the facility failed to provide residents and their representatives with written transfer notices including required information for four of 21 residents reviewed that were transferred out to the hospital (Residents R55, R68, R42 and R95) .

Findings include:

Resident R55's clinical record revealed an admission date of 10/16/18, with diagnoses including but not limited to, diabetes, stomach issues, heart problems and high blood pressure. A nursing note, dated 12/03/18 at 2:27 p.m. revealed that Resident R55 was transferred to the hospital with an increase in temperature, vomiting and breathing difficulties. A nursing note, dated 12/11/18, at 7:28 p.m. revealed that Resident R55 had returned to the facility. There was no evidence that a written notice of transfer including the required information was provided to Resident R55 and their representative related to the transfer to the hospital.

Resident R68's clinical record revealed an admission date of 10/31/18, with diagnoses including but not limited to, diabetes, stomach issues, heart problems and high blood pressure. A nursing note, dated 2/19/19, at 12:01 p.m. revealed that Resident R68 was transferred to the hospital with breathing difficulties. A nursing note, dated 2/25/19, at 3:08 p.m. revealed that Resident R68 had returned to the facility. There was no evidence that a written notice of transfer including the required information was provided to Resident R68 and their representative related to the transfer to the hospital.

Resident R42's clinical record revealed an admission date of 7/07/18, with diagnoses including but not limited to, fractured leg, dementia, osteoporosis (bones become more porous and fragile, the risk of fracture is greatly increased), urinary tract infection, and right artificial hip. A nursing note, dated 5/06/19, at 5:05 p.m. revealed that Resident R42 was transferred to the hospital with urinary retention and increased pain in left hip. A nursing note, dated 5/13/19 at 6:29 p.m. revealed that Resident R42 had returned to the facility. There was no evidence that a written notice of transfer including the required information was provided to Resident R42 and their representative related to the transfer to the hospital.

Resident R95's clinical record revealed an admission date of 5/04/19, with diagnoses including but not limited to, spinal stenosis, muscle weakness, spondylosis (type of arthritis that affects the spine) of lumbar spine, and high blood pressure. Review of resident assessment history revealed that Resident R95 was discharged to the acute care hospital on 5/09/19. There was no evidence that a written notice of transfer including the required information was provided to Resident R95 and their representative related to the transfer to the hospital.

During an interview on 5/31/19, at 9:03 a.m. the Nursing Home Administrator confirmed that a written notice of transfer including the required information was not sent to the residents and/or resident representatives when a residents are transferred out of the facility and hospitalized.

Pa. Code. 211.5(f) Clinical records

Pa. Code. 211.12(d)(1)(3)(5) Nursing services









 Plan of Correction - To be completed: 07/01/2019

Based on survey completed 05/31/2019, this plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation or position and Bradford Ecumenical Home reserves all rights to raise all possible contestations and defenses in any civil or criminal claim, action or proceeding.

The identified residents R55, R68, R42 and R95 were provided a notice of transfer for dates identified at the time of transfer and written notice was issued. A copy of the notice is maintained in the resident medical record. An audit was conducted to confirm copies of notices were issued and included resident name, reason for the transfer, location the resident was transferred, date of transfer, signed by resident or resident representative and dated.

The Medical Billing Supervisor/Social Worker/Facility Designee will audit all transfers for the last 30 days to ensure appropriate notification was issued. All residents or resident representatives were notified of the transfer and received a written copy for their records.

Bradford Ecumenical Home will continue to follow policy and procedure regarding transfer notification requirements. Transfer notification will be audited monthly for three months by Medical Billing Supervisor/Social Worker/Facility Designee. Findings will be reported for each of the three months to Quality Assurance Committee to ensure compliance.




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