Nursing Investigation Results -

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

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CLIVEDEN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  119 surveys for this facility. Please select a date to view the survey results.

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CLIVEDEN NURSING 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 completed on May 16, 2019, it was determined that Cliveden Nursing and Rehabilitation 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:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 observation, review of medical records, review of facility documentation and facility policy and interviews with staff, it was determined that the facility failed to ensure that one of four residents reviewed were protected from neglect. This resulted in actual harm to resident (Resident CL1) who sustained a fracture hip related to a fall.

Findings include:

Review of a facility policy titled Abuse and Neglect and dated February 9, 2017, revealed that residents have the right to be free from abuse and neglect in accordance with State and Federal regulations. Continued review of the policy revealed that the facility defined neglect as the failure to provide goods and services necessary to avoid physical harm.

Review of an undated facility policy titled Fall Risk Assessment revealed that residents who are at risk for falls are identified and proper preventative measures are taken to minimize their risk, promote safety, improve quality of nursing care, and ensure resident needs are met in a timely manner.

Review of medical records for Resident CL1 revealed diagnoses, including but not limited to, repeated falls, fall from chair, lack of coordination and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). Further review of medical records for Resident CL1 revealed that on April 25, 2019, the resident had fallen while left unattended in the bathroom. The medical records further indicated that the resident had sustained a fractured left hip following her fall.

Review of Resident CL1's care plans revealed the resident required the physical assistance of one staff member to transfer (move from one area to another). Additionally, the care plan indicated that the resident required close monitoring when going to the bathroom because she would attempt to get up by herself. The care plan further indicated that close monitoring would avoid the resident trying to ambulate by herself.

Interview with the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON) on May 16, 2019, at 11:00 a.m. regarding their investigation into Resident CL1's hip fracture revealed that on April 25, 2019, Employee E8, NA (nurse's assistant), took Resident CL1 to the toilet and left her alone on the toilet. Then shortly thereafter, Resident CL1 activated the call bell for assistance and Employee E11, LPN, responded to the call bell. The ADON stated that Employee E11 told the resident to wait for assistance while she went to find a NA to help her mobilize the resident. Shortly after Employee E11 left Resident CL1's room, Employee E7, NA, heard a scream and ran to the resident's room to find her lying on the floor.

Review of the facility investigation into Resident CL1's fall revealed a witness statement by Employee E8, NA, which noted, "When I went in the room she stated she needed to use the bathroom. I put her on the toilet and when she was finish she put the light on to the bathroom". A witness statement from Employee E11, LPN, revealed that "at or around 12:00 p.m. Resident CL1's call bell was going off. Resident stated 'I'm done now', I said OK, I will get someone to help you. As I was coming out room Employee E12, NA, was walking pass [sic] me and I said she was done in the bathroom. Employee E12, NA, stated 'she goes back and forth'. At or around 12:20 p.m. I was alerted by Employee E7, NA, that the resident was on the floor". A witness statement provided by Employee E7, NA, revealed that "when coming off the elevator the resident was screaming and I went to the room and resident was on the bathroom floor and I notified the nurse".

Continued review of the facility investigation into Resident CL1's fall on April 25, 2019, revealed a statement made by the resident. The resident stated, in response to the question "did you report this to anyone?" that "I told you (Employee E11, LPN), you said you was getting someone".

Interview with the NHA and ADON on May 16, 2019, at 1:00 p.m. revealed the statement from Employee E11, LPN, where she stated "she (Resident CL1) goes back and forth" meant that the resident was able to self-ambulate between the toilet and the wheelchair independently. The ADON revealed that Employee E11, a licensed nurse, took the advice of Employee E12, a nursing assistant that the resident was capable of walking independently. The ADON confirmed that no employees returned to help resident CL1 or to explain that she would not receive help after being told to wait by Employee E11, LPN.

Interview with Employee E8, NA, on May 16, 2019, at 1:57 p.m. in the presence of the NHA, DON, ADON and the Director of Human Resources (DHR), confirmed that the employee took Resident CL1 to the toilet at 11:50 a.m. on April 25, 2019. Employee E8 stated in interview, "normally, I would stay with her in the bathroom by the door. I was the only one on the floor and had dirty linen, so I went to the linen chute".

Interview with the NHA and DON on May 16, 2019, at 4:00 p.m. confirmed that the Nursing Assistant (Employee E8) who placed Resident CL1 on the toilet and the Licensed Practical Nurse (Employee E11) who responded to Resident CL1's call bell both had the opportunity to follow Resident CL1's care plan and remain with the resident while she was on the toilet to prevent her from self-ambulating. Continued interview with the DON on May 16, 2019, at 4:00 p.m. revealed, "I should have reported this as neglect" in reference to Resident CL1 obtaining a hip fracture following her fall on April 25, 2019.

The facility failed to follow the care plan for one resident which resulted in the resident experiencing harm and being neglected by two employees and

Freedom from Abuse and Neglect
CFR(s): 483.12(a)(1) - Previously cited 04/17/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/06/18, 07/31/17

28 Pa. Code 201.14(e) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Management
Previously cited 10/06/18, 06/19/18, 04/17/18, 10/13/17, 07/31/17

28 Pa. Code 201.18(b)(3) Management
Previously cited 10/06/18, 04/17/18, 07/31/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 10/06/18

28 Pa. Code 201.29(c) Resident rights
Previously cited 10/06/18

28 Pa. Code 201.29(d)(j) Resident rights
Previously cited 08/08/18, 10/13/17

28 Pa. Code 211.10(d) Resident care policies
Previously cited 07/31/17

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 08/08/18, 04/17/18, 10/13/17, 07/31/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 06/19/18

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 10/06/18, 08/08/18, 06/19/18, 04/17/18, 10/13/17







 Plan of Correction - To be completed: 07/15/2019

- CL1 no longer resides at the facility
- DON/designee reviewed the care plans of all residents that require supervision and close monitoring with transferring/toileting. Any residents identified with the need for close monitoring with transfer/toileting will be care planned accordingly.
- Unit Managers/designee will do observational rounds to validate residents are being supervised for toileting/transfers as per the care plan. Observational rounds q shift times two weeks then daily times one month. This is to validate that residents are being supervised for toileting/transfers as per the care plan.
- DON/designee will audit by observing 1 CNA/unit (3total) that provide ADLs 2x's/week x6 weeks then randomly x2 months to make sure they are following the resident's ADL plan of care. Results will be reported to QAPI times three months for evaluation.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on observation, review of medical records, facility documentation and facility policy and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation to rule out abuse and/or neglect for one of three residents reviewed who had falls with major injury (Resident CL1).

Findings include:

Review of a facility policy " Abuse and Neglect", dated February 9, 2017, revealed that residents have the right to be free from abuse and neglect in accordance with State and Federal regulations. All alleged or suspected incidents of abuse and neglect are thoroughly investigated and findings documented in a report. The facility defined abuse as the infliction of injury with resulting physical harm, pain or mental anguish. This also included the deprivation by caregivers of goods or services necessary to attain or maintain physical, mental or psychological well-being. The facility defined neglect as the failure to provide goods and services necessary to avoid physical harm.

Review of medical records for Resident CL1 revealed diagnoses, including but not limited to, repeated falls, fall from chair, lack of coordination and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain). Further review of medical records for Resident CL1 revealed that on April 25, 2019, the resident had fallen while left unattended in the bathroom. The medical records further indicated that the resident had sustained a fractured left hip following her fall.

Review of Resident CL1's care plans revealed the resident required the physical assistance of one staff member to transfer (move from one area to another). Additionally, the care plan indicated that the resident required close monitoring when going to the bathroom because she would attempt to get up by herself. The care plan further indicated that close monitoring would avoid the resident trying to ambulate by herself.

Interview with the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON) on May 16, 2019, at 11:00 a.m. regarding their investigation into Resident CL1's hip fracture revealed that on April 25, 2019, Employee E8, NA, took Resident CL1 to the toilet and left her alone in the bathroom. Then shortly thereafter, Resident CL1 activated the call bell for assistance and Employee E11, LPN, responded to the call bell. The ADON stated that Employee E11 told the resident to wait for assistance while she went to find a NA to help her mobilize the resident. Shortly after Employee E11 left Resident CL1's room, Employee E7, NA, arriving onto the floor from the elevator heard a scream, dropped her belongings and ran to the resident's room to find her lying on the floor with the fractured hip.

Review of the facility investigation into Resident CL1's fall revealed a witness statement by Employee E8, NA, which noted, "When I went in the room she stated she needed to use the bathroom. I put her on the toilet and when she was finish she put the light on to the bathroom". A witness statement from Employee E11, LPN, revealed that "at or around 12:00 p.m. Resident CL1's call bell was going off. Resident stated 'I'm done now', I said OK, I will get someone to help you. As I was coming out room Employee E12, NA, was walking pass [sic] me and I said she was done in the bathroom. Employee E12, NA, stated 'she goes back and forth'. At or around 12:20 p.m. I was alerted by Employee E7, NA, that the resident was on the floor". A witness statement provided by Employee E7, NA, revealed that "when coming off the elevator the resident was screaming and I went to the room and resident was on the bathroom floor and I notified the nurse".

Review of the facility investigation into the fall for Resident CL1 that happened on April 25, 2019, revealed a witness statement by the resident and provided to Employee E11, LPN, the assigned nurse for Resident CL1, where she stated, in response to the question "did you report this to anyone?" that "I told you, you said you was getting someone".

Interview with the Director of Nursing (DON) and NHA on May 16, 2019, at 2:00 p.m. revealed confirmation that the facility investigation process did identify discrepancies in the version of events that led to the discovery of Resident CL1 on the bathroom floor with a hip fracture. The DON further indicated that these differences were not reconciled as part of the investigatory process. The NHA revealed the facility maintained video camera recordings for some investigations but indicated that they had not used video review as part of this investigation.

Review of the camera footage for the second-floor clinical nursing unit hallway leading to Resident CL1's former room and for the second-floor nursing station for April 25, 2019, from 11:45 a.m. to 12:30 p.m. revealed the following:
At 11:50 a.m. Employee E8, NA, enters Resident CL1's room
At 11:53 a.m. Employee E8, NA, exits Resident CL1's room
At 11:57 a.m. Resident CL1's call light activates
At 11;58 a.m. Employee E11, LPN, enters resident CL1's room
From 12:01 p.m. Employee E11, LPN, is observed on video having conversations with multiple employees in the hallway
At 12:12 p.m. Employee E11, LPN, enters the nursing station,
At 12:13 p.m. Employee E9, NA, joins Employee E11, LPN, at the nursing station;
At 12:15 p.m. Employee E7, NA, gets off the elevator with a black bag and walks to the nursing station.
At 12:24 p.m. Employee E7, NA, walks towards Resident CL1's room with the black bag in her hand and entered Resident CL1's room;
At 12:25 p.m. and 24 seconds Employee E11, LPN, leaves the nursing station and entered Resident CL1's room.

Interview with the NHA and Director of Human Resources (DHR) on May 16, 2019, at 2:32 p.m. confirmed that the witness statement by Employee E7, NA, where she stated, "when coming off the elevator the resident was screaming and I went to the room and resident was on the bathroom floor. I notified the nurse" was not accurate because the employee had not just got off the elevator, she had been conversing at the nursing station for nine minutes after leaving the elevator and before going to Resident CL1's room.

Further interview with the NHA and DHR on May 16, 2019, at 2:32 p.m. confirmed that after Employee E11, LPN, went into Resident CL1's room in response to her call light at 11:58 a.m. that per the video footage the employee interacted multiple times with other NAs who could have assisted her in helping Resident CL1 off the toilet safely.

The facility failed to conduct a complete and thorough investigation to rule out the possibility of abuse and/or neglect for one resident.

Investigate/Prevent/Correct Alleged Violation
CFR(s): 483.12(c)(2)-(4) - Previously cited 10/06/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/06/18, 07/31/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 10/06/18, 06/19/18, 04/17/18, 10/13/17, 07/31/17

28 Pa. Code 201.18(b)(3) Management
Previously cited 10/06/18, 04/17/18, 07/31/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 10/06/18

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 201.29(d) Resident rights
Previously cited 10/13/17, 07/31/17

28 Pa. Code 211.5(f) Clinical records
Previously cited 10/06/18, 08/08/18, 07/31/17







 Plan of Correction - To be completed: 07/15/2019

- The DON/ADON has reviewed the event reports for the past thirty days to ensure investigations are complete and thorough to determine if abuse/neglect occurred.
- The DON/Designee will complete weekly audits of all incidents/events for timely reporting and thorough investigations.
- The administrator or designee will review all investigations to ensure that follow up and corrective action is taken as indicated and appropriate.
- The administrator or designee will audit by observing 1 report per unit x6 weeks then randomly x2 months to make sure incident reports and investigations are completed correctly and timely. Results will be reported to QAPI times three months for evaluation.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on observation, review of medical records and facility policy and interview with staff, it was determined that the facility failed to develop a comprehensive resident-centered care plan related to the use of mechanical lifts and failed to implement a comprehensive resident-centered care plan related to bathroom assistance for two of four residents reviewed (Residents R4 and CL1).

Findings include:

Review of facility policy "Mechanical Lift", undated, revealed that two or more personnel must be in attendance when a mechanical lift is used, and that the procedure involves, among other things, pulling the curtains to maintain privacy.

Review of facility policy "Fall Risk Assessment", undated, revealed that residents who are at risk for falls are identified and proper preventative measures are taken to minimize their risk, promote safety, improve quality of nursing care, and ensure resident needs are met in a timely manner.

Review of facility policy "Body Mechanics", undated, revealed that to prevent injuries to residents, staff will ask another member of staff for assistance if they need assistance during transfers.

Review of medical records for Resident R4 revealed diagnoses including cerebral infarction (a blockage of oxygenating blood in the brain causes death of brain tissue), muscle weakness, high blood pressure and anxiety disorder (intense, excessive, persistent worry or fear). Review of care plans revealed the resident did not have a care plan for the use of a Hoyer lift (a mechanical device designed to lift residents safely). Review of physician orders revealed no order for the use of a Hoyer lift. Review of progress notes going back one-year revealed no mentioned of the use of a Hoyer lift.

Observation of Resident R4 on May 16, 2019, at 10:15 a.m. revealed Employee E5, Nursing Assistant (NA), using a Hoyer lift on her own to transfer Resident R4 out of bed. Upon observing the surveyor's presence, Employee E5 ceased the lifting motion of the resident whose head, arms and legs were raised off the bed and whose back was still touching the bed surface.

Interview with the Nursing Home Administrator (NHA) on May 16, 2019, at 12:10 p.m. revealed confirmation that Employee E5, NA, did not follow the facility procedure for utilizing a Hoyer lift and that Resident R4 did not have a care plan for the use of Hoyer lifts.

Review of medical records for Resident CL1 revealed diagnoses including repeated falls, fall from chair, lack of coordination and epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain).

Further review of medical records for Resident CL1 revealed that on April 25, 2019, the resident fractured her left hip following a fall in the bathroom. Review of care plans for Resident CL1 revealed that the resident required the physical assistance of one staff member to transfer and required close monitoring when going to the bathroom because she would attempt to get up by herself. The care plan further stated that close monitoring would avoid the resident trying to ambulate by herself.

Interview with the NHA and DON on May 16, 2019, at 4:00 p.m. confirmed that Resident R4 did not have a care plan for the use of Hoyer lifts and that staff did not follow the comprehensive resident-centered care plan for Resident CL1 when she fell after being left unattended in the bathroom.

The facility failed to develop and implement comprehensive resident-centered care plans for two residents.

28 Pa. Code 211.5(f) Clinical records
Previously cited 10/06/18, 08/08/18, 07/31/17

28 Pa. Code 211.10(d) Resident care policies
Previously cited 07/31/17

28 Pa. Code 211.11(c) Resident care plan

28 Pa. Code 211.11(d) Resident care plan
Previously cited 10/06/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 08/08/18, 04/17/18, 10/13/17, 07/31/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 06/19/18

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 10/06/18, 08/08/18, 06/19/18, 04/17/18, 10/13/17



 Plan of Correction - To be completed: 07/15/2019

- CL1 no longer resides at the facility
- R4 care plan was updated as needed
- Unit Managers/designee will review and update care plans for Comprehensive Assessments
- Therapy Director/Educator are in-servicing the CNAs on the proper way of transferring residents
- DON/designee will audit 5 residents per week, for two months and report results to QA.

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 staff interview it was determined that the facility failed to provide access to medical records for one of four residents reviewed (Resident CL1).

Findings include:

Interviews with the Nursing Home Administrator (NHA) on May 16, 2019, at 11:00 a.m., 12:04 p.m. and 2:46 p.m., where requests were made for the closed record (medical records contained within the paper chart of a discharged resident) for Resident CL1 confirmed that the closed paper-based medical record was unavailable for surveyor review.

Interview with the NHA on May 16, 2019, at 4:00 p.m. confirmed that the facility did not provide access to the closed paper record for Resident CL1.

The facility failed to provide access to paper-based medical records for a closed record as required.

28 Pa. Code 211.5(f) Clinical records
Previously cited 10/06/18, 08/08/18, 07/31/17



 Plan of Correction - To be completed: 07/15/2019

- CL 1 medical record was provided to the surveyor
- Other resident closed medical record request will be provided in a timely fashion. The medical records coordinator will be educated to respond timely and accurately to all closed medical record requests.
- Administrator/designee will monitor and audit all closed medical record requests to ensure deficient practice does not recur.
- Administrator/designee will audit two closed medical record requests/month x 3 months.


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