Nursing Investigation Results -

Pennsylvania Department of Health
OAKWOOD HEALTHCARE & REHABILITATION CENTER
Patient Care Inspection Results

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OAKWOOD HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

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OAKWOOD HEALTHCARE & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on January 8, 2020, it was determined that Oakwood Healthcare 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 as they relate to the Health portion of the survey process.



 Plan of Correction:


483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on a review of personnel files and interviews with staff, it was determined that the facility failed to complete skills competencies on nurse aides for three of three nurse aide personnel files reviewed (Employee E5, Employee E6 and Employee E7).

Findings include:

Review of Employee E5's personnel file revealed that the employee, a nurse aide, was hired by the facility on May 17, 2019. Continued review revealed a job description, signed and dated by the employee on May 17, 2019, that contained a self-evaluation of skills completed by Employee E5. Further review of the job description revealed that it was not signed or reviewed by a supervisor. There were no other skills reviews or competencies available in the file.

Review of Employee E6's personnel file revealed that the employee, a nurse aide, was hired by the facility on October 25, 2019. There was no job description or self-evaluation available in the file. Continued review revealed an orientation checklist, dated and signed by the employee on October 25, 2019. Further review of the orientation checklist revealed that the pages marked "Clinical Orientation" were blank. There were no other skills reviews or competencies available in the file.

Review of Employee E7's personnel file revealed that the employee, a nurse aide, was hired by the facility on November 8, 2019. There was no job description or self-evaluation available in the file. Continued review revealed that orientation was completed on November 8, 2019. There were no other skills reviews or competencies available in the file.

Interview with Employee E4, registered nurse, on January 7, 2020, at 11:45 a.m., revealed that the facility did not have a process for verifying the skills competencies of nurse aides upon hire or annually.

The facility failed to complete skills competencies on nurse aides.

28 Pa Code 201.20(a) Staff development






 Plan of Correction - To be completed: 02/26/2020

F726
1) The facility has developed a skills competency checklist for nurse aides upon hire.
2) The facility will complete skills competencies for nurse aides hired in the past 90 days. Skills competencies will be reviewed and signed by a Supervisor.
3) The Staffing Coordinator and/or designee will track the skills competencies to ensure completion upon hire prior to completion of orientation.
4) The Staffing Coordinator and/or designee will audit the tracking and skills competency checklists to ensure nurse aides have completed a skills competency in the past year. Audits will be completed monthly. Results of audits will be reviewed by QA committee for further recommendations as needed.


483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident 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(f) Automated data processing requirement-
483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on review of clinical records and interviews with staff, it was determined that the facility failed to transmit resident assessments to the Centers for Medicare and Medicaid Services, (CMS) within 14 days of completion, as required, for one of one resident reviewed (Resident R3).

Findings include:

Review of the clinical record for Resident R3, revealed an Annual Minimum Data Set (MDS - periodic assessment of needs), dated December 1, 2019, was not submitted until January 2, 2020.

An interview with the Licensed Nurse Assessment Coordinator, Employee E9, on Janaury 8, 2020, at 11:50 a.m. confirmed, that Resident R3's MDS, dated December 1, 2019, was not submitted timely, to the CMS system within the required time frame.

The facility failed to ensure that a Resident R4's assessment was submitted to the CMS system within the required time frame.

28 Pa Code 201.14(a) Responsibility of licensee
Previously cited 11/15/18

28 Pa Code 201.18(b)(3) Management
Previously cited 11/15/18

28 Pa Code 211.12(c) Nursing services
Previously cited 11/15/18







 Plan of Correction - To be completed: 02/26/2020

F0640
1) The MDS for resident R3 dated December 1, 2019 has been submitted.
2) Staff will review the upcoming MDS schedule to ensure that MDS' will be submitted timely.
3) The facility RNAC's will receive an in-service regarding the regulations surrounding MDS submission.
4) The Regional Clinical Reimbursement Coordinator and/or designee will complete an audit on a monthly basis for six months to ensure that MDS will be submitted timely.
Results of the audits will be reviewed by the QAPI committee for further recommendations as needed.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on observation, clinical record review and interviews with staff, it was determined that the facility failed to ensure that a nutritional supplement for weight maintenance was provided for one of 34 residents reviewed (Resident R73).

Findings include:

Review of Resident R73's quarterly Minimum Data Set (MDS-assessment of resident care needs) dated November 3, 2019 revealed that Resident R73 required supervision and the physical assistance of one person for eating (how a resident eats and drinks regardless of skill). The assessment also indicated that this resident was 75 inches in height, weighed 184 pounds and was 75 years old.

Review of the dietary notes revealed that the dietitian had identified Resident R73 at nutritional risk in August 2019. Based on the resident's height of 75 inches, the dietitian established that the resident's ideal body weight as 196 pounds +/- 10% and usual body weight 176 to 216 pounds. Further, the resident body mass index was assessed at 20.4. The National Quality Forum for Preventative Care and Screening indicated that a body mass index for age 65 years and older be between 23 and 30.

Observation of Resident R73 on January 3, 2020 during the noon meal service, in the main dining room revealed that the resident had difficulty removing plastic lids or opening containers from food items (milk, tomato soup, hot beverage) on the meal tray. On January 7, 2020 at 9:30 a.m. Resident R73 was observed alone in the bed room in bed in a reclined position not upright at a 90 degree angle and trying to independently eat. The resident was greater than 12 inches away from the plate or breakfast meal tray.

Interview with Employee E13, registered nurse, at the time of the observation confirmed Resident R73's poor positioning in bed, making it difficult for the resident to eat the food. Further, the resident's food items (orange juice, milk, hot beverage, syrup for french toast and hot cereal) were observed not opened and not set up for the resident to eat.

Review of weight record revealed that the resident had experienced continuous weight loss since August 2019 as follows: August, 2019 189 pounds, September, 2019, 184 pounds, November, 2019, 181 pounds, December, 2019, 171 pounds and January, 2020 164 pounds. A total weight loss of 25 pounds over 6 months. This was considered significant unintended weight loss.

Review of Resident R73's nutrition care plan for October and November 2019 indicated that this resident was to receive a nutritional supplement routinely to maintain Resident R73's weight at 189 +/- 5 pounds. Review of the nutritional care plan revealed that a healthshake was planned to be provided by the nursing staff for Resident R73, three times a day.

Further review of the nutrition care plan for December 2019 and January 2020 revealed that in addition to the Healthshakes three times a day the resident was to receive Resource (a nutritional supplement to meet increased calorie and protein needs) once a day.

Review of Resident R73's clinical record revealed no documented evidence that the Healthshakes (nutritional supplement) was provided to Resident R73 as planned to prevent weight loss.

Interview with the Director of Nursing on January 7, 2020 at 10:45 a.m., confirmed that nursing staff had failed to document providing the nutritional supplement to the resident as care planned during October and November 2019.

The facility failed to ensure that Resident R73 had been administered a nutritional supplement as care planned to meet the resident's nutritional needs for weight maintenance.


28 Pa Code 211.6(d) Dietary services

28 Pa Code 211.10(c) Resident care policies









 Plan of Correction - To be completed: 02/26/2020

F692
1) The MAR for Resident R73 has been updated to include the administration of the nutritional supplement.
2) Residents on nutritional supplements will be reviewed by the Dietician along with nursing to ensure proper documentation in the MAR and plan of care is in place.
3) The Dietician will be re-educated on ensuring that Physician addresses her recommendations.
New supplement recommendations will be brought to morning clinical meeting for review and implementation as needed.
4) The Dietician and/or designee will audit to ensure her recommendations are addressed by the Physician. Audits will be conducted weekly for one month and then monthly for 6 months. Results of audit will be reviewed by QAPI committee for further recommendations as needed.

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 clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate related to nutritional supplement documentation for one of 34 residents reviewed (Resident R73).

Findings include:

Review of Resident R73's quarterly Minimum Data Set (MDS-assessment of resident care needs) dated November 3, 2019 revealed that Resident R73 required supervision and the support of one person physical assistance for eating (how a resident eats and drinks regardless of skill).

Review of Resident R73's nutrition care plan for October 2019 and November 2019 indicated that the resident was to receive a nutritional supplement routinely to maintain the resident's weight at 189 +/- 5 pounds. The nutritional care plan further revealed that a healthshake was to be provided by the nursing staff three times a day. Further review of the nutrition care plan for December 2019 and January 2020 revealed that in addition to the healthshake, the resident was to received Resource (a nutrional supplement to meet increased calorie and protein needs) once a day.

Review of Resident R73's December 2019 Medication Administration Record (MAR- documentation of medications adminstered to the resident) revealed that the supplement Resource was documented as given to Resident R73 on December 18, 2019 through December 31, 2019; however, the amount consumed was not recorded. The lack of record keeping of Resident R73's amount consumed 0 to 100% by the nursing staff was confirmed by the Director of Nursing on January 7, 2020 at 10:50 a.m.

The facility failed to ensure that clinical records were complete related to the intake of nutritional supplements.

28 Pa Code 211.5(f) Clinical record

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 11/15/18








 Plan of Correction - To be completed: 02/26/2020

F842
1) Resident R73's doctor was contacted and order updated.
2) Residents on nutritional supplements will be reviewed by the Dietician along with nursing to ensure proper documentation is in place.
3) Licensed nursing staff will be re-in served on documentation of nutritional supplements.
4) The DON and/or designee will complete an audit to ensure intake is recorded for nutritional supplements. Audits will be conducted weekly for four weeks and monthly for 6 months. Results of audits will be reviewed by QAPI committee for further recommendations as needed.


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