Pennsylvania Department of Health
HEINZ TRANSITIONAL REHABILITATION UNIT
Patient Care Inspection Results

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HEINZ TRANSITIONAL REHABILITATION UNIT
Inspection Results For:

There are  48 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.
HEINZ TRANSITIONAL REHABILITATION UNIT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification, State Licensure, and Civil Rights Compliance survey completed on January 5, 2024, it was determined that Heinz Transitional Rehabilitation Unit 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:


483.25 REQUIREMENT Quality of Care: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.
§ 483.25 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 a review of clinical records and select facility policy and protocol, and resident and staff interview it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for the bowel protocol prescribed for three residents out of 13 sampled (Residents 21, 176 and 82) to promote normal bowel activity to the extent possible.

Findings include:

According to the American Academy of Family Physicians primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week).

A review of the facility policy titled "Bowel Elimination Protocol", last reviewed by the facility on November 2, 2023, indicated that the facility will record bowel movements on each shift. The 11pm-7 am nurse will check the EMR (electronic medical record) each night. If no bowel movement is recorded, the nurse will check the previous documentation to determine the need for the bowel protocol. Bowel Protocol:
1. Any resident who has not had a bowel movement (BM) in three (3) days will be given Milk of Magnesia (MOM)/Lactulose on the 11pm-7 am shift (in the am of the 4th day). The nurse will assess bowel sounds and document accordingly.
2. If the resident has not had a bowel movement by the end of the day shift, Dulcolax Suppository will be given at the end of the shift.
3. If the Dulcolax suppository is not effective, a Fleets enema will be given by the 3pm-11pm shift.
4. If no results from the enema, bowel sounds will be assessed, and the physician informed. Nursing will document assessment and notification of physician in nursing notes as well as any new physician orders received for follow-up.

A review of the clinical record revealed that Resident 21 was admitted to the facility on December 12, 2023, with diagnoses to include, diabetes, and acquired absence of the right leg below the knee (below the knee amputation).

The resident had physician orders dated December 12, 2023, for the following bowel regimen:

- Lactulose Solution 20 GM/30 ML. Give 30 ml by mouth as needed for constipation. Give daily if no BM in 3 days.
- Bisacodyl Suppository 10 MG. Insert 1 suppository rectally as needed for constipation if Lactulose is ineffective. Administer next morning at 6:00 AM.
- Fleet Enema 7-19 GM/118 ML (Sodium Phosphates). Insert 1 unit rectally as needed for constipation. Administer on day 4 if Dulcolax suppository is ineffective. .

Review of Resident 21 's report of bowel activity from the Documentation Survey Report v2 for the month of December 2023 and the Medication Administration Record (MAR) for December 2023, revealed the that the resident did not have a bowel movement on:

-December 16, 2023 - day one without a bowel movement
-December 17, 2023 - day two without a bowel movement
-December 18, 2023 - day three without a bowel movement, 30 ml of Lactulose was ordered but no evidence that it was administered to the resident.
-December 19, 2023 - day four without a bowel movement, Bisacodyl suppository was ordered but no evidence that it was administered.
-December 20, 2023 - day five without a bowel movement, Fleet enema was ordered but no evidence that it was administered.

There was no documented evidence that the staff had notified the physician that the resident went five consecutive days, December 16, 17, 18, 19, and 20, 2023, without a bowel movement.

A review of the clinical record revealed that Resident 176 was admitted to the facility on December 27, 2023, with diagnoses to include, fracture of the pelvis, and difficulty in walking.

The resident had physician orders dated December 27, 2023, for the following bowel regimen:

- Lactulose Solution 20 GM/30 ML. Give 30 ml by mouth as needed for constipation. Give daily if no BM in 3 days.
- Bisacodyl Suppository 10 MG. Insert 1 suppository rectally as needed for constipation if Lactulose is ineffective. Administer next morning at 6:00 AM.
- Fleet Enema 7-19 GM/118 ML (Sodium Phosphates). Insert 1 unit rectally as needed for constipation. Administer on day 4 if Dulcolax suppository is ineffective.

Review of Resident 176 's report of bowel activity from the Documentation Survey Report V2 for the month of December 2023 and the Medication Administration Record (MAR) for December 2023, revealed the that the resident did not have a bowel movement on:

-December 27, 2023 - day one without a bowel movement
-December 28, 2023 - day two without a bowel movement
-December 29, 2023 - day three without a bowel movement, 30 ml of Lactulose was ordered and administered at 8:55 AM and documented as ineffective.
-December 30, 2023 - day four without a bowel movement, Bisacodyl suppository was ordered but no evidence that it was administered.
-December 31, 2023 - day five without a bowel movement, Fleet enema was ordered but no evidence that it was administered.

There was no documented evidence that the staff had notified the physician that the resident went five consecutive days, December 27, 28, 29, 30, and 31, 2023, without a bowel movement.

A review of the clinical record revealed that Resident 82 was admitted to the facility on December 28, 2023, with diagnoses to include Parkinson's disease (a disorder of the central nervous system that affects movement often including tremors).

The resident had physician orders dated December 28, 2023, for the following bowel regimen:

- Lactulose Solution 20 GM/30 ML. Give 30 ml by mouth as needed for constipation. Give daily if no BM in 3 days.
- Bisacodyl Suppository 10 MG. Insert 1 suppository rectally as needed for constipation if Lactulose is ineffective. Administer next morning at 6:00 AM.
- Fleet Enema 7-19 GM/118 ML (Sodium Phosphates). Insert 1 unit rectally as needed for constipation. Administer on day 4 if Dulcolax suppository is ineffective.

During interview with Resident 82 on January 3, 2024 at 11:30 AM the resident stated that he felt constipated.

A physician order dated January 3, 2024, noted an order for Bisacodyl EC tablet delayed release 5 mg one tablet one time only for constipation.

Review of Resident 82 's report of bowel activity from the Documentation Survey Report for the month of December 2023 though January 4, 2024 and the Medication Administration Record (MAR) for December 2023 though January 4, 2024, revealed the that the resident did not have a bowel movement on:

-December 30, 2023 - day one without a bowel movement
-December 31, 2023 - day two without a bowel movement
-January 1, 2024 - day three without a bowel movement, 30 ml of Lactulose was administered as ordered.
-January 2, 2024 - day four without a bowel movement, Bisacodyl suppository was ordered but no evidence that it was administered.
-January 3, 2024 - day five, Bisacodyl EC delayed release 5mg was administered as per physician order received on January 3, 2024, and a medium formed bowel movement at 9:43 PM was indicated on the resident's bowel activity survey documentation report.

During an interview with the Director of Nursing (DON) on January 4, 2024, at 8:54 AM, the DON confirmed that staff failed to carry out the physician ordered bowel protocol prescribed for Residents 21, 176 and 82 to prevent constipation and promote normal bowel activity and was unable to provide documented evidence that the physician was notified of the five consecutive days without a bowel movement for Residents 21 and 176.



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

28 Pa. Code 211.5(f) Medical records




 Plan of Correction - To be completed: 02/14/2024

1.Residents 21, 176 and 82 have been discharged.
2. An audit will be completed of in-house residents to ensure the bowel protocol was followed and physician notification was completed.
3. Education will be completed with nursing staff on the facility's bowel elimination protocol including physician notification.
4. The DON, or designee, will complete audits on residents to ensure that the bowel protocol was followed including physician notification. Results of these audits will be reviewed with the QAA committee x 3 months and then re-evaluated.
483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning 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.
§483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Observations:

Based on clinical record review and resident and staff interview it was determined that the facility failed to demonstrate that a resident was afforded the right to participate in care planning to meet the resident's nutritional needs and had incorporated the resident's personal preferences for weight loss and assure the resident received items included in the plan of care, to include snacks and additional protein, for one resident out of 13 sampled (Resident 13).

Findings included:

Review of Resident 13's clinical record revealed admission on December 19, 2023, with diagnoses of orthopedic aftercare, pneumonia, and diabetes.

A review of an Admission Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan a resident's care) dated December 26, 2023, indicated that the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact).

The resident's care plan indicated that he was at risk for nutritional deficits related to a therapeutic diet initiated December 19, 2023, with a goal that the resident's weight will remain stable without significant changes through next review, target Date of January 5, 2024. Interventions planned were to honor food preferences and/or assist with menu completion, monitor weights, provide diet as ordered and monitor intake/tolerance, and provide education on therapeutic diet and/or food-drug interactions.

A Nutritional Assessment dated December 20, 2023, indicated that the resident was on a carbohydrate (CHO) controlled regular diet and received a nutritional supplement, Glucerna, with breakfast and dinner. The assessment noted that the resident stated he would like snacks in-between his meals and supplements were added as snacks.

Review of the resident's weight record revealed that the resident was 74.0 inches tall and his body mass index (BMI - a value derived from the weight and height of a person) was 31.8 (BMI of 30 and above indicates obesity).

December 19, 2023 (2:38 PM) - 264.0 lbs
December 20, 2023 (7:44 AM) - 264.0 lbs
December 26, 2023 (6:35 AM) - 259.2 lbs - a 4.8 lbs weight loss (1.82 %) in 7 days.
December 26, 2023 (6:47 AM) - 259.2 lbs
January 2, 2024 (7:09 AM) - 248.0 lbs - a 16.0 lbs weight loss (6.06 %) in 14 days.

The resident lost a total of 16.0 lbs or 6.06 % loss of body weight in 14 days (December 19, 2023 through January 2, 2024).

A nutrition update note dated December 23, 2023, at 1:39 PM, indicated that the resident requested to speak with dietary staff. He informed staff that he has been diabetic since 2006, and he stated being hungry between meals and at hour of sleep (HS). The entry noted that Glucerna was provided twice daily. The resident requested additional protein.

The resident's care plan was not updated to identify the additional protein portions with meals, when reviewed at the time of the survey ending January 5, 2024.

A Nutrition update note dated December 30, 2023, at 1:45 PM indicated that the resident again requested to speak with someone from the kitchen. The resident complained that he gets his snacks a few days a week but has not received them since Tuesday and said his blood sugar was low today around breakfast. The entry noted that the dietary staff reviewed requested food items, and would discuss with kitchen staff.

Interview with Resident 13 on January 3, 2024, at approximately 10:33 AM, and again at 11:55 AM, indicated he was dissatisfied with his current weight loss, stating "I didn't come here to lose weight." The resident stated that he knew he lost weight by the way he felt and by the way his clothing fit. The resident stated he frequently did not receive the additional protein, and or snacks requested, stating "it all depended on who worked in the kitchen, and whether it's a weekend or weekday." The resident stated he "got tired" of speaking with staff regarding his hunger and dietary concerns.

A review of a nursing progress note dated January 3, 2024, at 5:45 PM, revealed the resident was discharged home.

Interview with the Director of Nursing (DON) on January 5, 2024, at approximately 8:50 AM, confirmed Resident 13 had a significant weight loss and his care plan failed to identify the additional protein portions with meals the resident requested.


28 Pa. Code 201.29 (a) Resident rights






 Plan of Correction - To be completed: 02/14/2024

1. Resident #13 had discharged home.
2. An audit will be completed on residents requesting additional protein portions to ensure their care plan is updated accordingly with their personal preferences and that they are provided to the resident.
3.Education will be provided to licensed nursing staff, dietary and dietitians on incorporating resident preferences into the care plan and providing the requested item(s) to the resident.
4. The DON, or designee, will complete audits on residents requesting additional protein portions to ensure they are provided and care planned. Results of these audits will be reviewed with the QAA committee x 3 months then re-evaluated.
483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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.
§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:


Based on observation, review of select facility policy and clinical records and staff and resident interview, it was determined that the facility failed to determine a resident's capability to self-administer medication (Lantus Insulin) for one of 13 residents reviewed (Resident 13).

Findings include:

A review of facility policy entitled "Procedure for Medication Administration", and "Self Administration of Medications", last reviewed by the facility November 2, 2023, indicated it is the policy to safely administer medications to the resident as ordered by the physician. Medications are not to be left bedside.

It is the policy to promote the right of the resident to self administer drugs unless the interdisciplinary team (IDT) has determined that this practice would be unsafe. To assist in safe self administration the IDT will consider are the medications appropriate and safe for self administration, does the resident have the ability to ensure that the medications is stored safely and securely in a locked cabinet or drawer. If it is determined by the IDT that the resident is able to exercise this right, document in the medical record, nurse establish a plan to instruct the resident regarding his/her medications. This plan will be documented in the residents care plan. The resident may begin self administration after the instructions and understanding of the instructions has been demonstrated. This will be documented in the nursing notes. Medications must be locked in a cabinet or drawer.

Review of Resident 13's clinical record revealed admission on December 19, 2023, with diagnoses to have included orthopedic aftercare, pneumonia, and diabetes. The resident was assessed as cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact).

The resident's care plan indicated that he is at risk for complications of blood sugar fluctuations related to diagnosis of diabetes date initiated on December 20, 2023, with a goal that the resident will not exhibit complications of Diabetes or signs/symptoms of hypoglycemia or hyperglycemia through next review, target Date of January 5, 2024. Interventions planned were to administer medications, assess and report to physician signs / symptoms of hypoglycemia or hyperglycemia as indicated by cold, clammy skin; sweating; lethargy; confusion, blood glucose monitoring, monitor lab tests, skin, especially feet, every shift and report any reddened or open areas to physician, and to provide diet per physician orders. The resident's care plan failed to identify the self-administration of medication, insulin (Lantus), nor the storage of the medication.

A physician orders dated December 21, 2023, was noted for Lantus (diabetes medication) SoloStar subcutaneous solutions pen-injector 100 Unit/ML (Insulin Glargine), inject 42 unit subcutaneously two times a day for Diabetes Mellitus (DM) with scheduling details, that the Lantus is to be administered by a clinician at 0800 hrs (8:00 AM), and 2000 hrs (8:00 PM).

During observation and interview with Resident 13, in his room on January 3, 2024, at approximately 10:33 AM, revealed an opened Lantus Solo Star insulin pen was observed on the resident's bedside table next to his personal items. During the interview with the resident, he stated staff leaves the insulin pen with him for him to self administer.

A second observation of Resident 13 on January 3, 2024, at approximately 11:13 AM, revealed a Lantus Solo Star insulin pen remained on the resident's bedside table next to personal items.

A third observation of the resident on January 3, 2024, at approximately 12:00 PM, in the presence of Employee 1 (Registered Nurse) confirmed that a Lantus Solo Star insulin pen was on the resident's bedside table next to personal items. Employee 1 confirmed that Resident 13 does self administer the Lantus insulin.

During an interview on January 3, 2024, at approximately 12:05 PM, with Employee 1 (RN), Employee 1 confirmed that the resident's clinical record contained no physician order for Resident 13 to self-administer Lantus insulin, no self administration assessment of the resident's ability to self-administer, or care plan indicating that the resident does self administer the medication. Employee 1 further confirmed that the Lantus insulin pen was on the resident's bedside table and not securely stored

During an interview with the Director of Nursing (DON) on January 4, 2024, at approximately 10:30 AM, the DON confirmed that there was no self administration assessment of Resident 13, physician order for self-administration or care plan for the resident's self-administration and storage of the drug.

Refer F 656


28 Pa. Code: 211.9(a)(1) Pharmacy services.

28 Pa Code 211.10 (c)(d) Resident care policies

28 Pa Code 211.12 (d)(1)(5) Nursing services





 Plan of Correction - To be completed: 02/14/2024

1. Resident #13 has discharged home.
2. An audit will be completed on residents who self administer medication to ensure physician order is received, self administration assessment is completed and medication is securely stored and addressed in the care plan.
3. Education of licensed nursing staff on resident self administration of medication including the requirement to perform the self-administration assessment, obtain physician orders, securely store the medication and complete the care plan.
4. The DON, or designee, will complete audits on residents self administering medication to ensure the self-assessment is complete, the physician order obtained, medication securely stored and care planned. Results of these audits will be reviewed with the QAA committee x 3 months then re-evaluated.
483.21(b)(1)(3) 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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on observation, clinical record review and staff and resident interviews, it was determined that the facility failed to develop person-centered care plans that included individual resident needs and preferences for self-administration of medication and potential for pain for two residents out of 13 sampled (Resident 13 and 3).

Findings include:

A review of the clinical record revealed Resident 3 was admitted to the facility December 11, 2023, for orthopedic aftercare. An Nursing Admission Evaluation dated December 11, 2023, revealed the admission diagnosis as failure of recalled total hip arthroplasty hardware.

Hospital discharge instructions dated December 11, 2023, prior to the resident's admission to the skilled nursing facility, indicated that had been hospitalized for a left hip arthroplasty because of a left hip hardware failure.

A Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 18, 2023, revealed that the resident was cognitively intact, with a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 15. The MDS assessment noted that the resident has had pain or was hurting in the last 5 days.

A facility pain evaluation dated December 24, 2023, indicated that the resident has experienced pain at the left surgical hip.

Interview with Resident 3, in her room on January 3, 2024, at approximately 10:40 AM, revealed that currently she does experience pain

A review of Resident 3's care plan conducted during the survey ending January 5, 2024, revealed that the resident's comprehensive care plan did not include the resident's potential for pain or actual pain.

Interview with the Director of Nursing (DON) on January 4, 2024, at approximately 10:30 AM, confirmed the absence of potential for pain, and pain management needs, on Resident 3's care plan.

Review of Resident 13's clinical record revealed admission on December 19, 2023, with diagnoses to have included orthopedic aftercare, pneumonia, and diabetes.

A review of the clinical record indicated the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognitive function - a score of 13-15 indicates cognitively intact).

The resident's care plan indicated that the resident was at risk for complications of blood sugar fluctuations related to diagnosis of diabetes initiated December 20, 2023, with a goal that the resident will not exhibit complications of Diabetes or signs/symptoms of hypoglycemia or hyperglycemia through next review as of the target Date of January 5, 2024. Interventions planned were to administer medications, assess and report to physician signs/symptoms of hypoglycemia or hyperglycemia as indicated by cold, clammy skin; sweating; lethargy; confusion, blood glucose monitoring, monitor lab tests, skin, especially feet, every shift and report any reddened or open areas to physician, and to provide diet per physician orders.

The resident had current physician orders dated December 21, 2023, Lantus (diabetes medication) SoloStar subcutaneous solutions pen-injector 100 Unit/ML (Insulin Glargine), inject 42 unit subcutaneously two times a day for Diabetes Mellitus (DM).

Observation and interview with Resident 13, in his room on January 3, 2024, at approximately 10:33 AM, revealed an opened Lantus Solo Star insulin pen on the resident's bedside table next to his personal items. During the interview with the resident, he stated that staff leaves the insulin pen in his room for him to self-administer his insulin.

A second observation of Resident 13 on January 3, 2024, at approximately 11:13 AM, revealed the Lantus Solo Star insulin pen remained on the resident's bedside table next to his personal items.

A third observation of the resident on January 3, 2024, at approximately 12:00 PM, in the presence of Employee 1 (Registered Nurse) confirmed the Lantus Solo Star insulin pen on the resident's bedside table next to personal items. Employee 1 confirmed that resident 13 does self administer the Lantus insulin.

During an interview on January 3, 2024, at approximately 12:05 PM, with employee 1 (RN), a review of resident 13's clinical record confirmed the resident's comprehensive care plan failed to identify the resident's self administration of insulin.

During an interview with the Director of Nursing (DON) on January 4, 2024, at approximately 10:30 AM, confirmed the absence of medication (Lantus) self administration on Resident 13's care plan.

Refer F554

28 Pa. Code 211.10 (d) Resident care policies

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



 Plan of Correction - To be completed: 02/14/2024

1. Resident #13 is discharged home. Resident #3's care plan has been updated to address the resident's pain.
2. An audit will be completed on all in-house residents with actual or potential for pain and those that self-administer medication to ensure that a comprehensive care plan is developed and implemented.
3. Staff education will be completed with licensed nursing staff on person centered care planning for pain and self administration of medication.
4. The DON, or designee, will complete audits on residents with potential for or actual pain and those self-administering medications to ensure that a comprehensive care plan is developed and implemented. Results will be reviewed with the QAA committee x 3 months then re-evaluated.

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 review of select facility policy and clinical records, and resident and staff interviews it was determined that the facility failed to provide a physician ordered nutritional supplement prescribed to one out of four sampled residents sampled (Resident 77).

Findings include:

Review of the clinical record revealed that Resident 77 was admitted to the facility on December 30, 2023, with diagnoses which included left femur fracture (break in the thigh bone) with left hip hemiarthroplasty (surgical procedure similar to total hip replacement but only ball point of the hip joint is replaced).

A physician order dated January 2, 2024, was noted for Juven (a powdered nutritional supplement mixed with water or juice to support wound healing and maintain lean body mass) with meals for supplement, but failed to indicate the amount of Juven to be provided to the resident at each meal.

A clarification physician order dated January 4, 2024, noted an order for Juven 8 ounce with each meal.

Further review of the clinical record revealed no documented evidence that the physician ordered nutritional supplement was being provided.

Interview with Resident 77 on January 4, 2024, at 12:45 PM confirmed that he was not yet receiving Juven with his meals.

Interview with the director of nursing (DON) on January 4, 2024, at 1:15 PM confirmed that the physician's order for Juven was not timely implemented and provided to the resident as prescribed.


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












 Plan of Correction - To be completed: 02/14/2024

1. Resident #77 is receiving Juven with meals as ordered.
2. An audit will be completed of those residents with physician orders for nutritional supplements to ensure that they are being provided as ordered.
3. Dietary staff, dietitians and nursing staff will be educated on the provision of supplements as prescribed by the physician.
4. The DON, or designee, will complete audits on residents prescribed nutritional supplements to ensure timely implementation and provision as prescribed. Results of these audits will be reported to QAA committe x 3 months then re-evaluated.
483.40(d) REQUIREMENT Provision of Medically Related Social Service: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.
§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:


Based on review of clinical records and resident and staff interview, it was revealed that the facility failed to provide therapeutic social services to promote the mental and psychosocial well-being of one resident out of 13 sampled (Resident 127)

Findings include:

A review of the clinical record revealed that Resident 127 was admitted to the facility on December 24, 2023, with diagnoses to include left tibia fracture, diabetes, and depression.

The resident was cognitively intact with a BIMS score of 14 (Brief Interview for Mental, \ which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information).

The resident's care plan indicated that she was at risk for adverse reactions and behavior problems not easily altered related to current psychoactive medication date initiated on December 27, 2023. The goal was that the resident will be educated to use of medication and recognition of adverse reactions, along with interventions if adverse reaction occurs through next review, target Date of March 23, 2024. Interventions planned were to monitor the resident's mood and/or behavioral changes, and to offer ongoing support and encouragement with plan of care.

A review of a nursing progress note dated December 26, 2023, 2:13 PM indicated that the resident was very tearful and missing her husband. The resident stated he always helped her when she was here last time. The entry noted that nursing provided support.

Interview with the administrator during the survey ending January 5, 2024, revealed that the resident's husband was deceased.

A nursing progress note dated January 1, 2024, 7:42 AM indicated that the resident having breakfast at nurse's station. The entry noted that the resident was continuously crying and was inconsolable at this time. Nursing noted that the resident "wants her husband."

Nursing noted support was provided on December 26, 2023, but there was no evidence of further supportive therapeutic social service interventions implemented to assist the resident with her emotional distress regarding wanting her husband.

The resident's care plan failed to identify the known episodes of crying/tearfulness, and missing her husband and, did not include interventions for staff to implement when the resident was experiencing this distress and assist in coping with her grief.

A review of a nursing progress note dated January 2, 2024, 6:21 AM indicated that the resident displayed occasional tearful episodes and that nursing staff provided 1:1 emotional support, which was effective for short intervals.

There was no documented evidence of the provision of therapeutic social services developed and planned to assist the resident with her emotional distress and coping.

Interview with Resident 127, on January 3, 2024, at approximately 10:45 AM found her in her room tearful. The resident stated that she was lonely.

Interview with Employee 2, Social Worker, on January 4, 2024, at approximately 1:20 PM revealed she had not followed up, or conversed with Resident 127 in response to the resident's episodes of tearfulness and crying due to missing her husband.

During an interview on January 4, 2024, at approximately 1:55 PM, the Nursing Home Administrator was unable to provide evidence that the facility consistently provided the necessary therapeutic social services to assist and support this resident in dealing with her emotional distress (crying/tearful) and coping with her grief regarding the absence of her husband. The NHA confirmed that the resident's care plan had failed to identify the resident's emotional distress as evidenced by the episodes of crying/tearfulness, and missing her husband and, did not include interventions for staff to implement when the resident was experiencing this psychosocial distress.

28 Pa. Code 201.29 (a) Resident rights.









 Plan of Correction - To be completed: 02/14/2024

1. Resident #127's care plan has been updated to include interventions for staff to implement to assist the resident with her emotional distress and coping with her grief.
2. An audit will be completed of in-house residents to ensure care plans have therapeutic interventions for residents experiencing emotional distress.
3. Education will be provided by external MSW and Clinical Educator to social services, nursing, therapy and activities on identification, individualized intervention development,person centered care planning and implementation of strategies/interventions along with monitoring.
4. The DON, or designee, will perform audits to ensure residents experiencing emotional distress have interventions identified in the care plan. Results of these audits will be reviewed with the QAA committee x 3 months then re-evaluated.

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