Pennsylvania Department of Health
LOYALHANNA CARE CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LOYALHANNA CARE CENTER
Inspection Results For:

There are  184 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.
LOYALHANNA CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on January 26, 2024, it was determined that Loyalhanna Care 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.



 Plan of Correction:


483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that care-planned interventions for advanced directives were consistently implemented for one of six residents reviewed (Resident 3).

Findings include:

The facility's policy regarding Do Not Resuscitate orders, dated January 1, 2024, indicated that the interdisciplinary care planning team would review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 13, 2023, indicated that the resident was usually understood, could sometimes understand, was severely cognitively impaired, required extensive assistance with bathing, and was dependent on staff for transfers and toileting.

An advance directive care plan for Resident 3, dated December 28, 2021, indicated that the resident had a code status of do not resuscitate (DNR) and had a physician's order for life sustaining treatment (POLST) reviewed with the facility. An intervention indicated that the POLST would be reviewed upon readmission, quarterly, and with significant changes.

Resident 3's POLST, dated December 29, 2021, indicated that he was a DNR with limited interventions. The POLST was reviewed on the phone with the resident's representative and signed by two nurse signatures. The directions for healthcare professionals indicated that the form should be reviewed periodically and a new form completed if necessary when there is a substantial change in the person's health status, a change in treatment preferences, or transfer from one care setting or care level.

A nursing note for Resident 3, dated September 19, 2023, indicated that the resident had been discharged from hospice services and would continue to be a resident in long-term care.

There was no documented evidence that the POLST was reviewed quarterly or upon a significant change per Resident 3's care plan.

Interview with the Registered Nurse Assessment Coordinator on January 24, 2024, at 4:17 p.m. indicated that she attended the care conferences, and confirmed that Resident 3's POLST was not reviewed and should have been reviewed as care planned due to the resident's recent medical history.

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



 Plan of Correction - To be completed: 03/13/2024

Resident R3 continues to reside in the facility and is in stable condition. Resident R3's Physician Orders for LIfe Saving Treatment (POLST) was reviewed and is reflective of the resident's wishes.

A whole-house audit will be conducted for current residents to ensure that POLST/Code Status has been reviewed during the most recent care plan per existing policy. Residents in need of having their POLST reviewed will be contacted to verify current POLST status and document completion of review in the electronic medical record.

The director of nursing and/or designee will re-educate the interdisciplinary care plan team on the comprehensive care plan policy and the need to review the POLST at the annual and significant change care plan meetings with the resident and/or power of attorney. POLST reviews will be documented in the electronic medical record.

On-going POLST audits will be completed for all new admissions by the registered nurse assessment coordinator and/or designee.
The results of these audits, along with a root cause analysis of any identified issues, will come to the Quality Assurance Performance Improvement Committee for further analysis and recommendations.
In preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act, facility policies, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that treatments performed were documented by the nurse who performed the treatment for one of six residents reviewed (Resident 4).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.18. Standards of nursing conduct (a)(5)(8) indicated that the registered nurse was to document and maintain accurate records. Not to falsify or knowingly make incorrect entries into the patient's record or other related documents.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.148. Standards of nursing conduct (a)(5)(8) indicated that the licensed practical nurse was to document and maintain accurate records. Not to falsify or knowingly make incorrect entries into the patient's record or other related documents.

The facility's policy regarding charting and documentation, dated January 1, 2023, indicated that documentation of procedures and treatments will include care-specific details, including the name and title of the individual(s) who provided the care.

Physician's orders for Resident 4, dated January 15, 2024, included an order for the staff to drain the resident's pigtail catheter (a tube inserted through the chest wall to drain pleural fluid which lubricates the surfaces of the pleura - this is the thin tissue that lines the chest cavity and surrounds the lungs) once daily and record the amount. If the drainage is less than 50 milliliters (ml) for several days, the pigtail catheter may be removed if the attending physician deems it appropriate to be removed.

A nursing note for Resident 4, dated January 20, 2024, completed by Registered Nurse 1 revealed that the resident's PleurX (pigtail catheter) was drained by sterile procedure and 190 milliliters (ml) of yellow fluid was removed. The resident tolerated the procedure well. The dressing was changed with no signs or symptoms of infection. However, the resident's Medication Administration Record (MAR), dated January 20, 2024, was signed by Licensed Practical Nurse 2 as the person draining Resident 4's pigtail catheter.

A nursing note for Resident 4, dated January 21, 2024, completed by Registered Nurse 1 revealed that the resident's PleurX was drained by sterile procedure and 100 ml of yellow fluid was removed. The resident tolerated the procedure well. The dressing was changed with no signs or symptoms of infection. However, the resident's MAR, dated January 21, 2024, was signed by Licensed Practical Nurse 2 as the person draining the resident's pigtail catheter.

A nursing note for Resident 4, dated January 22, 2024, completed by Registered Nurse 3 revealed that the resident's PleurX was drained by sterile procedure and 200 ml of yellow fluid was removed. The resident tolerated the procedure well. The dressing was changed with no signs or symptoms of infection. However, the resident's MAR, dated January 22, 2024, was signed by Licensed Practical Nurse 4 as the person draining the resident's pigtail catheter.

Interview with Registered Nurse 1 on January 24, 2024, at 11:35 a.m. revealed that the registered nurses are the only staff that perform any care to Resident 4's pigtail catheter.

Interview with the Director of Nursing on January 24, 2024, at 2:40 p.m. confirmed that staff performing/completing a resident's treatment should be the one documenting in the resident's clinical record. She indicated that the registered nurses were educated on Resident 4's pigtail catheter and that registered nurses are the only ones to be providing care to Resident 4's pigtail catheter. She indicated that if the licensed practical nurses were signing Resident 4's MARs, then they were signing it off for the registered nurse completing the treatment.

Interview with Licensed Practical Nurse 2 on January 24, 2024, at 2:47 p.m. revealed that only the registered nurses are to do any care to Resident 4's pigtail catheter, and that if she was signing the MAR, it was because the registered nurse told her to do so.

Interview with the Director of Nursing on January 24, 2024, at 2:53 p.m. confirmed that Licensed Practical Nurses 2 and 4 signed Resident 4's MAR on the above dates.

28 Pa. Code 211.12(d)(1)(5) Nursing Services.



 Plan of Correction - To be completed: 03/13/2024

Resident R4 no longer resides at the facility.

A whole-house audit will be conducted for the past 14 days of current resident to ensure that documentation in the electronic treatment record is complete, and that care performed is documented by the nurse who provides the care or treatment.

The director of nursing and/or designee will provide education on the charting and documentation policy to current licensed nurses. Any new or agency licensed staff will receive education on facility policy as a part of their orientation to the facility.

The director of nursing and/or designee will complete ongoing audits of the electronic treatment records to ensure that documentation is accurate for five residents x fourteen days, then five residents weekly x four weeks, then five residents monthly x three months. The results of these audits, along with a root cause analysis of any identified issues will come to the Quality Assurance Performance Improvement Committee for further analysis and recommendations.

In preparation and/or execution of this plan of correction documentation does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of six residents reviewed (Resident 2).

Findings include:

The facility's policy regarding charting and documentation, dated January 1, 2023, indicated that the following information was to be documented in the resident medical record: Objective observations, changes in a resident's condition, treatments and services performed, and events, incidents, or accidents involving the resident.

An admission summary note, dated January 15, 2024, indicated that Resident 2 was admitted on January 14, 2024. The resident was alert and oriented to person, place and time.

A social service note for Resident 2, dated January 18, 2024, indicated that the facility received a call late at night regarding the resident sitting on a bed pan for four hours. Resident 2 told staff she was put on the bed pan but was not removed from it for four hours. Resident 2 stated she did not use her call light to get help, and she yelled for an employee. The resident was educated on importance of using her call light in time of need.

Information reported to the Department of Health on January 18, 2024, indicated that Resident 2's family member called the facility and reported that she was left on a bed pan.

There was no documented evidence in the medical record that Resident 2 was assessed by a registered nurse or that a skin assessment was completed by staff.

Interview with the Assistant Director of Nursing on January 24, 2024, at 12:50 p.m. revealed that she assessed Resident 2 with the supervisor on duty; however, the assessment was not documented in the medical record.

28 Pa. Code 211.5(f) Clinical Records.

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





 Plan of Correction - To be completed: 03/13/2024

Resident R2 continues to reside at the facility and is in stable condition. Resident R2 skin assessment documentation was entered into the point click care software program as a late entry.

The director of nursing and/or designee will audit all facility incidents and accidents during the previous fourteen days to identify any residents with missing documentation of a physical assessment and provide immediate education to nursing staff should findings arise.

The director of nursing and/or designee will provide education to current licensed nursing staff on the charting and documentation policy. Any new or agency licensed staff will receive education on facility policy as a part of their orientation to the facility.

The director of nursing and/or designee will audit facility incident and accident reports to ensure that complete and accurate data is present and documented in the medical record x thirty days, then weekly x four weeks, then monthly x three months. The results of these audits, along with a root cause analysis of any identified issues will come to the Quality Assurance Performance Improvement Committee for further analysis and recommendations.

In preparation and/or execution of this plan of correction documentation does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port