Nursing Investigation Results -

Pennsylvania Department of Health
JEFFERSON HILLS REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

JEFFERSON HILLS REHABILITATION AND WELLNESS CENTER
Inspection Results For:
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JEFFERSON HILLS REHABILITATION AND WELLNESS 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 January 21, 2020, it was determined that Jefferson Hills Rehabilitation and Wellness 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:

483.50(a)(1)(i) REQUIREMENT Laboratory Services:

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.

§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to provide timely lab services to one of six residents (Resident CR1).

Findings include:

The Admission Record indicated that Resident CR1 was admitted to the facility on 12/17/19, with diagnoses that included a fracture of the lumbar vertebrae, heart disease and the resident had a cardiac pacemaker.

A review of the nurse notes dated 12/17/19, and 12/19/19, indicated that Resident CR1 had loose stools.

A physician order dated 12/19/19, instructed the nurse to obtain a stool specimen from Resident CR1 for Clostridium Difficile (C-diff: a bacteria that causes persistent loose stool).

A review of the nurse notes dated 12/26/19, indicated that a stool specimen for C-diff was obtained from Resident CR1 however the laboratory phoned the facility and informed them that the stool specimen was inadequate in quantity so the test could not be performed and another specimen needed to be obtained.

A review of the clinical record revealed that no stool specimen was obtained from 12/29/19, through 1/16/20, although Resident CR1 continued to have loose stools.

During an interview on 1/21/20, at 3:25 p.m. the Interim Director of Nursing confirmed that the facility failed to provide timely lab services for Resident CR1.

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

Plan of Correction - To be completed: 02/11/2020

. The facility cannot retroactively correct that resident CR1 did not have a stool specimen collected as per physician's order. Resident CR1 had no negative outcomes related to the missed specimen collection.
2. The DON/designee will audit current residents to ensure that ordered labs have been obtained.
3. The nursing staff will be re-educated on the protocol for specimen collection and follow up.
4. The DON/designee will audit all new lab orders x 2 months to ensure the specimen has been collected and the lab results received at the facility. The results of these audits will be reported to the monthly Quality Performance Improvement Committee for review.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§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 facility policy and clinical record review and staff interviews, it was determined that the facility failed to maintain complete and accurate documentation of the condition/status of one of six residents (Resident CR1).

Findings include:

The facility policy "Nursing Documentation" dated 2/20/19, indicated that nursing documentation communicated the resident's status and provided an accurate accounting of care and monitoring.

The Admission Record indicated that Resident CR1 was admitted to the facility on 12/17/19, with diagnoses that included a fracture of the lumbar vertebrae, heart disease and that the resident had a cardiac pacemaker.

A review of the nurse notes dated 12/26/19, indicated that Resident CR1 continued with nausea, had an emesis after dinner, continued with loose stools and that the laboratory notified the facility that a stool specimen obtained from the resident earlier was of inadequate quantity so a test for Clostridium Difficile (C-diff: a bacteria that causes persistent loose stool) could not be performed.

The next entry in the nurse notes for Resident CR1 was dated 1/16/20, when the resident was discharged from the facility; 21 days later.

During interviews on 1/21/20, at 3:25 p.m. and at 4:00 p.m. the Interim Director of Nursing and the Nursing Home Administrator confirmed that the facility failed to maintain complete and accurate documentation of the condition/status of Resident CR1 from 12/26/19, through 1/16/20.

28 Pa. Code: 211.5(f) Clinical records.

Plan of Correction - To be completed: 02/11/2020

The facility cannot retroactively correct that resident CR1 had no documentation to address changes in condition form 12/26/19 through 1/16/20. Resident CR1 had no negative outcomes related to the lack of documentation, and did discharge home on 1/16/20.
2. The facility will implement a system to identify residents who require documentation, and the type of documentation required.
3. The nursing staff will be educated on resident documentation requirements and the system that will be used to identify resident's requiring documentation and the specific documentation required.
4. The DON/designee will audit 5 resident records a week x 3 weeks then monthly x 2 months to ensure that changes in condition have been documented in the residents medical record. The results of these audits will be reported to the monthly Quality Performance Improvement Committee for review.

§ 211.12(i) LICENSURE Nursing services.:

(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.

Observations:
Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on eight of 21 days (12/11/19, 12/12/19, 12/13/19, 12/16/19, 12/19/19, 12/21/19, 12/22/19 and 12/25/19).

Findings include:

Nursing time schedules for the period 12/7/19, through 12/27/19, revealed that the facility failed to maintain 2.7 hours of general nursing care to each resident in a 24 hour period on the following dates:

12/11/19 - 2.66
12/12/19 - 2.37
12/13/19 - 2.09
12/16/19 - 2.57
12/19/19 - 2.29
12/21/19 - 2.33
12/22/19 - 2.41
12/25/19 - 2.56

During interviews on 1/21/20, at 3:30 p.m. and at 3:55 p.m. the Interim Director of Nursing and the Nursing Home Administrator confirmed that the facility failed to meet the nursing hour requirements for those eight days.

Plan of Correction - To be completed: 02/11/2020

. The facility cannot correct that on 12/11/19, 12/12/19, 12/13/19, 12/16/19, 12/19/19, 12/21/19, 12/22/19, and 12/25/19 the facility did not meet the minimum direct care hours of 2.7. Quality care to residents was maintained and there were no negative outcomes to the residents related to not meeting the 2.7 direct care hours.
2. The facility will maintain a minimum of 2.7 hours of direct resident care. The facility will utilize certified/licensed professionals from other departments as direct care providers in the event PPD is found to be below 2.7.
3. Staffing hours will be reviewed by the Nursing Home Administrator and Director of Nursing daily and prior to next day schedule posting. The Nursing Home Administrator/designee will re-educate RN supervisors, director of nursing and scheduler on calculating and maintaining required 2.7 nursing hours, Act 102, Mandatory Overtime Protocol and notifying Nursing Home Administrator if hours are not being maintained.
4. The Nursing Home Administrator/designee will complete an audit 5 times a week for 4 weeks then weekly for 4 weeks, then monthly for 3 months to validate required nursing hours are met. The results of these audits will be reported to the monthly Quality Performance Improvement Committee for review.

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