Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT CAMP HILL, THE
Patient Care Inspection Results

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GARDENS AT CAMP HILL, THE
Inspection Results For:

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GARDENS AT CAMP HILL, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an abbreviated survey completed on October 9, 2019, in response to a complaint, it was determined that The Gardens at Camp Hill was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirement for Long Tern Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.








 Plan of Correction:


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 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.
483.20(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 reviews and staff interview, it was determined that the facility failed to maintain clinical records which are complete and accurate for three of three Resident records reviewed (Residents 1, 2 and 3).

Findings include:

Review of Resident 1's current physician orders revealed diagnoses which included, Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), 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).
Review of resident 1's care plan revealed a focus area for alteration in bowel and bladder function (frequently incontinent). An intervention in the care plan is to provide assistance to the toilet and encourage resident to be as independent as able.
Documentation for incontinence care revealed that from the time period of September 1, 2019 to October 9, 2019, there are 24 shifts for which there is no documentation of care.

Review of Resident 2's current physician orders revealed diagnoses which included Cerebral Palsy (a group of disorders that affect movement and muscle tone or posture).
Review of resident 2's care plan revealed a focus area for alteration in bowel and bladder function, lacks ability to know when she needs to toilet. An intervention in the care plan is to check and change and to provide assistance to the toilet.
Documentation for incontinence care revealed that from the time period of September 1, 2019 to October 9, 2019, there are 25 shifts for which there is no documentation of care.

Review of Resident 3's current physician orders revealed diagnoses which included unspecified psychosis (delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior about which there is inadequate information to make a specific diagnosis) and overactive bladder.
Review of resident 3's care plan revealed a focus area for incontinence of urine and bowel Interventions in the care plan include to provide assistance to the toilet as needed and to provide incontinence care as needed.
Documentation for incontinence care revealed that from the time period of September 23, 2019 to October 9, 2019, there are 18 shifts for which there is no documentation of care.

During an interview with the Director of Nursing on October 9, 2019, at approximately 2:30 PM, regarding the missing documentation of incontinence care, she stated that documentation should be done when care is given.

28 Pa. Code 211.5(f) Clinical records.







 Plan of Correction - To be completed: 10/25/2019

1. R1, R2, and R3 were assessed and were not found to have any adverse effect from the missing bowel and bladder continence documentation.
2. A review has been completed of current residents to ensure there are no adverse effects from missing bowel and bladder documentation.
3. The certified nursing assistants and licensed staff have been educated on the policy for completing their documentation timely.
4. The Director of Nursing or designee will audit 10 random bowel and bladder continence records for completion weekly x 4 weeks, then monthly x 2 months. Findings will be discussed with the interdisciplinary team at QAPI monthly.
5. Date of compliance is October 25th, 2019.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:


Based on clinical record review, as well as staff interviews, it was determined that the facility failed to notify the resident's representative of achange in the resident's condition one of three residents reviewed (Resident 1).

Findings include:

Review of facility policy, "Change in Resident's Condition or Status," dated May 2017, revealed, "Our facility shall promptly notify the resident,his or her attending physician and representative of changes in tbe resident's medical/mental condition and/or status." The policy goes on to state that a significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.

Review of Resident 1's clinical record revealed diagnoses that included 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) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

Additionally, review of Resident 1's clinical record revealed that she had been assessed by the Nurse Practitioner on September 10, 2019, for left sided facial drooping for which she diagnosed Bell's palsy and prescribed Prednisone (a medication used to treat inflammation) Further review of the clinical record failed to reveal any notification of the diagnosis or treatment to the resident's responsible party.

During an interview with the Director of Nursing (DON) on October 9, 2019, at 2:45 PM she revealed the expectation that the resident representative should have been notified of the resident's change in condition.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.













 Plan of Correction - To be completed: 10/25/2019

1. R1's responsible party was contacted and informed of all interventions placed for the new onset of Bell's Palsy.
2. A review has been completed of all current residents with a change in condition over the past 30 days to ensure their responsible parties were notified.
3. The licensed staff have been educated on the policy for notifying the responsible parties of any changes in condition.
4. The Director of Nursing or designee will audit 5 random changes in condition for responsible party notification weekly x 4 weeks, then monthly x 2 months. Findings will be discussed with the interdisciplinary team at QAPI monthly.
5. Date of compliance is October 25th, 2019.


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