Pennsylvania Department of Health
CHAPEL MANOR
Patient Care Inspection Results

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CHAPEL MANOR
Inspection Results For:

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CHAPEL MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to three complaints completed on April 10, 2024, it was determined that Chapel Manor 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 related to the health portion of the survey process.




 Plan of Correction:


483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:

Based on staff interviews, and the review of clinical records, it was determined that the facility failed to ensure that residents were informed of the discontinuation of a medication for one out of four residents reviewed (Resident R3).

Findings include:

Review of the April 2024 physician orders for Resident R3 included the following diagnosis: anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); bipolar (a mental illness that causes mood episodes that range from extremely high to extremely low); heart failure (a long-term condition that affects your heart's ability to pump blood well); chronic kidney disease (a gradual loss of kidney function occurs over a period of time); asthma (a chronic lung disease); and cerebral infarction (a stroke).

Review of the Resident R3's March 2024 physician orders included a physician's order dated March 7, 2024 for the resident to be administered 1-0.5 milligram tablet of the medication, Lorazepam (brand name, Ativan), by mouth every 8 hours for the treatment of anxiety and agitation. The times of administration that were listed in the physician's order were: 12:00 a.m., 6:00 p.m., 12:00 p.m. and 6:00 p.m.

Continued review of the March 2024 physician's order indicated that the order was discontinued on March 29, 2024 by the Nurse Practioner at 4:20 p.m.

Review of April 2024 physician orders indicated a physican's ordered with a start date of April 2, 2024 at 6:00 p.m. for the resident to be administered 1-0.5 milligram tablet of the medication Ativan, by mouth every 8 hours for the treatment of anxiety. The times of administration that were listed in the physician's order were: 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m.

Review of various nursing notes that were dated April 2nd 3rd and 4th indicated that although the medication was re-ordered by the physician for the resident to start on taking on April 2, 2024 at 6:00 p.m., the medication did not arrive from the pharmacy for nursing staff to administer to Resident R3 until April 4, 2024 at 6:00 p.m., which was when the resident was administered his first dose. Nursing notes indicated "awaiting for med from pharmacy," on the above referenced dates April 2nd, 3rd and 4th. Review of the Medication Administration Record ( MAR) for April 2024 also indicated that the resident received his first does of Ativan on April 4, 2024 at 6:00 p.m.

During an interview with Resident R3 on April 10, 2024 at 2:40 p.m. Resident R3 reported that he had not received his Ativan "for about four or 5 days." Resident R3 reported that he was told by his nurse that the Nurse Practitioner did not write the prescription for him to continue taking it. Resident reported that he was not provided with a reason as to why he could not longer take the Ativan.

During an interview with Employee E5 (licensed nurse) and Employee E3 (licensed nurse) on April 10, 2024 at 3:10 p.m., Employee E5 confirmed that the last time that the resident was administered Ativan was on March 29, 2024 at 12:00 p.m. and that he did not get the 6:00 p.m. dose on this date.

Review of the clinical record did not show evidence as to why the Nurse Practitioner discontinued the resident's Ativan from March 29, 2024 through April 1, 2024, and then reordered it on April 2, 2024.

Continued review of the clinical record also did not show evidence that the resident was notified by the physician, nurse practitioner, or nursing staff that he would not be prescribed Ativan during the above referenced time period, along with an explanation as to why a change in his medication regime was occuring.

Continued interview with the Regional Nurse revealed that there was no documentation in the clinical record that Resident R3 was notified by facility staff that his Ativan prescription would be discontinued on March 29, 2024 after the 12:00 p.m. dose was administered, along with an explanation to the resident as to why it was discontinued.



28 Pa. Code 201.18(b)(1)(2) Management

28 Pa. Code 211.2(d)(3)(6) Medical director

28 Pa. Code 211.12(c) Nursing services

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







 Plan of Correction - To be completed: 04/17/2024

Doctor met with resident R3 and reviewed the discontinuation of medications.
Licensed nurses were re-educated on the importance of ensuring residents are fully informed of medication changes and any changes made to the treatment plan.
DON or designee will perform MAR audits of 5 random residents weekly x 3 months
Results will be reviewed on QAPI

483.40 REQUIREMENT Behavioral Health 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.
483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:


Based on observations, interviews and the review of clinical records, it was determined that the facility failed to ensure that behavioral health care services were attained for two out of four residents reviewed (Resident R1 and Resident R2).

Findings include:

Review of the April 2024 physician orders for Resident R1 indicated that the resident was admitted on March 21, 2024 from the hospital after receiving treatment for injuries that he sustained after falling out of a 2nd floor window at his home. The resident's admission diagnosis included the following: aphasia (a comprehension and communication, reading, speaking, or writing disorder resulting from damage or injury to the specific area in the brain); difficulty in walking, intellectual disabilities, hearing loss, in addition a dislocated left elbow and a left wrist fracture that he sustained after a fall while at home.

Review of the resident's Admission Minimum Data Set Assessment (MDS-a periodic assessment of a resident's needs) dated March 28, 2024, revealed that the resident was cognitively impaired.

Review of a physician's note dated March 27, 2024, at 3:58 p.m. indicated "The patient with chronic intellectual delay and through processes ongoing with limitation of comprehensive reduced ability." Review of documentation from the resident's visit with the psychiatrist at the facility on March 25, 2024 at 11:55 a.m. indicated ..." Patient arousable to verbal stimuli, makes brief eye contact, but does not offer verbal response. Patient unable to fully participate in exam. Patient with baseline intellectual disability. Unable to follow some commands." Resident R1 required the use of a wheelchair while in the facility.

During an interview with Licensed nurse, Employee E3 on April 10, 2024, at 3:20 p.m. Employee E3 reported that Resident R1 is hearing impaired, and that nursing staff communicates with the resident by writing down their questions or statements on paper for him.

During an interview with Resident R1 on April 10, 2024 at 3:40 p.m. Resident R1 pointed to his ear and stated "I can't hear well," and motioned his hands as if he had a pen in his hand, shook his hand back and forth as if he was holding a pen, making the motion to communicate with his by writing things down on paper.


Review of the April 20224 physician orders for Resident R2 included the following diagnosis: mood disorder (a mental health condition that impacts your emotional state and causes persistent changes in mood for an extended period of time); post-traumatic stress disorder (a mental health condition that some people develop after they experience or witness a traumatic event); right and left leg amputations, and opioid abuse (opioid-a broad group of pain relieving medications). Resident R2 required the use of a wheelchair while in the facility.

Review of the resident's quarterly MDS dated April 3, 2024 indicated that Resident R2 was awake, alert and oriented.

Review of a nursing note dated on April 2, 2024 at 1:40 p.m. documented by Employee E3 (licensed nursing staff) indicated that Employee E3 overheard Resident R1 and Resident R2 arguing, with Resident R2 telling Employee E3 that his roommate (Resident R1) was "touching his stuff." Continued review of the note indicated that Resident R2 made threats to Resident R1. Employee E3 documented that she reported the above referenced incident to the Nursing Home Administrator (NHA).

Review of a nursing note dated April 4, 2024, at 10:34 p.m. documented by Employee E4 (licensed nursing staff) indicated that Resident R2 stated that he would like to ask for his roommate to be moved to another room.

Review of a second nursing note dated April 4, 2024 at 11:29 p.m. documented by Employee E4 indicated that Resident R2 requested that his roommate be moved, and that he was irritated by his roommate's invasion of privacy/boundaries.

Review of a nursing note on April 8, 2024 1:47 p.m. documented by Employee E3 indicated that Resident R1 and Resident R2 were arguing and making threats to each other. Employee E3 documented that she notified the Director of Nursing (DON) of the incident.

During an interview with Employee E3 on April 10, 2024, at 3:20 p.m. Employee E3 reported that both residents have conflicts with each other, and that she has notfied the NHA and the DON regarding this. Employee E3 reported that she has asked the Admission Director if their rooms could be changed, but Employee E3 was told by the Admissions Director that there were no rooms available for a room change.

During the above referenced interview, Employee E3 also reported that during her nursing shift on the 7:00 a.m. through the 3:00 p.m. shift on April 10, 2024, Resident R1 slammed the door in Resident R2's face as Resident R2 was trying to enter their shared room.

Review of Resident R1 and Resident R2s' clinical records did not show evidence that the facility address the verbal altercations that were occuring between Resident R1 and Resident R2 in order to ensure appropriate care and services and safety for both resident with documented history of verbal altercations.

During an interview with the Nurising Home Administrator on April 10, 2024 at 6:30 p.m. it was discussed that there was no documentation in the clinical record to show evidence that the facility addressed the verbal threats between both residents that was documented by nursing staff.

28 Pa. Code 201.18(b)(1)(2) Management

28 Pa. Code 211.2(d)(3)(6) Medical director

28 Pa. Code 211.5 (f) Medical records

28 Pa. Code 211.12(c) Nursing services

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




 Plan of Correction - To be completed: 04/17/2024

Residents were separated via room change

Facility Staff were re-educated on the importance of documenting and reporting verbal threats or aggressive behaviors promptly and through the process of completing a concern form

DON/Designee will conduct weekly audits x 3 months of clinical records, incident reports, and documentation related to behavioral health services of 5 random residents to identify any recurrent issues

Results will be reviewed on QAPI


483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on resident and staff interviews, and review of clinical records, it was determined that the facility failed to ensure the timely delivery of an anti-anxiety medication for one out of four residents reviewed (Resident R3).

Findings include:


Review of Resident R3's April 2024 physician orders revealed the diagnoses of anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); and bipolar (a mental illness that causes mood episodes that range from extremely high to extremely low);

Continued review of April 2024 physician orders indicated an ordered with a start date of April 2, 2024 at 6:00 p.m. for the resident to be administered 1-0.5 milligram tablet of the medication Ativan, by mouth every 8 hours for the treatment of anxiety. The times of administration that were listed in the physician's order were: 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m.

Review of nursing notes dated April 2, 2024; April 3, 2024 and and April 4, 2024, indicated that although the medication was re-ordered by the physician for the resident to start on taking on April 2, 2024 at 6:00 p.m., the medication did not arrive from the pharmacy for nursing staff to administer to Resident R3 until April 4, 2024 at 6:00 p.m. Nursing notes indicated "awaiting for med from pharmacy," on the above referended dates.

Review of the Medication Administration Record ( MAR) for April 2024 also indicated that the resident received his first does of Ativan on April 4, 2024 at 6:00 p.m.

During an interview with Resident R3 on April 10, 2024 at 2:40 p.m. Resident R3 reported that he had not received his Ativan "for about four or 5 days."

During an interview with Employee E5 (licensed nurse) and Employee E3 (licensed nurse) on April 10, 2024 at 3:10 p.m., Employee E5 confirmed that the last time that the resident was administered Ativan was on March 29, 2024 at 12:00 p.m. and that he did not get the 6:00 p.m. dose on this date. Employee E5, reported that after March 29, 2024 does, Resident R3 was not administerd Ativan again until April 4, 2024 at 6:00 p.m. During the above referenced interview Employee E3 reported that she notified the unit manager "the week prior to March 31, 2024" that Resident R3 needed more Ativan ordered since he was going to run out of it soon.

During an interview with the Regional Nurse (Employee E6) on April 10, 2024, at 6:00 p.m. it was confirmed that the order for the Ativan was discontinued by the nurse practitioner on March 29, 2024 after his 12:00 p.m dose was administered. Continued interview with the Regional Nurse indicated that the Ativan was then re-ordered on April 2, 2024, with the medication not being adminstered to the resident until April 4, 2024 at 6:00 p.m. due to the Ativan not being delivered by pharmacy services until 2 days after it was prescribed by the Nurse Practitioner for the resident to take again.

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

28 PA. Code 211.9(j.1)(1) Pharmacy services




 Plan of Correction - To be completed: 04/17/2024

The pharmacy immediately contacted to expedite the delivery of the anti-anxiety medication for Resident R3.

Licensed nursing staff are being re-educated on medication management protocols, emphasizing the importance of timely medication delivery and the procedures for addressing delays.

DON or designee will conduct weekly audits for 3 months of medication refills for 5 random residents to ensure compliance.

Results will be reviewed on QAPI


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