Nursing Investigation Results -

Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT POTTSTOWN
Patient Care Inspection Results

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KADIMA REHABILITATION & NURSING AT POTTSTOWN
Inspection Results For:

There are  80 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT POTTSTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, completed on December 11, 2021, it was determined that Kadima Rehabilitation and Nursing at Pottstown 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 for the health portion of the survey.



 Plan of Correction:


483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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.
483.45(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:


Based on clinical record review, facility policy and procedure review, and staff interview it was determined the facility failed to respond to recommendations made by the consultant pharmacist for three of five residents reviewed. (Residents 12, 21, and 22)

Findings include:

Review of facility policy and procedure titled Pharmacy Services, last revised on August 28, 2018, revealed a licensed pharmacist will review the drug regimen of each residents at least once a month. The pharmacist will report any irregularities to the attending physician, the director of nursing, and the medical director. These reports will be acted upon.

Review of Resident 12's clinical record revealed there were pharmacy reviews completed on August 2, 2021, June 12, 2021, May 6, 2021, April 18, 2021, March 21, 2021, February 16, 2021, January 3, 2021 and December 3, 2021 in which the pharmacist identified irregularities to be addressed by the facility.

Review of Resident 21's clinical record revealed there were pharmacy reviews completed on July 4, 2021, June 11, 2021, April 18, 2021, March 21, 2021, February 16, 2021, November 5, 2021 in which the pharmacist identified irregularities to be addressed by the facility.

Review of Resident 22's clinical record revealed there were pharmacy reviews completed on May 6, 2020, July 6, 2020, September 11, 2020, December 3, 2020, January 3, 2021, February 16, 2021, and April 18, 2021 in which the pharmacist identified irregularities to be addressed by the facility.

Interview with the Director of Nursing and the Nursing Home administrator on December 9, 2021 at 10 a.m. confirmed the facility could not provide evidence that the irregularities were acted upon by the facility when reported by the pharmacist for Residents 12, 21, and 22.

28 Pa. Code 211.5(f) Clinical records

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





 Plan of Correction - To be completed: 02/01/2022

0756:
1. Pharmacy recommendations for resident 12, 21 and 22 have been addressed.
2. A baseline pharmacy recommendation audit was completed. Pending pharmacy recommendations were addressed.
3. The DON will be re-educated on the Drug Regime Review Policy and Procedure. Pharmacy recommendations will be reviewed as part of the morning meeting process.
4. The NHA or designee will perform audits on a monthly basis x 3 months to ensure that pharmacy reviews and recommendations have been completed. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

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, facility policy and procedure review, and staff interview it was determined the facility failed to report a change in medical status for one 16 residents reviewed. (Resident 21)

Findings Include:

Review of facility policy titled Psychotropic Medication Use, revised August 29, 2018, revealed AIMS testing (Abnormal Involuntary Movement Scale- a total of twelve items rating involuntary movements of various areas of the patient's body possibly caused by psychotropic medications) is to be completed every six months.

Review of Resident 21's physician orders revealed the resident was admitted on October 26, 2020 and has been receiving Zyprexa (anti-psychotic medication) since admission.

Review of Resident 21's clinical record revealed the resident had an AIMS completed on February 26, 2021 with a score of 0 indicating no involuntary movements. An AIMS was completed on September 6, 2021 with a score of 10 indicating the resident had newly developed involuntary movements.

Review of the entire clinical record revealed there was no evidence the physician was notified of this change in the resident status.

Interview with the Nursing Home Administrator and the Director of Nursing on December 9, 2021 at 10:00 a.m. confirmed the physician was not notified on the change in Resident 21's AIMS assessment.

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

28 Pa. Code 211.5(f) Clinical records

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






 Plan of Correction - To be completed: 02/01/2022

0580:
1. The physician was notified on 12/8/21 of resident 21's AIMs result of 10 completed on 9/6/21. The physician ordered that the AIMs be re-evaluated. The Don completed another AIMs on 12/8/21 and noted a result of zero.
2. A facility wide audit of residents receiving antipsychotic medications will be completed and AIMS will be completed on residents requiring one.
3. Licensed Nursing staff will be re-educated on the AIMS process. The DON will monitor the forms tabs to ensure AIMS tests are completed when indicated.
4. The DON or designee will conduct an audit of AIMS results weekly x 4 weeks, then monthly x 2months to ensure that notification of AIMS results is relayed to the MD. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

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 clinical record review, faciltiy policy and procedure review and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for two of 13 residents reviewed (Residents 17 and 38).

Findings include:

Review of facility policy and procedure titled, Skin and Wound Management Policy, revised February 28, 2018, revealed an assessment of skin integrity is to be performed on each resident upon admission to the center by completing a head-to-toe physical evaluation of skin condition. Weekly evaluations of resident's skin will be completed and documented in PCC [Point Click Care, documentation software] on the "Weekly Skin Evaluation" form. Residents identified with skin impairments .... wound status will be evaluated and documented in PCC on the "Wound Evaluation Flow Record". For residents followed by contracted Wound Physicians Services or Wound Clinic Physician; the facility will utilize the physician wound progress note to monitor wound status.

Review of Resident 17's progress notes revealed a nursing entry on October 26, 2021 at 11:04 a.m. revealed that Resident 17 was admitted to the facility on October 25, 2021 with a surgical wound to the stump from a below the knee amputation on the left leg. Further review of all progress notes did not give a full description of the wound with measurements of open areas and description of drainage or wound bed.

Review of Resident 17's physician orders revealed the resident had been receiving wound care since admission and had been out of the facility to see a wound specialist on November 3, 2021 and November 24, 2021. Review of these consult reports revealed there was no documentation of the wound.

Further review of the clinical record revealed there were no "Weekly Skin Evaluation" forms or Wound evaluation Flow Records completed fully to give a full discription of the status of the wound.

Interview with the Nursing Home Administrator and the Director of Nursing on December 9, 2021 confirmed the clinical record did not completely document resident 17's surgical wound since admission.

Review of Resident 38's closed clinical record revealed the resident was discharged from the facility as of September 13, 2021.

Review of Resident 38's progress notes revealed a skin/wound progress note on September 13, 2021 at 6:55 a.m. which stated: "Not seen on wound rounds, is in active process of end of life."

Further review of Resident 38's progress notes revealed a subsequent note dated September 15, 2021, at 4:04 p.m. from social services stating "Call placed to residents daughter to schedule a time when she would like to pick up her mothers belongings."

Further review of Resident 38's progress notes revealed additional progress note dated September 16, 2021 at 6:18 p.m. from nursing stating "Death certificate faxed to [Resident 38's] funeral home."

Interview with the Nursing Home Administrator and Director of Nursing on December 9, 2021, at 10:18 a.m. confirmed that there was no progress note indicating the date and time the resident expired at the facility.

28 Pa. Code: 211.5 (f) Clinical records

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



 Plan of Correction - To be completed: 02/01/2022

0842:
1. The facility reviewed resident 17's records. It was noted that resident was being sent out to a surgical wound provider and that weekly would care documentation was not completed. The resident has since chosen, effective 12/10/21 to be followed by his previous physician in the community, Dr. Monteiro. Dr. Monteiro's CRNP, William Dilkes, comes to the facility on a weekly basis to follow the residents and he provides the required documentation.
2. Facility residents with wounds had wound assessments completed.
3. Licensed Nurses will be re-educated on the Wound Management Policy. The DON will complete weekly wound rounds and ensure assessments are documented timely.
4. The DON or designee will conduct an audit of wound assessments weekly x 4 weeks and then monthly x 2 months to ensure that documentation is completed and timely. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:

Based on clinical record review and staff interview it was determined the facility failed to provide dental services for one of 16 residents reviewed. (Resident 36)

Findings Include:

Review of Resident 36's progress notes revealed a nursing entry on August 31, 2021 at 12:10 p.m. stating Resident 36 "c/o (complained of) sore upper gum. Upon inspection she is wearing upper dentures. Lower teeth are her own. Added to dental list. Will look at down grading diet."

Review of Resident 36's clinical record revealed there was no order for the resident to been seen by the dentist and no dental consults since August 31, 2021.

Interview with the Nursing Home Administrator and Director of Nursing on December 9, 2021 at 10:00 a.m. confirmed dental service had been in the facility after August 31, 2021 and Resident 36 did not receive dental services after experiencing mouth pain and requiring a downgrade in diet.

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



 Plan of Correction - To be completed: 02/01/2022

0791:
1. The facility reviewed resident 36's overall care documentation. She is not experiencing any oral pain issues at this time. Her diet was downgraded on 8/31/21. The dentist has been contacted and the facility is awaiting their response as to her next visit. Speech therapy and the Dietician were made aware with their request for services.
2. The facility will perform an audit of current residents to ensure that Dental services have been provided.
3. Licensed Nurses will be re-educated on the need to provide routine/emergent dental services in a timely manner. The DON will monitor routine dental visits via a log.
4. The DON or designee will perform audits of PCC documentation weekly x 4 weeks then monthly x 2 months to ensure dental needs have been identified and addressed on a timely basis. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

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 a review of closed clinical records and staff interview, it was determined that the facility failed to ensure the disposition of medication was reconciled for two of three closed records reviewed (Residents 38 and 39).

Findings include:

Review of Resident 38's closed clinical record revealed that the resident expired at the facility on September 13, 2021.

Further review of Resident 38's entire closed clinical record failed to reveal documentation of the disposition of the resident's medications.

Interview with the Nursing Home Administrator and Director of Nursing on December 9, 2021 at 10:18 a.m. confirmed there was no documentation showing the disposition of Resident 38's medications.

Review of Resident 39's closed clinical record revealed that he was admitted on August 13, 2021 and was discharged to the hospital on September 9, 2021.

Review of Resident 39's December 2018's physician's orders revealed the resident was receiving Morphine Sulfate (narcotic pain reliever) 5 milligrams as needed every three hours for pain or shortness of breath.

Review of the resident's entire closed clinical record revealed no documentation of reconciliation of the destruction of the morphine with two staff member signatures.

Interview with the Nursing Home Administrator and Director of Nursing on December 9, 2021 at approximately 1:15 p.m. confirmed there was no documentation of the reconciliation with two staff signatures for the destruction of Resident 39's Morphine medication.


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

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





 Plan of Correction - To be completed: 02/01/2022

0755:
1. The facility is unable to retroactively complete a disposition of medication on the cited residents.
2. A 30 day look back will be completed to ensure disposition of medication is present on discharged residents.
3. Licensed Nurse will be re-educated on the process for documentation of reconciliation and destruction of medications, including the process for controlled medications. The DON will conduct random audits of disposition of medications following resident death or discharge.
4. The DON or designee will audit discharges from the facility weekly x 4 weeks and monthly x 2 months to ensure that a disposition of medication is present. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-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.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:

Based on review of the facility's staff education records and interview with staff, it was determined that the facility failed to complete performance reviews at least once every 12 months for one of one nurse aides (Employee E3).

Findings include:

Review of the facility's nurse aide education records for the past 12 months revealed that there was no documented evidence that Employees E3 received performance reviews at least once every 12 months and there was no evidence in-service educations was provided for Employee E3 based on the performance review.

Interview with the Director of Nursing on February 6, 2019, at 9:15 a.m. confirmed that performance evaluations and in-servicing had not been completed for the above employee at least once every 12 months.

28 Pa. Code 201.20(a)(c) Staff development.






 Plan of Correction - To be completed: 02/01/2022

0730:
1. Employee 3 is out on FMLA since 12/8/2021. She will receive a performance evaluation and mandatory education upon her return.
2. A baseline performance evaluation was completed on Certified Nursing Assistants and corresponding mandatory education was completed.
3. The DON will be re-educated on completing Certified Nursing Assistant performance evaluations and mandatory education. The NHA will conduct random audits of staff development compliance.
4. The NHA or designee will complete a one time audit of employee files to ensure that annual performance evaluations and mandatory education has been completed. After initial audit, an audit will then be completed monthly x 2 months to ensure compliance. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to adequately treat pain for one of 13 residents reviewed (Resident 22.)

Findings include:

Review of Resident 22's physician's orders revealed an order dated September 25, 2021 for morphine sulfate (narcotic pain reliever) 20 milligram (mg) per 5 milliliters (ml); give 5 mg every four hours as needed for shortness of breath, anxiety, and end of life care.

Review of Resident 22's progress notes revealed a nurse's note dated October 7, 2021 at 2:34 p.m. which stated, "Alert with confusion, vital signs [within normal limits], no coughing/sob [(shortness of breath)] noted this shift. Patient complained of #10 pain 0900, Morphine sulfate did not come in from pharmacy, nursing supervisor made aware."

Review of Resident 22's October 2021 Medication Administration Record (MAR), revealed on October 7, 2021 on day and evening shift, the resident complained of pain of 10 on a scale of 1-10. Further review of Resident 22's October MAR failed to reveal evidence that the resident received morphine on October 7, 2021.

Review of the facility's list of emergency medications revealed that the facility has an emergency supply of morphine.

Interview with the Nursing Home Administrator and Director of Nursing on December 9, 2021 at 10:23 a.m. confirmed that Resident 22's morphine that was ordered on September 25, 2021 should have been available for the resident on October 7, 2021; and if it wasn't, nursing should have contacted the resident's physician and utilized medication from the facility emergency supply.

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



 Plan of Correction - To be completed: 02/01/2022

0697:
1. Resident 22's pain records have been reviewed. She is showing no signs or symptoms of pain at present.
2. Facility residents will receive a pain assessment.
3. Licensed Nursing staff will be re-educated on the Pain Management Policy and Procedures. The DON will review pain management of residents via 24 hour report.
4. The DON or designee will conduct an audit of pain assessments weekly x 4 weeks then monthly x 2 months to ensure pain management is in place. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

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 facility policy, clinical record review, and staff interview, it was determined that the facility failed to assess, monitor, and address weight loss in a timely manner for two of three residents reviewed for weight loss (Residents 22 and 34.)

Findings include:

Review of facility policy titled, "Nutrition Management," with revision date of August 2018, revealed "parameters of nutritional status which are unacceptable include unplanned weight loss ...Suggested parameters for evaluating significance of unplanned and undesired weight loss are 5% significant loss/gain in 1 month, 7.5% significant loss/gain in 3 months, and 10% significant loss/gain in 6 months. In evaluating weight loss, the dietitian will consider: the resident's usual weight through adult life, and the potential for weight loss related to any medical conditions." Further review of the policy revealed "the clinical record, interdisciplinary staff, the physician, resident ands responsible party will assess and plan for the resident ...to promote optimal nutrition. A Nutrition meeting will be held at least monthly to review residents at risk due to significant weight change. These residents will be reviewed for nutrition needs in conjunction with the primary diagnosis."

Review of Resident 22's clinical record and weights revealed that on June 4, 2021, the resident weighed 124.2 pounds (lbs.) On August 3, 2021, the resident weighed 99 lbs, which is a -20.29% loss in two months.

Review of Resident 22's progress notes revealed a nurse's note dated August 5, 2021 at 3:55 p.m. which stated, "Dietician recommendation for resident to start pro-source 30 ml (milliliters) po (by mouth) for wound healing. Order obtained and noted." An additional nurse's note was written on August 5, 2021 at 3:58 p.m. stating "Recommendation for fortified foods with all meals. Order noted."

Review of Resident 22's August 2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) failed to reveal that the above orders were implemented and administered to the resident.

Review of dietary notes failed to reveal evidence that the dietitian further addressed Resident 22's weight loss until September 27, 2021.

The facility's failure to address Resident 22's significant weight loss in a timely manner was confirmed with the Nursing Home Administrator and Director of Nursing on December 9, 2021, at 10:22 a.m.

Review of Resident 34's weights revealed a weight obtained on November 3, 2021 of 118.2 pounds and a weight obtained on December 3, 2021 of 108.9 pound which is a decrease of 7.87%.

Review of Resident 34's clinical record revealed the dietitian, and the physician were not notified of the weight decrease and no new interventions were developed to address the residents weight loss.

Interview with the Director of Nursing and the Nursing Home Administrator on December 9, 2021 at 10:00 a.m. confirmed Resdient 34 had a significant weight decrease of over 5% in a month and the physician and dietitian were not notified of the weight loss to develop interventions to prevent further weight loss.

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.10(c) Resident Care Policies

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




 Plan of Correction - To be completed: 02/01/2022

0692:
1. The IDT reviewed residents 22 and 34's weight variances and made recommendations for care plan changes.
2. A 30 day look back of weight changes was conducted. The IDT reviewed these weight changes and made recommendations for care plan changes as indicated.
3. The IDT team will be re-educated on the Nutrition Management Policy and Procedures.
4. The DON or designee will conduct an audit of weight variances weekly x 4 weeks then monthly x 2 months to ensure review and recommendations for care plan changes as indicated. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:


Based on review of facility policy, clinical record review, and staff interview it was determined the facility failed to accurately assess and develop a program to maintain or improve a resident's continence status for one of one resident reviewed for incontinence (Resident 20).

Findings include:

Review of facility policy, "Incontinence Management Protocol," last revised August 28, 2018, revealed that "based on the resident's comprehensive assessment, the facility will ensure that a resident who is incontinent will be evaluated for appropriate intervention to regain or maintain ability to control bowel and bladder function." Furthermore, the policy revealed "Bowel status will be monitored and interventions will be implemented to promote bowel continence."

Review of Resident 20's August 19, 2021 Quarterly Minimum Data Set (MDS - periodic assessment of resident care needs) revealed at the time the resident was always continent of bowel.

Review of Resident 20's most recent MDS (quarterly dated November 2, 2021) revealed the resident had no cognitive impairment and was frequently incontinent of bowel.

Review of Resident 20's Bowel & Bladder Evaluation dated September 28, 2021, revealed the resident scored a 20, indicating the resident was a good candidate for individualized bowel and bladder training.

Review of Resident 20's clinical record failed to reveal evidence that the resident was receiving an individualized retraining program to address the resident's incontinence.

Interview with the Nursing Home Administrator on December 9, 2021, at 12:25 p.m. confirmed the above findings.

28 Pa. Code 211.5(f) Clinical records

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





 Plan of Correction - To be completed: 02/01/2022

0690:
1. A review of resident 20's incontinence status has been initiated. The physician was notified and has requested a voiding diary.
2. A facility wide bowel and bladder program audit was completed. New voiding diaries were initiated on residents. Programs will be developed for residents as indicated.
3. Nursing staff will be re-educated on the Incontinence Management Protocol. Bowel and bladder programs will be re-evaluated by the DON quarterly, annually and on significant change.
4. The DON or designee will complete audits of 25% of bowel and bladder programs weekly x 4 weeks then monthly x 2 months to ensure compliance with the Incontinence Management Protocol. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:

Based on clinical record review, policy and procedure review, and staff interview it was determined the facility failed to develop discharged planning and a discharge summary for one of three discharged residents reviewed. (Resident 40)

Findings Include:

Review of facility policy and procedure titled Discharge Planning revealed the facility's Care Planning/Interdisciplinary Team is responsible for the development of a discharge plan. The Interdisciplinary Team will complete a Discharge Summary upon discharge.

Review of Resident 40's clinical record revealed the resident was discharged to another skilled nursing facility on October 22, 2021.

Review of Resident 40's clinical record revealed there was no discharge planning completed by the interdisciplinary team or discharge summary completed by the physician.

Interview with the Director of Nursing and the Nursing Home Administrator on December 9, 2021 at approximately 11:15 a.m. confirmed there was no discharge planning or discharge summary completed for Resident 40.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(2)(3) Management

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







 Plan of Correction - To be completed: 02/01/2022

0661:
1. The facility completed a discharge summary on the cited residents.
2. A 30 day look back of discharges will be conducted to ensure discharged residents have discharge summaries.
3. The IDT will be re-educated on the discharge summary process. The Social Worker will review upcoming discharges in morning meeting and determine which departments need to complete their portion of the discharge summary.
4. The DON or designee will conduct an audit of discharged residents weekly x 4 weeks, then monthly x 2 months to ensure discharge summaries were completed. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

483.21(b)(1) 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.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan regarding anticoagulant (blood thinning) medication for one of five residents reviewed for unnecessary medications (Resident 37.)

Findings include:

Review of Resident 37's clinical record revealed a physician's order dated November 5, 2021 for Apixaban (blood thinning medication) 5 milligrams (mg) one tablet by mouth twice daily for acute embolism and thrombosis of deep veins of left upper extremity (blood clot in the left arm.)

Review of Resident 37's care plan failed to reveal a plan of care to monitor the resident for being on an anticoagulant medication.

Interview with the Nursing Home Administrator on December 9, 2021 at 11:44 a.m. confirmed there was no care plan in place for Resident 37's anticoagulant medication.

28 Pa. Code 211.11 (b)(d) Resident Care Plan

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

28 Pa. Code 211.5(f) Clinical records




 Plan of Correction - To be completed: 02/01/2022

0656:
1. Resident 37's care plan was updated on 12/9/21 to include the risks involved with the use of anticoagulant therapy.
2. A facility wide care plan audit was completed to address use of anticoagulant therapy as needed.
3. Licensed Nurses were re-educated on the care planning policy. The DON will complete a daily order listing summary review and ensure care plans are added as indicated.
4. The DON or designee will conduct an audit of residents receiving anticoagulant therapy weekly x 4 weeks, then monthly x 2 months to ensure it is careplanned. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:


Based on a review of select facility policies and procedures, closed financial record review, and staff interview, it was determined that the facility failed to ensure the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage was provided to three of three residents reviewed (Residents 88, 90, and 91).

Findings include:

Review of the form entitled "Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN)" states that this notice is given to make residents aware of care that no longer meets Medicare coverage requirements and they may have to pay out of pocket for the care listed. The provider must ensure that the beneficiary or their representative signs and dates the SNFABN to demonstrate that the beneficiary or their representative received the notice of possible out of pocket costs.

Review of the facility's list of residents discharged from a Medicare covered Part A stay with benefit days remaining in the past six months revealed that Resident 88's last day of service was July 14, 2021, and indicating the form NOMNC CMS-10055 given to resident or resident representative explaining the out-of-pocket cost. There were no further documentation stating why it was not provided.

Review of the facility's list of residents discharged from a Medicare covered Part A stay with benefit days remaining in the past six months revealed that Resident 90's last day of service was November 17, 2021 and indicated the form NOMNC CMS-10055 given to resident or their representative explaining the out-of-pocket cost. There were no further documentation stating why it was not provided.

Review of the facility's list of residents discharged from a Medicare covered Part A stay with benefit days remaining in the past six months revealed that Resident 91's last day of service was June 16, 2021, and indicated the form NOMNC CMS-10055 given to resident or their representative explaining the out-of-pocket cost. There were no further documentation stating why it was not provided.

Interview with Nursing Home Administrator on December 8, 2021, at 1:45 p.m. confirmed that the facility could not find documented evidence that Residents 88, 90, and 91 or their representatives received or signed the advanced beneficiary notice.

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

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(a) Resident rights






 Plan of Correction - To be completed: 02/01/2022

0582:
1. The facility is unable to retroactively provide SNF ABN notification on cited residents.
2. A facility wide audit was completed to identify residents with a Medicare stay ending in the last 30 days. SNF ABNs were delivered as required.
3. The BOM was re-educated on providing SNF ABN forms per policy. The NHA will monitor Medicare cuts during morning meeting to ensure SNF ABN forms are delivered as required.
4. The NHA or designee will conduct an audit of Medicare cuts weekly x 4 weeks, then monthly x 2 months to ensure SNF ABN forms are delivered as required. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.

211.5(d) LICENSURE Clinical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Clinical information pertaining to a resident's stay shall be centralized in the resident's record.
Observations:


Based on clinical record review and staff interview it was determined the facility failed to complete a discharge summary for a resident with an unplanned discharge for two of three residents reviewed. (Residents 38 and 39)

Findings include:

Review of Resident 38's clinical record revealed the resident expired at the facility on September 13, 2021.

Further review of Resident 38's clinical record failed to reveal a discharge summary completed and signed by the physician.

Review of Resident 39's progress notes revealed a nursing entry on September 9, 2021 at 12:01 p.m. stating Resident 39 was sent out to the hospital and did not return to the facility.

Review of Resident 39's clinical record revealed there was no discharge summary completed and signed by the physician.

Interview with the Nursing Home Administrator and Director Nursing on December 9, 2021 at approximately 1:30 p.m. confirmed there was no discharge summary completed for Residents 38 and 39 after they were discharged.




 Plan of Correction - To be completed: 02/01/2022

0710:
1. Discharge summaries have been completed and signed by Dr. Kataria for resident 38 and 39.
2. The facility will complete an audit of residents discharged from 12/11/21 to ensure that a Discharge summary has been completed and signed by the Physician.
3. The Physician will be re-educated to ensure the regulatory requirements are clearly understood and will be completed within 30 days of discharge from the facility.
4. The DON or designee with perform audits weekly x 4 weeks, then monthly x 2 months to ensure that discharge summaries have been completed within the 30 day requirement and have been signed by the physician. The results will be submitted thru QAPI committee for review and analysis of needed ongoing monitoring.


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