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

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KADIMA REHABILITATION & NURSING AT POTTSTOWN
Inspection Results For:

There are 102 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:
Findings of an Abbreviated Complaint Survey completed on June 14, 2024, at Kadima Rehabilitation & Nursing at Pottstown, identified deficient practice, related to the reported complaint allegations, under the 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.25 REQUIREMENT Quality of Care:

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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on interview and clinical record review failed to ensure that residents attend medical appointments using reliable transportation service for two of three residents reviewed (Residents R1 and R3).

Findings include:

Review of Resident R1's clinical record including eMedication Administration Note dated May 20, 2024 (9:14 a.m.) revealed "Orthopedic follow up ...transport did not take."

Further review of Resident R1's clinical record failed to reveal reason for missed transportation to medical appointment.

Review of Resident R3's clinical record revealed diagnoses including but not limited to following: Peripheral Vascular Disease; Depression; Prostatic Hyperplasia w/ lower urinary tract symptoms; Muscle weakness; Diabetes Mellitus II; Muscle wasting and Atrophy; Anemia; Urinary Retention; and Pulmonary Hypertension (high blood pressure).
Interview with Resident R3 on June 11, 2024, approximately 5:24 p.m. was conducted. Resident R3 indicated that he/she missed medical appointments, including veteran's appointments due to the transportation issues. Resident stated that he/she was at an eye doctor appointment and was told they (resident and transportation personnel) had to leave before the appointment was finished due to a conflict with another resident's medical appointment. The resident further stated that one of the medical appointments was rescheduled due to transportation driver had personal conflict.

Review of Resident R3's nursing progress note dated June 4, 2024 (12:44 p.m.) "Pt returned from [Physician] optometry. Eyes dilatated and injection of Avastin given. Pt (Patient) noted with severe non proliferative diabetic retinopathy and macular edema to R (right) eye and proliferative diabetic retinopathy to L (left) eye. F/U (follow/up) in 4 weeks. LVM at office tocall back to schedule follow up."

Review of Resident R3's nursing progress note dated May 21, 2024 (13:58/1:58 p.m.) "Nephrology appt cancelled due to transport conflict. Administrator spoke to office who states patient can get missed labs at (his/her) urology appt 6/18 and then nephrology will let us know when f/u is to be rescheduled."

Further review of Resident R3's nursing progress note dated April 30, 2024 (09:16 a.m.) "Patient upset with missed GI appointment. Nurse speaking with (him/her) and (he/she) began to yell and then states "I'm not yelling, I am raising my voice."

Review of Resident R3's nursing progress note dated April 30, 2024 (08:18 a.m.) "No transport available for patients 0830 GI appt with [Physician]. Appt (appointment) rescheduled for 5/30 @ 8am with [Provider, Nurse Practitioner]. Pt (Patient) aware. (Doctor) aware."

Additional review of Resident R3's nursing progress note dated April 26, 2024 (11:13 a.m.) "Spoke with [Physician office representative] office as resident states [resident] did not have full appointment yesterday. Per [office representative], patient had most of the tests done but "the aide had him leave because he had to pick up someone else so he did not see the doctor." Appointment rescheduled for 5/14/24 @ 1420. Pt (patient) and PCP (primary care physician) aware."

Review of Resident R3's nursing progress note dated April 25, 2024 (7:55 a.m.) "Pt to go OOF (out of facility) today for cataract surgery consultation."

Review of Resident R3's nursing progress note dated April 25, 2024 (16:15/4:15 p.m.) "Pt came back from ophthalmology appointment, no paperworks, no follow ups sent with the pt. Pt said his appointment for "dilation of his eye" needs to be rescheduled."

Interview conducted on June 11, 2024, at approximately 6:56 p.m. with the Nursing Home Administrator when the above information was discussed.

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: 08/05/2024

1. The facility is unable to retroactively provide transportation to previous medical appointments for Resident 1 and resident 3.
2. A 48 hour look back was completed to ensure there were no outstanding Transports for the residents needing to go to their medical appointments. Facility has a transport van for wheelchairs and litters.
3. The transporter was educated on the importance of each resident receiving transportation to their medical appointments.
4. The NHA or designee will conduct an audit of resident's medical transports weekly x 4 then monthly x 2 months to ensure residents are being transported to their medical appointments. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

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