Pennsylvania Department of Health
SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER
Inspection Results For:

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SHIPPENSBURG REHABILITATION AND HEALTH CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on June 13, 2024, it was determined that Shippensburg Rehabilitation and Health Care 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:

483.20(g) REQUIREMENT Accuracy of Assessments:

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(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Plan of Correction - To be completed: 07/31/2024

Facility cannot retroactively correct clinical records to accurately reflect the resident status for resident 9, and 26 as it relates to their Minimal Data Set. (MDS)

Facility will immediately correct MDS assessment for resident #9 to reflect resident does use a non-invasive mechanical ventilator. Facility will immediately correct MDS assessment for resident #26 to reflect that resident does not have an active cancer dx.

Facility policy on Resident Assessment Instrument as it relates to accuracy of assessments was reviewed.

RNAC and LPNAC will be re-educated on ensuring proper data is recorded on the MDS prior to submission.

Random 5 MDS to be audited by Registered Nursing Assessment Coordinator (RNAC) and License Practical Nursing Assessment Coordinator (LPNAC) weekly x 4 weeks; monthly x 3 months to ensure compliance is achieved. Findings will be discussed with DON or designee and reported to the Quality Assurance Performance Improvement Committee.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 23 residents reviewed (Resident 8).

Findings include:

Based on facility policy, titled "Care Plan Policy", not dated, read, in part, Changes in the resident's condition must be reported to the MDS Assessment Coordinator (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) so that a review of the resident assessment and care plan should be made.

Review of Resident 8's clinical record revealed diagnoses that included difficulty in walking and muscle weakness.

Review of Resident 8's clinical record on June 11, 2024, at 9:28 AM, revealed she was discharged to the hospital on May 1, 2024, and returned to the facility on May 2, 2024.

Observation of Resident 8 on June 11, 2024, at 09:49 AM, revealed her face was heavily bruised.

Interview with Resident 8 on June 11, 2024, at 09:52 AM, revealed she had a fall after an appointment and went directly to the hospital on May 1, 2024.

Review of Resident 8's clinical record revealed she had an MDS assessment completed after her return from the hospital on May 15, 2024.

Review of Resident 8's care plan on June 11, 2024, at 1:57 PM, revealed a focus area: "[Resident 8] is at risk for falls due to deconditions (decline in physical fitness), last revised April 24, 2024, with a goal "Minimize [Resident 8's] risk for injury related to falls through the next review" last revised March 21, 2024.

Interview with the Director of Nursing on June 13, 2024, at 10:25 AM, revealed she would expect Resident 8's fall care plan to be revised that she has had a fall with injury.

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

Plan of Correction - To be completed: 07/31/2024

Facility cannot retroactively correct clinical records to accurately reflect that the care plan was revised and revised for Resident #8 as it related to a fall on June 11,2024.

Facility will immediately correct care plan for resident #8 to reflect resident did have a fall on June 11,2024.

Facility policy on Care plan as it relates to timing and revision was reviewed and amended to meet the regulation.

Licensed staff will be re-educated to ensure that care plans are updated at the time of a fall to maintain compliance with care planning.

Incident reports to include falls are reviewed daily to ensure that care plans are updated and reflective of resident's current status.

Random 5 care plans will be audited by Registered Nursing Assessment Coordinator (RNAC) and License Practical Nursing Assessment Coordinator (LPNAC) weekly x 4 weeks; monthly x 3 months to ensure compliance is achieved. Findings will be discussed with DON or designee and reported to the Quality Assurance Performance Improvement Committee

483.25 REQUIREMENT Quality of Care:

§ 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 clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 23 residents reviewed (Resident 100).

Findings include:

Review of Resident 100's clinical record revealed that they were admitted to the facility on April 4, 2024, with diagnoses that included hypertension (high blood pressure), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and presence of cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions).

Observation of Resident 100 on June 10, 2024, at 10:19 AM, revealed a pacemaker monitoring device (a device used by a cardiologist [heart specialist] to perform an electronic periodic pacemaker function test) that was noted to be plugged into the electrical outlet and turned on.

Review of Resident 100's physician orders on June 11, 2024, at 12:08 PM, failed to reveal any orders regarding their pacemaker monitoring or follow-up cardiology appointments.

Review of Resident 100's care plan on June 11, 2024, at 12:15 PM, revealed a care plan focus for cardiac disease related to hypertension, initiated on April 5, 2024, which included an intervention for pacemaker checks as ordered, but failed to include any safety interventions associated with the presence of the pacemaker or cardiology follow-up visits.

Review of Resident 100's hospital discharge paperwork dated April 5, 2024, revealed that the Resident had a cardiology follow-up appointment on Thursday, September 12, 2024, at 1:30 PM.

During an interview with the Nursing Home Administrator, Director of Nursing (DON), and Assistant Director of Nursing on June 12, 2024, at 11:10 AM, the DON indicated that Resident 100 had not had any pacemaker checks since admission as none were due to be completed. The DON further indicated that when Resident 100 returned from an appointment at the wound clinic on June 11, 2024, all their cardiac appointments including pacemaker checks were listed on the after-visit summary and nursing staff added them to Resident 100's orders. The DON confirmed that the facility knew that Resident 100 had a pacemaker at their admission on April 4, 2024, and that nursing staff should have obtained all necessary information from Resident 100's cardiologist regarding pacemaker checks and follow-up appointments. The DON also confirmed all safety measures associated with the presence of a pacemaker should have been implemented at the time of Resident 100's admission and that their care plan has now been revised.

During a follow-up interview with the DON on June 13, 2024, at 10:15 AM, the DON indicated that she had researched Resident 100's pacemaker checks a little further that morning. The DON said that Resident 100 was to have an electronic remote check on April 18, 2024, however, the POA had canceled it because the pacemaker monitoring device was still at Resident 100's prior assisted living facility. The DON provided a copy of an after-visit summary dated June 12, 2024, that indicated that a remote electronic pacemaker check was completed on June 12, 2024. The DON also indicated that the cardiologist's office said that if there were to be a problem with Resident 100's pacemaker, an alert would be sent to the cardiologist's office who would then contact the facility.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident Care Policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/31/2024

Facility cannot retroactively correct clinical records to accurately reflect the resident status for resident 100 as it relates to missed pacer check.

No resident harm occurred as a result of the missed pacer check. Primary care physician was updated.

The facility immediately contacted the cardiology office for resident #100 and had a remote pacer check completed on June 12, 2024.

Admission notice paperwork was updated on June 13, 2024 to include pacemaker model and next pacer check to ensure that data is captured on admission.

A facility wide audit will be completed to verify that residents with pacemakers have orders for next pacer check.

Admissions director and or designee educated on 6/13/24 to acquire information as it relates to the pacemaker model and next pacer check when applicable.
Education will be provided to licensed staff to obtain pacemaker information and next pacer check on admission and as needed.

All new admissions will be audited to ensure ongoing compliance is maintained as it relates to resident's pacemaker and next pacemaker check by Assistant Director of Nursing (ADON) or designee weekly x 4 weeks; monthly x 3 months to ensure compliance is achieved. Findings will be discussed with DON or designee and reported to the Quality Assurance Performance Improvement Committee.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on review of facility policy, clinical record review, and Resident Responsible Party and staff interviews, it was determined that the facility failed to ensure that the residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of two residents reviewed (Resident 91).

Findings include:

Review of facility policy, titled "Policy and Procedure Trauma Informed Care", last revised April 15, 2024, read, in part: "Residents who display or are diagnosed with a mental disorder, psychosocial adjustment difficulty, and/or PTSD [Post Traumatic Stress Disorder] will be provided with appropriate treatment and services to attain the highest practicable level of mental and psychosocial wellbeing. ... Procedure ... 7. When a Resident has experienced a traumatic event, The Social worker will interview the resident/resident representative regarding potential/actual triggers that may cause re-traumatization. Experiences, preferences, and/or other interventions that eliminate or mitigate triggers that may cause re-traumatization of the resident. 8. The IDT team will ensure that an individualized resident centered care plan is developed for resident that has experienced a traumatic event. The care plan will include but is not limited to the following: Identification of the stressor/past life trauma. Identification of interventions that mitigate against re-traumatization. Identify triggers that could cause re-traumatization."

Review of Resident 91's clinical record revealed diagnoses that included Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event. The condition may last months or years, with triggers that can bring back memories of the trauma, accompanied by intense emotional and physical reactions) and severe recurrent major depressive disorder with psychotic symptoms (a serious mental health condition that combines a depressed mood with psychosis [a disconnection from reality] that can manifest as hallucinations or delusions).

During an interview on June 10, 2024, at 1:24 PM, with Resident 91's Responsible Party, it was revealed that Resident 91 suffered from PTSD from fighting in the Vietnam War and being exposed to harmful chemicals.

Review of Resident 91's clinical record revealed a social services assessment dated April 5, 2024. The assessment indicated Resident 91's PTSD was related to fighting in a war and witnessing various acts of violence, being a prisoner of war, and being exposed to harmful chemicals while in the war. The assessor indicated active signs or symptoms of trauma and interventions were needed.

Review of Resident 91's comprehensive plan of care revealed a focus area for "risk for changes in mood related to dementia, depression, PTSD and is at risk for adverse effects related to use of antipsychotic and depression medication use", but failed to indicate the source of Resident 91's PTSD or any known triggers or interventions.

Further review of Resident 91's clinical record failed to reveal evidence that the facility identified or attempted to identify Resident 91's PTSD triggers.

During a staff interview with Employee 2 (Social Services Director), on June 12, 2024, at 2:00 PM, it was revealed that she had no further information to provide and that the previous social services director had completed Resident 91's screening.

During a staff interview on June 13, 2024 at 10:14 AM, with Employee 1 (Assistant Director of Nursing), in the presence of the Director of Nursing, it was revealed that the facility was unable to provide any further evidence that culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident had been provided.

28 Pa. Code: 201.14(a) Responsibility of licensee
28 Pa. Code: 201.18(b)(1) Management
28 Pa. Code 211.12(d)(3)(5) Nursing Services

Plan of Correction - To be completed: 07/31/2024

Facility cannot retroactively correct clinical records to accurately reflect the resident status as it relates to Post Traumatic Stress Disorder diagnosis for resident #91

Facility will immediately update plan of care for resident #91 to eliminate or mitigate triggers that may cause a re-traumatization for resident #91.

Facility policy on Care Plan as it relates to trauma informed care was reviewed and amended to meet the regulation

RNAC, LPNAC, and Social Services director will be re-educated to ensure that trauma assessment, how to identify triggers associated with re-traumatization and an appropriate care plan is developed for residents who are diagnosed with PTSD.

Facility will conduct a facility wide audit to capture any resident traumatic life events as indicated by the Stressful Life Event Assessment form or with a diagnosis of PTSD. This will be conducted by Social Services. All new admissions will be monitored during clinical meeting by the Social Worker and Nursing Assessment Coordinator (RNAC), and License Practical Nursing Assessment Coordinator (LPNAC). 5 chart audits for new admissions will be done weekly x 4 weeks; monthly x 3 months to ensure compliance is achieved. Findings will be discussed with DON or designee and reported to the Quality Assurance Performance Improvement Committee.

§ 201.14(j) LICENSURE Responsibility of licensee.:

(j) The facility shall conduct a facility-wide assessment that meets the requirements of 42 CFR 483.70(e) (relating to administration), as necessary, but at least quarterly.

Observations:

Based on facility document review and staff interview, it was determined that the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both daily operations and emergencies at least quarterly.

Findings include:

Review of facility assessment documentation provided by the Nursing Home Administrator (NHA) on June 12, 2024, revealed that the facility had two documented facility-wide assessments to provide for review.

Review of the first facility assessment provided revealed that it was completed on July 1, 2023, and there was no date indicated in the section as to when the assessment was reviewed with the facility Quality Assurance Performance Improvement Committee. The attached "Certification of Facility Assessment Approval" signature page was signed by the NHA on "June 2023"(no day provided); by the Director of Nursing on May 31, 2023; and by the Medical Director and Maintenance Director on June 5, 2023.

Review of the second facility-wide assessment provided revealed that it was completed on May 31, 2023, and that it was reviewed with the facility Quality Assurance Performance Improvement Committee on November 10, 2023. The attached "Certification of Facility Assessment Approval" signature page was signed by the NHA on "November 2023"(no day provided); and by the Director of Nursing, the Medical Director, and the Maintenance Director on November 10, 2023.

During an interview with the NHA on June 12, 2024, at 12:15 PM, the NHA indicated that the facility has only conducted a facility assessment annually.

Plan of Correction - To be completed: 07/31/2024

Facility cannot retroactively correct previous quarterly assessments. No harm was identified with any residents.

Facility assessments will be completed on a quarterly basis moving forward in accordance with Quality Assurance Performance Improvement meeting schedule to ensure compliance is achieved.

All managers will be in serviced on the regulation in regard to the facility assessment including completion, dating and reviewing on a quarterly basis.

The Administrator and/or designee will review completion of facility assessment for the next four quarters that will be reflected in the quarterly Quality Assurance Performance Improvement meeting minutes.

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