Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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ROLLING MEADOWS HEALTH CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a complaint completed on 6/27/22, it was determined that Rolling Meadows 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 related 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.

Based on facility policy, clinical record review, and staff interview, it was determined that the facility failed to provide neurological checks (a neurological examination that evaluates a person's nervous system after a fall) for one of two residents (Resident R1).

Findings include:

A review of facility policy "Neurological Assessments" dated 2/16/22, indicated the facility will assess level of consciousness for a period of time for a traumatic or potentially traumatic injury to the head, after any loss of consciousness or change in condition that may have resulted from an adverse event, including an unwitnessed fall. The nurse will complete the Neurological Assessment Flowsheet for data collection.

A review of clinical record indicated Resident R1 was admitted to the facility on 4/25/22, with diagnosis that included malignant neoplasm of parietal lobe (brain cancer), muscle weakness, communication deficit, and seizures.

A review of progress notes dated 4/27/22, stated that Resident R1was found lying on the floor after having an unwitnessed fall. Neurological checks were initiated at that time.

A review of the medical record revealed that 11 of 19 neurological checks required were not documented as completed.

During an interview on 6/27/22, at 4:12 p.m. the Director of Nursing (DON) confirmed the above findings and that the facility failed to produce documentation that neuro checks were completed for Resident R1.

28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited: 10/16/21

28 Pa. Code: 201.18(b)(1)(e)(1) Management.
Previously cited: 10/16/21

28 Pa. Code: 211.10(c) Resident care policies.
Previously cited: 10/16/21

28 Pa. Code:211.12(d)(1) Nursing services.
Previously cited: 10/16/21

28 Pa. Code:211.12(d)(5) Nursing services.
Previously cited: 10/16/21

 Plan of Correction - To be completed: 07/27/2022

Resident R1 has been discharged from the facility. A review of resident incidents over the last 7 days that required a neurological assessment be completed will be reviewed for completion. Any incomplete assessments will be reviewed with physician to determine if any further follow-up needed. Re-education of the Neurological Assessment policy and Neurological flowsheet will be completed with licensed nurses by the DON/designee. Active Neurological assessments that are in progress will be monitored by DON/designee daily for 7 days, 3 x's week for 3 weeks, then weekly x's 2 weeks. All findings will be reported to QAPI for further review.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.

Based on staff interview and review of nursing time schedules it was determined that the facility failed to provide the minimum number of general nursing hours for each resident in a 24-hour period, on 7 of 21 days reviewed (6/1/22, 6/5/22, 6/11/22, 6/12/22, 6/13/22, 6/18/22, and 6/19/22).

Findings include:

Nursing time schedules for the period 6/1/22, through 6/21/22, revealed that the facility failed to maintain 2.7 hours of general nursing care to each resident in a 24 hour period on the following dates:

6/1/22 = 2.68 hours
6/5/22 = 2.46 hours
6/11/22 = 2.43 hours
6/12/22 = 2.41 hours
6/13/22 = 2.58 hours
6/18/22 = 2.57 hours
6/19/22 =2.53 hours

During an interview on 6/27/22 at 3:18 p.m., the Nursing Home Administrator confirmed that the facility failed to meet the nursing hour requirements for nine of 21 days.

Previously Cited 11/30/21, 10/6/21.

 Plan of Correction - To be completed: 07/14/2022

The dates identified were reported via ERS on 7/5/22. A review of Pa Code 211.12 was completed by NHA and DON. Additional education was then provided to scheduling staff. The facility has contacted additional staffing agencies in the Tri-State area to find available nurses and aides. The facility has established a Recruitment and Retention Committee that meets bi-weekly to address staffing challenges and retain current staff thru appreciation/acknowledgement events and offering incentives. The Staff Scheduler projects PPD for 2 weeks which is discussed in a staffing meeting daily. The NHA/DON/Staff Scheduler/Human Resources Director will review previous day, actual PPD and address projected 2-week schedule on an ongoing basis. The DON/designee will report to the DOH monthly if PPD is below 2.7. The results will be provided to the QAPI Committee for review.

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