Pennsylvania Department of Health
FOREST PARK NURSING AND REHABILITATION
Patient Care Inspection Results

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FOREST PARK NURSING AND REHABILITATION
Inspection Results For:

There are  173 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
FOREST PARK NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on findings of an abbreviated complaint survey completed on April 5, 2024, it was determined that Forest Park Nursing & Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.21(c)(1)(i)-(ix) REQUIREMENT Discharge Planning Process: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.
483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by 483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to reevaluate and update the discharge plan for two of four residents reviewed (Residents 1 and 4); and failed to develop an effective discharge plan for one of four residents reviewed (Resident 3).

Findings include:

Review of Resident 1's clinical record revealed diagnoses that included prostate cancer, legal blindness, abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily), aftercare of a fracture (a break) of the right femur (large bone located in the thigh area of the leg), and unspecified fall encounter.

Resident 1 was admitted to the facility on February 26, 2024, and discharged home on March 7, 2024.

Review of Resident 1's progress notes revealed a note dated March 3, 2024, at 4:50 PM, written by the Social Worker that indicated Resident 1's Representative was contacted to discuss the discharge plan, and that they would "work on HH [home health] nursing, PT [Physical Therapy]/OT [Occupational Therapy] referrals to support resident's needs upon discharge."

Further review of Resident 1's clinical record revealed a progress note dated March 6, 2024, at 6:09 PM, by the Social Worker that indicated "referrals sent for HH services upon discharge. Currently waiting for response on agency able to accept resident for skilled services at home."

The next note written regarding Resident 1's discharge planning process was a progress note dated March 7, 2024, at 11:00 AM, written by a Registered Nurse, that indicated that the Resident was discharged home and that discharge instructions, which included home health and therapy services, were reviewed.

The clinical record failed to identify which home health agency referrals or any information as to which home health agency had accepted the referral for Resident 1.

Review of Resident 1's "Discharge Instructions" dated March 7, 2024, revealed in "Section E. In Home Care or Services" that the Resident was to have in-home care services provided by a Home Health agency and a phone number was provided. In addition, the "Discharge Instructions" were not signed by Resident 1 or their Representative.

During a phone interview with the Home Health agency community liaison on April 4, 2024, at 1:16 PM, they reviewed emails and phone messages and confirmed that the agency did not receive a referral for Resident 1. They further indicated that the referral was also not found in their electronic health record system. She also indicated that, based on the city that Resident 1 resided in, they would not have accepted the referral because they do not currently have staff to cover the area where Resident 1 resides.

Review of Resident 3's clinical record revealed diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), compression fracture (collapse of a vertebra possibly due to trauma or a weakening of the vertebra) of the lower back, abnormalities of gait and mobility, and muscle weakness.

Resident 3 was admitted to the facility on February 28, 2024, and discharged home on March 15, 2024.

Review of Resident 3's clinical record revealed a progress note dated March 6, 2024, at 5:31 PM, by the Social Worker that indicated they had spoken to Resident 3's Representative on the phone and that they wanted to have Resident 3 discharged. The note further indicated that alternatives were offered (room or roommate change), that they were appreciative of the plan, and that the Social Worker would continue to offer support towards discharge planning goals to the Resident and family.

Review of Resident 3's clinical record did reveal two physician progress notes dated March 11, 2024, at 7:57 PM, and March 13, 2024, at 1:38 PM, that indicated Resident 3 was planning to discharge home.

Further review of Resident 3's clinical record progress notes revealed no other Social Services documentation of discharge planning and referrals being made to appropriate community agencies. In addition, there was no documentation of Resident 3 being discharged from the facility.

Review of Resident 3's "Discharge Instructions" dated March 15, 2024, revealed in "Section E. In Home Care or Services" that the Resident was to have in-home care services, but subsections "2a. Agency; 2b. Contact; and 2c. Phone Number were all blank. In addition, these "Discharge Instructions" were not signed by Resident 3 or their Representative.

Review of Resident 4's clinical record revealed diagnoses that included liver abscess (a collection of pus that has built up within the liver tissue), viral hepatitis (an infection that causes liver inflammation and damage), and hypertension (high blood pressure).

Resident 4 was admitted to the facility on March 23, 2024, and discharged home on March 27, 2024.

Review of Resident 4's clinical record progress notes revealed a note dated March 25, 2024, at 11:04 AM, by the Social Worker that indicated they met with Resident 4 to discuss desire to discharge home. The note indicated that Resident 4 felt comfortable taking care of their intravenous (IV) therapy and their surgical drains with the support of HH (home health) services. The note further indicated that the referral was made for HH services, that a referral was being made for IV therapy (no provider name given) at home, and that they would continue to offer support for discharge planning as needed.

Review of Resident 4's clinical record progress notes revealed a note dated March 25, 2024, at 2:45 PM, by the Social Worker that indicated that that specific Home Health agency was unable to accept the referral for Resident 4 related to a high census, and that referrals were made to additional home health companies (no providers named).

Review of Resident 4's clinical record progress notes revealed a note dated March 26, 2024, at 12:08 PM, by the Social Worker that indicated they met with Resident 4 to update them that HH has stated that, due to staffing, they are unable to accept the referral as it was sent; and spoke with another agency for possible HH services.

Review of Resident 4's progress note dated March 27, 2024, at 11:02 AM, by Social Worker, indicated that a call placed to confirm the Resident's discharge and delivery of IV medications at home, and that Resident 4 indicated that the Resident would be leaving around noon that date.

Further review of Resident 4's clinical record progress notes failed to reveal any documentation that Resident 4 was made aware of his confirmed home health provider.

Review of Resident 4's "Discharge Instructions" dated March 25, 2024, revealed in "Section E. In Home Care or Services" that the Resident was to have in-home care services, but subsections "2a. Agency; 2b. Contact; and 2c. Phone Number were all blank. These "Discharge Instructions" were signed by Resident 4 and dated March 27, 2024.

During an interview with the Director of Nursing (DON) on April 4, 2023, at 2:30 PM, all the aforementioned concerns for Residents 1, 3, and 4 regarding the lack of documentation of discharge planning, home care services being arranged/finalized, and Discharge Instructions being incomplete or inaccurate were shared. The DON confirmed that that there was lacking documentation of identified services being arranged prior to or at discharge for Residents 1 and 3. The DON further indicated that there was some confusion over the home health services for Resident 1. She said that she had received a call from Resident 1's Representative to report that no home health agency had shown up since their discharge from the facility. She said that after she spoke to Resident 1's Representative, the DON called the Social Worker to see what had happened. She revealed that the Social Worker said she was having difficulty setting up services and that she would make some additional calls. The DON indicated that they then did find a HH provider and that she called and informed Resident 1's Representative of the agency to provide services. She said that she called Resident 1's Representative the next day and they confirmed home health services had begun.

At the time of the interview, the DON could not provide dates as to when the above communication occurred, but said she would look at her phone logs, email communications, and would follow-up with the Social Worker as they had been off the past couple of days. She also indicated that she would follow-up on Resident 3's lack of documentation regarding their discharge and their referral to home health. She also indicated that she would see if she could find any additional information to provide for the aforementioned concerns.

During a final interview with the Nursing Home Administrator, DON, and Assistant DON on April 5, 2024, at 11:49 AM, the DON confirmed she had no additional information to provide for review for Residents 1, 3, and 4. She confirmed that she would expect the discharge planning process to be completed and documented for each Residents' discharge. She further confirmed that she would expect all appropriate services based upon the Resident's identified needs at the time of discharge to be arranged prior to or at the time of discharge, as well as documentation completed to reflect the arrangements made and that the resident and/or their Representative were made aware. She confirmed that she would expect staff to complete a Resident's Discharge Instructions form accurately and completely, as applicable, and that it should be signed by the Resident or their Representative at time of discharge.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c) Resident Care Policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services


 Plan of Correction - To be completed: 04/29/2024

1. Residents 1, 3 and 4 no longer reside at the facility.
2. The NHA/Designee will complete an audit of the Discharge Plans for current residents to ensure that an appropriate discharge plan has been established and encompasses all requirements including but not limited to an interdisciplinary approach, resident's discharge goals, effective transition for post discharge care and obtaining medications and disposition of medications upon discharge. Any discharge plan not established, or meeting said requirements will be revised as appropriate.
3. The Interdisciplinary Team will be educated on the Discharge Planning process.
4. To ensure sustained solutions/compliance the Interdisciplinary team will review the resident's discharge plan on a weekly basis as part of the Utilization review meeting and make revisions to established plan as needed to ensure all requirements are met. The DON/designee will review discharged resident records post discharge to ensure appropriate disposition of medications. A random sample audit of 5 residents will be conducted by the Nursing Home Administrator to ensure discharge planning requirements are met including referrals made for home care services when appropriate and disposition of medications. The audits will be completed weekly for four weeks and monthly for two months. The results of the audits will be reviewed by the Quality Assurance Committee for further recommendations.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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.
483.21(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 facility policy review, clinical record reviews, and staff interviews, it was determined the facility failed to develop a discharge summary that included a recapitulation of the resident's stay, reconciliation of medications, and post-discharge plan of care that indicated 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 for four of four residents reviewed (Residents 1, 2, 3, and 4).

Findings Include:

Review of facility policy, titled "Discharging the Resident", revealed the following, in part: "5. If the resident is being discharged home, ensure that resident and/or responsible party receive teaching and discharge instructions"; and in section titled "Documentation" that "The following information should be recorded in the resident's medical record: 1. The date and time the discharge was made. 2. The name and title of the individual(s) who assisted in the discharge. 3. All assessment data obtained during the procedure, if applicable. 4. How the resident tolerated the procedure, if applicable. 5. If the resident refused the discharge, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data."

Review of Resident 1's closed clinical record revealed diagnoses that included prostate cancer, legal blindness, abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily), aftercare of a fracture (a break) of the right femur (large bone located in the thigh area of the leg), and unspecified fall encounter.

The review of the closed clinical record for Resident 1 on April 4, 2024, revealed that Resident 1 was admitted to the facility on February 26, 2024, and that the Resident was discharged home on March 7, 2024.

Review of Resident 1's clinical record progress notes revealed a note dated March 7, 2024, at 11:00 AM, written by a Registered Nurse, that indicated that the Resident was "discharged to home. Transported by family via personal vehicle. Discharge instructions including home health and therapy services to be provided, medications, and upcoming appts reviewed at bedside."

Review of Resident 1's hospital discharge summary dated February 26, 2024, revealed that the Resident was to schedule a follow-up appointment in 1-2 weeks at a Neurosurgery Clinic. The physcian name and clinic address and phone number were listed; but this information was not provided to the resident on the discharge instructions at the time of discharge from the facility.

Further review of Resident 1's clinical record revealed a "Consultation Report" dated March 6, 2024, that indicated Resident 1 had a scheduled follow-up appointment with their orthopedic surgeon on May 1, 2024, at 1:15 PM.

Review of Resident 1's "Discharge Instructions" dated March 7, 2024, revealed that the following sections were blank: D. Pharmacy; G. Housing Arrangements; J. Emergency Contact Information if Emergency or Symptoms Get Worse; K. Brief Medical History; M. Scheduled Appointments and Tests; and N. If Problems Arise during Discharge, Please contact the Following Individual(s) at the Nursing Facility.

In addition, the following sections were partially completed as indicated: E. In Home Care or Services that they were to have in-home care services provided by Home Health, name and a phone number provided, but no contact name provided; Section O. Signatures: Resident 1 nor their Representative had signed the document; and in Section R. Medications no medications were listed and the section was marked to see attached with no medication list attached.

Review of Resident 2's clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), hypertension (high blood pressure), and hemiplegia (paralysis of one side of body) and hemiparesis (muscle weakness on one side of the body) following cerebrovascular (blood flow to the brain) disease affecting the left dominant side.

Review of the closed clinical record for Resident 2 on April 4, 2024, revealed that Resident 2 was admitted to the facility on February 29, 2024, and discharged home on March 1, 2024.

Review of Resident 2's clinical record revealed a progress note dated March 1, 2024, at 12:41 PM, which was identified as Discharge Summary Note written by a Registered Nurse, which indicated "Resident and wife given discharge instructions. Daughter in resident's room, as well. All verbalized understanding of instructions and denied having any questions. Pt. discharged on 3/1/2024 @1241 with wife and daughter. Pt. left facility by w/c [wheelchair], escorted by CNA [Certified Nurse Assistant]. All belongings sent with resident and family. Medications sent with resident and family. Resident out of building in w/c with no incident."

Review of Resident 2's Discharge Instructions dated March 1, 2024, revealed that the following sections were blank:
C. Primary Physician(s); D. Pharmacy; J. Emergency Contact Information if Emergency or Symptoms Get Worse; and M. Scheduled Appointments and Tests.

In addition, the following sections were partially completed as indicated: Section E. In Home Care or Services it was marked that the Resident was to receive services but no contact number was provided; at Section F. Medical Equipment Arrangements it was noted that Medical Equipment Arrangements were made for a bedside commode, but the Medical Equipment Provider was left blank as well as phone number; in Section O. Signatures: Resident 2 nor their Representative had signed the document; and in Section R. Medications no medications were listed, and the section was marked to see attached with no medication list attached.

Review of Resident 3's clinical record revealed diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), compression fracture (collapse of a vertebra possibly due to trauma or a weakening of the vertebra) of the lower back, abnormalities of gait and mobility, and muscle weakness.

The review of the closed clinical record for Resident 3 on April 4, 2024, revealed that Resident 3 was admitted to the facility on February 28, 2024, and that the Resident was discharged home on March 15, 2024.

Review of Resident 3's clinical record progress notes revealed no other Social Services documentation of their discharge planning and referrals being made to appropriate community agencies. In addition, there was no documentation of Resident 3 being discharged from the facility.

Review of Resident 3's "Discharge Instructions" dated March 15, 2024, revealed that the following sections were blank: D. Pharmacy; J. Emergency Contact Information if Emergency or Symptoms Get Worse; K. Brief Medical History; L. Current Treatments and Therapies; M. Scheduled Appointments and Tests; N. If Problems Arise during Discharge, Please contact the Following Individual(s) at the Nursing Facility.

In addition, the following sections were partially completed as indicated: Section E. In Home Care or Services it was marked that the Resident was to receive services, but no agency with contact information was listed; and in Section O. Signatures in Section R. Medications a notation was in the first drug name box to see medication discharge instructions, however, nothing was attached to the Discharge Instructions.

Review of Resident 4's clinical record revealed diagnoses that included liver abscess (a collection of pus that has built up within the liver tissue), viral hepatitis (an infection that causes liver inflammation and damage), and hypertension (high blood pressure).

Review of the closed clinical record for Resident 4 on April 4, 2024, revealed that Resident 4 was admitted to the facility on March 23, 2024, and that the Resident was discharged home on March 27, 2024.

Review of Resident 4's clinical record progress notes revealed a note dated March 27, 2024, at 12:19 PM, written by a Registered Nurse, that indicated "res[ident] discharged via wheelchair with brother @1200pm. discharge paperwork signed and copies sent with. meds sent with resident."

Review of Resident 4's "Discharge Instructions" dated March 25, 2024, revealed that the following sections were blank: D. Pharmacy; F. Medical Equipment; I. Prevention and Disease Management Education; and N. If Problems Arise during Discharge, Please contact the Following Individual(s) at the Nursing Facility.

In addition, the following sections were partially completed as indicated: "Section E. In Home Care or Services" that the Resident was to have in-home care services, but no agency or contact information was provided; and at Section R. Medications no medications were listed and the section was marked to see attached with no medication list attached.

During an interview with the DON on April 4, 2024, at 2:30 PM, all the aforementioned concerns for Residents 1, 2, 3, and 4 regarding the lack of complete discharge summary documentation were shared. The DON confirmed that that there was lacking documentation. She also indicated that she would follow-up on Resident 3's lack of documentation regarding their discharge and their referral to home health. She also indicated that she would see if she could find any additional information to provide for the aforementioned concerns.

During a final interview with the Nursing Home Administrator, DON, and Assistant DON, on April 5, 2024, at 11:49 AM, the DON confirmed she had no additional information to provide for review for Residents 1, 2, 3, and 4. She confirmed that she would expect staff to complete a Resident's Discharge Summary/Instructions form accurately and completely, as applicable, and that it should be signed by the Resident or their Representative at time of discharge.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.5(f) Medical Records
28 Pa. Code 211.10(c) Resident Care Policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services




 Plan of Correction - To be completed: 04/29/2024

1. Residents 1, 2, 3 and 4 no longer reside at the facility.
2. The NHA/Designee will complete an audit of Discharge Summaries for the last 30 days.
3. The licensed staff and Interdisciplinary Team will be educated on completion of the Discharge Summary.
4. A weekly audit will be completed on the Discharge Summaries by the NHA/Designee. These audits will be completed weekly for four weeks and monthly for two months. The results of the audits will be reviewed by the Quality Assurance Committee for further recommendations.

483.40(d) REQUIREMENT Provision of Medically Related Social Service: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.
483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for residents transitioning to home by not making appropriate referrals for home care services for two of four residents reviewed (Residents 1 and 3); and failing to inform a resident of a change in their discharge plan for one of four residents reviewed (Resident 4).

Findings Include:

Review of Resident 1's clinical record revealed diagnoses that included prostate cancer, legal blindness, abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily), aftercare of a fracture (a break) of the right femur (large bone located in the thigh area of the leg), and unspecified fall encounter.

Resident 1 was admitted to the facility on February 26, 2024 and was discharged home on March 7, 2024.

Review of Resident 1's progress notes revealed a note dated March 3, 2024, at 4:50 PM, written by the Social Worker, that indicated they had notified Resident 1's Representative to discuss a discharge plan and that they would "work on HH [home health] nursing, PT [Physical Therapy]/OT [Occupational Therapy] referrals to support resident's needs upon discharge."

Further review of Resident 1's clinical record revealed a progress note dated March 6, 2024, at 6:09 PM, by the Social Worker that indicated "referrals sent for HH services upon discharge. Currently waiting for response on agency able to accept resident for skilled services at home."

Further review of Resident 1's clinical record progress notes revealed that the next note written regarding Resident 1's discharge planning process was a note dated March 7, 2024, at 11:00 AM, written by a Registered Nurse, that indicated that the Resident was discharged home and that discharge instructions, which included home health and therapy services, were reviewed.

The clinical record failed to identify which home health agency referrals were sent or any information as to which home health agency had accepted the referral for Resident 1.

Review of Resident 1's "Discharge Instructions" dated March 7, 2024, revealed in Section E. In Home Care or Services that the Resident was to have in-home care services provided by a specific Home Health agency and a phone number was provided, but no contact name provided.

During a phone interview with the the Home Health agency community liaison on April 4, 2024, at 1:16 PM, they reviewed emails and phone messages and confirmed that the agency did not receive a referral for Resident 1. They further indicated that the referral was also not found in their electronic health record system. She stated that, based on the city that Resident 1 resided in, they would not have accepted the referral because they do not currently have staff to cover the area where Resident 1 resides.

Review of Resident 3's clinical record revealed diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), compression fracture (collapse of a vertebra possibly due to trauma or a weakening of the vertebra) of the lower back, abnormalities of gait and mobility, and muscle weakness.

Resident 3 was admitted to the facility on February 28, 2024, and that the Resident was discharged home on March 15, 2024.

Review of Resident 3's clinical record revealed a progress note dated March 6, 2024, at 5:31 PM, by the Social Worker, that indicated they had spoken to Resident 3's Representative on the phone and that they wanted to have Resident 3 discharged as soon as possible. The note further indicated that alternatives were offered (room or roommate change), that they were appreciative of the plan, and that the Social Worker would continue to offer support towards discharge planning goals to resident and family.

Review of Resident 3's clinical record revealed two physician progress notes dated March 11, 2024, at 7:57 PM, and March 13, 2024, at 1:38 PM, that indicated Resident 3 was planning to discharge home.

Further review of Resident 3's clinical record progress notes revealed no other Social Services documentation of their discharge planning and referrals being made to appropriate community agencies.

Review of Resident 4's clinical record revealed diagnoses that included liver abscess (a collection of pus that has built up within the liver tissue), viral hepatitis (an infection that causes liver inflammation and damage), and hypertension (high blood pressure).

Resident 4 was admitted to the facility on March 23, 2024 and was discharged home on March 27, 2024.

Review or Resident 4's progress notes revealed a note dated March 25, 2024, at 11:04 AM, by the Social Worker, that indicated they met with Resident 4 to discuss their desire to discharge home. The note indicated that Resident 4 felt comfortable taking care of their intravenous (IV) therapy and their surgical drains with the support of HH (home health) services. The note further indicated that the referral was made for HH services, that a referral was being made for IV therapy (no provider name given) at home, and that they would continue to offer support for discharge planning as needed.

Review of Resident 4's clinical record progress notes revealed a note dated March 25, 2024, at 2:45 PM, by the Social Worker that indicated that one Home Health was unable to accept the referral for Resident 4 related to a high census, and that referrals were made to additional home health companies (no providers named).

Review of Resident 4's clinical record progress notes revealed a note dated March 26, 2024, at 12:08 PM, by the Social Worker that indicated they met with Resident 4 to update them that HH has stated that, due to staffing, they were unable to accept the referral as it was sent; and spoke with another HH agency for possible services.

Review of Resident 4's clinical record progress notes dated March 27, 2024, at 11:02 AM, by the Social Worker, that indicated that a call placed to confirm the Resident's discharge and delivery of IV medications at home, and that Resident 4 indicated that the Resident would be leaving around noon that date.

Further review of Resident 4's clinical record progress notes failed to reveal any documentation that Resident 4 was made aware of his confirmed home health provider.

During an interview with the DON on April 4, 2023, at 2:30 PM, all of the aforementioned concerns for Residents 1, 3, and 4 regarding the lack of documentation of discharge planning and home care services being arranged/finalized were shared. The DON confirmed that that there was lacking documentation of identified services being arranged prior to or at discharge for Residents 1 and 3. The DON further indicated that there was some confusion over the home health services for Resident 1. She said that she had received a call from Resident 1's Representative to report that no home health agency had shown up since their discharge from the facility. She said that, after she spoke to Resident 1's Representative, the DON called the Social Worker to see what had happened. She said that the Social Worker said she was having difficulty setting up services and that she would make some additional calls. The DON indicated that they then did find a HH provider, and that she called and informed Resident 1's Representative of the agency to provide services. She said that she called Resident 1's Representative the next day and confirmed home health services had begun. At the time of the interview, the DON could not provide dates as to when the above communication occurred, but said she would look at her phone logs, email communications, and would follow-up with the Social Worker as they had been off the past couple of days. She also indicated that she would follow-up on Resident 3's lack of documentation regarding their discharge and their referral to home health. She also indicated that she would see if she could find any additional information to provide for the aforementioned concerns.

During a final interview with the Nursing Home Administrator, DON, and Assistant DON, on April 5, 2024, at 11:49 AM the DON confirmed that she had no additional information to provide for Residents 1, 3, and 4. She confirmed that she would expect the Social Worker to complete all the necessary steps of the discharge planning process, and that this would all be clearly and accurately documented in the Resident's clinical record. She further confirmed that she would expect all appropriate services based upon the Resident's identified needs at time of discharge to be arranged prior to or at the time of discharge, documentation completed to reflect the arrangements made, and that the Resident and/or their Representative were made aware.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10 (c)(d) Resident Care Policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing Services


 Plan of Correction - To be completed: 04/29/2024

1. Residents 1, 3 and 4 no longer reside at the facility.
2. The NHA/Designee will complete an audit of the Discharge Plans for current residents to ensure that an appropriate discharge plan has been established and includes referrals for home care services when appropriate. Revisions/adjustments will be made to discharge plans for those residents identified as not meeting requirements related to needed home care services.
3. The Social Services Director will be educated on the process of obtaining home care services referrals and communication with the resident on the discharge plans.
4. The Interdisciplinary team will review discharge plans for residents on a weekly basis as part of the Utilization Review meeting to ensure an appropriate discharge plan has been established including but not limited to referrals for home care services when appropriate to ensure solutions are sustained. A random sample audit of 5 residents will be conducted by the Nursing Home Administrator to ensure discharge planning requirements are met including referrals made for home care services when appropriate. These audits will be conducted by the Nursing Home Administrator weekly for four weeks and monthly for two months. The results of the audits will be reviewed by the Quality Assurance Committee for further recommendations.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure pharmaceutical services provide an accurate account for the obtaining of medications and disposition of medications during the discharge process for four of four residents reviewed (Residents 1, 2, 3, and 4).

Findings include:

Review of facility policy, titled "Discarding and Destroying Medications", with a last revised date of April 2019, revealed "11. The medication disposition record will contain the following information: a. The resident's name;
b. Date medication disposed; c. The name and strength of the medication; d. The name of the dispensing pharmacy;
e. The quantity disposed; f. Method of disposition; g. Reason for disposition; and h. Signature of witnesses. 12. Completed medication disposition records shall be kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records."

Review of Resident 1's closed clinical record revealed diagnoses that included prostate cancer, legal blindness, abnormalities of gait (walking) and mobility (the ability to move or be moved freely and easily), aftercare of a fracture (a break) of the right femur (large bone located in the thigh area of the leg), and unspecified fall encounter.

The review of the closed clinical record for Resident 1 on April 4, 2024, revealed that Resident 1 was admitted to the facility on February 26, 2024, and that the Resident was discharged home on March 7, 2024.

Review of Resident 1's closed record physician orders revealed that the Resident had a total of five prescription medications at the time of their discharge, and that the Resident had an order that the facility could send any remaining medications home with them at discharge.

Review of Resident 1's form, titled "Medication Disposition", revealed that only two medications, simvastatin (a medication used to treat high cholesterol) one dose and abiraterone acetate (a hormone therapy medication used to treat prostate cancer) 12 doses, were returned to the pharmacy. The form gave the reason for returning the medication to the pharmacy as discharged.

Review of Resident 1's clinical record progress notes revealed a note written by a Registered Nurse dated March 7, 2024, at 11:00 AM, that indicated that Resident 1 was discharged home, that their medications were reviewed at bedside, and that the Resident was transported home by family. The note failed to reveal any documentation that medications were sent home with Resident 1.

During an interview with the Director of Nursing (DON) on April 4, 2024, at 1:40 PM, she indicated that nursing staff reviews all the residents' medications with them at discharge as part of the discharge process. She said that they either give the resident the Transfer/Discharge Report or a copy of their physician orders that includes all their ordered medications. She said that they send the medications home with the resident, unless they have physician orders not to do so. She said that the medication packs that are given to the resident indicate when the resident is to take the next doses, and that all this is reviewed verbally with the resident at time of discharge.

During an interview with the DON on April 4, 2024, at 2:30 PM, the aforementioned concerns for Resident 1 were shared. The DON indicated that she could not answer as to why the simvastatin was returned to the pharmacy, but that the abiraterone acetate was returned secondary to the cost and because the Resident had his own supply that he brought into the facility. She further shared that, when the facility received the referral from the hospital, that it was indicated that Resident 1 would be bringing their own supply of abiraterone acetate from home because it was very costly. She confirmed that there was no documentation of the medication being brought into the facility or the amount that was brought into the facility. The DON also indicated that on the day Resident 1 was being discharged, that the nurse had forgotten to get the medication from the cart to give to Resident 1's family member. She said the family member specifically asked about it and that the DON went to the medication cart, retrieved the medication, and gave it to Resident 1's family member. The DON confirmed that there was no documentation that the medication was given to Resident 1 or their family member, and that there was no documentation to reflect how many tablets were sent home with them. She also confirmed that there should have been documentation of the medication being brought into the facility to include the amount (tablets) received.

A follow-up review of Resident 1's clinical record also failed to reveal any documentation of the abiraterone acetate being brought into the facility by them at the time of admission or the number of tablets present.

Review of Resident 2's closed clinical record revealed diagnoses that included chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high), and hypertension.

The review of the closed clinical record for Resident 2 on April 4, 2024, revealed that Resident 2 was admitted to the facility on February 29, 2024, and discharged home on March 1, 2024.

Review of Resident 2's closed record physician orders revealed that the Resident had a total of 11 prescription medications at the time of discharge, and that the Resident had an order that the facility could send any remaining medications home with them at discharge.

Review of Resident 2's form, titled "Medication Disposition", revealed that all 11 medications were listed on the form and were being returned to the pharmacy with the indication of "D/C" [discharged] written in the box titled "Reason."

Review of Resident 2's clinical record progress notes revealed a note written by a Unit Manager dated March 1, 2024, at 12:41 PM, that indicated the Resident was discharged home, family was in attendance, and that medications were sent home with them.

Review of Resident 3's clinical record revealed diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), and hypertension (high blood pressure).

Review of closed clinical record for Resident 3 on April 4, 2024, revealed that Resident 3 was admitted to the facility on February 28, 2024, and discharged home on March 15, 2024.

Review of Resident 3's physician orders revealed that the Resident had a total of four prescription medications at the time of their discharge, and that the Resident had an order that the facility could send any remaining medications home with them at discharge.

Further review of Resident 3's clinical record failed to reveal any form, titled "Medication Disposition", or documentation of their medication reconciliation being completed.

Review of Resident 3's clinical record progress notes failed to reveal any documentation of their actual discharge from the facility.

Review of Resident 4's clinical record revealed diagnoses that included liver abscess (a collection of pus that has built up within the liver tissue), viral hepatitis (an infection that causes liver inflammation and damage), and hypertension.

Review of the closed clinical record for Resident 4 on April 4, 2024, revealed that Resident 4 was admitted to the facility on March 23, 2024, and was discharged home on March 27, 2024.

Review of Resident 4's closed record physician orders revealed that the Resident had a total of 10 prescription medications at the time of their discharge, and that there was no order indicating if the facility could or could not send any remaining medications home with them at discharge.

Further review of Resident 4's clinical record failed to reveal any form, titled "Medication Disposition", or documentation of their medication reconciliation being completed.

Review of Resident 4's clinical record progress notes revealed a note written by a nurse dated March 27, 2024, at 11:02 AM, that indicated the Resident was discharged home, accompanied by a family member, and that their medications were sent home with them.

During an interview with the DON on April 4, 2024, at 2:30 PM, all the aforementioned concerns for Residents 1, 2, 3, and 4 were shared for further follow-up.

During a final interview with the Nursing Home Administrator, DON, and Assistant DON, on April 5, 2024, at 11:49 AM, the DON confirmed that she had no additional information to provide regarding Residents 1, 2, 3, and 4's medication reconciliation and disposition. She further indicated that she would expect all medications to be reconciled at time of discharge with clear documentation of the final disposition of medications.

28 Pa. Code 211.9(f)(2)(j) Pharmacy services
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services



 Plan of Correction - To be completed: 04/29/2024

1. Residents 1, 2, 3 and 4 no longer reside at the facility.
2. The DON/Designee will audit the discharged residents for the previous thirty days for accounting of obtaining medications and disposition of medications upon discharge.
3. The licensed staff will be educated on the policy for obtaining medications and documentation of disposition of medications.
4. A weekly audit will be completed on Discharged residents for disposition of medications by the DON/Designee. The audits will be completed weekly for four weeks and monthly for two months. The results of the audits will be reviewed by the Quality Assurance Committee for further recommendations.


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