Nursing Investigation Results -

Pennsylvania Department of Health
SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Patient Care Inspection Results

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SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T
Inspection Results For:

There are  54 surveys for this facility. Please select a date to view the survey results.

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SUMMIT AT BLUE MOUNTAIN NURSING AND REHABILITATION CENTER, T - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey and Abbreviated Complaint Survey completed on February 14, 2020, it was determined that The Summit at Blue Mountain Nursing and Rehabilitation 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) 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 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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

During the initial tour of the food and nutrition services department on February 11, 2020, at 9:40 AM revealed the following sanitation issues, with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

The perimeter of the floors throughout the department were visibly soiled.

There was a layer of dust located on the deli slicer located in the cook's area.

There was a wrapped package of cooked corned beef dated, February 3, 2020, with a discard date of February 6, 2020, and a stack of sliced Lebanon bologna dated, February 3, 2020, wrapped in plastic wrap on the shelf in the walk-in refrigerator.

Interview with the food and nutrition services director at this time noted both items were to be used or discarded within three days (February 6, 2020).

Observation on February 13, 2020, at 11:40 AM revealed an approximate 6 by 6 inch floor drain located under the dishwasher without a cover.

Interview with the food and nutrition services director at this time confirmed the department was to be maintained in a sanitary manner.

28 Pa. Code 207.2(a) Administrator's responsibility

28 Pa Code 211.6(c) Dietary services











 Plan of Correction - To be completed: 04/07/2020

The floors which include the perimeters in the kitchen have been power scrubbed. The deli slicer was out of service and has been discarded. The package of cooked corned beef and the stack of sliced Lebanon bologna have been discarded. The area identified under the dishwasher without a cover had been covered.

A weekly power scrubbing will be completed to the floors in the kitchen. The executive chef/designee will complete rounding daily to monitor labeling and dating of food items. The Food and Nutrition Services Director/designee will complete weekly rounds of the kitchen which will include ensuring drains are covered as appropriate.

Food and Nutrition Services Director/designee will complete re-education with the culinary staff on cleanliness of the kitchen and labeling and dating of the food items. Food and Nutrition Services Director will develop a cleaning schedule for the kitchen which will include staff education on the schedule.

Food and Nutrition Services Director/designee will develop a weekly audit tool to ensure the cleanliness of the kitchen, the labeling and dating of food items, and that drains are covered as appropriate which will completed weekly x8 and monthly x2 and will provide a summary at the monthly QAPI.
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 a review of clinical records and staff interview, it was determined that pharmacist failed to identify drug irregularities in the medication regimen of one resident (Resident 69) and the physician failed to document action to a pharmacist recommendation for one resident (Resident 18) out of 18 sampled.

Findings include:

A review of the clinical record revealed that Resident 69 was admitted to the facility on August 4, 2017, and had diagnoses that included depression, anxiety and dementia (a type of brain disease that causes a long-term and often gradual decrease in the ability to think and remember how to perform normal activities such as bathing, dressing and eating) with psychosis.

The resident had physician's order initially dated October 13, 2018, for Trazodone (antidepressant) 50 milligrams (mg) two times a day. On August 9, 2019, the dosage was increased to Trazodone 50 mg three times a day, which remained current at the time of the survey ending February 14, 2020, for depression.

The resident also had physician's order dated August 14, 2019, for Seroquel (an antipsychotic drug used to treat certain mental/mood conditions) 25 mg at bedtime. This dosage was increased on November 29, 2019, to Seroquel 25 mg in the morning and at bedtime. This dosage was again increased on December 16, 2019, remaining current at the time of the survey ending February 14, 2020, to Seroquel 50 mg two times a day for for dementia with behavioral disturbance.

A review of the monthly "Medication Regimen Reviews" conducted by the pharmacist from March 2019 through February 2020, revealed no indication that the pharmacist identified the absence of an attempt at a gradual dose reduction of the Trazodone 50 mg and the Seroquel 50 mg during the last year.

Interview with the Director of Nursing on February 13, 2020, at approximately 9:25 a.m. confirmed that there was no evidence that the pharmacist had identified the lack of a gradual dose reduction attempt in the last year and the continued use and dose of these psychoactive medications.

A review of the clinical record revealed that Resident 18 was admitted to the facility on April 6, 2018, and had diagnoses that included psychosis, anxiety and depression.

The resident had physician's order dated May 15, 2019, for Ativan (an anti-anxiety medication) 0.5 milligrams (mg) at bedtime, which was increased on October 28, 2019 to Ativan 0.5 mg twice daily. The dosage was again increased on December 9, 2019, remaining current at the time of the survey ending February 14, 2020, to Ativan 0.5 mg three times daily for anxiety.

A review of the monthly "Medication Regimen Reviews" conducted by the pharmacist from March 2019 through current at the time of the survey ending February 14, 2020, indicated that on July 23, 2019, a recommendation was made for a gradual dosage reduction of the Ativan.

There was no evidence that the physician responded to the recommendation. No dose reduction had been attempted nor physician documentation of the clinical rationale for continued administration of the current dosage to the resident.

During interview with the Director of Nursing on February 13, 2020, at approximately 9:25 a.m. the DON confirmed the lack of physician documentation of the clinical justification for the continued dosage of Ativan and rationale for the lack of attempt at a dose reduction of Ativan as the pharmacist recommended.


28 Pa. Code 211.9 (k) Pharmacy services.

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing services.
Previously cited 3/29/19, 5/21/19.

28 Pa. Code 211.2(a) Physician Services

28 Pa. Code 211.5(f)(g)(h) Clinical records












 Plan of Correction - To be completed: 04/07/2020

Resident 69's medication review was conducted and a recommendation of a gradual dose reduction (GDR) of trazadone and Seroquel was completed. Resident 18's physician addressed the GDR request of the Ativan.

DON/designee will complete a review of current residents to ensure residents on psychoactive medications have a recommended GDR by the pharmacist and a response documented by the physician.

NHA/designee will provide re-education to the consulting pharmacist on regulations of medication regimen reviews specifically GDR's. Physician education will be provided on responding to pharmacist recommendation. The consulting pharmacist will provide a report monthly to the NHA/Assistant NHA/DON after completion of the monthly medication regimen review.

DON/Designee will develop an audit to monitor recommendations for GDRs that are made per the regulation including documented physician response to the recommended GDR. A random 10% sampling will be completed monthly x3 and reported at the monthly QAPI.
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 and staff interview, it was determined that the facility failed to timely consult with the physician regarding significant weight changes for one out of nine sampled residents (Resident 33).

Findings include:

Review of Resident 33's clinical record indicated that the resident was admitted to the facility on July 30, 2014, and had diagnoses that included Vitamin B deficiency, thiamine deficiency, acute kidney failure and dysphagia.

A review of the resident's weight record revealed the following:

December 3, 2019 150.8 pounds
December 18, 2019 136.2 pounds 14.6 pounds or 9.68 % significant weight loss in fifteen days December 30, 2019 138.1 pounds January 22, 2020 164.4 pounds 26.3 pounds or 19.04 % significant weight gain in twenty-two days
February 3, 2020 153.0 pounds 11.4 pounds or 6.93 % significant weight loss in twelve days

Interview with the Director of Nursing on February 13, 2020, at approximately 10:00 a.m., confirmed that there was no evidence that the physician was timely notified of the resident's significant weight changes.



28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services
Previously cited 5/21/19




 Plan of Correction - To be completed: 04/07/2020

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

Resident 33's physician was notified of significant weight changes.

Reviewed of current residents for the month of February 2020 will be completed to ensure timely consult with the physician regarding significant weight changes.

DON/designee will complete re-education with the nursing staff on the weight policy. A review of weights will be completed at the clinical meeting for timely notification with the physician for significant weight changes.

DON/designee will develop an audit to monitor for timely notification to physician for significant weight changes. A 10% random sampling will be completed weekly x4 and monthly x2 and a summary of the audit will be reported at the monthly QAPI.
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.
Observations:

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 21 sampled (Resident 90).

Findings include:

A review of Resident 90's discharge MDS Assessment dated January 10, 2020, revealed in Section A2100 Discharge Status that Resident 90 was discharged to an acute care hospital.

A review of nurses' notes in the resident's clinical record dated January 10, 2020, at 11:00 a.m. and the Physicians Discharge Summary, revealed that Resident 90 was discharged to home.

Interview with the Director of Nursing on February 14, 2020, at 10:15 a.m. she confirmed Resident 90 was discharged to home and that the discharge MDS Assessment dated January 10, 2020, was inaccurate.


483.20(g) Accuracy of Assessments
Previously cited 3/29/19, 5/21/19.

28 Pa. Code 211.5(g)(h) Clinical records.
Previously cited 3/29/19, 5/21/19.

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.
Previously cited 3/29/19, 5/21/19.





 Plan of Correction - To be completed: 04/07/2020

Resident 90's MDS was modified and resubmitted to reflect that resident was discharged to home.

An audit was completed on all discharge residents from 12/1/19 to present to verify the accuracy of A2100 discharged status.

NHA/designee will provide re-education on MDS accuracy of A2100 per RAI manual guidelines.

RNAC/designee will develop an audit tool to ensure accuracy of A2100 prior to submission of discharged residents. Audit will be completed monthly x3 and summary will be reported at monthly QAPI.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(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 review of clinical records and staff interview, it was determined that the facility failed to review the comprehensive care plan of a resident at risk for falls to meet the resident's goal for one resident out of four sampled (Resident 6).

Findings include:

A review of the clinical record revealed that Resident 6 was admitted to the facility on March 8, 2018, with a history of falls.

A review of the resident's comprehensive plan of care, initially dated, March 9, 2018, revealed that the facility identified the resident's risk for falls with the goal that Resident 6 will be free of falls.

The resident, however, did not meet this goal to be free of falls. A further review of the clinical record and facility provided documentation revealed that Resident 6 fell on December 1st and 5th, 2019, and again on January 7, 2020, without injuries.

Further review of the resident's care plan revealed that the facility failed to review the adequacy of the resident's existing care plan for fall risk in response to the resident's multiple falls and develop and implement applicable safety approaches to deter additional falls and prevent injuries.

Interview with the Director of Nursing on February 13, 2020, at approximately 12:10 PM confirmed the resident's care plan had not been revised in response to the multiple falls.

A review of the clinical record revealed that Resident 39 was admitted to the facility on September 30, 2018, with diagnoses including Major Depressive Disorder, Non-traumatic Intracerebral Hemmorhage, Parkinsons Disease and Edema.

Review of Resident 39's clinical record revealed a nursing progress note dated February 7, 2020, indicating thte resident had worsening edema to bilateral lower legs.

Further review of Resident 39's clinical record on February 12, 2020, that the care plan did not address the resident's edema.

Interview with the Director of Nursing on February 13, 2020, at 10:00 a.m. confirmed that the care plan for the residents edema had not been initiated.



28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing Services.
Previously cited 5/21/19

28 Pa. Code 211.11(d) Resident Care Plan.
Previously cited 5/21/19




 Plan of Correction - To be completed: 04/07/2020

Resident 6's fall careplan was reviewed and revised. Resident 39's careplan was revised to reflect resident's edema.

The interdisciplinary team (IDT)will complete a review of current residents careplans to ensure they reflect resident's current status.

RNAC/DON/designee will complete re-education to the IDT and licensed nurses on careplanning process. Changes identified at clinical meeting will be reviewed by IDT to ensure careplan is updated and revised as appropriate to reflect residents current condition.

DON/designee will develop an audit to ensure careplan is updated and revised as appropriate. A 10% random sampling will be completed weekly x4, monthly x2 and a summary will be reported at monthly QAPI.


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 clinical record review and staff interview, it was determined that the facility failed to promptly carry out physician orders and a person-centered care plan for management of edema displayed by one resident (Resident 39) out of 18 sampled

Findings include:

A review of the clinical record revealed that Resident 39 was admitted to the facility on September 30, 2018, with diagnoses including major depressive disorder, non-traumatic intracerebral hemmorhage, Parkinsons Disease and edema.

Nursing documentation dated February 7, 2020, indicated that Resident 39 had worsening edema. A nurse aide was toileting the resident and found that the resident's bilateral lower extremities and feet were red, swollen, and discolored. Upon nursing assessment, pitting edema, warmth, and redness were noted in the resident's bilateral lower legs and feet. Purple discoloration noted in toes.

A communication form to the physician was completed and faxed on February 7, 2020. The physician responded on February 7, 2020, advising nursing that Resident 39 had chronic edema and to elevate and monitor redness through the weekend.

However, a review of Resident 39's clinical record revealed no documented evidence that nursing staff had began monitoring redness and elevating the resident's legs until February 9, 2020.

A review of Resident 39's comprehensive care plan conducted on February 12, 2020, revealed that the resident's care plan did not address the resident's chronic edema or the interventions to elevate the resident's legs and monitor for redness.

Interview with the Director of Nursing on February 13, 2020, at 10:00 a.m. confirmed that the resident's problem of edema, and corresponding interventions, were not addressed on the resident's care plan. The DON also confirmed during interview on February 13, 2020, that staff failed to promptly carry out physician orders for the resident's edema to bilateral lower extremities.



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

28 Pa. Code 211.5 (f) Clinical records

28 Pa. Code 211.11(d) Resident care plan




 Plan of Correction - To be completed: 04/07/2020

Facility can not retroactively go back and correct Resident 39's documentation. Resident 39's careplan was updated to reflect chronic edema.

The IDT will complete a review of current residents documentation and careplans and any areas identified will updated as appropriate.

DON/RNAC/designee will complete re-education with the IDT and licensed nurses on the careplanning process and documentation in follow up of physicians orders.

The IDT will review physician orders, clinical notes and careplans at the clinical meeting to ensure that documentation supports physicians orders and careplans are updated and revised appropriately.

DON/RNAC/designee will develop an audit and a 10% random sampling will be completed weekly x4 and monthly x2 to ensure that documentation supports physicians orders and careplans are updated and revised appropriately and reported at monthly QAPI.

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