Pennsylvania Department of Health
BEAVER HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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BEAVER HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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BEAVER HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to one complaint completed on April 4, 2024, at Beaver Healthcare And Rehabilitation Center, it was determined that there were no federal deficiencies, related to the Health portion of the survey process, identified under the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as it relates to the Health portion of the survey process; however, the facility was not in compliance with 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on review of reports to the local State field office, resident clinical records, and staff interview, it was determined that the facility failed to timely report a resident discharging from the facility against medical advice (AMA) for two out of five closed resident records (Closed Resident Record CR1 and CR2).

Findings include:

Review of Closed Resident Record CR1's admission record indicated he was admitted to the facility on 11/22/23.

Review of Closed Resident Record CR1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/23/24, indicated diagnoses of muscle weakness, hyperlipidemia (high levels of fat in the blood), and hemiplegia (paralysis on one side of the body).

Review of Closed Resident Record CR1's clinical documentation dated 3/31/24, indicated that his daughter took him on a leave of absence (LOA) from the facility on 3/31/24, with the intention of returning him to the facility later that same day.

Review of Closed Resident Record CR1's clinical documentation dated 4/1/24, indicated that the resident was never returned to the facility and the facility contacted his daughter, who stated she would return the resident to the facility on the evening of 4/1/24.

Review of Closed Resident Record CR1's clinical documentation dated 4/2/24, indicated that the resident was never returned to the facility on 4/1/24. The facility attempted to contact the daughter on 4/2/24, with no answer. It was noted at this time that the resident's belongings had been removed from the resident's room. The facility contacted the local police department on 4/2/24. Later in the day of 4/2/24, the daughter called the facility back and stated she would return the resident to the facility. The daughter was educated on the discharge process at this time.

Review of Closed Resident Record CR1's clinical documentation dated 4/3/24, indicated that the resident was never returned to the facility on 4/2/24. The facility contacted Adult Protective Services (APS).

Review of reports to the local State field office revealed a report submitted on 4/4/24, of Closed Resident Record CR1 discharging from the facility against medical advice.

Review of Closed Resident Record CR2's admission record indicated he was admitted to the facility on 3/21/24.

Review of Closed Resident Record CR2's MDS dated 3/23/23, indicated diagnoses of hyperlipidemia, unspecified hearing loss, and abdominal aortic aneurysm (an enlargement of the aorta, the main blood vessel that delivers blood to the body, at the level of the abdomen).

Review of Closed Resident Record CR2's clinical documentation dated 3/23/24, indicated his family stated they wanted to sign the resident out AMA. The physician was notified, who stated they refused to discharge the resident due to not having yet assessed the resident. The family signed the resident out AMA at this time. The facility explained to the family that they could not provide any discharge medications at this time.

Review of reports to the local State field office did not include a report of Closed Resident Record CR2 discharging from the facility against medical advice.

During an interview on 8/2/24, at 1:15 p.m. the Nursing Home Administrator confirmed that the facility failed to timely report a resident discharging from the facility against medical advice as required for two out of five closed resident records (Closed Resident Record CR1 and CR2).


 Plan of Correction - To be completed: 04/19/2024


- Residents CR1 and CR2 has discharged from the facility.
- AMA report submitted to ERS for CR1 and CR2.
- NHA re-educated by Everest Operation support on state reporting requirements.
- NHA/Designee with audit discharges weekly x2 monthly x1 for any AMA discharges to ensure ERS reporting is completed as required.
- Results of these audits will be reported and reviewed by the QAPI committee monthly for recommendations as needed.
- Allegation of compliance: 04/19/2024.


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