Nursing Investigation Results -

Pennsylvania Department of Health
GREENSBURG CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GREENSBURG CARE CENTER
Inspection Results For:
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GREENSBURG CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a complaint survey completed on September 17, 2019, it was determined that Greensburg 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:

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

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.

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for one of 10 residents reviewed (Resident 2).

Findings include:

The facility's policy regarding bed holds, dated August 1, 2019, indicated that the facility would hold the bed for the resident if they or their responsible party indicated that they would pay the facility to keep the bed vacant in anticipation of the resident's return.

A diagnosis record for Resident 2, dated May 24, 2019, revealed that the resident had diagnoses that included Alzheimer's dementia (loss of cognitive function), psychosis (thought disorder), seizures and major depression. A nursing note, dated July 26, 2019, revealed that the resident was transferred to the hospital for an evaluation following a change in condition and that she was admitted to behavioral health.

There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 2.

Interview with the Director of Nursing on September 13, 2019, at 3:24 p.m. revealed that a bed hold notice was not issued to Resident 2 or her responsible party and that it should have been.

42 CFR 483.15(d)(1)(2) Notice of Bed Hold Policy Before/Upon Transfer.
Previously cited 3/22/19.

28 Pa. Code 201.29(d) Resident rights.
Previously cited 3/22/19.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 6/21/19, 5/15/19, 3/22/19.

Plan of Correction - To be completed: 10/11/2019

Facility attempted to contact Resident 2 responsible party with no reply.

Licensed nursing personnel have been educated on bed hold policy by the Director of Nursing. New and agency personnel will be educated on policy by Director of Nursing designee.

System changes include carbonless copy of bed hold policy to be initiated upon transfer of residents to hospital. Original will be sent with resident to hospital. Copy will be placed in resident's medical record. If resident's responsible party is unable to be reached by telephone, notification will be sent by postal service.

Audits of process will be conducted by Director of Nursing or designee to ensure completion of procedure on each transfer to hospital.

Outcomes of audits will be reviewed during the Quality Assurance Process Improvement meeting monthly.

483.15(e)(1)(2) REQUIREMENT Permitting Residents to Return to Facility:

§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid
nursing facility services.
(ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.

§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to permit the readmission of a hospitalized resident without providing evidence that the facility was not able to meet the resident's needs for one of 10 residents reviewed (Resident 2).

Findings include:

Admission information for Resident 2 revealed that the resident was admitted to the facility in May 2019 with diagnoses that included Alzheimer's dementia (cognitive loss), psychosis (thought disorder), seizures, and major depressive disorder. A nursing note, dated July 23, 2019, indicated that the resident was sent to a hospital for a psychiatric admission due to an increase in behaviors at the facility; however, the physician did not feel that she required inpatient treatment and sent her back to the facility. A nursing note, dated July 24, 2019, indicated that the social worker contacted Resident 2's spouse and informed him that the resident needed inpatient psychiatric treatment because she was witnessed shaking another resident earlier that morning. The facility arranged for the resident to be admitted to the behavioral health unit at another hospital and she was admitted to the hospital on July 26, 2019.

A hospital note, dated July 26, 2019 indicated that Resident 2 was being admitted to the hospital's behavioral health unit and that the nursing facility would accept her back when she was ready for discharge. A hospital note, dated August 5, 2019, indicated that the hospital was ready to discharge Resident 2 back to the nursing facility; however, when the nursing facility was contacted they indicated that they would not be able to meet her needs due to dementia.

There was no documented evidence that the facility was not able to meet Resident 2's needs related to dementia, and no documented evidence that the resident's discharge was based on a valid discharge reason.

Interview with the Director of Nursing on September 13, 2019 at 3:20 p.m. confirmed that the facility did not accept Resident 2 back following her hospitalization, and she was not able to provide documented evidence that the facility was not able to meet the resident's needs.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 7/26/19, 6/21/19, 5/15/19, 3/22/19.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 3/22/19.

28 Pa. Code 201.18(b)(3) Management.

Plan of Correction - To be completed: 10/11/2019

Referrals for readmission of residents transferred or hospitalized for voluntary or involuntary psychiatric admissions will be reviewed by the Interdisciplinary team to determine the facility's ability to meet resident needs for readmission.

Policy and system changes will include a determination that resident needs can or can not be met by the facility. If the facility determines that the resident needs can not be met, the resident's clinical record will be updated to present reasons or evidence of why needs can not be met. Furthermore the clinical record will show all attempts to meet resident needs were exhausted, or that readmission would present a danger to the resident or other residents prior to denial for readmission.

Education will be provided to the Admission team and the Interdisciplinary Team by the Director of Nursing designee. Education will be provided to any new members of the admission and Interdisciplinary team.

No other residents are affected by this practice.

Audits of the process for referrals for readmission will be conducted on all readmission referrals.

Results of audits will be reviewed by the Quality Assurance Process Improvement Committee monthly.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Observations:

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to implement care plan interventions for dining for one of 10 residents reviewed (Resident 5).

Findings include:

An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 31, 2019, revealed that the resident was usually understood, could usually understand, required supervision after set-up for eating, and had medical diagnoses that included dementia (decline in memory and thinking skills) and dysphasia (difficulty swallowing). The resident's care plan, dated May 29, 2019, revealed that he needed a mechanically altered diet due to dysphagia, that he did well with his meals with the other residents in the Memory Impaired Unit dining area, and that he needed assistance, encouragement and monitored for impulsivity. A care plan dated August 9, 2019, revealed that the resident requires 100 percent supervision for all meals by one staff.

Physician's orders from Resident 5's previous facility, dated March 17, 2019, included an order for the resident to be on a regular mechanical soft diet with one-to-one supervision to decrease impulsive eating. A medical nutrition data collection assessment, dated May 29, 2019, revealed that speech pathology noted impulsivity and the need for supervision with meals.

A restorative registered nurse note for Resident 5, dated August 29, 2019, revealed that a quarterly review of the resident's restorative nursing program was completed and the resident continued on the restorative nursing program for dining. At times he was impulsive and required supervision with all of his meals. He may feed self; however, he must have a staff member with him at all times to cue him for safe swallowing strategies.

Observations during the supper meal on the Memory Impaired Unit on September 17, 2019, at 5:08 p.m. revealed that Resident 5 was brought from his room and placed at the dining table. At 5:13 p.m. another male resident sitting at the same table was served his meal. At 5:19 p.m., Resident 5 was served his meal and began feeding himself. The staff member who delivered Resident 5's meal tray left and continued to serve other residents their meal trays, as did the other staff members assigned to the Memory Impaired Unit. At 5:24 p.m. the other male resident sitting at the same table took Resident 5's small bowl containing pureed peaches and began to eat them. The other male resident then took a small glass containing a thickened red-colored juice belonging to Resident 5 and began to eat it. At 5:38 p.m. Resident 5 backed himself away from the table. During the observations, there were no staff members directly supervising Resident 5 while he was eating his meal.

Interview with the Director of Nursing on September 17, 2019, at 8:20 p.m. confirmed that Resident 5's care plan indicated that he required 100 percent supervision by one staff for all meals. She indicated that 100 percent supervision would be when the resident requests to eat in his room, and that when eating in the dining room it would involved general observations by staff.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 6/21/19, 3/22/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/26/19, 6/21/19, 5/15/19, 3/22/19.

Plan of Correction - To be completed: 10/11/2019

Restorative dining program was initiated for Resident 5. Resident 5 will be supervised for meals at the restorative dining table. Resident 5's care plan has been updated to reflect this change.

An audit was performed that identified 6 other residents affected. These residents have also been included in the supervised restorative dining program.

nursing staff educated by Director of Nursing designee regarding supervised restorative dining process. New and agency personnel will be educated on policy by the Director of Nursing designee.

Audits of residents included in the restorative dining program will be conducted by Director of Nursing Designee daily for 3 weeks, weekly for 3 weeks and monthly for 2 months.

Results of audits will be reviewed during monthly Quality Assurance Process Improvement meetings.

483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns:

§483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
§483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of 10 residents reviewed (Resident 1).

Findings include:

The facility's behavior data collection policy, dated August 2, 2019, revealed that the facility was to identify behaviors during the admission process and as needed, precipitating factors, and specific interventions for residents. The behavior data collection form was used to determine if identified behaviors could be addressed, precipitating factors/triggers causing behaviors, and specific interventions that may modify behaviors. The behavior data collection form would be used to update the care plan and activities of daily living (ADL) sheet, and forwarded to the activities department for changes in programming. If a new behavior was identified, nursing staff were to complete the behavior data collection form and update the care plan and ADL sheet, and forward it to Activities for changes in programming.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 13, 2019, revealed that the resident could be understood and could understand others, had moderately impaired cognition, had verbal behaviors, rejected care, and had diagnoses that included dementia (causes a decline in memory and other important mental functions) with behavioral disturbances.

A nursing note for Resident 1, dated August 10, 2019, at 9:45 a.m. revealed that the resident was agitated and threatened to hit a male resident walking past him. The resident was assessed as having moderate anxiety due to exit seeking and a desire to go home. At 11:17 a.m., Resident 1 made several threats to male residents anytime they would walk past him or sit near him in the common areas.

Resident 1's care plan, reviewed by the facility on August 13, 2019, revealed that the resident was resistive to care, had decreased socialization, agitation, actual threatening behaviors, yelled at others, threatened other male residents and had exit-seeking behaviors. Staff were to allow the resident to make decisions about the treatment regimen, encourage participation during care activities, approach from the front and give a clear explanation of all care, re-approach later when the resident resisted care, praise the resident when his behavior was appropriate, have meals in the dining room at a table alone or in his room as preferred, complete psychiatric evaluations and treatments as ordered, keep his routine consistent, administer Seroquel (anti-psychotic), Haldol (anti-psychotic), and Depakote (used to treat psychiatric conditions) as ordered by the physician, anticipate the resident's needs (food, thirst, toileting, comfort, pain, body positioning), and divert his attention and remove from the situation to an alternate location.

A nursing note, dated August 14, 2019, at 1:07 p.m. revealed that Resident 1 expressed agitation when approached by fellow residents. During breakfast, another resident walked past him and Resident 1 yelled at the resident and began shaking his cane in the air. The resident preferred to eat at a table alone or in his room. The resident ate lunch in his room with no problem.

A nursing note for Resident 1, dated August 15, 2019, at 6:08 p.m. revealed that the resident was very agitated when other residents approached him or when he was unable to go outside. He threatened to punch residents and staff. On August 16, 2019, at 2:05 p.m. it was noted that the resident became verbally agitated during lunch for no apparent reason and was yelling at another resident for looking at him. A nursing note dated August 17, 2019, at 1:43 p.m. revealed that the resident appeared to get agitated when other male residents were near him.

Nursing notes dated August 19, 2019, at 5:10 p.m. and 6:14 p.m. revealed that during the meal service, Resident 1 was becoming combative with another resident. As the nurse turned to assess the situation, Resident 1 struck another male resident in the face. The other resident was assisted to the floor and had an injury to the right lower lip. Resident 1 was observed by staff to get upset when another resident moved the table cloth while Resident 1 was eating. At 7:25 p.m. the resident was yelling in the hallway that he was going to get out of here and stated, "I am going to break the glass to get out of here if I have to. I just need a gun. I don't care who I have to go through." The resident was making self-harm statements and also threatening to harm staff. A state trooper was in the facility to interview the resident about the resident-to-resident incident, and Resident 1 became agitated and punched the state trooper in the face. Resident 1 was transferred to the hospital for a mental health evaluation.

After identifying that other residents continued to agitate Resident 1, there was no documented evidence that staff developed a plan for keeping Resident 1 away from other residents as much as possible, and no documented evidence that staff followed the resident's care plan for keeping him away from other residents during meals by having him eat at a table alone or in his room.

An interview with the Director of Nursing on August 27, 2019, at 8:56 p.m. confirmed that on August 19, 2019, Resident 1 was sitting at the table across from another resident during meal service, and the other resident grabbed the tablecloth and spilled Resident 1's drink, which resulted in Resident 1 punching the other resident in the face. She confirmed that the resident's care plan was not followed to eat alone at a table in the dining room or in his room.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 3/22/19.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 7/26/19, 6/21/19, 5/15/19, 3/22/19.

Plan of Correction - To be completed: 10/11/2019

Process changes have been implemented. Process change includes the Interdisciplinary Team will review each referral for the Memory Impaired Unit to determine the facilities ability to provide adequate care prior to acceptance for admission.

A review of behavior data collection forms was completed. No other residents have been identified as having been affected.

New interventions will be reviewed by the Interdisciplinary Team prior to inclusion and implementation of behavioral care plans.

Identified behaviors are reviewed daily during clinical startup to assess need for interventions and to update and revise existing interventions as needed. Behavioral interventions will also be reviewed as indicated per individualized care planning.

Nursing Staff have been educated by the Director of Nursing Designee regarding the system changes. New and agency personnel will be educated on policy by the Director of Nursing designee.

Audits of the process will be conducted daily for 3 weeks, weekly for 3 weeks, and monthly for 2 months.

Results of audits will be reviewed at the monthly Quality Assurance Performance Improvement committee meeting.

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