Pennsylvania Department of Health
 HARMAR VILLAGE HEALTH & REHAB CENTER
Patient Care Inspection Results

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HARMAR VILLAGE HEALTH & REHAB CENTER
Inspection Results For:

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HARMAR VILLAGE HEALTH & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey in response to two complaints completed on June 12, 2024, it was determined that Harmar Village Health & Rehab 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of facility policy, clinical records, observations and staff interviews it was determined that the facility failed to provide an environment that was free of accident hazards, failed to ensure that residents received neurological assessments after a fall, consistently document incident report and post-fall investigation in the (Electronic Health Record -E.H.R.), failed to complete a new nursing fall risk evaluation (E.H.R.) after a fall, and failed to consistently document regarding post-incident response/symptoms for seventy two hours after a fall, for one of three residents (Resident R1).

Findings include:

The facility "Incident and accident" policy dated 11/7/22, indicated that an accident is any occurrence which is not consistent with routine care. The incident/accident will be recorded in the health record. Documentation regarding post-incident response and symptoms will be completed every shift for 72 hours post-occurrence.

Review of the Facility provided undated, "Fall Prevention and Management Program: One-Page Guide" indicated Incident report and post-fall investigation in E.H.R. Risk Management. New Nursing fall risk evaluation in E.H.R. Update care plan.

Review of the admission record indicated Resident R1 was admitted to the facility on 5/2/24.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs dated 5/9/24, indicated the diagnoses of Parkinson ' s Disease (disorder of the nervous system that results in tremors), chronic obstructive pulmonary disease (COPD- a group of diseases that block airflow and make it hard to breathe), and high blood pressure.

Review of Resident R1's care plan dated 6/1/24, indicated resident is at risk for falls.

Review of Resident R1's progress note dated 5/20/24, at 10:52 a.m. indicated resident was found on the floor in the dining room in right side lying position with bleeding coming from right temporal area.

Review of Resident R1's "Safety Events - Fall" form dated 5/20/24, at 10:54 a.m. indicated the same information as the progress note.

Review of Resident R1's assessments on 6/12/24, at 10:30 a.m. failed to include neurological checks (Post incident response and symptom) and failed to include a new nursing fall risk evaluation in the E.H.R as required for the fall that occurred on 5/20/24.

Review of Resident R1's care plan dated 6/1/24, failed to include an update as required, following the fall on 5/20/24.

Review of Resident R1's progress note dated 5/22/24, at 6:57 p.m. indicated staff coming off elevator heard a thump and noticed resident lying on the floor on the right. Blood noted under right side of head. Moderate amount of bleeding noted to right eyebrow by temporal area.

Review of the E.H.R. on 6/12/24, at 10:30 a.m. failed to include a "Safety Events - Fall" form for the fall on 5/22/24.

Review of Resident R1's assessments on 6/12/24, at 10:30 a.m. failed to include neurological checks, and failed to include a new nursing fall risk evaluation as required for the fall that occurred on 5/22/24.

Review of Resident R1's care plan dated 6/1/24, failed to include an update as required, following the fall on 5/22/24.

Review of Resident R1's progress note dated 6/1/24, at 8:27 p.m. indicated staff got called into room by Nurse Aide, resident lying on the floor on the left side with head towards the window and wheelchair behind his buttocks.

Review of Resident R1's "Safety Events - Fall" form dated 6/1/24, at 8:20 p.m. indicated the same information as the progress note.

Review of Resident R1's assessments on 6/12/24, at 10:30 a.m. failed to include complete neurological checks for one of the four every four-hour checks, and seven of seven of the every eight hour checks, and failed to include a new nursing fall risk evaluation as required for the fall that occurred on 6/1/24.

Review of Resident R1's progress notes failed to have documentation regarding post-incident response/symptoms every shift for seventy-two hours, with only one of three required entries on 6/2/24, only one of three required entries on 6/3/24, and zero of two entries required on 6/4/24, after fall on 6/1/24.

Interview with the Director of Nursing on 6/12/24, at 2:00 p.m. confirmed the above findings and that the facility failed to provide an environment that was free of accident hazards, failed to ensure that residents received neurological assessments after a fall, consistently document incident report and post-fall investigation in the E.H.R., failed to complete a new nursing fall risk evaluation (E.H.R.) after a fall, and failed to consistently document regarding post-incident response/symptoms for seventy two hours after a fall, for one of three residents (Resident R1).

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.18(e)(1) Management.

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

28 Pa. Code: 211.10(d) Resident care policies.


 Plan of Correction - To be completed: 06/24/2024

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. R1 is out to the hospital so no additional neuro checks can be completed at this time. Scans in the hospital were completed and negative for adverse outcomes. The fall care plan and fall risk evaluation for R1 will be upon R1's return. The Safety Events – Fall form will be completed for the event on 5/22. Licensed nursing staff will be educated by the DON/designee to complete the post-fall documentation. Audits will be completed weekly x 4 then monthly x 2 for this documentation. Results will be reported to the QAPI committee for recommendations.
§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on review of nursing time schedule documents, resident, and staff interviews, it was determined that the facility failed to provide a minimum of one nurse aide per 12 residents during the evening shift for one of 21 days reviewed (6/8/24).

Findings include:

Review of the facility census data and nursing time schedules from 5/20/24 - 6/9/24, revealed on 6/8/24, the facility census was 101 which required 8.42 Nurse Aides for the evening shift, and the facility only had 7.2.

Interview with the Nursing Home Administrator on 6/12/24, at 2:00 p.m. confirmed the facility failed to provide a minimum of one nurse aide per 12 residents during the evening shift for one of 21 days reviewed (6/8/24).


 Plan of Correction - To be completed: 06/24/2024

The facility cannot retroactively correct past staffing issues. Moving forward the facility will utilize on call rotations, sister facilities and staffing agencies to assist in meeting mandated requirements. To prevent this from reoccurring the Regional Director of Clinical Services will reeducate the NHA and DON on the updated staffing regulations regarding staffing ratios. Audits of ratio compliance for past and upcoming schedules will occur weekly x 4 and monthly x 2. Ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24-hour period on one of 21 days.
(6/8/24).

Findings include:

Nursing time schedules for the time periods of 5/20/24 - 6/9/24, revealed that the facility failed to maintain 2.87 hours of general nursing care to each resident in a 24-hour period on 6/8/24.

The census was 101 on 6/8/24, and the facility's general nursing hours was only 2.82.

During an interview on 6/12/24, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to meet nursing hours requirements on one of 21 days (6/8/24).


 Plan of Correction - To be completed: 06/24/2024

The facility cannot retroactively correct past staffing issues. Moving forward the facility will utilize on call rotations, sister facilities and staffing agencies to assist in meeting mandated requirements. To prevent this from reoccurring the Regional Director of Clinical Services will reeducate the NHA and DON on the updated staffing regulations regarding HPPD. Audits of HPPD compliance for past and upcoming schedules will occur weekly x 4 and monthly x 2. Ad hoc education will be provided as needed. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

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