Nursing Investigation Results -

Pennsylvania Department of Health
HAMPTON HOUSE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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HAMPTON HOUSE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  88 surveys for this facility. Please select a date to view the survey results.

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HAMPTON HOUSE REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on November 9, 2021, it was determined Hampton House Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 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:


483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:

Based on review of the facility's abuse prohibition policy and procedures, clinical records, and incident report, and staff interview it was determined that the facility failed to implement their established procedures for identifying resident abuse and the subsequent reporting, investigation and protection of residents following an incident of resident abuse of one resident out of five reviewed (Resident CR1).


Findings include:

Review of facility's policy entitled "Freedom from abuse, neglect and exploitation,", indicated that the facility will assure that the facility will provide a safe resident environment and protect residents from abuse. The facility will keep resident free from abuse, neglect, misappropriation of resident property and exploitation. This includes freedom from verbal, mental, sexual or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. All reports of aforementioned areas will be thoroughly investigated in an effort to determine if abuse, neglect, exploitation and/or mistreatment occurred. The investigation will attempt to identify any person involved or who may have knowledge of the allegation. The investigation will include interviews with the alleged victim, alleged perpetrator, witnesses, and other who may have knowledge of the allegations. Additionally, upon suspicion/ allegation of potential abuse or neglect, administrative personnel will immediately take measures to protect the alleged victim and integrity of the investigation. The alleged victim will be examined for any signs of injury, including psychosocial injury. Identified injuries will be documented, measured and treatment as necessary.

A review of Resident CR1's clinical record revealed admission October 9, 2021, with diagnoses including depression and anxiety disorder.

Resident CR1's admission MDS Assessment dated October 21, 2021, (Minimum Data Set - a federally mandated standardized assessment completed at intervals to plan resident care) revealed that the resident's cognition was intact with a BIMS (brief interview for mental status) score of 13 out of 15.

A review of Resident 1's clinical record revealed admission to the facility September 21, 2021, with diagnoses including anxiety, depression, and non- Alzheimer's dementia without behavioral disturbance (the loss of cognitive functioning; thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life) A review of Resident 1's admission MDS Assessment dated September 26, 2021, revealed that the resident's cognition was moderately impaired (BIMS score of 12 out of 15).

An incident report dated October 24, 2021, indicated that an incident had occurred involving the residents in room 10W. According to the incident report the staff heard a resident yelling for help, coming from room 10w. The resident then became quiet and when staff entered the resident room, staff observed Resident 1, at the side of her roommate's bed (Resident CR1). Resident 1 then threatened to stab her roommate, Resident CR1.

The facility did not obtain statements from the residents involved and/or staff who may have knowledge of the incident. At the time of the survey ending November 9, 2021, the facility had not reported the incident to the State Survey Agency, completed an investigation into the potential abuse of Resident CR1 and not implemented corrective measures to protect Resident CR1 from potential for further abuse or protect other residents from potential abuse perpetrated by Resident 1

Review of Resident CR1's clinical record revealed a progress note dated October 24, 2021 at 10:31 PM indicating "Resident yelling out, help me, help me and then went quiet. Went in to find resident's roommate at her bedside telling her to shut up and threatening to stab her."

Further Review of Resident CR1's clinical record failed to revealed no indication that nursing staff had assessed Resident CR1 (alleged victim) for any sign of physical injury or had evaluated the resident's psychosocial status as a result of being threatened by Resident 1, despite Resident CR1 being alone with Resident 1 and yelling for help prior to staff arrival.

Interview with the NHA at approximately 11:00 a.m. regarding the facility's failure to implement their abuse policy for identifying, reporting, and investigating this incident of potential resident abuse, the NHA stated that Resident 1 said that (threatening to stab Resident CR1) "out of frustration" and "she (Resident 1) did not mean it."

Interview with the nursing home administrator (NHA) on November 9, 2021, at approximately 2:00 p.m., confirmed that the facility failed to implement it's abuse policy for timely, investigation, reporting, and protection of residents after an abuse allegation.


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

28 Pa. Code 201.29(a)(c)(d) Resident rights

28 Pa. Code 201.14(a)(c)(e) Responsibility of Licensee









 Plan of Correction - To be completed: 01/04/2022

Resident CR1 is no longer in the building.

A two week look back of current residents will be completed to determine if there were potential allegations of abuse/neglect that need to be investigated.

Staff will be re-educated on the facility abuse policy.

Facility NHA or designee will complete weekly audits X 4 weeks and monthly X 3 to ensure policy is being followed appropriately. The audits will be reviewed at the monthly QA meeting.

January 4, 2022
483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and the residents' representative in a language and manner that could be understood for two out of five residents reviewed (Residents CR1 and CR2).

Findings include:

A review of the clinical record revealed that Resident CR1 was transferred to the hospital on October 25, 2021 and did not return.

The facility was unable to provide evidence of the written transfer notice provided to Resident CR1's responsible party.

A review of the clinical record revealed that Resident CR2 was transferred to the hospital on October 31, 2021 and did not return.

A review of the transfer notice provided to Resident CR2's responsible party indicated that the resident was transferred to the hospital for " 'triangle symbol' in condition." The triangle symbol indicates "change," a medical symbol taken from the Greek letter delta which stands for difference used for change.

Interview with the Nursing Home Administrator on November 9, 2021, at 2:00 PM, confirmed that written notices provided to the resident and residents' representative did not note the reason for the residents' transfer in a language that could be easily understood.


28 Pa. Code 201.29(h) Resident rights

28 Pa. Code 201.14(a) Responsibility of Licensee




 Plan of Correction - To be completed: 01/04/2022

Resident CR1 is no longer in the facility. Resident CR2 family has been notified that he was transferred and the reasoning for the transfer.

A two week look back of current residents will be completed to ensure any residents that transferred out of the facility had the appropriate paperwork in a language they can understand sent with them.

Licensed nurses will be re-educated on not using Greek symbols when documenting. Licensed nurses will also be re-educated on the paperwork that needs to accompany residents when a transfer occurs. A copy of the paperwork will then be placed with the receptionist.

Facility DON or designee will complete a weekly audit X 4 weeks and monthly X 3 to licensed staff are not using Greek symbols when documenting and transfer paperwork is having been completed and sent with the resident at time of a transfer. The audits will be reviewed at the monthly QA meeting.

January 4, 2022
483.40 REQUIREMENT Behavioral Health Services: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.
483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to ensure each resident is provided with necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of five residents reviewed (Resident 1).

Findings include:


Review of Resident 1's clinical record revealed admission to the facility on September 21, 2021, and had diagnoses of Major Depression (major loss of interest in pleasurable activities, characterized by change is sleep patterns, appetite and/or daily routine); Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability); Anxiety (intense, excessive and persistent worry and fear about everyday situations); and Suicidal Ideation (means thinking about or wanting to take your own life.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's needs) of Resident 1, dated September 26, 2021, revealed that the resident's BIMS score (brief interview for mental status) indicated she was moderately impaired with a score of 12 out of 15.

Nursing noted on October 20, 2021, at 11:11 PM, Resident 1 was "getting irritated with roommates yelling."

Nursing noted on October 23, 2021 at 2:34 PM that Resident 1 was "upset with roommate yelling all night and throwing items around the room. Requesting a room change."

On October 24, 2021, staff heard a resident yelling "help me, help me, coming from resident in 10 window (Resident CR1) and she became quiet so I ran in to check on her. Found this resident (Resident 1) on the side of the roommates bed. This resident (Resident 1) then threatened to stab window bed roommate"

There was no documented evidence that the facility had developed and implemented a person-centered care plan that included and supporedt the behavioral health care needs of Resident 1 and to manage the resident's major depression and displayed agitation. There was no documented evidence that the facility had provided the resident with meaningful activities which promoted engagement and that addressed the resident's customary routines, interests, preferences, etc. and enhance the resident's well-being;

Interview with the Nursing Home Administrator on November 9, 2021, at approximately 2:00 PM revealed that the facility was unable to provide evidence that Resident 1 that when the resident was expressing irritation due to outbursts from roommate and requested a room change that the facility had provided the necessary care and services to address the resident's behavioral health needs.



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

28 Pa. Code 211.16(a) Social Services

28 Pa. Code 211.11(d)(e) Resident care plan







 Plan of Correction - To be completed: 01/04/2022

Resident 1 will have a comprehensive activity assessment completed to ensure that the facility can provide her with meaningful activities which promote engagement and that the resident's customary routines, interests, preferences, etc. to enhance the resident's well-being. Resident 1 will have a person-centered care plan completed to include and support the behavioral health care needs to manage the resident's major depression and agitation.

An audit of current residents will be completed to ensure the facility is providing meaningful activities which promote engagement and the resident's customary routines, interests and preferences. A facility audit will be completed to ensure current residents have a person-centered care plan completed to support behavioral health care concerns, major depression and agitation.

Activities staff will be re-educated on assessing resident preferences, customary routines and interests in order to provide meaningful activities. Licensed staff and the activity director will be re-educated on developing person centered care plans to include and support behavioral health care needs to manage a resident's major depression and agitation.

The DON or designee will complete weekly audits X 4 and monthly X 3 to ensure residents have person centered care plans to include and support behavioral health care needs and major depression are completed. Director of Activities or designee complete weekly audits X 4 and monthly X 3 to ensure residents have meaningful activities which promote self-engagement, interests and preferences. The audits will be reviewed at the monthly QA meeting.

January 4, 2022

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