Nursing Investigation Results -

Pennsylvania Department of Health
COMPLETE CARE AT HARSTON HALL LLC
Patient Care Inspection Results

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COMPLETE CARE AT HARSTON HALL LLC
Inspection Results For:

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COMPLETE CARE AT HARSTON HALL LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey, completed on November 2, 2021, it was determined that Complete Care at Harston Hall, was not in compliance with the 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 related to the health portion of the survey process.



 Plan of Correction:


483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record reviews, review of facility policy and interviews with residents and staff, it was determined that the facility failed to implement restorative nursing programs for five of 25 residents reviewed (Residents R62, R3, R32, R48 and R12).

Findings include:

Review of facility policy, revised October 2019, "Restorative Nursing Services" revealed residents will receive restorative nursing care as needed to help promote optimal safety and independence. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care.

Interview conducted on October 29, 2021, at 12:12 p.m. with Resident R32 stated that it's been over one week since he has gotten out of bed because staff do not offer assistance to get him out of bed. Resident R32 also indicated that he does not receive therapy or restorative nursing services.

Clinical record review for Resident R32 revealed a Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated September 1, 2021, which indicated that the resident required extensive assistance from two or more staff persons for transfers, extensive assistance from one staff person for toileting and hygiene, and that the resident used a walker and wheelchair for mobility.

Review of Resident R32's care plan, dated last updated September 28, 2021, revealed that the resident has a restorative nursing program with a goal to ambulate 40 to 50 feet daily.

Review of Resident R32's Physical Therapy Discharge Summary, dated September 17, 2021, revealed that a restorative nursing program (RNP) was recommended for ambulation (walking) and that the resident's prognosis to maintain his current level of function was excellent with participation in the established RNP. Review of Resident R32's Rehab Referral to Restorative Nursing, dated September 15, 2021, revealed that physical therapy recommended for the resident to ambulate 40 to 50 feet daily with a rolling walker with caregiver support.

Review of Resident R32's Occupational Therapy Discharge Summary, dated October 14, 2021, revealed that a RNP was recommended for toilet/commode transfers. Review of Resident R32's Rehab Referral to Restorative Nursing, dated October 12, 2021, revealed that occupational therapy recommended for the resident to complete toilet or bedside commode transfers with contact guard and that staff are to provide assistance with transfers and hygiene.

Review of nurse aide documentation from October 4, 2021, through November 2, 2021, for Resident R32 related to his RNP for walking revealed that the resident received this RNP only one day, on October 19, 2021. All the other dates with documentation available indicated "not applicable" was documented by nurse aide staff.

Review of nurse aide documentation from October 14, 2021, through November 2, 2021, for Resident R32 related to his RNP for transfers revealed that the resident received this RNP only one day, on October 19, 2021. The resident refused on November 2, 2021. All the other dates with documentation available indicated "not applicable" was documented by nurse aide staff.

Interview on October 29, 2021, at 11:25 a.m. Resident R12 stated that he needs exercises to improve his strength because he is in a wheelchair and that he does not receive therapy or RNP services.

Review of Resident R12's Annual MDS, dated August 26, 2021, revealed that the resident required extensive assistance from two or more staff persons for bed mobility and transfers. The resident had functional limitations in range of motion to both lower extremities and used a wheelchair for mobility.

Review of Resident R12's care plan, dated last updated September 30, 2021, revealed that the resident has a restorative nursing program with a goal to complete an exercise program daily.

Review of Resident R12's Rehab Referral to Restorative Nursing, dated April 21, 2021, revealed that occupational therapy recommended for the resident to complete an exercise program daily when in wheelchair.

Review of nurse aide documentation from October 5, 2021, through November 2, 2021, for Resident R12 related to his RNP for range of motion revealed that the resident received this RNP on ten days. All the other dates with documentation available indicated "not applicable" was documented by nurse aide staff.

Interview on October 29, 2021, at 11:44 a.m. Resident R62 stated that he has not been receiving therapy services or any daily exercises and that he is not offered assistance to get out of bed.

Review of Resident R62's Annual MDS, dated October 11, 2021, revealed that the resident required extensive assistance from two or more staff persons for bed mobility and used a wheelchair for mobility.

Review of Resident R62's care plan, dated last updated May 3, 2021, revealed that the resident has a restorative nursing program with a goal to move bilateral upper and lower extremities through a normal range of motion without discomfort.

Review of Resident R62's Physical Therapy Discharge Summary, dated December 24, 2020, revealed that a RNP was recommended for therapeutic exercises and that the resident was "very motivated." Review of Resident R62's Rehab Referral to Restorative Nursing, dated December 3, 2020, revealed that physical therapy recommended for the resident to perform active range of motion exercises daily to bilateral hips, knees and ankles.

Review of nurse aide documentation from October 4, 2021, through November 2, 2021, for Resident R62 related to his RNP for range of motion revealed that the resident received this RNP only two days, on October 19 and 27, 2021. All the other dates with documentation available indicated "not applicable" was documented by nurse aide staff.

Interview on October 29, 2021, at 12:55 p.m. Resident R48 stated that he his therapy services just ended and that he wants RNP services.

Review of Resident R48's Quarterly MDS, dated September 29, 2021, revealed that the resident required extensive assistance from two or more staff persons for bed mobility and transfers. The resident had functional limitations in range of motion to both upper and lower extremities and used a wheelchair for mobility.

Review of Resident R48's care plan, dated last updated October 22, 2021, revealed that the resident has a restorative nursing program with a goal to receive assistance with wheelchair to bed transfers via stand pivot and contact assistance.

Review of Resident R48's Physical Therapy Discharge Summary, dated October 15, 2021, revealed that a RNP was recommended for transfers from bed to wheelchair.

Review of nurse aide documentation from October 25, 2021, through November 2, 2021, for Resident R48 related to his RNP for transfers revealed that the resident did not receive this RNP on any days. All dates with documentation available indicated "not applicable" was documented by nurse aide staff.

Interview on November 1, 2021, at 1:15 p.m. Employee E9, nurse aide, stated that nurse aide staff provide RNP to residents and document all RNP provided in the residents' electronic health record.

Interview on November 1, 2021, at 4:00 p.m. the Director of Nursing (DON) indicated that he was aware that nurse aide staff were documenting "not applicable" and that education was being provided to nurse aide staff regarding proper coding and documentation of RNP. The DON was unable to provide any documentation to indicate if RNP services were actually being offered or provided to residents by nurse aide staff for days marked "not applicable."

Review of facility in-service education records, dated October 21, 2021, revealed that Employees E9 and E10, nurse aides, received education regarding RNP and proper documentation and coding in electronic health records.

Further review of nurse aide documentation for Resident R62 revealed that Employee E9 continued to document "not applicable" related to the resident's RNP for range on motion on October 23, 26, 28 and November 1, 2021. Employee E10 also continued to document "not applicable" related to the resident's RNP for range on motion on October 30 and 31, 2021.

Further review of nurse aide documentation for Resident R32 revealed that Employee E9 continued to document "not applicable" related to the resident's RNP for walking on October 23, 26, 27, 28, 29 and November 1 and 2, 2021, as well as for the resident's RNP for transfers on October 23, 26, 27, 28, 29 and November 1, 2021.

Follow-up interview on November 2, 2021, at 11:39 a.m. the DON confirmed that Employees E9 and E10 continued to document "not applicable" for RNP services even though they attended the in-service education on October 21, 2021. The DON stated, "that's why there's another in-service scheduled."

Review of clinical record for Resident R3 revealed the resident was admitted to the facility on October 12, 2020 with diagnoses that included contracture (tightening of the muscles, tendons, skins, and nearby tissues that causes joints to become stiff) of left/right knee, right ankle, and right hand.

Review of Resident R3's Annual MDS dated October 26, 2021 revealed the resident required extensive assistance for bed mobility from two or more staff, and had impaired range of motion to bilateral, lower extremities.

Review of Resident R3's Physical Therapy Discharge Summary dated November 10, 2020, revealed that a restorative nursing program was recommended for bilateral lower extremity active and active assisted range of motion for both ankles, both knees and hips within available range as tolerated to improve functional mobility and skills.

Review of Resident R3's clinical record revealed no evidence that the restorative nursing program was initiated as recommended by physical therapy.

Interview on November 2, 2021 at 1:00 p.m. with alert and oriented Resident R3 indicated that the resident was not offered daily therapeutic exercises.

Review of Resident R3's comprehensive care plan revealed it did not address the resident's need for restorative nursing program with goals and objectives that are individualized and resident-centered.

Interview on November 2, 2021 at 2:30 p.m. with the Director of Nursing revealed the facility was unable to explain why the restorative nursing program was not initiated for Resident R3.

28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.12(d)(5) Nursing services



 Plan of Correction - To be completed: 12/28/2021

#1 Resident R32 is not on a restorative program for refusal to participate. Resident re-educated on Restorative Nursing Program benefits but has declined to participate. Resident R12 is currently on a restorative nursing program with the correct documentation. Resident R62 is currently on a restorative nursing program with the correct documentation. Resident R48 is currently on a restorative nursing program with the correct documentation. Resident R3 is not on a restorative program for refusal to participate. Resident re-educated on Restorative Nursing Program benefits but has declined to participate.
#2 Current residents on a restorative nursing program will be reviewed to ensure that the facility implements a Restorative Nursing Program.
#3 Nurse Practice Educator/Designee will re-educate nursing staff on ensuring the facility implements a Restorative Nursing Program.
#4 Center Nurse Executive/Designee will conduct random weekly audits to ensure the facility provides restorative nursing care as needed to help promote optimal safety and independence and ensure goals and objectives are individualized and resident-centered and are outlined and documented accurately in the resident's plan of care.
#5 Results of audits will be reviewed at monthly Quality Assurance Meeting.

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 review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that the consultant pharmacist recommendations were reviewed by the physician in a timely manner for three of six residents reviewed for medication regimen reviews (Residents R24, R32 and R28).

Findings include:

Review of facility policy, "Pharmacy Services - Role of Consultant Pharmacist" dated revised April 2019, revealed that, "The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to develop, implement, evaluate and revise the procedures for the provision of all aspects of pharmacy services, including procedures to support resident quality of life such as safe, individualized medication administration programs ... [and] develop mechanisms for communicating, addressing and resolving issues related to pharmaceutical services."

Review of facility policy, "Medication Regimen Review" dated November 28, 2016, revealed that, "The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record." Continued review revealed, "Facility should alert the Medical Director when Medication Regime Reviews are not addressed by the attending physician in a timely manner." Further review revealed, "The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident."

Review of Resident R28's clinical record revealed the resident was admitted to the facility July 30, 2020 and had diagnoses including dependence on renal dialysis, major depressive disorder, anemia (blood does not contain enough healthy red blood cells), and type 2 diabetes.

Review of consultant pharmacist's consultation report dated June 12, 2021, for Resident R28 revealed a recommendation to discontinue the resident's sliding scale insulin as prolonged use is not recommended. The report was not dated by the physician. Review Resident R28's physician orders revealed the sliding scale was not discontinued until September 29, 2021.

Review of consultant pharmacist's consultation report dated July 2, 2021, for Resident R28 revealed recommendations to discontinue one of the two renal (kidney specific) multivitamins Resident R28 was prescribed and to re-evaluate the need for additional folic acid (can treat certain types of anemia). The report was signed by the physician, with no date, to discontinue folic acid. Review of Resident R28's physician orders revealed the folic acid was not discontinued until November 1, 2021.

Review of consultant pharmacist's consultation report dated August 11, 2021, for Resident R28 revealed recommendations to discontinue Duloxetine (anti-depressant medication) as this medication is not recommended in individuals with end-stage renal disease receiving dialysis. Report was not signed and dated by the physician until November 1, 2021. Review of Resident R28's physician orders revealed the medication was not adjusted until November 1, 2021.

Review of consultant pharmacist's consultation report dated August 25, 2021, for Resident R28 revealed recommendations to discontinue use of Lorazepam (anti-anxiety medication). Review of Resident R28's physician orders revealed Ativan was not discontinued until November 1, 2021. The report was not signed and dated by the physician until November 2, 2021.

Review of Resident R32's Quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) dated September 1, 2021, revealed diagnoses including heart failure, high blood pressure, peripheral vascular disease (impaired blood flow), renal (kidney) failure, diabetes (a group of diseases that result in too much sugar in the blood) high cholesterol and depression.

Review of the consultant pharmacist's consultation report, dated April 14, 2021, for Resident R32 revealed a recommendation to reduce the dose or discontinue the resident's Pioglitazone (medication used to treat diabetes).

Review of the consultant pharmacist's consultation report, dated May 18, 2021, for Resident R32 revealed recommendations to reduce the resident's dose of Escitalopram (medication used to treat depression) and to clarify a diagnosis or rationale for the resident's use of Rivaroxaban (a blood thinning medication used to treat blood clots).

Review of the consultant pharmacist's consultation report, dated June 10, 2021, for Resident R32 revealed a repeated request to reduce the dose or discontinue the resident's Pioglitazone (medication used to treat diabetes).

Continued review of consultant pharmacist reports for Resident R32 revealed that the report from April 14, 2021, was not signed or dated by the physician until June 23, 2021. The dosage was reduced at that time.

Further review of consultant pharmacist reports for Resident R32 revealed that the reports from May 18 and June 10, 2021, were not dated by the physician.

Review of physician orders for Resident R32 revealed that the order for Escitalopram was not clarified until November 1, 2021. Continued review revealed that the order for Rivaroxaban was not clarified until November 2, 2021.

Interview on November 2, 2021, at 10:46 a.m. Employee E4, unit manager, confirmed that the consultant pharmacist recommendations for Resident R32 were not reviewed by the physician in a timely manner and stated that the process "needs to be worked on."

Review of Resident R24's Quarterly MDS dated August 13, 2021, revealed diagnoses including anemia (low red blood cells), diabetes, high cholesterol, stroke, paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), anxiety and depression( a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.)

Review of the consultant pharmacist's consultation report, dated April 14, 2021, for Resident R24 revealed recommendations to clarify the instructions for the resident's use of Alendronate (a medication used to treat osteoporosis/thinning bones). The report was not signed or dated by the physician until June 23, 2021.

Review of the consultant pharmacist's consultationrReport, dated June 10, 2021, for Resident R24 revealed recommendations for monitoring lab values, including complete blood count monthly and liver and kidney function tests every two months, related to the resident's use of Methotrexate (an immunosuppressive drug used to treat rheumatoid arthritis). Review of laboratory results revealed that the resident has not had any of the above monitoring completed since February 19, 2021.

Review of the consultant pharmacist's consultation report, dated August 24, 2021, for Resident R24 revealed recommendations to consider discontinuing medications that have not been used in the past 60 days, including Voltaren gel (topical medication for pain relief), Simethicone (medication used to treat stomach discomfort), miralax (laxative), Loratadine (medication used to treat seasonal allergies) and Tums (medication used to treat stomach discomfort).

Further review of consultant pharmacist reports for Resident R24 revealed that the reports from June 10 and August 24, 2021, were not dated by the physician.

Review of physician orders for Resident R24 revealed that laboratory studies for a complete blood count and liver and kidney function tests were not ordered until November 2, 2021. Continued review revealed that the resident's Simethicone, Miralax, Loratadine, Tums were discontinued on November 2, 2021.

Interview on November 2, 2021, at 12:33 p.m. Employee E11, wound nurse, revealed that the consultant pharmacist reports for Resident R24 were just reviewed and addressed today. Employee E11 confirmed that the report from April 14, 2021, was not addressed timely and that the reports from June 10 and August 24, 2021, were not addressed until they were requested for review by the surveyor.

28 Pa Code 211.2(a) Physician services

28 Pa Code 211.9(k) Pharmacy services

28 Pa Code 211.12(d)(3) Nursing services






 Plan of Correction - To be completed: 12/28/2021

#1 Resident R28 pharmacy recommendations are completed, and medication list is accurate. Resident R32 pharmacy recommendations are completed, and medication list is accurate. R24 pharmacy recommendations are completed, and medication list is accurate.
#2 Current residents will be reviewed to ensure that the consultant pharmacist recommendations were reviewed by the physician in a timely manner.
#3 Nurse Practice Educator/Designee will re-educate nursing staff on ensuring that the consultant pharmacist recommendations were reviewed by the physician in a timely manner.
#4 Center Nurse Executive/Designee will conduct a monthly audit to ensure the consultant pharmacist recommendations were reviewed by the physician in a timely manner.
#5 Results of audits will be reviewed at monthly Quality Assurance Meeting.


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