Pennsylvania Department of Health
HICKORY HOUSE NURSING HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

HICKORY HOUSE NURSING HOME
Inspection Results For:

There are 87 surveys for this facility. Please select a date to view the survey results.

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HICKORY HOUSE NURSING HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance Survey and an Abbreviated survey in response to a complaint completed on May 31, 2024, it was determined that Hickory House Nursing Home 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 as they relate to the Health portion of the survey.

Plan of Correction:

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

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.

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on facility policy and procedure review, clinical record review, and staff interviews, it was determined the facility failed to thoroughly investigate incidents for three of 32 residents reviewed. (Residents 2, 95, and 155)

Findings include:

Review of facility policy and procedure titled Protection of Residents: Reducing the Threat of Abuse & Neglect, reviewed May 15, 2020, revealed "when an incident of or suspected incident of resident abuse and/or neglect of unknown source, exploitation or misappropriation of resident property is reported the administrator/designee will investigate the occurrence. The administrator/designee will complete an Incident Report and will utilize the Incident Investigation Questionnaire Form to document the investigation. The written summary of the investigation should include, but is not limited to: a review of the incident report, an interview with the person reporting the incident, interviews of any witnesses to the incident, an interview with the resident if appropriate, a review of the residents medical record, an interview with employees as needed, a review of the employees file as needed, Interviews with staff members on all shifts having contact with the resident at the time of the incident. Interview with the resident's roommate, family, and or visitors which may have information regarding the incident, interview other resident who received care and services from the alleged perpetrator, a review of all circumstances surrounding the incident."

Review of Resident 2's clinical record revealed the following diagnosis: Unspecified Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Cognitive communication deficit (difficulty with communication that is caused by a problem with thinking), Anxiety disorder (intense, excessive and persistent worry and fear about everyday situations.), Major Depressive disorder (a persistent feeling of sadness and loss of interest).

Additional review of Resident 2's clinical record revealed Resident 2 was actively prescribed Eliquis (blood thinner, blocks the activity of certain clotting substances in the blood).

Review of Resident 2's progress notes revealed a progress note dated April 23, 2024, which states the following "On this night the CAN (Certified nursing assistant) informed me that this resident had blood on his hand, wrist and on many tissues in the trash can. When assessing the situation, there was a band aide soaked with blood on his left wrist. When the band aide was removed the area was still bleeding. There was approximately a straight line cut approximately 1 centimeter long with no depth nor width on his left wrist. The area kept bleeding. The edges were approximated with 2 steri strips (strong adhesive bandages. They're often used to hold together the edges of a cut or wound, providing support for healing) after cleansing with NSS (normal saline solution). A pressure dressing of 4x4's was applied and wrapped with cling".

Interview conducted with Resident 2 on May 29, 2024, at 1:18 p.m. reported that he/she does not remember how he/she sustained a laceration but remembers a male nurse placing a band aid on his wrist.

Review of incident report, provided by the Director of Nursing (DON) on May 30, 2024, failed to contain any documentation identifying the nurse that treated Resident 2's wound and failed to provide any evidence of the nurse notifying the supervisor.

Additional review of the incident report revealed the DON failed to attain any witness statements.

Interview conducted with the Nursing Home Administrator on May 31, 2024, at 11:47 a.m. confirmed the incident was not thoroughly investigated.

Review of Resident 95's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and Metabolic Encephalopathy (A group of neurological disorders that affects the brain due to a chemical imbalance in the blood).

Review of Resident 95's Admission Minimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) revealed resident had a severe cognitive impairment.

Review of Resident 95's nursing progress notes dated April 26, 2024, at 7:57 p.m., revealed that at around 9:30 p.m., the nursing supervisor received a call from a state trooper stating that the resident had called 911 due to feeling of not being safe in the facility. The resident informed the nursing supervisor that he/she did not feel safe and would like his/her sleeping pill. The state trooper came to the facility and spoke to the resident who reported that he/she was beaten and tossed into bed by two men. Documentation revealed that as per the trooper, the resident's description of the men who tossed him/her in bed was that of an EMT staff.

Review of the facility documentation, Incident Report revealed that on April 26, 2024, at 7:30 p.m., the RN supervisor received a call from the state trooper stating that the resident had called 911 due to not feeling safe in the facility. The report revealed that as per the resident description, he/she was beaten and tossed in bed by two men. The resident was assessed, and the physician and POA were notified.

Review of Resident 95's clinical records and facility documentation failed to reveal that a statement was taken from staff that had or possibly was in contact with the resident.

Interview with the Director of Nursing conducted on May 31, 2024, confirmed that there was no documented evidence that staff who had or possibly had contact with the resident was interviewed.

The facility failed to ensure Resident 95's allegation of physical abuse was comprehensively investigated.

Review of Resident 155's census tab of the clinical record revealed the resident was admitted to the facility on April 22, 2024 from the hospital after a surgical repair of a fractured hip.

Review of Resident 155's Progress Notes revealed a Nursing Entry dated April 23, 2024 at 12:03 a.m. stating, "This RN (Registered Nurse) was alerted by CNA (Certified Nursing Assistant) that while providing incont (incontinent) care she saw a gold point sticking out of resident's anus; while attempting to wipe resident's buttocks a fully intact writing pen came out of resident's rectum. Resident Alert with confusion and unable to explain how the pen became lodged in his rectum and denied pain. Resident was assessed for trauma none noted".

Facility was asked to provide all documentation related to the investigation of this incident upon admission for Resident 155. An incident report was provided but there was no documented evidence any staff, or residents had been interviewed or that the company that had transported the resident to the facility from the hospital, or the hospital itself was contacted by the facility for investigation into this incident.

Interview with the Nursing Home Administrator and the Director of Nursing on May 31, 2024 at 11:30 a.m. confirmed there was not a thorough investigation into the incident to Resident 155 upon admission on April 22, 2023.

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

28 Pa. Code 201.29(a)(d) Resident Rights

28 Pa. Code 211.5(f) Clinical Records

Plan of Correction - To be completed: 06/19/2024

This Plan of Correction constitutes the facility's written allegation of compliance for the deficiencies cited. However, submission of the Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.

The incidents for Residents 2, 95 and 155 were reviewed by the interdisciplinary team and a thorough investigation completed as able.

An audit will be completed by the Director of Nursing/designee of the last 30 days of incidents to ensure a thorough investigation was completed.

Education will be given by Staff Development/designee to interdisciplinary staff on how to complete a thorough investigation including review of the incident report, obtaining of required interviews and a review of all circumstances surrounding the incident.

An audit will be completed weekly x 4 weeks and monthly x 2 months on incident investigations by the DON/Designee. Findings will be reviewed during QAPI.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Plan of Correction - To be completed: 06/19/2024

Physician updated on R9's missing vancomycin doses and R51 and R95's medications given outside of the parameters as noted in the physician order.

A random audit of the last 30 days of physician orders will be completed by the Director of Nursing/designee to ensure orders were followed and the physician notified of any missed doses.

Education will be given by Staff Development/designee to nursing staff on following physician orders and notifying the Physician of any missed medications.

A random audit will be completed weekly x 4 weeks then monthly x 2 months on physician orders to ensure orders were followed and the physician was notified of missed medications. Findings will be reviewed during QAPI.

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 clinical records review, facility documentation review, and staff interviews, it was determined that the facility failed to provide appropriate assessment and supervision to prevent a fall for one of the 24 residents reviewed (Resident 35).

Findings include:

Review of resident 35's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), and Cerebral Vascular Accident (CVA- interruption in the flow of blood to cells in the brain).

Review of Resident 35's AdmissionMinimum Data Set (MDS- standardized assessment tool that measures health status in long-term care residents) dated November 22, 2023, revealed Resident 35 had a severe cognitive impairment and was dependent on transfers. The same MDS revealed car transfer assessment was not attempted due to medical conditions or safety concerns.

Review of the active care plan initiated on November 22, 2023, revealed a care plan for ADLs (activities of daily living) which indicated that Resident 35 was an extensive assistance with two (persons) with transfers using the hemi walker (A kind of walker used for patient with full or partial paralysis on one side of the body).

Review of the facility documentation and incident Report revealed that on January 1, 2024, at 11:45 a.m., the resident was found on the floor in the driveway outside of the facility by the main entrance on the passenger side of the family van. The family (grandson) signed the resident out for an outing. As per the resident, her/his knees got weak, and was unable to stand to get into the van causing the fall.

Interview conducted with the Director of Nursing on May 31, 2024, revealed that for a resident going out on pass and requiring a two-person assist with transfers, rehab will be notified to assess the resident's safety with car transfers.

Interview conducted with licensed Physical Therapist Employee E3 conducted on May 31, 2024, revealed that the rehab department was not notified that Resident 35 was going out on pass with a family. Employee E3 reported that a car transfer assessment would have been done if they had been informed.

Review of the facility documentation revealed that on January 1, 2024, at 10:22 p.m., Resident 35 was assisted by an aide from a wheelchair to the bed but slipped from the chair, the aide lowered the resident to the floor and called for help.

Review of the unlicensed employee E5 statement dated January 1, 2024, revealed: "I attempted to pivot transfer patient from a chair to bed". The same statement revealed resident was lowered to the floor when she/he slipped.

Interview conducted with the Diretor of Nursing on May 31, 2024, confirmed Resident 35 was provided with one person to assist with transfers on the night of January 1, 2024, despite needing a two-person assist with the use of hemi-walker as documented on the resident's plan of care.

The facility failed to ensure Resident 35 was provided with appropriate assessment and supervision to prevent two falls in a day.

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

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 06/19/2024

A transfer assessment was completed for R35. Employee E5 is no longer working at the facility.

An audit will be completed by the Director of Rehab/designee to identify residents who have a leave of absence order and require assistance for transfers to ensure an assessment was completed for safe car transfers.

Education will be provided to nursing staff by Staff Development/designee to be aware of resident transfer status before transferring a resident. Education will be provided by Staff Development/designee to staff on ensuring a transfer assessment has been completed by the Rehab Department and the family is aware of the resident's transfer status prior to the resident leaving on a leave of absence.

An audit will be completed weekly x 4 weeks and monthly x 2 months on residents leaving the facility for LOA to ensure a transfer assessment was completed and the family educated on transfer status. Findings will be reviewed during QAPI.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Plan of Correction - To be completed: 06/19/2024

A physician order was obtained for R205's oxygen use.

An audit will be completed by the Director of Nursing/designee for resident's using oxygen to ensure a physician order is in place.

An education will be provided by Staff Development/designee to licensed nursing staff to ensure that an oxygen order is in place prior to administering oxygen.

A random observation audit will be completed weekly x 4 weeks then monthly x 2 months by the Director of Nursing/designee on residents using oxygen to confirm a physician order is in place. Findings will be reviewed during QAPI.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on facility policy and procedure review, clinical record review and staff interview it was determined the facility failed to ensure residents did not receive unnecessary medications for one of six residents reviewed. (Resident 79)

Findings Include:

Review of facility policy and procedure titled Definition of Infections for Surveillance Activities, last reviewed May 16, 2024 revealed "Identification of infection should not be based on a single piece of evidence but should always consider the clinical presentation and any microbiologic (lab studies) or radiologic (X-rays, CT scan etc. ...) information that is available. Microbiologic and radiologic findings should not be the sole criteria for defining an event as an infection. Similarly, diagnosis by a physician alone is not sufficient for a surveillance definition of infection and must be accompanied by documentation of complete signs and symptoms."

Review of Resident 79's progress notes revealed a nursing entry dated May 10, 2024 at 2:17 p.m. stating "CNA (Certified Nursing Assistant) to desk stating resident complaining of dysuria (pain during urination) and was noted to have drops of blood on his penis and in brief." Doctor's office "called, await call back."

Review of the entire clinical record revealed there was no documented evidence of an assessment of the resident completed by a nurse on Resident 79 related to his complaint of dysuria and the blood noted by the CNA.

Further review of Resident 79's progress notes revealed a nursing entry dated May 10, 2024 at 2:30 p.m. stating Doctor's office "returned phone call and was updated on resident. He said because it is Friday afternoon and resident is symptomatic with noted blood, he ordered antibiotic."

Review of the entire clinical record revealed there was no evidence Resident 79's urine was tested to confirm a urinary infection.

Review of Resident 79's Medication Administration Record (MAR) revealed the resident received Amoxicillin-Pot Clavulanate (antibiotic) Tablet 500-125 MG (milligrams) twice a day for five days from May 11-15 2024 for a diagnosis of probable UTI (Urinary Tract Infection).

Interview with the Director of Nursing and the Nursing Home Administrator on May 31, 2024 at 11:30 a.m. confirmed Resident 79 did not have a nursing assessment to confirm the signs and symptoms reported to the RN by the CNA or a laboratory study to confirm a UTI and the sensitivity of the organism causing the infection prior to the administration of antibiotics.

28 Pa Code 211.5 (f) Clinical records

28 Pa code 211.10 (c) Resident care policies

28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/19/2024

A clinical review for R79 was completed after completion of antibiotic which shows resolution of urinary infection symptoms with no adverse effects.

An audit was completed of the last 60 days of antibiotic orders by the Director of Nursing/designee to determine if clinical presentation of infection was present with nursing assessment and laboratory testing completed with a positive result prior to the administration of medication.

An education will be completed by Staff Development/designee on documentation of a clinical presentation of infection, completion of a nursing assessment and obtaining of laboratory testing prior to obtaining a physician order for treatment of infection.

An audit will be completed weekly x 4 weeks then monthly x 2 months by the Director of Nursing/designee on antibiotic orders to confirm an infection is present, assessment completed and documentation in place prior to administration of medication. Findings will be reviewed during QAPI.

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