Nursing Investigation Results -

Pennsylvania Department of Health
SUSQUEHANNA HEALTH AND WELLNESS CENTER
Patient Care Inspection Results

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SUSQUEHANNA HEALTH AND WELLNESS CENTER
Inspection Results For:

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SUSQUEHANNA HEALTH AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated survey completed on June 23, 2022, in response to four complaints at Susquehanna Health and Wellness Center, it was determined that the facility was not in compliance with the following requirements of the 42 CFR part 483, Subpart B, Requirements for Long Term Care and the PA 28 Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.


 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to timely notify the resident representatives of a positive Covid19 test for 14 of 31 residents reviewed (Residents 1-14).

Findings include:

Review of facility policy, "Change in a Resident's Condition or Status", revised February 2021, revealed that a nurse will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status.

Review of Resident 1's annual MDS (Minimum Data Set - periodic assessment of resident needs) dated June 1, 2022, revealed a BIMS (brief interview for mental status) score of 10, indicating moderate cognitive impairment.

Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.

Review of Resident 2's quarterly MDS assessment of May 20, 2022, revealed a BIMS score of 4, indicating severe cognitive impairment.

Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.

Review of Resident 3's annual MDS assessment of May 5, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.

Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.

Review of Resident 4's admission MDS assessment of May 3, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.

Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.

Review of Resident 5's quarterly MDS assessment of May 12, 2022, revealed a BIMS score of 4, indicating severe cognitive impairment.

Review of progress note of June 6, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.

Review of Resident 6's annual MDS assessment of March 3, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.

Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19,but failed to reveal timely notification to resident representative.

Review of Resident 7's annual MDS assessment of April 13, 2022, revealed a BIMS score of 1, indicating severe cognitive impairment.

Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.

Review of Resident 8's quarterly MDS assessment of April 14, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.

Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.

Review of Resident 9's quarterly MDS assessment of March 25, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.

Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19, but failed to reveal timely notification to resident representative.

Review of Resident 10's quarterly MDS assessment of March 29, 2022, revealed a BIMS score of 4, indicating severe cognitive impairment.

Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19.

Review of Resident 11's quarterly MDS assessment of May 30, 2022, revealed a BIMS score of 3, indicating severe cognitive impairment.

Review of progress note of June 7, 2022, revealed resident tested positive for Covid 19.

Review of Resident 12's annual MDS assessment of April 20, 2022, revealed a BIMS score of 9, indicating moderate cognitive impairment.

Review of progress note of June 8, 2022, revealed resident tested positive for Covid 19.

Review of Resident 13's quarterly MDS assessment of May 31, 2022, revealed both short and long term memory impairment.

Review of progress note of June 8, 2022, revealed resident tested positive for Covid 19.

Review of Resident 14's quarterly MDS assessment of March 16, 2022, revealed a BIMS score of 11, indicating moderate cognitive impairment.

Review of progress note of June 9, 2022, revealed resident tested positive for Covid 19.

Further review of the clinical records revealed no evidence that that resident representatives were made aware of the resident testing positive for Covid 19.

Interview with the Nursing Home Administrator on June 23, 2022, at 11:45 confirmed that there was no documentated evidence of the notification.

28 Pa. Code: 211.5(f) Clinical records
Previously cited 5/19/22

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




 Plan of Correction - To be completed: 07/12/2022

The facility cannot retroactively correct the deficiency for notification of resident representatives of significant changes timely.

The facility will complete a 7 day look back of resident changes in condition to ensure timely notification of resident changes to responsible parties as necessary. The IDCP team will review progress notes in the daily clinical meeting to identify any resident representatives that may need notified of a resident significant change in condition.

The Director of Nursing/designee will educate licensed nurses on the policy entitled, "Change in a Resident Condition." The education will include notifying resident representatives when there is a significant change in the resident's physical, mental or psychological status as necessary.

Audits will be completed 3 x weekly x 4 weeks then monthly x 2 months. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.


211.12(k) LICENSURE Nursing services.:State only Deficiency.
(k) Weekly time schedules shall be maintained and shall indicate the number and classification of nursing personnel, including relief personnel, who work on each tour of duty on each nursing unit.
Observations:
Based on review of facility nurse staffing data it was determined that the facility failed to maintain a minimum of 2.7 hours of direct resident care for each resident in a 24 hour period.

Findings include:

A review of nursing staffing hours for the weeks of May 29, 2022 through June 18, 2022, revealed that the facility's 24 hour daily nurse staffing was below 2.7 hrs per resident on the following days:

June 11, 2022 - 2.43 nursing hours per resident
June 13, 2022 - 2.32

Interview with the Nursing Home Administrator on June 23, 2022, at 2:00 p.m. confirmed that the facility was below the minimum of 2.7 hours on June 13, 2022, and had reported that through the event reporting system to the Department of Health.




 Plan of Correction - To be completed: 07/12/2022


The facility will provide staffing at a minimum of 2.7 hour per patient day or above to appropriately meet the needs of the residents. The Administrator, Nursing Management Team and Nursing Scheduler will review the nursing schedule and deployment sheets daily Monday through Friday, to include projected weekend hours and validate appropriate direct resident care hours.

Facility residents have the potential to be affected by this practice.

The Administrator, the Nursing Management team and the nursing scheduler will be re-educated concerning minimum nursing staffing hours, the calculation of direct resident care hours and the appropriate response to unplanned variations in hours. Direct care hours will be audited by the Nursing Home Administrator/designee during the daily review of nursing schedules and deployment sheets to ensure that 2.7 hours of direct resident care or more is maintained.

The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.


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