Nursing Investigation Results -

Pennsylvania Department of Health
SHOOK HOME, THE
Patient Care Inspection Results

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SHOOK HOME, THE
Inspection Results For:

There are  48 surveys for this facility. Please select a date to view the survey results.

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SHOOK HOME, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure and Civil Rights survey and abbreviated survey in response to one complaint and one incident completed on August 15, 2019, it was determined that The Shook 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.








 Plan of Correction:


483.70(e)(1)-(3) REQUIREMENT Facility Assessment:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:


Based on review of the facility-wide assessment and staff interview, it was determined that the facility failed to ensure that the assessment included all of the required elements.

Findings include:

Review of the current facility-wide assessment revealed that the assessment was not completed and left blank for the following areas: staff levels and competencies that are necessary to provide the level and types of care needed for the resident population.

During an interview with the Nursing Home Administrator on August 15, 2019, at 11:36 AM he confirmed that the aforementioned information was not included in the facility assessment.

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








 Plan of Correction - To be completed: 10/14/2019

Staff levels and competencies that are necessary to provide the level and types of care needed for the resident population will be completed and placed in the facility-wide assessment.

The Director of Corporate Compliance (or designee) conducted a root cause analysis of this incident and determined that the facility failed to include staff levels and competencies that are necessary to provide the level and types of care needed for the resident population in the facility-wide assessment.

Based on the root cause of the incident:

The Director of Corporate Compliance (or designee) will educate the Director of Nursing on the requirements of the facility-wide assessment including, but not limited to, staff levels and competencies.

The Director of Nursing (or designee) will update the facility assessment annually or upon a significant change in the resident population whichever comes first.

The Director of Corporate Compliance (or designee) will audit the facility wide assessment quarterly to ensure it is updated to reflect the needs of the current resident population.

The Director of Corporate Compliance (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.


483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on observations, select policy review, resident group interview and staff interviews, it was determined that the facility failed to ensure residents were knowledgeable and had access to forms to file an anonymous grievance for four of four residents interviewed (Residents 2, 13, 27, and 37).


Findings include:

During the Resident Group meeting on August 13, 2019, at 11:00 AM, the four residents attending (Residents 2, 13, 27, and 37) were asked if they knew how to file a grievance/concern and they responded that they would tell someone. When theses same residents were asked as to whether they knew how to filed an anonymous concern, they appeared to be puzzled and revealed they didn't know they could do that.

Review of the facility Policies and Procedures regarding Grievances (created November 2, 2016, with no revision date) revealed on Line 2 "Resident and/or Resident Representative may file a grievance either verbally or in writing by communicating the grievance with a member of the staff." Review of Line 4. revealed "RN (Registered Nurse ) Supervisor will complete a "Concern Form", located in the nursing medication room filing cabinet."

Observation was also made on August 13, 2019, that resident rooms had plastic holders mounted on the walls in their rooms which contained a binder with some resident directed information. Review of page 8 "CONCERNS" revealed the statement "The Shook Home makes every attempt to address concerns. See the Nursing Supervisor or Social Services for assistance. Your concerns will be addressed in a timely manner.

Review of facility grievance policy or written information provided to residents provided a process for enabling residents or Resident Representative to submit an anonymous grievance/concern.

During an interview with Nursing Home Administrator (NHA) on August 14, 2019, at 2:06 PM, the NHA revealed the expectation that filing an anonymous grievance would be an option.

28 Pa. Code 201.29(i) Resident Rights













 Plan of Correction - To be completed: 10/14/2019

Residents 2, 13, 27, and 37 will be educated on the process for filing an anonymous concern as contained herein.

All Residents and Resident Representatives will be educated on the process for filing an anonymous concern as contained herein.


The Director of Social Services (or designee) conducted a root cause analysis of this incident and determined that the facility failed to provide a means for residents and their representatives to file anonymous concerns.

Based on the root cause of the incident:

The Director of Social Services (or designee) will revise the facility policy regarding Grievances (created November 2, 2016) to include the process for filing anonymous concerns. This procedure will be as follows:

1. "Concern Forms" and return envelopes (self-addressed to the Director of Social Services) will be kept in the binders containing resident-directed information stored in the Resident rooms.

2. Residents and/or their Resident Representatives may complete the forms and place them in a mailbox located outside the Director of Social Services' office.

3. Residents may give the sealed envelopes to any nursing staff member to deposit them in the mailbox located outside the Director of Social Services' office if the Residents are unable to do so themselves.

4. The Director of Social Services (or designee) will check the mailbox Monday thru Friday during normal business hours. The Director of Social Services (or designee) will check the mailbox on the first business day following a weekend or holiday.

This procedure will also be added to page 8, titled "Concerns," in the binders containing resident-directed information stored in the Resident rooms.

The Director of Social Services (or designee) will educate all Registered Nurses (RNs), Licensed Practical Nurses (LPN's), and Certified Nurse Aides (CNAs) on the revised facility policy regarding Grievances (created November 2, 2016).

The Director of Social Services (or designee) will conduct an initial audit of all residents to ensure they know the process for filing an anonymous grievance.

The Director of Social Services (or designee) will then conduct a monthly audit of 25% of residents to ensure they know the process for filing an anonymous grievance.

The Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on observation, and interview it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety for one of two kitchenettes and in the main kitchen area.

Findings include:

Observation of the three compartment sink (three sinks attached together utilized to wash, rinse, and sanitize pots, pans, equipment and cooking/serving utensils) on August 12, 2019, at approximately 10:06 AM revealed that the Ph strips (litmus paper used to determine the concentration of the acidity of a liquid) utilized to test the concentration of the sanitizer solution contained an expiration date of October 18, 2018.

During an interview with the Food Service Director 1 (FSD 1) on August 12, 2019, at approximately 10:06 AM it was revealed that the facility obtains the Ph strips from the chemical supply company, and that she would request more test strips.

During an interview with the Nursing Home Administrator on August 14, 2019, at approximately 2:33 PM it was revealed that the test strips should not be expired.

Observation in the second floor kitchenette on August 12, 2019, at approximately 10:26 AM it was revealed that the bottom grate and inside the front edge of the white refrigerator was splattered with a red and brown liquid that was dried, the inside of the microwave was splattered with dried food particles, and the toaster was splattered with a dried brown liquid and excessive amount of crumbs.

During an interview with the Food Service Director 1 on August 12, 2019, at approximately 10:26 AM it was revealed that the aforementioned items are to be cleaned by dietary and/or housekeeping, and that the aforementioned items should be cleaned.

During an interview with the Nursing Home Administrator on August 14, 2019, at approximately 2:33 PM it was revealed that the aforementioned items should be clean.

28 Pa Code 211.6(b)(d) Dietary Services











 Plan of Correction - To be completed: 10/14/2019

The expired Ph. strips (litmus paper used to determine the concentration of the acidity of a liquid) used to test the concentration of the sanitizer solution will be replaced.

The refrigerator, microwave, and toaster in the second floor kitchenette will be cleaned.


The Director of Food Services (or designee) conducted a root cause analysis of this incident and determined that the facility failed to check the expiration dates on the Ph. Strips and failed clean the refrigerator, microwave, and toaster in the second floor kitchenette.

Based on the root cause of the incident:

The Director of Food Services (or designee) will draft a policy for checking the expiration dates on the Ph. Strips

The Director of Food Services (or designee) will draft a policy (including a schedule) for cleaning the refrigerators, microwaves, and toasters in both the first and second floor kitchenettes

The Director of Food Services (or designee) will educate the Cooks and Dietary Aides on the two aforementioned policies.


The Director of Food Services (or designee) will audit the Ph. Strips for expiration dates weekly.

The Director of Food Services (or designee) will audit the refrigerators, microwaves, and toasters in both the first and second floor kitchenettes daily to ensure they are clean and free of debris.

The Director of Food Services (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:


Based on surveyor observation, record review and staff interview, it was determined that the facility failed to review the risks and benefits of the use of enabler bars/side rails with residents or their representatives and obtain informed consent of this prior to their installation for four of 20 residents reviewed (Residents 4, 5, 13, and 31)

Findings include:

Review of Resident 4's clinical record revealed diagnoses of that included fusion of spine (a neurosurgical technique that joins two or more vertebrae) and gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining).

Review of Resident 4's clinical record revealed no evidence that the risks and benefits of enabler bars were obtained prior to installation of the enabler bars.

Observation of Resident 4's bed on August 12, 2019, at 10:00 AM revealed the presence of a side rails on the resident's bed.

Review of Resident 5's clinical record revealed diagnoses of that included Diabetes Mellitus (DM-failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment) and Gastro-Esophageal Reflux Disease (a digestive disease in which stomach acid or bile irritates the food pipe lining).

Review of Resident 5's clinical record revealed no evidence that the risks and benefits of enabler bars were obtained prior to installation of the enabler bars.

Observation of Resident 5's bed on August 12, 2019, at 10:20 AM revealed the presence of bilateral side rails on the resident's bed.

During an interview with the Nursing Home Administrator on August 14, 2019, at 2:36 PM, he confirmed that consents are not being completed and risk/benefit discussions are not being documented for side rails/enablers.

Review of Resident 13's clinical record revealed diagnoses including cerebral infarction (area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain) and hemiplegia (inability to move, severe weakness, or rigid movement on either the right or left side of the body).

An observation on August 12, 2019, at 10:11 AM revealed half side rails attached to each side of Resident 13's bed.

Review of Resident 13's clinical record revealed no evidence that the risks and benefits of the side rails were discussed with the resident or her responsible party or that informed consent was obtained prior to the installation of the rails.

During an interview with the Nursing Home Administrator on August 14, 2019, at 2:36 PM, he confirmed that consents are not being completed and risk/benefit discussions are not being documented for side rails/enablers.

Review of Resident 31's clinical record revealed diagnoses that included dysphagia (a medical term used to describe difficulty swallowing) and heart failure (a condition in which the heart can't pump enough blood to meet the body's needs).

Review of Resident 31's clinical record revealed no evidence that the risks and benefits of enabler bars were obtained prior to installation of the enabler bars or that beds were inspected to ensure appropriateness of the resident's size and weight.

Observation of Resident 31's bed on August 12, 2019, at 12:35 PM revealed the presence of a side rails on the resident's bed.

28 PA Code: 201.18(b)(1)(3) Management

28 PA Code: 211.12(d)(3)(5) Nursing services









 Plan of Correction - To be completed: 10/14/2019

The Director of Nursing (or designee) will review the risks and benefits of the use of enabler bars/side rails with Residents 4, 5, 13, and 31 and/or their Resident Representatives and obtain informed consents.

The Director of Nursing (or designee) will audit all Residents' care plans to identify those who use enabler bars/side rails. The Director of Nursing (or designee) will then review the risks and benefits of the use of enabler bars/side rails with the Residents and/or their Resident Representatives and obtain informed consents.

The Director of Nursing (or designee) conducted a root cause analysis of this incident and determined that the facility failed to review the risks and benefits of the use of enabler bars/side rails with the Residents and/or their Resident Representatives and obtain informed consents.

Based on the root cause of the incident:

The Director of Nursing (or designee) will draft a policy for reviewing the risks and benefits of the use of enabler bars/side rails with the Residents and/or their Resident Representatives and obtaining informed consents.

The Director of Nursing (or designee) will draft an informed consent form.

The Director of Nursing (or designee) will educate the Registered Nurses (RNs) and members of the Interdisciplinary Team (IDT) on the policy.

The Director of Nursing (or designee) will audit all new physician orders daily to identify Residents who were ordered enabler bars/side rails. The Director of Nursing (or designee) will verify that the risks and benefits of the use of enabler bars/side rails were reviewed with the Residents and/or their Resident Representatives and informed consents were obtained.

The Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:


Based on observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean and homelike environment for five out of 60 residents reviewed (Residents 6, 10, 11, 12, and 29).

Findings include:

Observation was made in Resident 6's room on August 12, 2019, at 10:29 AM that a large tan mat was alongside her bed on the floor. It was observed that there were parallel thin slits down the middle of the mat and a considerable amount of gouging.

Observation was made in Resident 10's room on August 12, 2019, at 10:40 AM that there was a large blue mat alongside her bed which was observed to have four gouges in it which appeared to be approximately two inches in circumference each.

On August 14, 2019, at 10:45 AM observation of Resident 6 and 10's mats were made with the Nursing Home Administrator (NHA). At 10:49 AM on this date, the NHA revealed that there was a process in place whereby nursing staff were responsible for documenting maintenance needs in the maintenance log book and maintenance would follow-up to repair/replace items. The NHA also revealed at this time the expectation that the mats would have been replaced.

Observations made in Resident 11 and 12's bathroom on August 12, 2019, at approximately 10:40 AM, and August 14, 2019, at approximately 10:35 AM revealed the raised toilet seat above the commode had white paint that was removed from the front support bar on both sides of the toilet seat, and the exposed metal was a reddish brown color that was not able to be wiped clean.

Observations made in Resident 29's room on August 12, 2019, at approximately 10:36 AM, and August 14, 2019, at approximately 10:40 AM revealed a red mat on the floor to the left of Resident 29's bed that the outer covering was torn and missing in three places with the foam exposed.

During an interview with the Nursing Home Administrator on August 14, 2019, at approximately 10:40 AM revealed that the process for obtaining new items is for nursing to document the request/concern in the maintenance book/log and maintenance should follow up to resolve the request/concern. The maintenance book/log on the aforementioned unit was reviewed with the Nursing Home Administrator on August 14, 2019, at approximately 10:45AM, and did not reveal documentation pertaining to the aforementioned floor mats and toilet seat. At that time, the Nursing Home Administrator revealed that the aforementioned items should be replaced.

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





 Plan of Correction - To be completed: 10/14/2019

Resident 6, 10, and 29's fall mats will be replaced with new fall mats.

Resident 11 and 12's raised toilet seat will be replaced with a new raised toilet seat.


The Director of Nursing (or designee) conducted a root cause analysis of this incident and determined that the nursing staff failed to identify the need to replace worn Durable Medical Equipment or DME (tools which are used in the residents' living spaces and are designed to help improve the quality of life for people with medical conditions) and subsequently failed to document the request/concern in the maintenance book/log for maintenance to follow up to resolve the request/concern.

Based on the root cause of the incident:

The Director of Nursing (or designee) will memorialize the procedure for identifying and replacing worn DME in a written policy. All Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurse Aides (CNAs), and Maintenance Aides will then be educated on the policy.

The Director of Nursing (or designee) will conduct an initial whole house audit of all resident rooms to ensure the DME contained therein is intact and free from damage.

The Director of Nursing (or designee) will then conduct a monthly whole house audit of all resident rooms to ensure the DME contained therein is intact and free from damage.

The Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.90(d)(3) REQUIREMENT Resident Bed: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.
483.90(d)(3) Conduct Regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible.
Observations:


Based on surveyor observation, record review and staff interview, it was determined that the facility failed to conduct regular inspections of bed rails/enabler bars to identify areas of possible entrapment for three of 20 residents reviewed (Residents 4, 5, and 31).
Findings include:

Review of Resident 4's clinical record revealed diagnoses of that included fusion of spine (a neurosurgical technique that joins two or more vertebrae) and gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining).

Observation of Resident 4's bed on August 12, 2019, at 10:20 AM revealed the presence of a side rails on the resident's bed.

Review of Resident 4's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails/enabler bars were conducted to identify areas of possible entrapment.

Review of Resident 5's clinical record revealed diagnoses of that included Diabetes Mellitus (DM-failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment) and Gastro-Esophageal Reflux Disease (a digestive disease in which stomach acid or bile irritates the food pipe lining).

Observation of Resident 5's bed on August 12, 2019, at 10:20 AM revealed the presence of bilateral side rails on the resident's bed.

Review of Resident 5's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails/enabler bars were conducted to identify areas of possible entrapment.

During an interview with the Nursing Home Administrator on August 14, 2019, at 2:36 PM, he confirmed that they do not complete ongoing measurements on bed rails/ enabler bars to identify areas of possible entrapment, but they would be starting.

Review of Resident 31's clinical record revealed diagnoses that included dysphagia (a medical term used to describe difficulty swallowing) and heart failure (a condition in which the heart can't pump enough blood to meet the body's needs).

Observation of Resident 31's bed on August 12, 2019, at 12:35 PM revealed the presence of a side rails on the resident's bed.

Review of Resident 31's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails/enabler bars were conducted to identify areas of possible entrapment.

During an interview with the Nursing Home Administrator on August 14, 2019, at 2:36 PM, he confirmed that they do not complete ongoing measurements on bed rails/ enabler bars to identify areas of possible entrapment, but they would be starting.

28 PA Code 201.18(b)(1) Management



 Plan of Correction - To be completed: 10/14/2019

Resident 4, 5, and 31's bed rails/enabler bars were inspected to identify areas of possible entrapment.

The Director of Plant Operations (or designee) will audit all Residents' care plans to identify those who use enabler bars/side rails. The Director of Plant Operations (or designee) will then inspect the Residents enabler bars/side rails to identify areas of possible entrapment.


The Director of Nursing (or designee) conducted a root cause analysis of this incident and determined that the facility failed to conduct ongoing inspections of bed rails/enabler bars to identify areas of possible entrapment.

Based on the root cause of the incident:

The Director of Nursing (or designee) will draft a policy for conducting ongoing inspections of bed rails/enabler bars to identify areas of possible entrapment.

The Director of Nursing (or designee) will educate the Registered Nurses (RNs), Licensed Practical Nurses (LPN), Certified Nurse Aids (CNAs) and the maintenance staff on the policy.

The Director of Nursing (or designee) will review maintenance records for existing resident who have bed rails/enabler bars quarterly to determine if ongoing inspections of bed rails/enabler bars to identify areas of possible entrapment are being conducted.

The Director of Nursing (or designee) will audit all new physician orders daily to identify Residents who were ordered bed rails/enabler bars. The Director of Nursing (or designee) will review maintenance records for new resident who were ordered bed rails/enabler bars to determine if initial inspections of the bed rails/enabler bars to identify areas of possible entrapment are being conducted.

The Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on observations, review of clinical records and staff interview, it was determined that the facility failed to be able to provide documentation regarding release of the restraint every two hours for one of two residents reviewed (Resident 15).

Findings include:

Review of facility Restraint Policy dated for June 1, 2009, revealed on Line 3 " If after assessment and care planning, it is determined a restraint may be deemed appropriate for an individual resident to attain or maintain his/her highest practicable physical and psychosocial well-being. obtain physician order for least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraint; include corroborating medical symptom, and when the restraint is to be used. a. Example: Soft seat belt release when in wheelchair to support trunk to enable resident to self propel wheelchair independently and safely. Release every 2 (two) hour for 10 minutes. Assist with change in position, i.e. ambulation if appropriate. check skin integrity. Report any redness or irritation immediately to charge nurse."

Review of the clinical record for Resident 15 revealed diagnoses that included History of Falling, Muscle Weakness, Abnormalities of Gait and Mobility, Abnormal Posture, and Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people).

Review of Resident 15's Quarterly Minimum Data Set (MDS- assessment tool used to determine resident care and services needs) dated for May 21, 2019, revealed under Section G-Functional Status, Sub-section G0400 that Resident 15 was coded as having both upper and lower impairment on one side. Review of this same MDS revealed in Section P- Restraints that Resident 15 was coded as using a Trunk restraint daily.

Review of Resident 15's current active physician orders revealed the order "Adaptive Equipment: Seatbelt w/alarm for safe positioning when self propelling in w/c (wheelchair) to reduce fall risk" with an order date of January 18, 2019.

Review of Resident 15's current/active Care Plan revealed the care Focus area " Seatbelt on w/c restraint use per physician order for medical symptom poor trunk control, leans forward unsafely" with imitated date of December 15, 2017. Intervention associated with this care Focus area include "Document use of restraint on residents treatment record; Remove seatbelt restraint at least every 2 (two) hours; Type of restraint Velcro alarming seatbelt on wheelchair."

Facility failed to provide any monitoring information to confirm that the seat-belt restraint was being released at least every two hours.

During an interview on August 15, 2019, at 11:40 AM with Director of Nursing (DON), the DON revealed the expectation that documentation would be available to show release of the seatbelt.

28 Pa Code 211.8(c)(d)(e)(f) Use of Restraints.






















 Plan of Correction - To be completed: 10/14/2019

Resident 15's soft seat belt will be released every two hours for ten minutes and documented in the clinical record.

The Director of Nursing (or designee) will audit all Residents' care plans to identify those who use restraints. The Director of Nursing (or designee) will then review those residents' clinical records to determine if monitoring information is present to confirm that the restraints were being released at least every two hours for ten minutes.

The Director of Nursing (or designee) conducted a root cause analysis of this incident and determined that the facility failed to provide the necessary documentation to verify that the seat belt restraint was being released at least every two hours for ten minutes.

Based on the root cause of the incident:

The Director of Nursing (or designee) will draft a policy for releasing restraints and documenting the release.

The Director of Nursing (or designee) will educate the Registered Nurses (RNs), Licensed Practical Nurses (LPN), Certified Nurse Aids (CNAs) and members of the Interdisciplinary Team (IDT) on the policy.

The Director of Nursing (or designee) will review the clinical records of existing resident who have restraints weekly to determine if monitoring information is present to confirm that the restraints were being released at least every two hours for ten minutes.

The Director of Nursing (or designee) will audit all new physician orders daily to identify Residents who were ordered restraints. The Director of Nursing (or designee) will then verify that the residents' clinical records contain documentation that the restraints were released at least every two hours for ten minutes.

The Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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.
483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:


Based on observation, clinical record review and staff interview it was determined that the facility failed to provide assistive feeding devices for three of 20 residents reviewed (Residents 25, 34, and 58).

Findings include:


Review of Resident 25's clinical record revealed diagnoses that included hemiplegia (inability to move, severe weakness, or rigid movement on either the right or left side of the body) and lack of coordination.
Review of Resident 25's current physician orders revealed an order for resident to use nosey cups (adapted drinking cup with nose cut out which allows for proper head and neck positioning) to increase coordination with drinking effective April 30, 2019.
Review of Resident 25's current care plan revealed a focus area related to nutritional risk with an intervention to provide resident with adaptive equipment she uses (nosey cup).

Surveyor observation on August 12, 2019, at 12:45 PM revealed resident eating lunch alone in her room. On her tray were two drinks, a nosey cup containing a clear liquid and a standard cup containing an amber colored liquid. No nosey cup was observed to have been provided for the drink in the standard cup.

Surveyor observation on August 13, 2019, at 12:47 PM revealed resident alone in her room with her lunch. On her tray were two drinks, a small can of gingerale with a straw inserted and a standard cup with a clear liquid and a straw inserted. Observation revealed no nosey cups were present for resident to utilize.
Review of Resident 25's meal ticket revealed nosey cups were to be provided for each meal.

During an interview with the Director of Nursing on August 15, 2019, at 1:10 PM, she revealed that nosey cups should have been provided as ordered to Resident 25.

Review of Resident 34's clinical record revealed diagnoses that included; dysphagia (difficulty swallowing), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), blindness, cognitive communication deficit, and lack of coordination.

Review of Resident 34's August 2019, Physician orders revealed order for a coated dysphagia spoon (a small plastic coated spoon) at meals for use with thicker textured liquefied items to improve intake as nursing measure, with an order date of July 9, 2019.

Review of Resident 34's meal ticket revealed the following tray aids; Kennedy cups, and burgundy spoon.

Observation in the 2nd floor dining room on August 13, 2019, at approximately 12:40 PM revealed that Resident 34 didn't have any adaptive utensils at her place setting at the table.

Observation in the 2nd floor dining room on August 14, 2019, at approximately 1:15 PM revealed that Resident 34 didn't have adaptive utensils at her place setting at the table.

During an interview with the Food Service Director 1 (FSD 1) on August 15, 2019, at approximately 12:10 PM revealed that the plastic coated dysphagia spoon was broken on Monday, and that the dietary and therapy departments didn't have another plastic dysphagia spoons in stock. It was also revealed that on Monday an order was placed for plastic coated dysphagia spoons.

Review of Resident 58's clinical record revealed diagnoses that included Glaucoma (a condition of increased pressure within the eyeball, causing gradual loss of sight), Lack of co-ordination, Dysphagia (difficulty swallowing), Muscle Weakness, and Protein-Calorie malnutrition (a form of malnutrition that is defined as a range of pathological conditions arising from coincident lack of dietary protein and/or energy (calories) in varying proportions; The condition has mild, moderate, and severe degrees).

Review of Resident 58's clinical record revealed that resident had received Occupational therapies which included recommendations and initiation of use of Kennedy cups (lightweight spillproof drinking cup that is used with a straw and is ideal for people of all ages to prevent spillage) and a lip guard (attachment for plates which allows a person to scoop food up against the lip to facilitate independent eating). Recommendation was also made for weighted utensils to facilitate grasp, however these were notedly adamantly refused by the resdient.

Review of Resident 58's current/active Care Plan revealed the care Focus area of "at risk for impaired nutrition/hydration r/t [due to] [resident name] being on a regular diet". Review of the Interventions associated with this care area revealed "[resident name] uses adaptive equipment: Kennedy cups and plateguard to aid self-feeding."

Observation was made in second floor dining room where Resident 58 dines on August 13, 2019, starting at 12:49 PM. It was observed that resident was struggling greatly with tremors to feed herself but was managing to consume most of her meal using lip guard on her main plate. It was observed that before she finished her main plate a portion of cake was served to her on a small dessert size plate and set above her main plate. At one point it was observed that the main plate was put to the side by a staff member and the cake moved closer. It was observed that Resident 58 was struggling tremendously to eat the cake and getting it all over, while observing that the small plate was not enhanced with use of plate guard.

During an interview with FSD 1 on August 15, 2019,, at approximately 1:18 PM it was revealed that the facility does not have plate guards that fit small plates, FSD 1 stated that they will be ordered, and that plate guards should be available to residents who have a plate guard ordered.

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





 Plan of Correction - To be completed: 10/14/2019

Resident 25 will be provided with a nosey cup (adaptive drinking cup with nose cut out which allows for proper head and neck positioning) as per her physician's orders and care plan.

Resident 34 will be provided with a coated dysphagia spoon (a small plastic coated spoon at meals for use with thicker textured liquefied items to improve intake) as per her physician's orders and care plan.

Resident 58 will be provided with a lip guard (attachment for plates which allows a person to scoop food up against the lip to facilitate independent eating) for her dessert plate.

The Director of Food Service (or designee) will audit all residents' care plans to identify those resident who require adaptive equipment and ensure the adaptive equipment is provided as per their physicians' orders.

The Director of Food Services (or designee) conducted a root cause analysis of this incident and determined that the facility failed to provide residents with the required adaptive equipment as per their physicians' orders and care plans.

Based on the root cause of the incident:

The Director of Food Services (or designee) will draft a policy for assessing residents for and providing residents with the required adaptive equipment as per their physicians' orders and care plans.

The Director of Food Services (or designee) will educate the Cooks, Dietary Aides, Speech Therapist, Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aids (CNAs) on the policy.

The Director of Food Services (or designee) will audit all new physician orders daily to identify Residents who were ordered adaptive equipment (or, conversely, whose adaptive equipment was discontinued). The Director of Food Services (or designee) will then verify that the Residents received the adaptive equipment (or had the adaptive equipment discontinued) as per their physicians' orders and care plans.

The Director of Food Services (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:


Based on observations, clinical record review and staff interviews it was determined that the facility failed to provide assistance during the noon meal for two of six dependent residents (Residents 34, and 48).

Findings include:


Review of Resident 34's clinical record revealed diagnoses that included dysphagia (difficulty swallowing), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), blindness, cognitive communication deficit, and lack of coordination. Further review of Resident 34's clinical record revealed that Resident 34 receives a liquified puree diet, and received Speech Therapy services which concluded on July 24, 2019. Review of a Speech Therapy note dated July 24, 2019, revealed "Patient requires anywhere from minimum to intrusive verbal and tactile cues in order to accept and initiate straw drinking."

Observation on the 2nd floor dining room on August 13, 2019, at approximately 12:40 PM revealed Resident 34 was sleeping in her Geri chair (a reclining wheel chair) with her noon meal placed in front of her in separate mugs.

At approximately 12:53 PM a staff member who was assisting another resident to the right side of Resident 34, took a straw from one of the cups in front of Resident 34 and touched her lip with it in an attempt to wake her up and/or see if she would take any of the liquid. Resident 34 didn't wake up or take any liquid from the straw. At no time did the surveyor observe staff taking with or utilizing tactile touch in an attempt to arouse Resident 34. At approximately 1:20 PM Resident 34 was wheeled out of the dining room, without any further attempt to wake or assist to feed her.

During an interview on August 14, 2019, at approximately 2:23 PM with the Nursing Home Administrator it was revealed that there is a procedure for serving meals in the dining room, and that staff should encourage residents to eat with multiple attempts if necessary, and offer to reheat food if it has sat for an extended time period. At that time it was also revealed by the Director Of Nursing that the facility is considering extended dining times, a plan is in place to trial the concept starting Monday August 20th for the breakfast meal. It is hopeful that the extended dining time trial will enable residents to be assisted as needed with minimized wait times and to accommodate resident meal time preferences.

Review of Resident 48's clinical record revealed diagnoses that included Muscle Weakness, Lack of coordination, and Heart Failure (severe failure of the heart to function properly).

Review of Resident 48's current/active physician orders revealed the diet order of Consistent carbohydrates No added Salt diet Puree texture, Regular/thin consistency, no mixed consistencies in diet with a start date of October 10, 2018.

Observation was made in the second floor dining room on August 12, 2019, starting at 12:43 PM that Resident 48
was served an Ensure Plus nutritional supplement. It was observed that at 12:45 PM he was served his hot meal of Puree consistency food which was placed in front of him uncovered. It was also observed that it was 1:01 PM when staff sat down to feed him, resulting in a 16 minute wait for feeding assistance while meal plate was in front of him uncovered and cooling. It was observed that no attempt was made to re-heat his food.

During an interview on August 14, 2019, at approximately 2:23 PM with the Nursing Home Administrator (NHA), the NHA revealed that there is a procedure for serving meals in the dining room, and that staff should encourage residents to eat with multiple attempts if necessary, and offer to reheat food if it has sat for an extended time period.

PA Code 211.12(d)(5) Nursing Services








 Plan of Correction - To be completed: 10/14/2019

Residents 34 and 48 will be screened by Speech Therapy to determine whether or not they would benefit from further treatment and/or require additional therapeutic interventions and/or assistive devices.

The Director of Food Services (or designee) will audit all Residents' care plans to identify those who require feeding assistance to ensure it is provided during the meal service (per the audit noted below).

The Director of Food Services (or designee) conducted a root cause analysis of this incident and determined that the facility failed to provide assistance to residents who need help with their Activities of Daily Living to maintain good nutrition.

Based on the root cause of the incident:

The Director of Food Services (or designee) will memorialize the facility's procedure for providing assistance to residents who need help with their Activities of Daily Living to maintain good nutrition in writing.

The Director of Food Services (or designee) will educate the Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) on the policy.

The Director of Food Services (or designee) will randomly audit one meal service per day (choosing from among the morning, noon, and evening meal), seven days per week, to ensure staff are providing assistance to residents who need help with their Activities of Daily Living to maintain good nutrition.

The Director of Food Services (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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.
483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:


Based on record review and interview it was determined that the facility failed to provide a recapitulation of the resident's stay, with a final summary at the time of discharge, for one of two closed resident records reviewed, (Resident 59).

Findings include:

Review of the closed clinical record for Resident 59 on August 15, 2019, at 10:00 AM revealed diagnosis that included Seizures (neurological disorders that cause brief episodes of spasms, unresponsiveness) and Coronary Artery Disease (narrowing of the blood vessels which supply the heart with blood and oxygen).

Further review of the clinical record revealed that the resident ceased to breath at the facility on June 25, 2019.

A review of the closed record failed to reveal that a Discharge Summary was completed by the physician.

During an interview with the Director of Nursing on August 15, 2019, at 12:57 PM, she confirmed that discharge summaries are not completed for residents that have a death at the facility.

28 Pa. Code 211.5(d)(f) Clinical records








 Plan of Correction - To be completed: 10/14/2019

A discharge Summary will be completed for Resident 59 posthumously.

The Director of Nursing (or designee) conducted a root cause analysis of this incident and determined that the facility failed to complete discharge summaries for residents who have a death at the facility.

Based on the root cause of the incident:

The Director of Nursing (or designee) will draft a policy for completing discharge summaries for residents including, but not limit to, those who have a death at the facility.

The Director of Nursing (or designee) will educate the members of the Interdisciplinary Team (IDT) who are responsible for completing the discharge summaries including the physician.

The Director of Nursing (or designee) will audit the closed records of all Residents discharged monthly to ensure that discharge summaries were completed on all Residents including, but not limited to, those that had a death at the facility.

The Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:



Based on clinical record review, facility policy review, and staff interview it was determined that the facility failed to ensure that the resident and resident representative received written notice of the facility bed hold policy at the time of transfer for three of 20 residents reviewed (Residents 31, 36, and 55).

Findings Include:

Review of Resident 31's clinical record revealed diagnoses that included dysphagia (a medical term used to describe difficulty swallowing) and heart failure (a condition in which the heart can't pump enough blood to meet the body's needs).

Review of nursing progress note dated December 31, 2018, revealed Resident 31 was transferred to the hospital with respiratory distress and was subsequently admitted.

Additional review of Resident 31's clinical record revealed there was no documented evidence to indicate that written notification regarding the bed hold policy was provided to Resident 31 and/or her responsible party before the transfer to the hospital.

Review of Resident 36's clinical record revealed diagnoses including hypertension collapsed vertebra and spinal stenosis (narrowing of the spinal canal which may result in pain, numbness and loss of motor control).

Further review of Resident 36's clinical record revealed that on June 3, 2019, Resident 36 was transferred out of the facility to the hospital and was subsequently admitted.

Additional review of Resident 36's clinical record revealed there was no documented evidence to indicate that written notification regarding the bed hold policy was provided to Resident 36 and/or her responsible party before the transfer to the hospital.

During an interview with the Nursing Home Administrator on August 14, 2019, at 1:16 PM he confirmed that resident are informed of the bed hold policy upon admission, but that notification of bed hold is not provided to residents or their representatives upon transfer.

Review of Resident 55's clinical record revealed diagnoses that included Dysphagia (a medical term used to describe difficulty swallowing) and Parkinson's Disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait).

Review of the clinical record, hospital discharge summary revealed that Resident 55 was transferred to the hospital from the facility on May 19, 2019, and was subsequently admitted.

Additional review of Resident 55's clinical record revealed there was no documented evidence to indicate that written notification regarding the bed hold policy was provided to Resident 55 and/or her responsible party before the transfer to the hospital.

During an interview with the Nursing Home Administrator on August 14, 2019, at 1:16 PM he confirmed that resident are informed of the bed hold policy upon admission, but that notification of bed hold is not provided to residents or their representatives upon transfer.

28 Pa. Code 201.14(a) Responsibility of Licensee










 Plan of Correction - To be completed: 10/14/2019

Resident 31, 36, and 55's and/or their Resident Representative will be provided, retrospectively, written notice of the facility bed hold policy secondary to the Residents' hospital transfers noted herein.

The Director of Social Services (or designee) conducted a root cause analysis of this incident and determined that the facility failed to provide the Resident and/or their Resident Representatives written notice of the facility bed hold policy at the time of transfer.

Based on the root cause of the incident:

The Director of Social Services (or designee) will draft a policy for providing the Resident and/or their Resident Representatives written notice of the facility bed hold policy at the time of transfer.

The Director of Social Services (or designee) will be responsible to issue the notifications.

The RNs and/or the Medical Records Clerk will issue the notifications in the Director of Social Services absence.

The Director of Social Services (or designee) will educate all Registered Nurses (RNs) and the Medical Records Clerk on the aforementioned policy.


The Director of Nursing (or designee) will audit the clinical record of all Residents transferred monthly to ensure that Residents and/or their Resident Representatives were provided written notice of the facility bed hold policy at the time of transfer.


The Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.12 REQUIREMENT Free from Misappropriation/Exploitation: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
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations:


Based on clinical record and facility policy review, review of select facility documentation as well as staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation for four of 20 residents reviewed (Resident 4, 36, 57, and 309).

Findings include:

Review of facility policy, "The Shook Home - Resident Abuse and Neglect Prevention Policy," issued February 2005 and updated December 14, 2017, stated, "The Shook Home (The Home") recognizes residents' right to be free from any verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of resident property."

Review of Resident 4's clinical record revealed diagnoses of that included fusion of spine (a neurosurgical technique that joins two or more vertebrae) and gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining).

Review of Resident 4's Medication Accountability Sheet for Oxycodone (controlled narcotic pain medication) 5 mg tabs revealed that 83 tablets of Oxycodone 5 mg were removed from the count by Licensed Practical Nurse 1 (LPN) 1 between April 30, 2019, and July 7, 2019.

Review of Resident 4's Medication Administration Record revealed that between April 30, 2019, and July 7, 2019, 27 tablets of Oxycodone 5 mg were administered by Licensed Practical Nurse (LPN) 1 to Resident 4. A difference of 56 tablets of Oxycodone 5 mg.

Review of Resident 36's clinical record revealed diagnoses including collapsed vertebra and spinal stenosis (narrowing of the spinal canal which may result in pain, numbness and loss of motor control).

Review of Resident 36's Medication Accountability Sheet for Oxycodone-Acetaminophen (controlled narcotic pain medication) 5-325 mg tabs revealed that 15 tablets of Oxycodone-Acetaminophen 5-325 mg were removed by LPN 1 from the count between June 11, 2019, and July 7, 2019.

Review of Resident 36's Medication Administration Record revealed that between June 11, 2019, and July 7, 2019, 13 tablets of Oxycodone-Acetaminophen 5-325 mg were administered by LPN 1 to Resident 36. A difference of two tablets of Oxycodone-Acetaminophen 5-325 mg.

Review of Resident 57's clinical record revealed diagnoses that included Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)) and chronic kidney disease (longstanding disease of the kidneys leading to renal failure).

Review of Resident 57's Medication Accountability Sheet for Tylenol with Codeine #3 (controlled narcotic pain medication) 300-30 mg tabs revealed that two tablets of Tylenol with Codeine #3 300-30 mg were removed by LPN 1 from the count between July 7, 2019, and July 9, 2019.

Review of Resident 57's Medication Administration Record revealed that between July 7, 2019, and July 9, 2019, one tablets of Tylenol with Codeine #3 300-30 mg were administered to Resident 36 by LPN1. A difference of one tablets of Tylenol with Codeine #3 300-30 mg.

Review of Resident 309's clinical record revealed diagnoses including Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose)) and chronic kidney disease (longstanding disease of the kidneys leading to renal failure).

Review of Resident 309's Medication Accountability Sheet for Tramadol HCL (controlled pain medication) 50 mg tabs revealed that one tablet of Tramadol HCL 50 mg was removed by LPN 1 from the count between July 3, 2019, and July 4, 2019.

Review of Resident 309's Medication Administration Record revealed that between July 3, 2019, and July 4, 2019, zero tablets of Tramadol HCL 50 mg were administered to Resident 309 by LPN1. A difference of one tablet of Tramadol HCL 50 mg.

Interview with the Nursing Home Administrator on August 15, 2019 at 2:35 PM revealed that his expectation of LPN 1 is that he would have followed the facility policy and not taken the medications.

28 Pa. Code 201.14(a) Responsibility of license.

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







 Plan of Correction - To be completed: 10/14/2019

Resident 4, 36, 57, and 309's diverted medications were replaced at the facility's expense.

The Assistant Director of Nursing cross-walked the Medication Accountability Sheets with the Medication Administration Records for all residents receiving controlled narcotic pain medications and ruled out further diversion.


The Assistant Director of Nursing (or designee) conducted a root cause analysis of this incident and determined that Licensed Practical Nurse (LPN) 1 failed to follow the facility's policy titled "The Shook Home Resident Abuse and Neglect Prevention Policy," issued February 2005 and updated December 2017.

Based on the root cause of the incident:

The Director of Human Resources and Corporate Compliance (or designee) opened a formal investigation into the matter. LPN 1 was immediately suspended and resigned his position when asked to come in for an interview and drug test.

The Director of Human Resources and Corporate Compliance (or designee) self-reported the incident to the following Authorities Having Jurisdiction (AHJ):

1. The Pennsylvania Department of Health, Division of Nursing Care Facilities
2. The Franklin County Area Agency on Aging, Protective Services
3. The Chambersburg Police Department
4. The Department of State, Bureau of Professional and Occupational Affairs


The Quality Assurance/Performance Improvement Committee will review the facility policy titled "The Shook Home Resident Abuse and Neglect Prevention Policy," issued February 2005 and updated December 2017 to determine if any revisions are required (including, but not limited to, the facility's procedure for recruiting, vetting, and onboarding new hires).

The Assistant Director of Nursing (or designee) will educate all Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) on the facility policy titled "The Shook Home Resident Abuse and Neglect Prevention Policy," issued February 2005 and updated December 2017.

The Assistant Director of Nursing (or designee) will cross-walked the Medication Accountability Sheets with the Medication Administration Records for all residents receiving controlled narcotic pain medications every other week to monitor for further diversion.


The Assistant Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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 that the facility failed to notify the resident/resident representative and the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing and with required transfer information for three of 20 resident records reviewed (Residents 31, 36, and 55).

Findings include:

Review of Resident 31's clinical record revealed diagnoses that included dysphagia (a medical term used to describe difficulty swallowing) and heart failure (a condition in which the heart can't pump enough blood to meet the body's needs).

Review of nursing progress note dated December 31, 2018, revealed Resident 31 was transferred to the hospital with respiratory distress and was subsequently admitted.

Review of Resident 31's clinical record revealed that no letter was provided to the Resident/Resident representative regarding the transfer and including the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, as well as information for the agency responsible for the protection and advocacy of individuals with intellectual or developmental disabilities and mental disorders or related conditions.

Review of Resident 36's clinical record revealed diagnoses including collapsed vertebra and spinal stenosis (narrowing of the spinal canal which may result in pain, numbness and loss of motor control).

Further review of Resident 36's clinical record revealed that on June 3, 2019, Resident 36 was transferred out of the facility to the hospital with a spinal infection.

Review of Resident 36's clinical record revealed that no letter was provided to the Resident/Resident representative regarding the transfer and including the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, as well as information for the agency responsible for the protection and advocacy of individuals with intellectual or developmental disabilities and mental disorders or related conditions.

During an interview with the Nursing Home Administrator on August 13, 2019, at 2:18 PM he confirmed that the facility does not send such a letter to the resident or resident representative and that notice of transfer was not being sent to the State Long-Term Care Ombudsman prior to August 7, 2019.

Review of Resident 55's clinical record revealed diagnoses that included Dysphagia (a medical term used to describe difficulty swallowing) and Parkinson's Disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait).

Review of the clinical record, hospital discharge summary revealed that Resident 55 was transferred to the hospital from the facility on May 19, 2019, and was subsequently admitted.

Review of Resident 55's clinical record revealed that no letter was provided to the Resident/Resident representative regarding the transfer and including the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, contact and address information for the Office of the State Long-Term Care Ombudsman, as well as information for the agency responsible for the protection and advocacy of individuals with intellectual or developmental disabilities and mental disorders or related conditions.

During an interview with the Nursing Home Administrator on August 13, 2019, at 2:18 PM he confirmed that the facility does not send such a letter to the resident or resident representative and that notice of transfer was not being sent to the State Long-Term Care Ombudsman prior to August 7, 2019.

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












 Plan of Correction - To be completed: 10/14/2019

Resident 31, 36, and 55's Resident Representative will be notified retrospectively of the Residents' hospital transfers noted herein in writing with the required transfer information.

The representative of the State Long-Term Care Ombudsman will be notified retrospectively of Resident 31, 36, and 55's hospital transfers noted herein in writing with the required transfer information.


The Director of Social Services (or designee) conducted a root cause analysis of this incident and determined that the facility failed to notify Resident Representatives and the representative of the State Long-Term Care Ombudsman of residents' hospital transfers in writing with the required information.

Based on the root cause of the incident:

The Director of Social Services (or designee) will draft a policy for notifying Resident Representatives and the representative of the State Long-Term Care Ombudsman of residents' transfers (including, but not limited to, hospital transfers) in writing with the required information.

The Director of Social Services (or designee) will be responsible to issue the notifications.

The RNs and/or the Medical Records Clerk will issue the notifications in the Director of Social Services absence.

The Director of Social Services (or designee) will educate all Registered Nurses (RNs) and the Medical Records Clerk on the aforementioned policy.


The Director of Nursing (or designee) will audit the clinical record of all Residents transferred monthly to ensure Resident Representatives and the representative of the State Long-Term Care Ombudsman were notified of the residents' transfers in writing with the required information.

The Director of Nursing (or designee) will report the results of the audits to the Quality Assurance/Performance Improvement Committee monthly to ensure the solutions are sustained over time. (The Quality Assurance/Performance Improvement Committee reviews all deficiencies monthly by having Quality Assurance/Performance Improvement Committee members gather proof/information and present it to the Quality Assurance/Performance Improvement Committee to show it is still in compliance). The audits will continue until no longer deemed necessary by the Committee.


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