Nursing Investigation Results -

Pennsylvania Department of Health
PROMEDICA SKILLED NURSING AND REHABILITATION (OXFORD VALLEY)
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PROMEDICA SKILLED NURSING AND REHABILITATION (OXFORD VALLEY)
Inspection Results For:

There are  141 surveys for this facility. Please select a date to view the survey results.

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PROMEDICA SKILLED NURSING AND REHABILITATION (OXFORD VALLEY) - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on March 31, 2022, it was determined that Promedica Skilled Nursing and Rehabilitation Oxford Valley was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on observation, clinical record review, it was determined that the facility failed to ensure that call bells were accessible for one of 29 sampled residents. (Resident 241)

Findings include:

Clinical record review revealed that Resident 241 had diagnoses that included a stroke, flaccid hemiplegia (severe loss of motor function on left side), and muscle weakness. The Minimum Data Set assessment, dated March 15, 2022, indicated that the resident was able to communicate needs to staff and required extensive assistance from staff for activities of daily living such as grooming and hygiene. On March 29, 2022, at 11:40 a.m., the resident was observed in bed. The resident was heard asking for help and was unaware where her call bell was. The call bell was located on the dresser, out of her reach. On March 30, 2022, at 10:30 a.m., the resident was observed in bed. The call bell was in the same place as the previous day, on the dresser.

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








 Plan of Correction - To be completed: 05/11/2022

1. Resident 241 have been evaluated and has had her call bell within reach.

2. A comprehensive review of current patients call bells will be completed to ensure call bell clips and proper placement of call bells.

3. Education will be provided to facility staff on proper procedure of call bell placement for residents while in their rooms.

4. Random Weekly audits will be completed to ensure compliance. Trends will be reported to Quality Assessment and Assurance Committee for further review and/or follow up as needed.
483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions prior to the administration of as needed pain medication for one of four sampled residents receiving medication for pain. (Resident 93)

Findings include:

Clinical record review revealed that Resident 93 had diagnoses that included spinal stenosis (a narrowing of space around the spinal cord) and muscle weakness. A physician's order dated February 28, 2022, directed staff to provide the resident with a narcotic pain medication, oxycodone, every four hours as needed for moderate pain. Review of the medication administration record revealed that the resident received the as needed pain medication seventy-five times in March 2022, without documented evidence to support that non-pharmacological interventions were offered to address the pain prior to the administration of the narcotic pain medication.

In an interview on March 31, 2022, at 9:45 a.m., the Director of Nursing confirmed that there was a lack of documentation to support that non-pharmacological interventions were offered to Resident 93 prior to the administration of the as needed pain medication.
.
28 Pa. Code 211.12(d)(1)(5) Nursing services.






 Plan of Correction - To be completed: 05/11/2022

1. Resident 93 clinical records have been reviewed as it relates to non-pharmalogical interventions prior to the administration of as need pain medication.

2. A comprehensive review of current patients will be completed to identify additional current patients who require non-pharmalogical interventions prior to the administration of as needed pain medication.

3. Education will be provided to licensed staff on attempting non-pharmalogical interventions prior to dispensing as needed pain medication.

4. Random Weekly audits will be completed to ensure compliance. Trends will be reported to the Quality Assessment and Assurance Committee for further review and/or follow up as needed.
483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

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

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

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide services to prevent further limitations in range of motion for one of eight sampled residents with splints. (Resident 241)

Findings include:

Clinical record review revealed that Resident 241 had diagnoses that included a stroke, flaccid hemiplegia (severe loss of motor function on left side), and muscle weakness. The Minimum Data Set assessment, dated March 15, 2022, indicated that the resident required extensive assistance from staff for dressing. Review of current physician's orders revealed that the resident was to wear a splint to her lower extremity in the morning and to have it removed at bedtime. Review of the care plan revealed that the resident was at risk for loss of range of motion related to weakness and physical limitations and staff were instructed to apply a splint to her left lower extremity in the morning. Observations on March 29, 2022, between 10:00 a.m., and 1:30 p.m., and again on March 30, 2022, between 10:00 a.m., and 12:30 p.m., revealed the resident was in bed without the splint in place. The splint was observed on the dresser.

In an interview on March 31, 2022, at 9:45 A.M. the Director of Nursing confirmed that the splint was to be applied in accordance with physician's orders.

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







 Plan of Correction - To be completed: 05/11/2022

1. Resident 241 clinical records have been reviewed as it relates to splints.

2. A comprehensive review of current patients will be completed to identify additional current patients splints to ensure splints are in place at times ordered by physicians.

3. Education will be provided to licensed staff to ensure splints are in place when ordered by physicians.

4. Random Weekly audits will be completed to ensure compliance. Trends will be reported to the Quality Assessment and Assurance Committee for further review and/or follow up as needed.
483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan to meet the current needs for one of 29 sampled residents. (Resident 69)

Findings include:

Clinical record review revealed that Resident 69 had diagnoses that included depression and dementia without behavioral disturbance. A physician's order since admission on January 14, 2022, directed staff to administer an anti-depressant (Lexapro) on a daily basis for depression. The Minimum Data Set assessments dated January 30, 2022, and February 14, 2022, indicated that the resident had been administered an anti-depressant for six days out of each assessment period. Review of the January, February and March 2022 Medication Administration Records revealed that staff had administered the anti-depressant (Lexapro) as ordered by the physician. There was no care plan developed or interventions to address and reflect the use of the anti-depressant medication.

In an interview on March 31, 2022, at 9:42 a.m., the Director of Nursing stated that there was no care plan to reflect the use of the anti-depressant medication.

CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plan
Previously cited May 20, 2021

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






 Plan of Correction - To be completed: 05/11/2022

1. Resident 69 no longer resides in the facility.

2. A comprehensive review of current patients will be completed to identify additional current patients who require the development of care plans and interventions for the use of anti-depressant medication.

3. Education will be provided to licensed staff on proper procedure for the development and implementation of a care plan and interventions for patients on anti-depressant medications.

4. Random weekly audits will be completed to ensure compliance. Trends will be reported to the Quality Assessment and Assurance Committee for further review and/or follow up as needed.
483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
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 review of facility policy, clinical record review and staff interview, it was determined that the facility failed to notify the residents and the residents' representatives of the transfers and the reasons for the moves in writing upon transfer from the facility for seven of seven sampled residents who were transferred to the hospital. (Residents 4, 53, 69, 102, 104, 126, 132).

Findings include:

Review of the facility policy entitled "Facility Initiated Transfer or Discharge", dated November 23, 2021, revealed that when a resident was transferred out of the facility, the facility was to provide a transfer/discharge notification, date of the transfer/discharge, and location of where the resident was being transferred or discharged to.

Clinical record review revealed that Resident 4 was transferred and admitted to the hospital on March 2, 2022, after a change in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 53 was transferred and admitted to the hospital on February 24, 2022, after a change in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 69 was transferred and admitted to the hospital on February 3, 2022, and again on March 12, 2022. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 102 was transferred and admitted to the hospital on December 28, 2021, January 12, 2022, and again on March 26, 2022. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 104 was transferred and admitted to the hospital on February 11, 2022. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 126 was transferred and admitted to the hospital on February 19, 2022, after a change in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital.

Clinical record review revealed that Resident 132 was transferred and admitted to the hospital on December 14, 2021, after a change in condition. There was no documented evidence that the resident's responsible party or legal representative was provided written information regarding the resident's transfer to the hospital.

In an interview on March 31, 2022. at 9:45 a.m., the Director of Nursing confirmed that there was no documented evidence that the aforementioned residents or responsible parties had been given transfer/discharge notices when the residents transferred out of the facility.















 Plan of Correction - To be completed: 05/11/2022

1. Residents 4, 53, 69, 102, 104, 126, and 132 clinical records have been reviewed as it relates to Notification to the resident or resident representative of the transfers and the reason for the transfer in writing upon transfer from the facility.

2. A comprehensive review of current patients will be completed to identify additional current patients who may be affected upon a discharge or transfer.

3. Education will be provided to licensed staff on proper procedure of notification of resident and/or resident representative of transfer and reason for resident resident transfer.

4. Random Weekly audits will be completed for 4 weeks to ensure compliance. Trends will be reported to the Quality Assessment and Assurance Committee for further review and/or follow up as needed.

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