Nursing Investigation Results -

Pennsylvania Department of Health
MCMURRAY HILLS MANOR
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MCMURRAY HILLS MANOR
Inspection Results For:

There are  91 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MCMURRAY HILLS MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint completed on 5/26/22, it was determined that McMurray Hills Manor 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 related to the health portion of the survey process.


























































































































 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on facility policy, clinical record review, and interviews, the facility failed to assess and identify the potential risk of elopement for one of four residents in the facility (Resident R1), placing the resident in Immediate Jeopardy.

The Facility policy "Elopement management program" dated 3/1/22, identifies the following conditions when a resident should be evaluated for elopement risk and interventions put in place: upon admission, per the MDS schedule, significant change and as needed. If a resident triggers an elopement risk per assessment, the following interventions may be implemented: Elopement care plan; a wander guard bracelet; a photograph and information sheet will be placed in the elopement risk binder, which will be kept by the front entrance office and/or nursing station.

Resident R1 was admitted to the facility on 4/10/20, with diagnoses that include Non-Traumatic Brian dysfunction, Alzheimer's disease, heart disease, and diabetes mellitus. Review of the quarterly Minimum Data Set(MDS- periodic assessment og care needs) dated 2/25/22 indicates the diagnoses remained current.

Clinical record review revealed on 4/29/22 Resident R1 as having "wandering behavior occurs daily" as a part of the weekly nursing note, identifying as a change in condition from previous assessments. Clinical documentation revealed the facility failed to assess the resident for elopement risk at that time.

During an interview on 5/19/22 at approximately 3:30 p.m. Nurse Aide Employee E3 reported that on 5/8/22 at approximately 9:00 p.m., a passerby called into the facility to alert staff a resident was along the road. Resident R1 was found sitting in his wheelchair in the facility driveway at the intersection of the public road "trying to get across." Employees Nurse Aide E3 and the Assistant Director of Nursing (ADON) returned Resident R1 to the building. A wander guard (an alarmed bracelet which alerts the facility when a resident attempts to exit) was placed on Resident R1 upon return to the building by the ADON. Review of the clinical record revealed the facility failed to document the resident was reassessed for elopement risk at that time.

During a telephone interview on 5/19/22 at approximately 3:10 p.m., Dietary Cook Employee E2 reported that on 5/11/22, at approximately 3:30 p.m., Resident R1 was witnessed in the main kitchen doorway external exit and was caught on the doorway threshold attempting to get his wheelchair over the doorway threshold into the parking lot. Staff was forced to intervene to prevent Resident R1 from exiting the building. Dietary Cook Employee E2 reported the incident to the facility NHA immediately. Dietary Cook Employee E2 reported no alarms were sounding and that the door from the dining room into the kitchen, which is usually closed, had been open. Dietary Manager Employee E4 confirmed at that time that the external door is not alarmed as it is not a resident accessible door.

Review of the clinical records indicated that the facility failed to document the resident was reassessed for elopement risk at that time.

Review of the facility "elopement binder" on 5/19/22 indicated Resident R1's photo and information were not added to the binder until 5/19/22.

During an interview on 5/19/22 at 2:12 p.m. Corporate Consultant RN Employee E2 confirmed the facility failed to identify the resident as a potential elopement risk, complete an updated elopement risk assessment with the initiation of wandering behaviors noted on 4/29/22, after the first elopement on 5/8/22, and the second elopement on 5/11/22.

The facility failed to follow through with elopement risk assessment, and policies and procedures for residents at risk for elopement when a resident was identified as having a change in condition.

Immediate Jeopardy was identified placing residents at ongoing risk and facility was provided the template on 5/19/22, at 7:25 p.m.

On 5/19/22, at 10:01 p.m. an acceptable action plan was approved which included the following interventions:

Corrective action taken:
1. Resident R1 was identified outside of facility on 5/8/22. He was then returned inside of facility to unit. Wander guard was applied to resident and care plan was updated.
2. An updated Elopement assessment was completed on 5/19/22 for Resident R1. Elopement book updated with resident information and photo on 5/19/22.
3. Resident R1 was transferred to local ER on 5/11/22 and returned to facility same day with no new orders.
4. Resident was evaluated by physician on 5/19/22 with new order for therapy evaluation.
5. On 5/19/22 elopement assessments initiated in all residents to identify potential risk for elopement. Care plans to be updated in the electronic medical record for these identified residents as needed. A current elopement form which includes Resident's name, room number, and picture will be placed in the elopement binders and place at each nursing station and the receptionist desk as identified. Elopement binders are designed to keep staff aware of all residents who have been identified at a risk for elopement and are wearing a wander guard device. Will be completed by 5/20/22 by 0800.
6. On 5/19/22 The Staff Development nurse began education for present staff. The education included the facility's elopement policy and change in condition. Remaining staff will be educated prior to the start of their next shift until we reach 100%. Facility's elopement policy will be provided to each contracted agency. A signed copy of the facility's elopement policy must be presented prior to agency staff receiving a shift or assignment. If in the future an elopement occurs, the resident will be re-assessed immediately upon return to the premises.
Education of all staff will be completed 5/20/22 by 3:00 PM.
7. The Director of Nursing, NHA and/or Designee will perform weekly audits on all new admissions and residents identified as elopement risks for 3 months. The results of the audits will be reviewed and revised by the QAPI committee.
8. On 5/19/22 Kitchen staff has been educated to leave the kitchen door to resident area closed unless kitchen staff is present in kitchen.
9. Elopement drill was held on 5/19/22 with staff responding appropriately. Weekly elopement drills will be conducted by Administrator or designated staff every week for 4 weeks and then once a month for 2 months.

During observations and document review the facility educated in-person staff and contacted all staff and provided preliminary education offsite by telephone from 5/19/22 10:01 p.m. through 5/20/22 at 2:33 p.m. Observations of training in house for staff members as they entered for work along with question and answer sessions was ongoing throughout the period and review of signature sheets verified the training sessions.

The Immediate Jeopardy was removed on 5/20/22 at 2:33 p.m. when the action plan implementation was verified.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/03/21

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

28 Pa. Code 201.18(e)(1) Management.
Previously cited

28 Pa. Code 211.10(c) Resident care policies.
Previously cited 12/03/21

28 Pa Code 211.10(d) Resident Care policies
Previously Cited 12/3/21

28 Pa. Code 211.11(d) Resident care plan.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 12/03/21



 Plan of Correction - To be completed: 06/23/2022

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for the purposes of general liability, professional malpractice or other court proceedings. This plan of correction constitutes our credible allegation of compliance

1.Resident 1 was identified outside of the facility on 5/8/22. He was assisted back inside of the facility by staff. An order was obtained from the physician for a wander guard, and it was placed on the resident by ADON to alert staff of any unassisted attempts from the facility. The care plan was updated at that time by the facility nurse
2.An updated Elopement assessment was completed on 5/19/22 by LPN for Resident 1. The Elopement book updated with resident information and photo on 5/19/22.
3.Resident 1 was transferred to the local ER on 5/11/22 and returned to the facility the same day with no new orders.
4.Resident 1 was evaluated by his Primary Care Physician on 5/19/22 with orders for a therapy evaluation.
5.On 5/19/22 elopement assessments were completed by DON/Floor Nurse on residents identifying those residents at risk for elopement. Care plans were also updated by facility nurse at that time to reflect the current risk status of elopement. An elopement binder was completed containing resident information of those residents deemed at risk for elopement and placed at each nursing station and at the receptionist desk. The binder contained resident's photographs, names, room number, and use of wander guard device alerting staff to vital information for those considered a substantial risk of elopement.
6.On 5/19/22 initiation of education for present staff by the Staff Development nurse was started. The education included following the facility policy on elopement policy and procedure, change of condition, and the kitchen door remain secure when not in use. Education includes any future identified resident elopement will result in immediate assessment of resident upon return to the premises.
The remainder of the facility staff received education of said topics on 5/20/22 by the Staff Development nurse. A signed elopement policy will be provided to each contracted agency staff member prior to receiving a shift or assignment newly hired facility staff will receive education on facility policy and procedure related to elopement risk, significant change in status, and security of closure of kitchen door when not in use.
7.New admissions will be assessed on admission for elopement risk by the Director of Nursing and or designee. Residents will then be reassessed quarterly, annually, and in the event of a significant change for increased risk of elopement. Those considered at risk for elopement will have updated resident information, photographs, names, room number, and wander guard device used information sheets placed in the Elopement binder located at each nursing station and at the receptionist desk for reference.
8.The Director of Nursing, LNHA and or designee will complete weekly audits ensuring newly admitted residents have elopement risk assessed on admission, quarterly, and in the event weekly for four weeks and monthly for one quarter. The monthly Quality Assurance Performance Improvement committee will review audits to determine need for continued auditing.
9.Elopement drill was held by Staff Development RN on 5/19/22 with staff responding appropriately. Weekly elopement drills will be conducted by the LNHA and or designee appropriate response to elopement drills. Audit of appropriate response to elopement drills will be conducted for a minimum of four weeks, and monthly for one quarter. Audits will be forwarded to the Quality Assurance Performance Improvement Committee to determine need for further auditing.

Affinity Health Services will provide directed in services regarding F689 42 CFR 483.25 (d) (1)(2) Accident Hazards and Supervision to facility staff.


483.35(b)(1)-(3) REQUIREMENT RN 8 Hrs/7 days/Wk, Full Time DON: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.
483.35(b) Registered nurse
483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis.

483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
Observations:
Based on staff interview, it was determined that the facility failed to have Director of Nursing (DON) working full-time in the building for the periods of 4/22/22-5/16/22, and 5/17/22-5/20/22.

Findings include:

During an interview on 5/20/22, at 3:02 p.m. the Nursing Home Administrator (NHA) confirmed that the DON had abruptly resigned her position on 4/22/22. The NHA confirmed that the additionally the facility did not have a designated full-time DON from 4/22/22-5/12/22, and that the most recent DON quit abruptly by test message on 5/18/22 at 6:00 a.m. and the facility was without a DON until 5/20/22.

28 Pa. Code: 201.3 Definitions.

28 Pa. Code: 201.14(a) Responsibility of licensee.
previously cited 12/03/21

28 Pa. Code 201.18(a) Management

28 Pa. Code: 211.12(b) Nursing services.



 Plan of Correction - To be completed: 06/16/2022

F727
The facility hired a Full-time Director of Nursing starting on 5/19/2022 at 6:30 pm. The Corporate Clinical Consultant educated the LNHA/HR Manager on need for Director of Nursing coverage with full time RN coverage and to notify Corporate Consultant and VP of Operations of any changes of DON status. LNHA and or designee will audit daily that facility maintains FT RN DON for 4 weeks and monthly for one quarter. Audits will be forwarded to the Quality Assurance Performance Improvement Committee to determine need for further auditing.
483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(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 facility policy and clinical record review and staff interview, it was determined that the facility failed to maintain accurate clinical records for five of five residents (R1, R2, R3, R4, R5)

Findings include:

The facility policy "Charting and documentation" dated 3/1/2022 states that "Nursing Assistant entries (tasks) are documented in the Point of Care (POC) portion of the PCC (medical record) system".

During a review of the aide documentation for tasks associated with the POC system for Resident R1 revealed for the month of April 2022, 27 of 30 days were missing documentation, and for the month of May 2022, 20 of 26 days were missing documentation during shifts.

During a review of the aide documentation for tasks associated with the POC system for Resident R2 revealed for the month of April 2022, 3 of 3 days were missing documentation during shifts, and for the month of May 2022, 7 of 13 days were missing documentation during shifts.

During a review of the aide documentation for tasks associated with the POC system for Resident R3 revealed for the month of April 2022, 27 of 30 days were missing documentation during shifts, and for the month of May 2022, 17 of 17 days were missing documentation during shifts.

During a review of the aide documentation for tasks associated with the POC system for Resident R4 revealed for the month of April 2022, 13 of 14 days were missing documentation during shifts.

During a review of the aide documentation for tasks associated with the POC system for Resident R5 revealed for the month of April 2022, five of five days were missing documentation during shifts.

During an interview on 05/26/22 at 10:55 a.m., the Nursing Home Administrator confirmed that the facility failed accurately document the completion of care in the POC system for Residents R1, R2, R3, R4, R5.

28 Pa. code: 211.5(f) Clinical records.


 Plan of Correction - To be completed: 06/16/2022

0842
Resident 1 and resident 3 were assessed by the Director of nursing on 5/26/22 and determined no ill effects resulted from missing ADL documentation. Resident's 2, 4, and 5 no longer reside at the facility. Resident 5 discharged home without incident. Resident 2, 4 discharged to the hospital unrelated to missing documentation. On 5/26 education provided to CNA's and nurses regarding ADL documentation requirements. On 5/26 DON did complete audit on current residents for missing documentations and any missing documentation was completed by DON and CNA'S. The Director of Nursing and or designee will conduct audits on 50% of current census every shift for documentation completion for one month, then weekly for one month, and monthly for one quarter. Audits will be forwarded to the Quality Assurance Performance Improvement Committee to determine need for further auditing.
51.3 (e) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(e) If a health care facility is
aware of information which shows that
the facility is not in compliance with
any of the Department's regulations
which are applicable to that health
care facility, and that the
noncompliance seriously compromises
quality assurance or patient safety,
it shall immediately notify the
Department in writing of its
noncompliance.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for the failure to comply and the
steps which the health care facility
shall take to bring it into compliance
with the regulation.
Observations:
Based on review of the facility submitted events to the Pennsylvania Department of Health (DOH) Event Reporting System(ERS), it was determined that the facility failed to notify the DOH of four required events.

Findings include:

Review of the clinical records, staff interviews, and ERS events submitted to DOH, the facility failed to notify the DOH of two resident elopment events on 5/8/22 and 5/11/22.

Review of the facility personnel files and staff interviews, the facility failed to notify the DOH that the facility failed to have a Director of Nursing for the periods of 4/22/22-5/12/22 and 5/18/22-5/20/22.

During an interview with the Nursing Home Administrator on 5/26/22 at 10:55 a.m., confirmed that the facility failed submit the events to the DOH ERS system.


 Plan of Correction - To be completed: 06/16/2022

0007 The Facility DON submitted one resident with two events occurring on the same day to Department of Health on 6/9/2022.
The Facility LNHA also submitted another event to the Department of Health related to Director of Nursing coverage on 6/9/2022. The LNHA was educated on 6/9/2022 by the Corporate Clinical Consultant related to timely reporting to Department of Health any reportable event. LNHA and or designee will audit daily any reportable events/incidents are reported to DOH timely for 4 weeks and monthly for one quarter. Audits will be forwarded to the Quality Assurance Performance Improvement Committee to determine need for further auditing.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port