Nursing Investigation Results -

Pennsylvania Department of Health
MURRYSVILLE REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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MURRYSVILLE REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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MURRYSVILLE REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health (DOH) on November 18, 2021. Murrysville Rehabilitation and Wellness Center was in compliance with 42 CFR 483.73 related to E-0024(b)(6).





























 Plan of Correction:


Initial comments:

Based on a Covid-19 Focused Infection Control Survey and an Abbreviated Survey in response to a complaint completed on November 18, 2021, it was determined that Murrysville Rehabilitation and Wellness Center 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:


483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(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 clinical record reviews and interviews with residents and staff, it was determined that the facility failed to ensure that residents were provided with showers as ordered for two of five residents (Residents R2 and R3).

Findings include:

Review of the Minimum Data Set (MDS) assessment (periodic assessment of care needs) for Resident R2, dated 11/2/21, indicated that she was readmitted to the facility on 6/30/21, had moderate cognitive impairment and required extensive assistance of two persons for personal hygiene and was totally dependent for bathing.

Review of a physician order dated 6/21/21, indicated that Resident R2 was to be showered on Mondays and Thursdays on the 3:00 p.m. to 11:00 p.m. shift.

Review of facility bathing schedule records for the period of 10/19/21 to 11/13/21, revealed that Resident R2 was showered on 10/29/21 and 11/9/21.

Review of the nursing notes for the period 10/19/21 to 11/13/21, did not include documentation of the reason that Resident R2 was not showered by staff.

During an observation on 11/6/21, at 1:00 p.m., Resident R2 was noted to have poorly groomed hair.

Review of the Minimum Data Set (MDS) assessment (periodic assessment of care needs) for Resident R3, dated 8/14/21, indicated that he had severe cognitive impairment and required extensive assistance of two persons for personal hygiene and was totally dependent for bathing.

Review of a physician order dated 12/15/20, indicated that Resident R3 was to be showered on Tuesday and Friday on the 7:00 a.m. to 3:00 p.m. shift and a nursing progress note with explanation was to be made if shower was not provided.

Review of facility bathing schedule records for the period of 10/18/21 to 11/16/21, revealed that Resident R3 was showered on 10/21/21 and 10/27/21.

Review of the nursing notes for the period 10/18/21 to 11/16/21, did not include documentation of Resident R3's refusal to be showered by staff, indicated that a bed bath was given on 11/5/21, but had no other documentation regarding why the showers were not given by staff.

Review of the Minimum Data Set (MDS) assessment (periodic assessment of care needs) for Resident R3, dated 8/14/21, indicated that he had severe cognitive impairment and required extensive assistance of two persons for personal hygiene and was totally dependent for bathing.

Review of a physician order dated 12/15/20, indicated that Resident R3 was to be showered on Tuesday and Friday on the 7:00 a.m. to 3:00 p.m. shift and a nursing progress note with explanation was to be made if shower was not provided.

Review of facility bathing schedule records for the period of 10/18/21 to 11/16/21, revealed that Resident R3 was showered on 10/21/21 and 10/27/21.

Review of the nursing notes for the period 10/18/21 to 11/16/21, did not include documentation of Resident R3's refusal to be showered by staff, indicated that a bed bath was given on 11/5/21, but had no other documentation regarding why the showers were not given by staff.

During an interview on 11/6/21, at 2:35 p.m., the Nursing Home Administrator and Director of Nursing confirmed that Resident R2 and R3 did not receive showers as ordered by the physician.


28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 1/11/21.


 Plan of Correction - To be completed: 12/17/2021

0677 ADL Care for Dependent Residents:

The facility will correct the deficiency by reviewing all orders for showers/ADL care and updating them per the residents' preferences. Charge nurses will be re-educated by the DON and the regional nurse to follow up on shower schedules and monitor the completion of showers. All residents that are scheduled will be offered a shower and if they refuse, the charge nurse will approach and encourage the resident to participate with the shower. If the resident continues to decline the care, it will be documented in the record, reported to the oncoming shift and the resident will be re-approached the following day regarding shower.

The above process will prevent all residents from experiencing a similar situation.

The IDT will review showers/documentation each day (in reference to the previous 24 hours) during stand-up meeting. Showers that are noted not to be given and/or lack of documentation will be addressed individually with the charge nurse and direct care staff that was responsible for providing that care. Re-education will be done with those failing to follow the process and if necessary the disciplinary process if the behavior repeats. The resident will be re-approached and shower will be offered.

Audits done in daily stand up meeting (as above) will be tracked and trended for QAPI. Guardian Angel rounds have been updated so that department managers/leaders are routinely interacting with the residents and are asking them specifically about showers and any concerns related to showers or ADL care.

This process will be in place by December 17th, 2021.

483.10(g)(2)(i)(ii)(3) REQUIREMENT Right to Access/Purchase Copies of Records: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(g)(2) The resident has the right to access personal and medical records pertaining to him or herself.
(i) The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays); and
(ii) The facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days advance notice to the facility. The facility may impose a reasonable, cost-based fee on the provision of copies, provided that the fee includes only the cost of:
(A) Labor for copying the records requested by the individual, whether in paper or electronic form;
(B) Supplies for creating the paper copy or electronic media if the individual requests that the electronic copy be provided on portable media; and
(C)Postage, when the individual has requested the copy be mailed.

483.10(g)(3) With the exception of information described in paragraphs (g)(2) and (g)(11) of this section, the facility must ensure that information is provided to each resident in a form and manner the resident can access and understand, including in an alternative format or in a language that the resident can understand. Summaries that translate information described in paragraph (g)(2) of this section may be made available to the patient at their request and expense in accordance with applicable law.
Observations:
Based on information provided to the State Survey Agency and resident family and staff interview, it was determined the facility failed to furnish medical records timely when requested by a resident's responsible party for one of one residents who requested a copy of the resident's complete medical record (Resident R1).

Findings include:

Based on clinical record review and staff interview it was determined that the facility failed to provide copies of a resident's clinical record in a timely manner following receipt of the legal representative's written request with two working days with advanced notice for one out of 19 residents reviewed (Resident 6.)

Findings include:

The facility policy entitled "Medical Records Review" dated 3/2/21, Indicated that the resident and/or his legal representative has the right upon oral or written requests, to access all records pertaining to himself or herself including clinical records, within 24 hours.

During an interview on 11/6/21, the legal representative/ family member of Resident R1 stated that she had emailed the Nursing Home Administrator requesting Resident R1's medical records on 8/23/21 but had never received the records.

During an interview on 11/6/21, at 2:30 p.m., the Nursing Home Administrator confirmed the facility failed to timely provide copies of the resident's clinical record to the legal representative of Resident R1 within 24 hours of the request.

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

28 Pa. Code 201.29 (a)(1)(2) Resident Rights.

28 Pa. Code 211.5 (b) Clinical Records.


 Plan of Correction - To be completed: 12/17/2021

483.10 Right to Access/Purchase Copies of Records
How to correct: Records that had been requested by the responsible party of R1 were sent on November 15th. A blank form was also sent to the sister so she would have it for future requests.

The facility will protect other residents with similar requests by putting a paper request form in place and logging requests so that completion of the task is not forgotten or overlooked. Requests will be approved by NHA to ensure that the requester has legal access to the documents in question and the Medical Records department will then collect the documents and send them to the requestor.

How to prevent: The Medical Record clerk was educated by the NHA that medical record requests need to be in writing and need to be addressed within 24 hours of the request. The policy was reviewed with her and a written copy was given to her. A request form has now been put into place. A log of requests will be used to ensure follow through and to be used as an audit tool to confirm requests are being followed up on in the appropriate time frame. The NHA will audit the tool weekly x 3 weeks. The audits will be reviewed at QAPI each month.

The process outlined above will be audited directly on the log to verify that requests were completed timely and accurately. The log will be compared to the written requests to verify that the log is accurate. This will be done by the NHA and will be included in the monthly QAPI REPORT.

The corrective action for this process will be completed by December 17th.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(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 review of facility policy, review of the facility grievance log, and resident interviews, it was determined that the facility failed to document and follow grievance procedures for grievances brought up at two of four Resident Council meetings (September and October, 2021).

Findings include:

Review of the facility's policy entitled "Grievances" dated 3/2/21, indicated that grievances may include a resident verbalized complaint to facility staff and that the facility will acknowledge complaints and grievances and will actively work toward resolution of that complaint or grievance.

During an interview on 11/6/21, at 12:35 p.m., Residents R50 and R51 stated that several residents had brought up issues about lengthy call bell response by staff and issues about the quality and palatability of the evening meal at Resident Council meeting held on 9/2/21 and 10/28/21.

Review of the Resident Council meeting minutes recording form indicated that that the documentation for new business concerns (any issues or concerns) is done as follows: the concern is to be recorded and show of attendees obtained and should be documented on Department Response Form or referred to appropriate department in the case of a single resident concern).

Review of the Resident Council meeting minutes documentation for the meetings dated 9/2/21 and 10/28/21, indicated that there was "no new business" brought up by the residents in attendance.

During an interview on 11/6/21, at 2:30 p.m., the Nursing Home Administrator confirmed that there were no resident grievances documented regarding the quality and palatability of the food and the untimely response to call bells by staff.


28 Pa. Code 201.29(j) Resident rights.
Previously cited 1/11/21.


 Plan of Correction - To be completed: 12/17/2021

0585 Grievances:
The deficiency will be corrected by education to the dietitian, dietary manager, and activity director as follows: Minutes from Resident council and food committee must include any concerns brought up by the residents in the meetings and appropriate grievance forms should be completed in order to ensure follow up and follow up documentation. Minutes from the food committee need to be written in a logical format and maintained in a binder. Concerns noted in the food committee meeting must also be formally addressed using the grievance form and handled in a reasonable time frame.

The process as above noted will protect residents in similar situations as all department managers will also be re-educated on the grievance process and will be responsible for updating their individual staff members. Re-education will include the grievance process, the importance of timely reporting and follow up. Grievances are tracked and trended monthly with QAPI. Re-education regarding the grievance process was provided by the NHA. The dietary manager was educated about the keeping of minutes for the food committee. (Minutes were kept by the previous manager but were not formally typed or reviewed by NHA or QAPI)

Department heads/leadership will document any grievances on grievance forms or offering blank forms to those that are capable during weekly Guardian Angel rounds. Grievances will then be managed by the Social Services Director who will review in stand up meetings and disseminate to appropriate departments.
Weekly audits will be conducted interviewing 5% of residents (interviewable residents) to determine if they have any concerns that they have reported and asking what type of follow up occurred. These results will be compared with reported grievances to ensure documentation of the grievance and that follow up is occurring timely. These results will also be tracked and trended and reported during monthly QAPI meetings.

Corrective action is in process and will be completed by December 17th.

51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:
Based on review of facility documents and policies, clinical records and staff interview, it was determined that the facility failed to notify the State Survey Agency (Department of Health) of a Covid-19 infection outbreak involving four residents (Resident R4, R5, R6 and R7).

Findings include:

The facility policy entitled "Covid-19 Policy" dated 3/2/21, indicted that the facility will follow Centers for Disease Control (CDC), local and/or State reporting guidelines for any possible Covid-19 infections in staff or residents.

Review of the Covid-19 line listing (comprehensive list of residents and staff with positive Covid-19 infection testing) indicated the following positive resident tests:

Resident R6 tested positive on 10/2/21
Resident R5 tested positive on 10/4/21
Resident R4 tested positive on 10/5/21
Resident R7 tested positive on 10/5/21

During an interview on 3/30/21, at 8:15 a.m. the Director of Nursing/ Infection Preventionist confirmed that the facility had not reported the positive Covid-19 infection testing to the State Department of Health as required.

28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited 1/11/21.

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



 Plan of Correction - To be completed: 12/17/2021

The residents that tested positive for Covid were reported via the ERS on November 7, 2021.

The Director of Nursing was re-educated by the NHA on the need for newly positive Covid-19 cases be reported via the ERS system.

The DON or designee will be responsible for maintaining an updated line listing of resident related Covid activity in the facility and will be responsible for reporting positive cases via the DOH ERS system.

The NHA will audit the line listing weekly and compare against the ERS website to ensure all cases have been reported x 3 weeks. These audits will be included in the Infection Control committee meeting monthly.

The process will be in place by December 17th, 2021.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:

Based on review of Pennsylvania Department of Health guidance memo, facility documentation, and staff interviews it was determined that the facility failed to notify the Department of Health of nursing staffing that did not meet requirements for minimum resident care hours of 2.7 for one of 17 days.

A Department of Health notice dated 4/19/20, entitled "Staffing Resources for Nursing Care Facilities During COVID-19 Pandemic" indicated that "28 Pa Code 211.12(i) requires a minimum number of general nursing care hours to be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period must, when totaled for the entire facility, be a minimum of 2.7 direct resident care for each resident. The Department understands that during the COVID-19 pandemic nursing care facilities may not be able to maintain the 2.7 Per Patient Day (PPD) requirement. Facilities must ensure resident quality of care continues despite the shortfalls in the 2.7 PPD. Please document on a monthly report when your facility drops below the 2.7 PPD, the reason behind the decrease, and how your facility is maintaining quality of care. Forward the report to the appropriate Department field office by the 10th of each month or until otherwise instructed by the Department."

Review of the facility provided nursing hour staffing indicated that the facility nursing staffing did not meet the required 2.7 resident care hours per day on 11/1/21.

During an interview on 11/6/21, at 2:30 p.m., the Nursing Home Administrator confirmed the facility did not meet the minimum number of hours of 2.7 per day as required.


 Plan of Correction - To be completed: 12/17/2021

2020 211.12 Licensure. Nursing Services:
The facility provided appropriate level of care to the residents on November 1, 2021 despite the PPD of 2.51.

The facility strives for a PPD of 2.7 or greater and has staffed accordingly. In order to protect the residents from PPD's below 2.7, the DON, ADON, LPNAC, and other clinical staff have assisted in care, answered call bells, and assisted in passing trays. Additional agency contracts have been obtained.
Staffing meetings to review daily PPD, projected PPD, and any potential areas of concern related to the nursing staffing are underway. HR has increased focus on recruitment and improved orientation. Orientation that will not only offer the information needed to be successful but the opportunity to develop relationships from day one with the goal of improving retention is being developed.

The staffing team monitors PPD daily and the schedule is a continual work in progress. Bonuses are offered to incentivize staff during challenging times. We also use an agency to provide travelling staff to fill in on 9-12 week assignments.

PPD grids are maintained. The NHA, in conjunction with the regional team, monitor and audit PPD weekly. If PPD were to fall below 2.7 as a result of the current staffing crises related to the pandemic, the NHA will report it via the ERS as per the guidance memo.

This process will be in place by December 17th, 2021


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