Nursing Investigation Results -

Pennsylvania Department of Health
HARBORVIEW REHABILITATION AND CARE CENTER AT LANSDALE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HARBORVIEW REHABILITATION AND CARE CENTER AT LANSDALE
Inspection Results For:

There are  98 surveys for this facility. Please select a date to view the survey results.

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HARBORVIEW REHABILITATION AND CARE CENTER AT LANSDALE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated Survey in response to a complaint, completed on February 12, 2020, it was determined that Harborview Rehabilitation and Care Center at Lansdale, was not in compliance with the 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.





 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(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 observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

An initial tour of the Food Service Department conducted on February 9, 2020, at 8:10 a.m. with Employee E3, Morning Cook/Supervisor, revealed the following:

Observations near the door to the receiving area revealed an area used to store mops and buckets where there were hoses that were leaking and the floor in the entire area was wet. Further observation revealed a large grey garbage can that was full of trash and had no lid covering the refuse.

Observation outside the receiving door revealed debris, paper, cup lids, plastic bags, and cigarette buts on the landing and the stairs which lead to the parking lot behind the building. Further observation outside revealed two blue dumpsters containing the facilities trash both of which had the lid on the top left open.

Observation in the walk-in refrigerator revealed one storage container containing grated cheese, and another container with brown gravy and neither container had a label or date. Further observation revealed a container with labeled prep for soup dated 2/22/20, egg salad labeled 2/25/20 and macaroni salad dated 2/20/20 and the actual date was 2/9/20. Interview with the morning cook on February 9, 2020, at 8:25 a.m. revealed that the cook was unaware why the foods were labeled with a date so far in the future.

Observation in the walk-in freezer revealed a container of low sodium beef patties that was open with the inner plastic liner open exposing the product to the circulating air.

Observation in the kitchen revealed a hand sink adjacent to the dish area that was left running and was difficult to turn all the way off to stop the flow of water.

Observation during a follow-up visit to the kitchen on February 10, 2020, at 12:47 p.m. with Employee E4, Food Service Director (FSD), revealed that the emergency food supply was mixed in with the regular food supply including hot cereal which they use one box a day for the regular menu.

Further observation in the kitchen revealed the hand sink adjacent to the dish area was leaking again.

Interview on February 10, 2020, at approximately 1:00 p.m. with the FSD confirmed the above findings and the FSD stated that they do not have a written policy on food storage that address how food products are labeled and dated.

The facility failed to store, prepare and serve food in accordance with professional standards for food service safety.


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

28 Pa. Code 211.6(c) Dietary services



 Plan of Correction - To be completed: 03/17/2020

a.All outdated dietary inventory was discarded

b.IDT will audit dietary inventory for proper storage, preparation and distribution of residents' food.

c.ED will educate FSD on proper techniques for storing, preparing and distribution of residents food.

d.Facility will conduct a kitchen sanitation audit weekly x4 and monthly x 3. Results from the audits will be reviewed at the facility QAPI meeting monthly x 3.

e.Completion date of 3/17/2020



483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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(f) Frequency of Meals
483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on the resident council interview, review of clinical records, and interviews with staff, it was determined that the facility failed to offer a nourishing snack for residents at bedtime, for six of six residents interviewed (Resident R5, R7, R10, R16, R87 and R88).

Findings include:

During the resident council interview conducted on February 9, 2020, at approximately 2:30 p.m., with five alert and oriented residents in attendance (Residents R5, R7, R10, R16 and R87), the residents stated that they were not consistenly offered an evening snack every night. The five residents indicated that residents with diabetes (diabetes mellitus-failure of the body to produce insulin to enable sugar to pass from the blood stream to the cells for nourishment) or other health problems get a labeled snack from the facility's kitchen (ex. half of a sandwich labeled with a specific resident's name on the wrapped sandwich), but that unless "you're diabetic, the kitchen brings up the snacks after dinner on a tray and most of the time, the snacks just sit there near the nurse's desk all night." One of the residents added that the facility, "used to have someone go around every night with a tray of snacks along with fresh water and ice, but that hasn't happened in a while."

Review of the Resident Council Meeting Minutes dated December 19, 2019, revealed 19 residents attended the meeting, including four of the five residents who participated in the resident council interview on February 9, 2020 (Residents R5, R7, R10, and R87). Further review of the minutes revealed documentation under the dietary concerns section indicating, "Snacks - Not Enough."

Review of data in the facility's electronic clinical record program on February 10, 2020, under the "Tasks" section during the past 30 days, under the heading of Snacks, "Was a snack offered at bedtime?" revealed the following documentation for the following residents:

Resident R5 had no documentation that an evening snack was offered on January 17, 18, 19, 27, and 31, 2020; and February 7 and 9, 2020; for a total of seven occurrences in a 30 day period.

Resident R7 had no documentation that an evening snack was offered on January 13, 19, 24, 25, and 31, 2020; and February 4, 7 and 9, 2020; for a total of eight occurrences in a 30 day period.

Resident R10 had no documentation that an evening snack was offered on January 15, 16, 20, 21, 22, 23, 24, 27, 30 and 31, 2020; and February 1, 2, and 4, 2020; for a total of 13 occurrences in a 30 day period.

Resident R16 had no documentation that an evening snack was offered on January 24 and 31, 2020; and February 2, 2020; for a total of three occurrences in a 30 day period.

Resident R87 had no documentation that an evening snack was offered on January 15, 19, 27 and 29, 2020; February 1, 3, 4 and 5, 2020; for a total of eight occurrences in a 30 day period.

Resident R88 had no documentation that an evening snack was offered for the full 30 day period from January 12, 2020, through February 9, 2020.

The facility failed to ensure that each resident was offered a suitable and nourishing snack every night at bedtime.

CFR(s): 483.60(f)(1)-(3) Frequency of Meals/Snacks at Bedtime

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

28 Pa. Code 201.11.12(d)(1) Nursing services

28 Pa. Code 201.11.12(d)(5) Nursing services










 Plan of Correction - To be completed: 03/17/2020

a. The facility does provide a nourishing snack at bedtime. The facility met with R5, R7, R10, R16, R87, R88 to review the facility's protocol on offering HS snacks.

b. Facility will conduct random interview with residents to gain insight on additional HS snacks that they would like to see offered.

c. IDT will educate staff on the importance and procedure of offering and documenting HS snack.

d. Facility will conduct audits, via random questionnaires, to ensure compliance with providing nourishing snacks each evening. Audits will be conducted weekly x4 and monthly x 3. Results from the audits will be reviewed at the facility QAPI meeting monthly x 3.

e. Completion date of 3/17/2020

483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
483.70(o) Hospice services.
483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in 418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at 483.24.
Observations:

Based on observations, review of clinical records, facility documentation and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that adequate communication was maintained between a hospice (end of life care to support resident and family) provider and the facility, for two of three residents reviewed receiving hospice services (Residents R69 and R88).

Findings include:

Review of facility policy, "Hospice Services," dated December 1, 2018, revealed that it is the policy of the facility to provide collaborative care with Hospice providers to ensure that the resident's end of life preferences and choices are honored.

Review of facility documentation, "Hospice Services Agreement," dated December 8, 2017, revealed that, "Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision of Facility Services under this agreement is in accordance with the Hospice Patient's Plan of Care, assessments, treatment planning and care coordination."

Review of Resident R69's Minimum Data Assessment (MDS- an assessment of a resident's need) dated December 26, 2019 revealed the resident was admitted to the facility on October 25, 2018 with diagnoses including dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), transient ischemic attack (TIA-when the blood supply to part of the brain is briefly blocked), anxiety (unpleasant sense of inner turmoil and anguish) and depression (major loss of interest in pleasurable activities characterized by change in sleep patterns, appetite and/or routine).

Review of Resident R69's Hospice Plan of Care, dated October 17, 2019, revealed that the resident will receive skilled nursing visits at least once per week and nurse aide visits three times per week.

Review of Resident R69's hospice documentation that was available in the facility, revealed that there were no nursing notes and no nurse aide notes from January 17, 2020 to February 12, 2020.

Interview on February 12, 2020 at approximately 10:55 a.m. with the Director of Nursing confirmed that there were no nurse aid or skilled nursing notes in the resident's Hospice binder after the date of January 17, 2020.

Review of Resident R69's Occupational Therapy discharge notes, dated May 24, 2019, revealed that "patient was issued a Rock n go chair form hospice ...pt [sic- abbreviation for patient] is laterally leaning to the left side unable to maintain midline with repositioning ...tends to gravitate toward lateral leaning." Further review revealed, "Pt positioned in narrow, high back reclining wheelchair fitted with anti-tippers and lateral support to help pt to maintain upright sitting. Pt also issued wedge cushion to position knees higher than hips for further sitting comfort and safety. Pt appears comfortable and is reclined when she falls asleep."

Review of physician order for Resident R69, dated December 9, 2019, revealed, "Hospice issued rock and go wheelchair."

Progress notes from December 10, 2019 revealed, "Nurse was trying to push resident from dining into room to put her in bed and she rocked herself out of the w/c [sic-abbreviation for wheelchair]"

Review of the facility fall incident report, dated December 10, 2019 revealed, "restlessness noted ...when staff went to assist resident she again began rocking and rocked forward from her chair. Resident is in a rock and go w/c provided by hospice."

Review of the facility fall incident report, dated February 6, 2020 revealed, "Resident is disoriented x3 (people, places and time). Dependent for all locomotion, resident is seated in rock and go w/c, provided by Hospice. Rocks back and forth while in w/c. Resident without an intended destination when she scooted to the floor."

Observation of resident on February 9, 2020 at approximately 9:15 a.m. and February 10, 2020 at approximately 9:05 a.m. in dining area revealed that Resident R69 was seated in a Rock N Go wheelchair. She was reclined back to an approximate 130 degree angle and she was observed to be grasping the armrests and attempting to pull herself up to a more upright position.

Observation of resident on February 9, 2020 at approximately 12:00 p.m. in dining area revealed that Resident R69 was seated in a Rock N Go wheelchair near a table. She was reclined to an approximate 130 degree angle and she was observed to be grasping the armrests and attempting to pull herself up to a more upright position while a staff member was attempting to spoon feed the resident her pureed lunch.

Review of facility document, "Nursing Facility and Hospice Services Agreement," dated June 12, 2019, revealed the nursing facility would coordinate with hospice personnel regarding the resident's plan of care. The Agreement additionally added that both the nursing facility and hospice provide would each prepare and maintain complete and detailed clinical records for resident's receiving hospice care, including, but not limited to, evaluations and treatments.

Review of the clinical record for Resident R88 revealed the resident was readmitted to the facility on September 19, 2019, with diagnoses including, but not limited to, worsening dementia and anxiety.

Review of a physician's order, dated October 17, 2019, instructed staff to have hospice staff evaluate and treat Resident R88.

Review of another physician's order, dated December 9, 2019, revealed, "Hospice issued gerichair."

Review of an IDG (Interdisciplinary Group) hospice note, dated January 15, 2020, for coordination of care, revealed the hospice provider would supply DME (durable medical equipment-wheelchairs, bedside commodes, etc.).

Observation during initial resident screening process on February 9, 2020, at 8:14 a.m. revealed Resident R88 was eating breakfast, with assistance of a staff member, in the dining room on the third floor nursing unit. Resident R88 was sitting upright in a geri chair, unreclined, with lockable tray in place over the resident's lap area.

Observation on February 9, 2020, at 9:21 a.m. revealed the breakfast meal was complete and Resident R88 was finished eating. Resident remained sitting in the unreclined geri chair and was observed to be slowly sliding down the chair, with upper torso partially under the locked tray, was grasping each armrest of the chair and was attempting to stop herself from sliding down. Resident R88 appeared to be unnerved and uncomfortable with her legs dangling unsupported while attempting to keep self from sliding down the chair (bottom portion of geri chair was not in recline position as she was seated upright, so there was no support for the resident's legs). When not being addressed by staff, Resident R88 was yelling out words, approximately every 15 seconds, unintelligible in an Asian dialect (Vietnamese).

Observation on February 9, 2020, at 9:44 a.m. revealed Resident R88 had slid down further in the geri chair and was askew in the chair, yelled out again in the Asian dialect, was grasping onto the tray, and when approached by a staff member, the resident clearly stated in English, "Lift me up!" The staff member was observed to physically lift the resident back up in the chair, then proceeded to wheel her back to her room to have incontinence care provided.

Observation on February 9, 2020, at 9:59 a.m revealed the same staff member brought Resident R88 back to dining area, placed her chair in the same location in the room as it was during breakfast, now with the geri chair in a reclined position. The locked tray was observed to remain in place.

Observation on February 9, 2020, at 10:12 a.m. revealed the locked tray was removed by a staff member. Resident remained in the inclined position.

Observation on February 9, 2020, at 11:52 a.m. revealed Resident R88 remained in inclined position and was sleeping.

Observation on February 10, 2020, at 11:51 a.m. revealed Resident R88's hospice aide was assisting the resident with her lunch meal. Resident R88 was seated in the geri chair, in an upright position, with locked tray in place. Interview with the hospice aide at the time of the observation revealed Resident R88 cannot remove tray on her own because it is designed to be locked in place so that staff can remove it, not the resident.

Further review of the clinical record revealed no documentation that the facility obtained a physician's order for use of a locked tray on Resident R88's geri chair, and no documentation that the interdisciplinary team, along with hospice staff, assessed this geri chair with lockable tray to determine the necessity of this device for the resident's medical diagnoses of dementia and anxiety.

Interview conducted with the Nursing Home Administrator and Director of Nursing on February 10, 2020, at approximately 2:00 p.m. revealed that the facility had not obtained a physician's order to use a lockable tray in conjunction with a geri chair, and confirmed that hospice staff provided this chair for Resident R88 without adequate documentation regarding communication with facility staff regarding the reason for use of lockable tray and assessment of safe and proper body positioning in the geri chair.

Refer to F604 and F688.

The facility failed to provide documentation that adequate communication was maintained between hospice providers and the facility to ensure the needs of residents were addressed and met.

CFR(s): 483.70(o)(1)-(4) Hospice Services
Previously cited 01/29/19

28 Pa Code 201.18(a) Management
28 Pa Code 201.18(b)(1) Management
28 Pa Code 201.14(a) Responsibility of licensee






 Plan of Correction - To be completed: 03/17/2020

a.Resident R 69 and R 88 hospice providers were called, and progress notes were obtained and placed on the chart.

b.Facility will review hospice residents' charts to ensure there is adequate communication between facility and hospice providers and the current documentation of hospice services is readily available.

c.Facility educated hospice providers of expectations of timely and adequate communication, in the form of documentation, being made readily available on resident's charts.

d.Medical Records will audit weekly x4 and monthly x3 the charts of hospice residents to ensure there is adequate communication between facility and hospice providers and the current documentation of hospice services is readily available. Results from the audit will be reviewed at the facility QAPI meeting monthly x 3. Medical Records will create an ongoing spreadsheet ensuring hospice charts are up to date.

e.Completion date of 3/17/2020

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

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.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on observations, review of clinical records, facility policies and procedures and facility documentation, and interviews with staff, it was determined that the facility failed to ensure that residents were free from physical restraints, for one of four residents reviewed (Resident R88).

Findings include:

Review of undated facility policy, "Restraint-Least Restrictive," defined a physical restraint as any mechanical device or equipment attached or adjacent to a resident's body, that the individual cannot remove easily, which restricts freedom of movement, and includes, but is not limited to, devices used with a chair such as a tray that the resident cannot easily remove or that prevents them from rising.

The policy added that the decision to use such devices would be comprehensively assessed by the interdisciplinary team who would consider the underlying cause of the medical sign/symptom requiring treatment with a physical restraint, and determine the least restrictive type of physical restraint to be applied to treat the resident's medical symptom.

Review of the clinical record for Resident R88 revealed the resident was readmitted to the facility on September 19, 2019, with diagnoses including, but not limited to, worsening dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and anxiety (unpleasant sense of inner turmoil and anguish).

Review of an Occupational Therapy (OT) Evaluation and Plan of Treatment evaluation for Resident R88, dated September 20, 2019, revealed the resident was being evaluated by OT so that the resident would, "exhibit anatomically correct positioning while sitting in W/C [wheelchair] with use for 3 hours with Good [sic] sitting balance during ADLs [activities of daily living] in order to enhance comfort, reduce the risk for falls and achieve proper joint alignment."

Review of an OT treatment encounter note dated September 23, 2019, revealed that facility OT staff had attempted to trial Resident R88 with a Rock N' Go wheelchair (specialized wheelchair that features a rocking motion, sling seat and back, that can ease agitation in dementia patients), but the resident was, "found to be actively sliding hips down in chair with inability to stay in upright position due to significant agitation and restlessness," and that a geri chair (specialized reclining chair) was recommended. An OT treatment encounter note dated September 24, 2019, indicated that Resident R88's positioning for safety continued to be evaluated as the resident, "continuously pushed hips forward and slides down in all types of positioning chairs. Severe pt [patient] restlessness and agitation continues to prevent pt from sitting." Another OT treatment encounter note dated September 30, 2019, and electronically signed by Employee E5, Occupational Therapist, revealed due to Resident R88's significant dementia, restlessness and inability to carry over training in safety due to dementia, recommendations as to safe and anatomically correct seating were made to Nursing and Administration, and that Resident R88 was discharged from skilled OT services due to being evaluated for hospice services (end of life care to support resident and family).

Further review of OT documentation did not identify what the "recommendations as to safe and anatomically correct seating" were for Resident R88 upon discharge from skilled OT on September 30, 2019. Interview with Employee E5 on February 11, 2020, at approximately 8:45 a.m. revealed that the recommended wheelchair from occupational therapy on September 30, 2019, for Resident R88 was a geri chair.

Review of a nursing progress note dated October 1, 2019, at 8:22 a.m. revealed Resident R88 was restless that morning, "continues to slide from chair greater than 4 times in 2 minutes, as soon as staff re position [sic] resident in chair she scoots herself forward," staff had to lower her to the floor, and then required two staff members to stand the resident up and boost back in the chair. Review of a nursing progress note dated October 6, 2020, at 3:35 p.m. revealed, "Resident was received in dining room at start of shift. She was in the Geri chair and was attempting to jump/fall out of it every few seconds... Resident was positioned numerous times throughout shift due to her intentionally trying to slide out or throw herself over the side of the chair." Review of a nursing progress note dated October 29, 2019, at 5:20 a.m. indicated Resident R88 was restless and was repeatedly attempting to get up out of the geri chair.

Review of the plan of care for Resident R88 related to hospice care, dated October 17, 2019, indicated that, "Resident spends majority of time in geri chair for safety/ monitoring and comfort."

Review of a nursing progress note dated November 17, 2019, at 10:31 p.m. revealed resident had visible signs of anxiety including, "rocking back and forth from geri-chair, grasping onto tray of geri-chair, and attempting to pry it off."

Review of a nursing progress note dated December 5, 2019, at 1:47 p.m. revealed, "Resident continuously slides out of Geri-Chair," and that the resident was found with a skin tear (site of skin tear not documented in this note dated December 5, 2019, at 1:47 p.m.). Review of facility documentation into the incident on December 5, 2019, revealed Resident R88 sustained a skin tear to her left elbow, that the resident was noted actively moving about in her geri chair at the time of discovery of the skin tear, and that the resident "most probably" brushed her elbow against the chair causing the skin tear.

Review of physician's orders dated December 9, 2019, revealed Resident R88 continued on hospice and that, "Hospice issued gerichair."

Observation of Resident R88 on February 9, 2020, at 8:14 a.m. revealed Resident R88 was eating breakfast, with assistance of a staff member, in the dining room on the third floor nursing unit. Resident R88 was sitting upright in a geri chair, unreclined, with lockable tray in place over the resident's lap area.

Observation on February 9, 2020, at 9:21 a.m. revealed the breakfast meal was complete and Resident R88 was finished eating. Resident remained sitting in the unreclined geri chair and was observed to be slowly sliding down the chair, with upper torso partially under the locked tray, was grasping each armrest of the chair and was attempting to stop herself from sliding down. Resident R88 appeared to be unnerved and uncomfortable with her legs dangling unsupported while attempting to keep self from sliding down the chair (bottom portion of geri chair was not in recline position as she was seated upright, so there was no support for the resident's legs). When not being addressed by staff, Resident R88 was yelling out words, approximately every 15 seconds, unintelligible in an Asian dialect (Vietnamese).

Observation on February 9, 2020, at 9:44 a.m. revealed Resident R88 had slid down further in the geri chair and was askew in the chair, yelled out again in the Asian dialect, was grasping onto the tray, and when approached by a staff member, the resident clearly stated in English, "Lift me up!" The staff member was observed to physically lift the resident back up in the chair, then proceeded to wheel her back to her room to have incontinence care provided.

Observation on February 9, 2020, at 9:59 a.m revealed the same staff member brought Resident R88 back to dining area, placed her chair in the same location in the room as it was during breakfast, now with the geri chair in a reclined position. The locked tray was observed to remain in place.

Observation on February 9, 2020, at 10:12 a.m. revealed the locked tray was removed by a staff member. Resident remained in the inclined position.

Observation on February 9, 2020, at 11:52 a.m. revealed Resident R88 remained in inclined position, with locked tray removed, and was sleeping.

Observation on February 10, 2020, at 11:51 a.m. revealed Resident R88's hospice aide was assisting the resident with her lunch meal. Resident R88 was seated in the geri chair, in an upright position, with locked tray in place. Interview with the hospice aide at the time of the observation revealed Resident R88 cannot remove tray on her own because it is designed to be locked in place so that staff can remove it, not the resident.

Further review of the clinical record revealed no documentation that the facility obtained a physician's order for use of a locked tray on Resident R88's geri chair, and no documentation that the interdisciplinary team assessed this geri chair with lockable tray to determine the necessity of this device for the resident's medical diagnoses of dementia and anxiety.

Interview conducted with the Nursing Home Administrator and Director of Nursing on February 10, 2020, at approximately 2:00 p.m. revealed that the facility had not obtained a physician's order to use a lockable tray in conjunction with a geri chair, and confirmed that a tray used with the geri chair met the facility's definition of a physical restraint as indicated in the facility's policy.

The facility failed to adequately assess and obtain a physician's order for a physical restraint for Resident R88.


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

28 Pa. Code 211.10(c) Resident care policies

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

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





 Plan of Correction - To be completed: 03/17/2020

a.Physical restraint for R88 was removed and discontinued

b. IDT will audit residents in-house to ensure no physical restraints are in use

c. IDT will educate staff on facility's restraint policy, prohibiting all use of physical restraints

d. IDT will conduct a random audit to ensure no physical restraints are in use weekly x4, monthly x3. Results will be reviewed at QAPI monthly x3.



483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Chemical Restraints: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) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

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.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on observation, review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that residents were free of chemical restraints to address behaviors, for one of 27 residents reviewed (Resident R88).

Findings include:

Review of the Behavior Observation Task in the facility's electronic clinical records system defined, "Behavior Symptoms" to include the following examples: frequent crying, repeats movement, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexual inappropriateness, and rejection of care.

Review of undated facility policy, "Behavior Management Program Overview," revealed that prior to the administration of a psychoactive medication (medication used to modify/treat one's behavior), non-chemical interventions would be the first choice in managing resident behavioral symptoms; with the policy adding that the facility does not use chemical restraints (defined as drugs used for discipline or convenience and are not required to treat medical symptoms).

Review of facility policy, "Behavior and Psychoactive Management Program," dated December 1, 2018, defined a psychotropic drug as any drug that affects brain activities associated with mental processes and behaviors, including antianxiety medications; and that prior to a nurse administering a medication to treat anxiety (unpleasant sense of inner turmoil and anguish), non-pharmacological interventions previously attempted without success, "must be documented."

Review of Davis's Drug Guide for Nurses, Twelfth Edition, dated 2011, defined that a geriatric patient is an adult over 65 years of age and that the older patient is at risk for toxic reactions to medications due to altered absorption, distribution, metabolism and excretion of medications. The Davis's Drug Guide for Nurses classified the medication lorazepam (Ativan) as a medication to treat anxiety with side effects including, but not limited to, drowsiness and lethargy (sleepy, fatigued, sluggish). Additionally, the Davis's Drug Guide for Nurses added that for geriatric patients, to treat a diagnosis of anxiety, the recommended dose is 0.5 mg (milligrams) to 2 mg per day.

Review of a psychiatric certified registered nurse practioner (CRNP) progress note, dated September 15, 2019, revealed Resident R88, had diagnoses including, but not limited to, dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) with behaviors, restlessness and anxiousness. The CRNP progress note added that Resident R88 continued with increasing restlessness per nursing, that the resident had difficulty sitting still for meals, and did not respond to redirection.

Review of the clinical record revealed Resident R88 was readmitted to the facility after hospitalization on September 19, 2019, with diagnoses including, but not limited to, worsening dementia and anxiety (unpleasant sense of inner turmoil and anguish).

Review of physician's orders dated August 30, 2019, and monthly thereafter, instructed staff to administer Risperdal (antipsychotic medication) 0.5 mg, one tablet orally two times a day, for a diagnosis of dementia. A physician's order, dated October 20, 2019, and monthly thereafter, instructed staff to administer Seroquel (antipsychotic medication) 12.5 mg orally two times a day for restlessness and agitation. Another physician's order, dated October 7, 2019, instructed staff to administer Ativan (lorazepam) 1 mg orally, every six hours prn (medical abbreviation for as needed), for restlessness and agitation.

Review of a quarterly Minimum Data Set assessment (MDS-periodic assessment of needs) dated January 10, 2020, revealed the resident had additional diagnoses of restlessness and agitation; and had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairmen) score of 3, indicating the resident was severely cognitively impaired. The MDS added under Section E, Behavior, that Resident R88 did not exhibit any behavioral symptoms including exhibiting no verbal/vocal symptoms like screaming or disruptive sounds.

Observation during initial resident screening process on February 9, 2020, at 8:14 a.m. revealed Resident R88 was eating breakfast, with assistance of a staff member, in the dining room on the third floor nursing unit. Resident R88 was sitting upright in a geri chair, unreclined, with lockable tray in place over the resident's lap area.

Observation on February 9, 2020, at 9:21 a.m. revealed the breakfast meal was complete and Resident R88 was finished eating. Resident remained sitting in the unreclined geri chair and was observed to be slowly sliding down the chair, with upper torso partially under the locked tray, was grasping each armrest of the chair and was attempting to stop herself from sliding down. Resident R88 appeared to be unnerved and uncomfortable with her legs dangling unsupported while attempting to keep self from sliding down the chair (bottom portion of geri chair was not in recline position as she was seated upright, so there was no support for the resident's legs). When not being addressed by staff, Resident R88 was yelling out words, approximately every 15 seconds, unintelligible in an Asian dialect (Vietnamese).

Observation on February 9, 2020, at 9:44 a.m. revealed Resident R88 had slid down further in the geri chair and was askew in the chair, yelled out again in the Asian dialect, was grasping onto the tray, and when approached by a staff member, the resident clearly stated in English, "Lift me up!" The staff member was observed to physically lift the resident back up in the chair, then proceeded to wheel her back to her room to have incontinence care provided.

Review of the Medication Administration Record (MAR) for Resident R88 revealed Ativan 1 mg was documented as administered by the licensed nurse at 9:46 a.m., on February 9, 2020.

Review of the Behavior Observation Task in the facility's electronic clinical record for Resident R88, regarding if the resident exhibited any behaviors, on February 9, 2020, at 11:08 a.m., "Yes" was checkmarked, and the documented behavior that was exhibited was "yelling/screaming."

Further review of the clinical record for Resident R88 revealed no documentation that the resident was assessed to determine possible underlying causes for the resident's "yelling/screaming" that occurred in the morning on February 9, 2020; no documentation regarding what other non pharmacological interventions were attempted prior to the administration of Ativan 1 mg for "yelling/screaming;" and no documentation that the Ativan could be administered to treat a documented behavior of "yelling/screaming." There was no documented evidence to support the administration of Ativan 1 mg, an antianxiety medication with documented side effects of drowsiness and lethargy, used as chemical restraint, to Resident R88 on February 9, 2020.

Interview with the Nursing Home Administrator and Director of Nursing on February 10, 2020, at approximately 1:45 p.m., confirmed Resident R88 received an antianxiety medication, ordered by the physician to use for "restlessness and agitation," and was documented as administered for "yelling/screaming," on February 9, 2020.


The facility failed to ensure that one resident was free from a chemical restraint.


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

28 Pa. Code 211.10(c) Resident care policies

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

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




 Plan of Correction - To be completed: 03/17/2020

a.R88 was evaluated by in-house psychology and changes were made to her anti-psychotropic medication

b.IDT will audit documentation of PRN anti-psychotropic medications to ensure the documented behaviors warranted the medication use to ensure residents are free from chemical restraints

c.IDT will educate nursing staff on required documentation of behaviors prior to administering PRN anti-psychotropic medication for appropriateness

d.IDT will conduct a random audit weekly x4, monthly x3 to ensure behaviors are documented prior to administering PRN anti psychotropic medication non-pharmaceutical interventions. Review of audits will be reported at QAPI monthly x3

e.Completion date of 3/17/2020

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 a review of clinical records and interview with staff, it was determined that the facility did not develop a comprehensive person-centered care plan with measurable objectives and goals related to medical equipment for two of 27 records reviewed (Resident R91 and R76).

Findings include:

Review of Resident R91's clinical record revealed the resident was admitted to the facility on March 21, 2019, with a diagnoses, including but not limited to, morbid obesity and obstructive sleep apnea (sleep disorder that is marked by pauses in breathing of 10 seconds or more during sleep, and causes unrestful sleep). Further review of Resident R91's clinical record revealed a physician's order dated March 21, 2019, for a CPAP (machine which pumps air into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing) on at HS (hour of sleep) with pressure setting of 10 cm H2O every evening and night shift.

A review of Resident R91's care plan completed on February 10, 2020, revealed no focus area, goals or interventions listed related to the use of a CPAP machine.

Interview with the Nursing Home Administrator and the Director of Nursing on February 10, 2020, at approximately 2:00 p.m. confirmed that no care plan interventions had been developed related to the use of a CPAP machine for Resident R91.

Review of Resident R76's clinical record revealed the resident was admitted to the facility on January 3, 2020, with diagnoses, including but not limited to, peripheral vascular disease (causes the blood vessels outside of your heart and brain to narrow, block, or spasm), and type 2 diabetes mellitus (a chronic condition that affects the way your body metabolizes sugar (glucose)). Further review of Resident R76's clinical record revealed a January 3, 2020, physician's order for a wound VAC (device that decreases air pressure on the wound; which can help the wound heal more quickly).

A review of Resident 761's care plan completed on February 10, 2020, revealed no focus area, goals or interventions developed related to the use of a wound VAC machine.

Interview with the Nursing Home Administrator and Director of Nursing on February 10, 2020, at approximately 2:00 p.m. confirmed that no care plan interventions were developed related to the use of a wound VAC machine for Resident R76.

The facility failed to ensure that comprehensive person-centered care plans were developed for two residents related to the use of medical equipment.



28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.11(d) Resident care plan

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

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







 Plan of Correction - To be completed: 03/17/2020

a. Careplans were reviewed and updated to reflect objectives and goals related to medical equipment for residents R91 and R76.

b. IDT will conduct an audit for resident's careplans to ensure that there are objectives and goals related to their medical equipment

c.ED will educate nursing administration on required development of person-centered careplans related to use of a resident's medical equipment

d.IDT will conduct a random audit weekly x4, monthly x3 to ensure all medical equipment is accurately reflected on resident careplans. Review of audits will be reported at monthly QAPI x3.

e.Completion date of 3/17/2020

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on observations, clinical record review, and interviews with staff, it was determined that the facility failed to obtain a physician's order for mobility equipment for one of 27 residents reviewed (Resident R4).

Findings include:

Review of the clinical record for Resident R4 revealed the resident was admitted to the facility on September 22, 2012, with diagnoses including, but not limited to, including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), glaucoma (a condition where the eye ' s optic nerve is damaged due to increased pressure in eye) and cataracts (is a clouding of the normally clear lens of your eye).

Review of Resident R4's December 2019 physician's orders revealed an order dated December 9, 2019 for a high-back reclining wheelchair

Observation on February 11, 2020 at 10:45 a.m. in the second-floor dining room of Resident R4 who was sitting in a reclined position in a Geri-chair next to a table resting during an activity program. This observation was confirmed by Employee E6, the LPN who was responsible for Resident R4's care.

An interview with Employee E5, the Registered Occupational Therapist (OTR), February 11, 2020 at 11:45 a.m. , revealed that the resident had been switched to the Geri-chair after being screened by therapy related to a request from the family to have the resident up out of bed. The OTR stated that the resident had been in a high-back wheelchair but was continually laying her head down on the table and resting. According to the OTR the therapy department could screen residents with a simple request, but the change to a Geri-chair should have generated a new order.

Further review of the clinical record for Resident R4 revealed a January 30, 2020 progress note from therapy stating that Physical Therapy (PT) has been issued a narrower ger-chair with anti-thrust cushion, dycem pad (a Non Slip Material which makes daily living activities easier by providing an unbeatable grip, place it wherever you need to add stability to a slippery surface without the need for adhesive) on seat and lateral supports to assist her in maintaining functional sitting position when out of bed.

An interview with the Director of Nursing on February 11, 2020 at 2:05 p.m. confirmed that Resident R4's physician orders were for a high-back reclining wheelchair, but the resident had been using the Geri-chair since therapy had issued it on January 30, 2020.

The facility failed to obtained a physcian's order for the use of a geri chair for Resident R4

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

28 Pa. Code 211.10(c) Resident care policies

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

28 Pa. Code 211.12(5) Nursing services







 Plan of Correction - To be completed: 03/17/2020

a.A physician's order was obtained for the mobility equipment for Resident R4.

b.IDT will assess residents to ensure a physician's order is in place for all mobility equipment in use.

c.IDT will educate therapy department on obtaining a physician order prior to issuing mobility equipment.

d.IDT will conduct a random audit weekly x4, monthly x3 to ensure a physician order is in place for residents using mobility equipment.

e.Completion date of 3/17/2020

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 observations, review of clinical records and facility documentation, and interviews with staff, it was determined that the facility failed to provide appropriate and timely services to maintain or improve proper body positioning, for two of 27 residents reviewed (Residents R88 and R69).

Findings include:

Review of the clinical record for Resident R88 revealed the resident was readmitted to the facility on September 19, 2019, with diagnoses including, but not limited to, worsening dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and anxiety (unpleasant sense of inner turmoil and anguish).

Review of an Occupational Therapy (OT) Evaluation and Plan of Treatment for Resident R88, dated September 20, 2019, revealed the resident was being evaluated by OT so that the resident would, "exhibit anatomically correct positioning while sitting in W/C [wheelchair] with use of up to 3 hours with Good [sic] sitting balance during ADLs [activities of daily living] in order to enhance comfort, reduce the risk for falls and achieve proper joint alignment."

Review of an OT treatment encounter note dated September 23, 2019, revealed facility OT staff had attempted to trial Resident R88 with a Rock N' Go wheelchair (specialized wheelchair that features a rocking motion, sling seat and back, that can ease agitation in dementia patients), but the resident was, "found to be actively sliding hips down in chair with inability to stay in upright position due to significant agitation and restlessness," and that a geri chair (specialized reclining chair) was recommended. An OT treatment encounter note dated September 24, 2019, indicated that Resident R88's positioning for safety continued to be evaluated as the resident, "continuously pushed hips forward and slides down in all types of positioning chairs. Severe pt [patient] restlessness and agitation continues to prevent pt from sitting." Another OT treatment encounter note dated September 30, 2019, and electronically signed by Employee E5, Occupational Therapist, revealed due to Resident R88's significant dementia, restlessness and inability to carry over training in safety due to dementia, recommendations as to safe and anatomically correct seating were made to Nursing and Administration, and that Resident R88 was discharged from skilled OT services due to being evaluated for hospice services (end of life care to support resident and family).

Further review of OT documentation did not identify what the "recommendations as to safe and anatomically correct seating" were for Resident R88 upon discharge from skilled OT on September 30, 2019. Interview with Employee E5 on February 11, 2020, at approximately 8:45 a.m. revealed that the recommended wheelchair from occupational therapy on September 30, 2019, for Resident R88 was a geri chair.

Review of a nursing progress note dated October 1, 2019, at 8:22 a.m. revealed Resident R88 was restless that morning, "continues to slide from chair greater than 4 times in 2 minutes, as soon as staff re position [sic] resident in chair she scoots herself forward," staff had to lower her to the floor, and then required two staff members to stand the resident up and boost back in the chair. Review of a nursing progress note dated October 6, 2020, at 3:35 p.m. revealed, "Resident was received in dining room at start of shift. She was in the Geri chair and was attempting to jump/fall out of it every few seconds... Resident was positioned numerous times throughout shift due to her intentionally trying to slide out or throw herself over the side of the chair." Review of a nursing progress note dated October 29, 2019, at 5:20 a.m. indicated Resident R88 was restless and kept attempting to get up out of the geri chair.

Review of the plan of care for Resident R88 related to hospice care, dated October 17, 2019, indicated that, "Resident spends majority of time in geri chair for safety/ monitoring and comfort."

Review of a nursing progress note dated November 17, 2019, at 10:31 p.m. revealed resident had visible signs of anxiety including, "rocking back and forth from geri-chair, grasping onto tray tray of geri-chair, and attempting to pry it off."

Review of a nursing progress note dated December 5, 2019, at 1:47 p.m. revealed, "Resident continuously slides out of Geri-Chair," and that the resident was found with a skin tear (site of skin tear not documented in this note dated December 5, 2019, at 1:47 p.m.). Review of facility documentation into the incident on December 5, 2019, revealed Resident R88 sustained a skin tear to her left elbow, that the resident was noted actively moving about in her geri chair at the time of discovery of the skin tear, and that the resident "most probably" brushed her elbow against the chair causing the skin tear.

Review of physician's orders dated December 9, 2019, revealed Resident R88 continued on hospice and that, "Hospice issued gerichair."

Review of hospice documentation revealed an IDG (interdisciplinary group) meeting note, dated January 15, 2020, indicating that Resident R88 was experiencing restlessness and agitation, was chair bound, and that the resident, "attempts to bet out from the geri chair." Review of a hospice RN (Registered Nurse) Skilled Nursing Visit note, dated January 28, 2020, revealed Resident R88 was sitting in her geri chair at the time of the hospice nurse's arrival and noted that, "As per facility staff report, patient is trying to get out from the geri chair."

Observation during initial resident screening process on February 9, 2020, at 8:14 a.m. revealed Resident R88 was eating breakfast, with assistance of a staff member, in the dining room on the third floor nursing unit. Resident R88 was sitting upright in a geri chair, unreclined, with lockable tray in place over the resident's lap area.

Observation on February 9, 2020, at 9:21 a.m. revealed the breakfast meal was complete and Resident R88 was finished eating. Resident remained sitting in the unreclined geri chair and was observed to be slowly sliding down the chair, with upper torso partially under the locked tray, was grasping each armrest of the chair and was attempting to stop herself from sliding down. Resident R88 appeared to be unnerved and uncomfortable with her legs dangling unsupported while attempting to keep self from sliding down the chair (bottom portion of geri chair was not in recline position as she was seated upright, so there was no support for the resident's legs). When not being addressed by staff, Resident R88 was yelling out words, approximately every 15 seconds, unintelligible in an Asian dialect (Vietnamese).

Observation on February 9, 2020, at 9:44 a.m. revealed Resident R88 had slid down further in the geri chair and was askew in the chair, yelled out again in the Asian dialect, was grasping onto the tray, and when approached by a staff member, the resident clearly stated in English, "Lift me up!" The staff member was observed to physically lift the resident back up in the chair, then proceeded to wheel her back to her room to have incontinence care provided.

Observation on February 9, 2020, at 9:59 a.m revealed the same staff member brought Resident R88 back to dining area, placed her chair in the same location in the room as it was during breakfast, now with the geri chair in a reclined position. The locked tray was observed to remain in place.

Observation on February 10, 2020, at 10:52 a.m. revealed the resident's hospice aide was wheeling the resident down the nursing unit hallway in her geri chair. Resident R88 was observed to be constantly sliding down in the geri chair with the hospice aide having to pull the resident up in her geri chair.

Further interview with Employee E5, Occupational Therapist, on February 11, 2020, at approximately 8:45 a.m. revealed that from Resident R88's discharge from OT on September 30, 2019, there was no documentation that facility staff reevaluated and assessed the resident for proper body positioning in the geri chair, or if the resident required assessment for alternative seating equipment other than the geri chair.


Review of Resident R69's Minimum Data Assessment (MDS- an assessment of a resident's need) dated December 26, 2019 revealed the resident was admitted to the facility on October 25, 2018 with diagnoses including dementia (a broad category of brain diseases most notable for decline in memory and other mental abilities), transient ischemic attack (when the blood supply to part of the brain is briefly blocked), anxiety (a disorder characterized by feelings of worry, anxiety, or fear that interfere with one ' s daily activities) and depression (a disorder characterized by depressed mood or loss of interest in activities, causing significant impairment in daily life).

Observation on February 9, 2020 at approximately 9:15 a.m. in dining area revealed that Resident R69 was seated in a Rock N Go (wheelchair which can be tilt back) wheelchair. The resident was reclined back to an approximate 130 degree angle and she was observed to be grasping the armrests and attempting to pull herself up to a more upright position.

Observation on February 9, 2020 at approximately 12:00 p.m. in dining area revealed that Resident R69 was seated in a Rock N Go wheelchair near a table. She was reclined to an approximate 130 degree angle and she was observed to be grasping the armrests and attempting to pull herself up to a more upright position while a staff member was attempting to spoon feed the resident her pureed lunch.

Observation on February 10, 2020 at approximately 9:05 a.m. in the dining area revealed that Resident R69 was seated in a Rock N Go wheelchair. She was reclined to an approximate 130 degree angle and she was observed to be grasping the armrests and attempting to pull herself up to a more upright position.

Review of Resident R69's Occupational Therapy discharge notes, dated May 24, 2019, revealed that "patient was issued a Rock n go chair form hospice ...pt [sic- abbreviation for patient] is laterally leaning to the left side unable to maintain midline with repositioning ...tends to gravitate toward lateral leaning." Further review revealed, "Pt positioned in narrow, high back reclining wheelchair fitted with anti-tippers and lateral support to help pt to maintain upright sitting."

Review of physician's order summary dated December 9, 2019, confirmed an order, "Hospice issued rock and go wheelchair."

Progress notes from December 10, 2019 revealed, "Nurse was trying to push resident from dining into room to put her in bed and she rocked herself out of the w/c [sic-abbreviation for wheelchair]"

Review of the facility fall incident report, dated December 10, 2019 revealed, "restlessness noted ...when staff went to assist resident she again began rocking and rocked forward from her chair. Resident is in a rock and go w/c provided by hospice."

Review of a second fall incident report, dated February 6, 2020 revealed, "Resident is disoriented x3. Dependent for all locomotion, resident is seated in rock and go w/c, provided by Hospice. Rocks back and forth while in w/c. Resident without an intended destination when she scooted to the floor."

The facility failed to ensure that Residents R88 and R69 were adequately assessed for proper body positioning for specialized wheelchairs.



28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.10(d) Resident care policies

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

28 Pa. Code 211.12(5) Nursing services




 Plan of Correction - To be completed: 03/17/2020

a.Residents R88 and R69 were assessed by OT for proper body positioning in specialized wheelchairs.

b.IDT will audit body positioning of residents with specialized wheelchairs

c.IDT will educate therapy department on need of evaluating resident's appropriateness for a specialized wheelchair

d.IDT will conduct a random audit weekly x3, monthly x4 to ensure the appropriateness for a resident's specialized wheelchair. Review of audit will be completed at monthly QAPI x3

e.Completion date of 3/17/2020

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on observation, review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that individualized, non-pharmacological behavioral interventions were attempted prior to the administration of an antianxiety medication, for one of 27 residents records reviewed (Resident R88).

Findings include:

Review of undated facility policy, "Behavior Management Program Overview," revealed that prior to the administration of a psychoactive medication (medication used to modify/treat one's behavior), non-chemical interventions would be the first choice in managing resident behavioral symptoms.

Review of facility policy, "Behavior and Psychoactive Management Program," dated December 1, 2018, defined a psychotropic drug as any drug that affects brain activities associated with mental processes and behaviors, including antianxiety medications; and that prior to a nurse administering a medication to treat anxiety (unpleasant sense of inner turmoil and anguish), non-pharmacological interventions previously attempted without success, "must be documented."

Review of Davis's Drug Guide for Nurses, Twelfth Edition, dated 2011, defined that a geriatric patient is an adult over 65 years of age and that the older patient is at risk for toxic reactions to medications due to altered absorption, distribution, metabolism and excretion of medications. The Davis's Drug Guide for Nurses classified the medication lorazepam (Ativan) as a medication to treat anxiety with side effects including, but not limited to, drowsiness and lethargy (sleepy, fatigued, sluggish). Additionally, the Davis's Drug Guide for Nurses added that for geriatric patients, to treat a diagnosis of anxiety, the recommended dose is 0.5 mg (milligrams) to 2 mg per day.

Review of the clinical record for Resident R88, a geriatric resident, revealed the resident was readmitted to the facility on September 19, 2019, with diagnoses including, but not limited to, worsening dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and anxiety (unpleasant sense of inner turmoil and anguish).

Review of a quarterly Minimum Data Set (MDS-periodic assessment of needs) dated January 10, 2020, revealed that the resident had additional diagnoses of restlessness and agitation; and had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment) score of 3, indicating the resident was severely cognitively impaired. The MDS added under Section E, Behavior, that Resident R88 did not exhibit any behavioral symptoms including exhibiting no verbal/vocal symptoms like screaming or disruptive sounds.

Review of physician's orders dated October 7, 2019, and monthly thereafter, instructed staff to administer Ativan (lorazepam) 1 mg orally, every six hours PRN (medical abbreviation for as needed), for restlessness and agitation.

Review of the December 2019 Medication Administration Record (MAR) for Resident R88 revealed Ativan 1 mg was documented as administered on December 1, 2019, at 10:45 p.m.; December 2, 2019, at 11:27 p.m.; and at 3:00 a.m. on December 12, 2019.

Review of nursing progress notes revealed the following Medication Administration Notes: December 1, 2019, at 10:45 p.m. revealed Ativan 1 mg was administered for restlessness; December 2, 2019, at 11:27 p.m. revealed Ativan 1 milligram (mg) was administered because the resident was anxious; and on December 12, 2019, at 3:00 a.m. revealed no documentation regarding the reason for administration of Ativan 1 mg to Resident R88.

Review of the February 2020 Medication Administration Record for Resident R88 revealed Ativan 1 mg was documented as administered on February 9, 2020, at 9:46 a.m.; and at 11:30 p.m.; February 11, 2020, at 9:44 a.m.; and at 9:41 p.m.

Review of nursing progress notes revealed the following Medication Administration Notes: February 9, 2020, at 9:46 a.m. revealed Ativan 1 mg was administered because the resident was anxious; February 9, 2020, at 11:30 p.m. revealed Ativan 1 mg, "Resident received PRN as ordered"; February 11, 2020, at 9:44 a.m. revealed Ativan 1 mg was administered because the resident was restless and agitated; and February 11, 2020, at 9:41 p.m. revealed Ativan 1 mg was administered for restlessness.

Further review of the clinical record revealed no documentation regarding what non-pharmacological alternatives were attempted prior to the administration of Ativan 1 mg to Resident R88 on December 1, 2019, at 10:45 p.m.; December 2, 2019, at 11:27 p.m.; December 12, 2019, at 3:00 a.m.; and on February 9, 2020, at 9:46 a.m.; February 9, 2020, at 11:30 p.m.; February 11, 2020, at 9:44 a.m.; and on February 11, 2020, at 9:41 p.m., for a total of seven occurrences in a two month period.

Interview with the Nursing Home Administrator and Director of Nursing on February 10, 2020, at approximately 1:45 p.m., confirmed that Resident R88 received antianxiety medication on seven occurrences in a two month period and confirmed there was no documented evidence that non-pharmacological interventions were attempted prior to the administration of Ativan 1 mg to treat the resident's behaviors.

The facility failed to ensure that behavioral interventions were attempted prior to the administration of a PRN antianxiety medication for Resident R88.

Refer to F605.

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

28 Pa. Code 211.10(c) Resident care policies

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

28 Pa. Code 211.12(5) Nursing services





 Plan of Correction - To be completed: 03/17/2020

a.R88 was evaluated by in-house psychology and changes were made to her anti-psychotropic medication

b.IDT will audit documentation of non-pharmaceutical interventions attempted prior to the administration of PRN anti-psychotropic medications to ensure residents are free from unnecessary use of psychotropic medication.

c.IDT will educate nursing staff on required documentation of non-pharmaceutical interventions prior to administering PRN anti-psychotropic medication

d.IDT will conduct a random audit weekly x4, monthly x3 to ensure non-pharmaceutical interventions are in place before administering a PRN anti-psychotropic. Review of audits will be reported at QAPI monthly x3

e.Completion date of 3/17/2020

205.26(e) LICENSURE Laundry.:State only Deficiency.
(e) Equipment shall be made available and accessible for residents desiring to do their personal laundry.
Observations:

Based on observations, resident council interview and interviews with staff, it was determined that the facility failed to have equipment available or accessible to the residents who desired to do their own personal laundry, for five of five residents attending the resident council interview (Residents R5, R7, R10, R16 and R87).

Findings include:

During the Resident Council Interview conducted on February 9, 2020, at approximately 2:30 p.m., with five alert and oriented residents in attendance (Residents R5, R7, R10, R16 and R87), the residents stated that they did not have access to a washer and dryer if they wanted to wash their own clothes. The residents unanimously stated that they liked the idea of being able to launder their own clothing, and that they felt there were most likely other residents in their facility who would be interested in washing their own clothes as well.

Observation tour of the residents' clinical/living areas and skilled rehabilitation gym/treatment areas on February 10, 2020, at approximately 10:00 a.m. revealed that there was no laundry equipment, non-industrial washer or dryer, available for the residents to do their personal laundry.

Interview with the Nursing Home Administrator on February 10, 2020, at approximately 2:00 p.m. confirmed that there was no laundry equipment, washer or dryer, available and accessible to the residents that desired to do their personal laundry.





 Plan of Correction - To be completed: 03/17/2020

a.A washer and dryer have been purchased and made available for resident who desire to do their own personal laundry. R5, R7, R10, R16, R87 were educated on their right have access to do their personal laundry.

b.IDT team, during the next resident council meeting, will review the placement of washer and dryer.

c.IDT will review facility policy/ procedure of use of washer and dryer for residents who desire to do their personal laundry.

d.IDT will audit availability of washer and dryer for resident use weekly x 4 and monthly x 3. Results from the audit will be reviewed at the facility QAPI meeting monthly x 3.

e.Completion date of 3/17/2020


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