Nursing Investigation Results -

Pennsylvania Department of Health
OAK HILL HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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OAK HILL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  110 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
OAK HILL HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on June 29, 2022, it was determined that Oak Hill Healthcare and Rehabilitation 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.






















































 Plan of Correction:


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 policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to make ongoing efforts to resolve the grievances of residents and/or their legal representatives for one of five residents reviewed (Resident 5).

Findings include:

The facility's policy regarding filing grievance and complaints, dated February 2022, indicated that all grievances and complaints filed with the facility were to be considered, the allegations would be investigated, and a report would be submitted to the administer within five days. The Nursing Home Administrator would review the findings with the Grievance Office to determine what corrective action, if any, and would take immediate action to prevent potential violations of resident rights.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 27, 2022, revealed that the resident was cognitively intact, was understood, could understand, and required limited assistance of one for eating.

A tour of the kitchen's dry storage area on June 29, 2022, at 8:27 a.m., revealed 13 racks of fresh bread products (sliced loaves, hamburger and hot dog rolls) that had a handwritten sign that said, "Check break for mold before serving."

An interview with the Dietary Director on June 29, 2022, at 11:34 a.m., revealed that Resident 5 received moldy bread on his meal trays twice. The first time was over a month ago, and then again on June 23, 2022. After the first occurrence she filed an orange grievance form with management. The Dietary Director further explained that she provided education to staff and planned to monitor breads for mold. The Dietary Director was off during the second incident and did not file another grievance form.

There was no documented evidence that grievances were filed on behalf of Resident 5 related to his concerns about moldy food.

During an interview with Resident 5 on June 29, 2022, at 12:20 p.m. he indicated that he was served a moldy dinner roll in a plastic sealed bag on May 28, 2022. At that time he communicated his concern to administration, the Director of Nursing, and kitchen staff. Resident 5 indicated that the kitchen apologized, but he felt like his concern was not taken seriously. Following the incident the Nursing Home Administrator came to talk to him, but his roommate was receiving care, and the Nursing Home Administrator did not return to discuss the concern. The second incident occurred on June 23, 2022, when Resident 5 was served a ham and cheese sandwich on bread with mold on the crust, and he was very upset. Resident 5 was told he would sign a paper, but that did not occur. Resident 5 had no resolution regarding moldy food.

Interview with the Regional Director of Clinical Operations on June 29, 2022, at 1:02 p.m. revealed that there was no documented evidence that any grievance was filed after April 11, 2022, or any grievances related to Resident 5's expressed concerns about being served moldy food. Furthermore, after talking to the dietary staff an initial grievance was filed, but there was no documented evidence of the grievance form, investigation, or staff education. There was also no documented evidence that a grievance was filed following the second incident of moldy food on June 23, 2022.

Interview with the Director of Nursing on June 29, 2022, at 2:06 p.m. confirmed that when any concerns are verbalized by residents, the concerns should be investigated and resolved following the facility's policy.

28 Pa. Code 201.29(i) Resident rights.







 Plan of Correction - To be completed: 08/02/2022

R5 grievance was entered into electronic grievance system. Dietary staff was re-educated on visual inspection of bread prior to serving.
All bread was check in house to ensure no other moldy bread present.

follow up was completed by dietary manager with resident and ongoing plan.

Grievance process will be reviewed with residents at resident council. Any reported items will be logged by the administrator/ designee into electronic grievance system. Follow up will be completed by social service director or designee and reported to resident and person filing the grievance

Interdisciplinary team will be in-serviced by Director of Clinical Operations on grievance policy procedure.
Audits will be completed weekly x2, and monthly x2 to ensure grievances are logged and completed timely.
Findings of audits will be submitted to the monthly quality assurance committee for review.
483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to conduct an investigation to rule out abuse or neglect for one of five residents reviewed (Resident 2) who made an allegation.

Findings include:

The facility's policy for abuse, dated February 2022, indicated that all allegations of abuse would be investigated.

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 27, 2022, revealed that the resident was alert and oriented and required limited assistance of one for ambulation and extensive assistance of two for toileting.

The bladder record for Resident 2 indicated that she was incontinent of urine on the 2-10 shift on April 22 and 25, 2022, otherwise she was continent of urine.

A nursing note for Resident 2, dated May 12, 2022, indicated that the resident's daughter called the facility and informed them that the resident was going to sign herself out against medical advice (AMA). She indicated that the resident was signing herself out due to the nurse aides being mean to her and would not take her to the bathroom. The note further indicated that the physician and the Nursing Home Administrator were aware.

There was no documented evidence that an investigation was conducted to rule out abuse or neglect as a possible cause for the resident signing out of the facility against medical advice.

Interview with the Regional Director of Clinical Operations on June 29, 2022, at 1:58 p.m. confirmed that there was no documented evidence that the allegation was investigated to rule out neglect or abuse, and that an investigation should have been completed.

42 CFR 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition.

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

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





 Plan of Correction - To be completed: 08/02/2022

R2 Resident no longer resides in the facility. Allegations submitted via electronic reporting system.
no other residents identified.
progress notes and 24 hour report are reviewed daily for any allegations of abuse and neglect.
Staff will be educated on abuse/neglect policy and procedure by Director of nursing/ designee.
Interdisciplinary team will be in-serviced on policy and procedure.

Administrator/ Director of Nursing will review progress notes at the next clinical meeting for items needing addressed. Progress notes/ 24 hour report will be audited weekly x2, and monthly x2.
Findings will be submitted to the monthly quality assurance committee for review.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice for one of five residents reviewed (Resident 3).

Findings include:

The facility's policy regarding oxygen administration, dated February 2022, revealed that residents are to receive safe oxygen administration and should be provided equipment and supplies as needed.

A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 7, 2021, revealed that the resident was cognitively intact, required limited assistance with daily care tasks, had diagnoses that included heart failure and acute/chronic respiratory failure requiring supplemental oxygen. Physician's orders, dated June 6, 2022, included an order for the resident to receive continuous oxygen at a flow rate of 0-5 liters per minute by nasal cannula (tubes that deliver oxygen into the nostrils) to keep oxygen saturation at or above 92 percent (amount of oxygen in the blood). The resident's care plan for respiratory impairment, initiated on June 6, 2022, revealed that she required oxygen at 5 liters per minute by nasal cannula.

Observations during an interview with Resident 3 in her room on June 29, 2022, at 9:44 a.m., revealed that the resident was receiving oxygen via nasal cannula at 5 liters per minute. The resident revealed that she removes her oxygen tubing to use her toilet because the tubing was not long enough to reach.

Observations of Resident 3 on June 29, 2022, at 10:24 a.m. revealed that she had removed her oxygen tubing and ambulated to the bathroom.

Interview with Registered Nurse 1 on June 29, 2022, at 10:28 a.m. revealed that extension tubing had previously been provided to the resident, but she puts it in her closet because she prefers to be independent and does not like help. While in the bathroom Resident 3's pulse ox was 84 percent.

Observations during a follow-up interview with Resident 3 in her room on June 29, 2022, at 1:04 p.m. revealed that the resident was receiving oxygen at 5 liters per minute via nasal cannula with extension tubing in place.

Interview with the Director of Nursing on June 29, 2022 at 2:07 p.m. revealed that she just recently started at the facility and staff have reported that Resident 3 had been provided extension tubing but takes it off and puts it away. She confirmed that the resident's oxygen saturation should be maintained at or above 92 percent as ordered. There is no documented evidence that extension tubing was provided previously.

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




 Plan of Correction - To be completed: 08/02/2022

R3 Resident tubing was replaced at time of survey.
Resident no longer resides in facility.
All other residents utilizing longer tubing will be identified and provided longer tubing if needed. Nursing staff will be educated on oxygen tubing and administration by Director of Nursing/ designee.
Audits of oxygen tubing will be completed weekly x2 and monthly x2. Findings will be submitted to monthly quality assurance committee for review.

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