Nursing Investigation Results -

Pennsylvania Department of Health
PHOEBE BERKS HEALTH CARE CENTER, INC.
Patient Care Inspection Results

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PHOEBE BERKS HEALTH CARE CENTER, INC.
Inspection Results For:

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PHOEBE BERKS HEALTH CARE CENTER, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on May 27, 2022, it was determined that Phoebe Berks Health Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.














 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity in two of three dining rooms. (Coventry Corner South Hallway, Heritage Court) In addition the facility failed to provide up to date activity schedules to one of 18 sampled residents. (Resident 81)

Findings include:

Clinical record review revealed that Resident 45 was admitted to the facility with diagnoses including Alzheimer's disease, dementia, and dysphagia. Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. On May 21, 2022, the physician ordered for staff to feed Resident 45 all meals. On May 24, 2022, from 12:25 p.m. through 12:50 p.m. LPN 1 was observed standing while feeding the resident her lunch.

Clinical record review revealed that Resident 32 was admitted to the facility with diagnoses including Alzheimer's disease, dementia, and dysphagia. Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. On March 31, 2022, the physician ordered for staff to feed Resident 32 all meals. On May 24, 2022, from 12:50 p.m. through 1:00 p.m., and on May 25, 2022, from 12:20 p.m. through 12:50 p.m. LPN 1 was observed standing while feeding the resident her lunch.

Clinical record review revealed that Resident 41 was admitted to the facility with diagnoses including Alzheimer's disease, dementia, and dysphagia. Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. According to the Minimum Data Set (MDS) assessment dated April 25, 2022, the resident required extensive assistance from staff with eating. On May 25, 2022, from 11:55 a.m. through 12:10 p.m. RN 1 was observed standing while feeding the resident his lunch.

Clinical record review revealed that Resident 47 was admitted to the facility with diagnoses including Alzheimer's disease, dementia, and dysphagia. Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. According to the MDS assessment dated April 28, 2022, the resident required extensive assistance from staff with eating. On May 25, 2022, from 12:35 p.m. through 12:45 p.m. RN 1 was observed standing while feeding the resident his lunch.

Clinical record review revealed that Resident 19 was admitted to the facility with diagnoses including Alzheimer's disease, dementia, and dysphagia. Review of the current care plan revealed that the resident had cognitive impairment and staff was to provide assistance with all activities of daily living. According to the MDS assessment dated April 28, 2022, the resident required supervision from staff while eating. On May 11, 2022, the physician ordered that the resident was to have finger foods when possible. On May 25, 2022, at 12:20 p.m. Resident 19 was served turkey and mashed potatoes with gravy and cooked carrots for lunch. Resident 19 was observed eating her lunch with her fingers and picking food off her clothing through 1:00 p.m. At no time during the observation did staff provide assistance to Resident 19 with her meal.

Clinical record review revealed that Resident 46 had diagnoses including Alzheimer's disease, diabetes, and chronic kidney disease. Review of the MDS assessment dated April 28, 2022, revealed that the resident had cognitive impairments and required supervision with eating. On May 26, 2022, from 11:55 a.m. until 12:23 p.m., Resident 46 was observed seated in the dining room watching a resident at her table eat her lunch while calling out to staff "I'm hungry.", "Where's my lunch?", and "When is my food coming?".

Clinical record review revealed that Resident 81 was admitted to the facility on May 8, 2022 with diagnoses that included femur fracture, anxiety, and depression. Review of the MDS assessment dated May 13, 2022, revealed the resident had no cognitive impairments, and that involvement in activities was important to her. In an interview on May 24, 2022 at 11:50 a.m., Resident 81 stated that she does not usually go to activities because she does not know what they are and she wishes she had more people to talk to. Observations on May 24 and 25, 2022 revealed an activity schedule posted in the hallway outside Resident 81's room. The posted schedule was for the previous week, May 15, 2022 through May 21, 2022.

28 Pa. Code 201.29(j) Resident Rights













 Plan of Correction - To be completed: 07/11/2022

1. The incident could not be retroactively rectified; however, staff was educated in ensuring that when feeding residents, they are required to sit down to be on the same level with the residents. The calendar was immediately changed during the survey and was rectified with an updated one.

2. All activity calendars were audited to ensure that they were updated. Random audits were completed to ensure that staff were sitting while feeding. These audits will continue to ensure compliance.

3. Education was offered to nursing staff in making sure that all residents are fed while staff are seated. Also, community staff were educated in ensuring that the calendars in display in all areas of the building are up to date.

4. Audits will be completed on feeding residents and updated activity calendars and discussed at QAPI with the inter-disciplinary team. Daily audits will be completed to both areas (6 residents will be audited daily with feeding) and all calendars will be audited daily to ensure compliance for 4 weeks and then weekly for 4 weeks and randomly thereafter.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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

Based on clinical record review and observation, it was determined that the facility failed to provide adequate supervision and interventions to prevent accidents for two of eight sampled residents at risk for falls. (Residents 60, 82)

Findings include:

Clinical record review revealed that Resident 60 had diagnoses that included dementia with behavioral disturbance, muscle weakness, difficulty in walking, and a history of falling. The Minimum Data Set (MDS) assessment dated May 5, 2022, indicated that the resident was cognitively impaired, required extensive staff assistance with dressing, required limited staff assistance with walking, and had fallen since the previous assessment completed on February 3, 2022. A physician's order dated January 21, 2020, indicated that the resident was to ambulate all destinations on the unit without a device with supervision; assistance of one as needed. The care plan identified that the resident was at risk for falls and that the resident had four falls since December 21, 2021, including three that were unwitnessed. Interventions included to ensure that the resident was wearing proper footwear. Observation of Resident 60 on May 24 and May 26, 2022, at multiple times, revealed that the resident was wearing long, loose sweatpants and gripper socks. The excessive length of the sweatpants obstructed the grip material of the socks and created a tripping hazard. Observation ofthe resident on both dates revealed that she was ambulating throughout the unit with her pants under her feet.

Clinical record review revealed that Resident 82 had diagnoses that included dementia, generalized muscle weakness, difficulty in walking, and other abnormalities of gait and mobility. The MDS assessments dated February 4, 2022, and May 5, 2022, indicated that the resident had memory problems and required extensive staff assistance for walking and transferring between surfaces. Review of the care plan revealed that the resident ambulated with a rolling walker and was at risk for falls. An intervention added on March 24, 2022, directed that the resident was to be encouraged and assisted to participate in activities or social settings that minimize the potential for falls and to ensure that she was wearing proper footwear. On March 30, 2022, an additional intervention directed that the resident was to be monitored for fatigue and to encourage periods of rest in the recliner in the common area for close observation due to poor safety awareness. Nursing documentation on April 2, 2022, stated that the resident frequently ambulated without her walker and that she had removed her shoes and socks at the time of an unwitnessed fall on that date. A physical therapy discharge summary dated April 27, 2022, indicated that the resident was to ambulate all destinations on the unit with supervision and required supervision to stand-by assistance for transferring. It was also noted that she needed reminders to use her walker. On May 1, 2022, the resident experienced an unwitnessed fall in her room and nursing noted that she had taken her shoes off and had not been using her walker. A nurse's note dated May 3, 2022, indicated that the resident was observed walking in her room without her walker. On May 19, 2022, at 2:55 p.m., Resident 82 experienced an additional unwitnessed fall in her room and was found with her shoes removed. Review of facility incident reports and nursing documentation revealed that the resident had fallen 10 times January 7, 2022, through May 19, 2022, and that eight of those falls were unwitnessed.

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





 Plan of Correction - To be completed: 07/11/2022

1. The incidents could not be retroactively rectified; however, nursing staff were educated in ensuring that adequate supervision on residents with falls are in place by ensuring that the interventions are followed to reduce falls.

2. All residents with fall interventions were audited to ensure that the interventions were appropriate and in place and that adequate supervision was in place to reduce falls.

3. Education was offered to staff in making sure that all residents with fall interventions are closely monitored and that all interventions are appropriate and followed to provide appropriate supervision on potential falls.

4. Audits will be completed on 3 residents who have fall interventions in place and discussed at QAPI with the inter-disciplinary team. Daily audits will be completed to ensure compliance for 4 weeks and then weekly for 4 weeks and randomly thereafter.

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 clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented or that a skin condition was addressed for three of 18 sampled residents. (Residents 45, 5, 51)

Findings include:

Clinical record review revealed that Resident 45 was admitted to the facility with diagnoses that included Alzheimer's disease and spinal stenosis. Review of the current care plan revealed that Resident 45 was cognitively impaired and required assistance from staff for most activities of daily living. On June 25, 2021, the physician ordered for staff to provide a blue bolster for positioning to her left side while in her wheelchair. On May 24, 2022, from 12: 20 p.m. through 1:30 p.m. Resident 45 was observed in her wheelchair without the blue bolster to her left side. On May 25, 2022, from 10:35 a.m. through 1:00 p.m., and on May 26, 2022, from 11:45 a.m. through 12: 40 p.m. Resident 45 was observed in her wheelchair with the blue bolster on the right side of her chair. In an interview on May 27, 2022, at 10:44 a.m. the occupational therapist (OT 1) stated that Resident 45's blue bolster was ordered for positioning while in her wheelchair and that it should have been placed on the left side of her wheelchair.

Clinical record review revealed that Resident 5 had diagnoses that included dementia and other disorders of bone density. Review of the Minimum Data Set (MDS) assessment dated February 24, 2022, indicated that the resident did not walk and required extensive staff assistance for transferring. The resident had a physician's order dated November 30, 2021, to utilize an abduction cushion to the lower extremities at all times to prevent her legs from crossing and contractures. The resident was observed on May 25, 2022, 12:00 p.m. through 1:17 p.m. seated in her wheelchair in the dining area with no abduction cushion in place.

Clinical record review revealed that Resident 51 had diagnoses that included type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage), long-term use of insulin, and long-term use of anticoagulants (blood thinners). The MDS assessment dated May 2, 2022, indicated that the resident was cognitively impaired and required extensive staff assistance for activities of daily living, including dressing. The care plan included a goal that the resident would be free of complications related to anticoagulant use and also identified the potential for alteration in skin integrity. Interventions included that skin was to be monitored daily by the nurse aide and any changes or abnormalities were to be reported to the nurse and that geri-sleeves or long sleeves must be on the resident. The resident had a physician's order dated August 8, 2020, for geri-sleeves or long sleeves every shift. Observation of Resident 51 on May 24, 2022, from 11:08 a.m. to 12:40 p.m. and May 25, 2022, at 11:56 a.m., revealed that the resident was seated in the dining room with no arm coverings and both arms exposed. In addition, on both dates, an undated dressing was observed on her left forearm. There was no documentation in the clinical record regarding the dressing or any skin abnormality of the left forearm. When the bandage was removed by LPN 2 on May 26, 2022, at 11:00 a.m., a scabbed area was observed. At that time, LPN 2 confirmed that she was unaware of the scabbed area or dressing and that there was no documentation in the resident's record regarding the area.

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






 Plan of Correction - To be completed: 07/11/2022

1. The incidents were corrected upon notification. Bolster, Abduction cushion and Geri sleeves were utilized and offered on residents who were missing adaptive(s).

2. All residents with Bolsters, Abduction cushions and Geri Sleeve orders were audited for the entire facility to ensure that staff were in compliant in offering adaptive requirements as per physician orders.

3. Education was offered to nursing staff in making sure that all residents with the Bolsters, Abduction cushions and Geri Sleeves are utilized and offered to residents as per physician orders.

4. Audits will be completed on 6 residents daily to ensure that Bolsters, Abduction cushions and Gerri Sleeves are in place and utilized and discussed at QAPI with the inter-disciplinary team. Daily audits will be completed to ensure compliance for 4 weeks and then weekly for 4 weeks and randomly thereafter.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement treatment and services to promote healing and prevent new ulcers from developing for one of three sampled residents with pressure sores. (Resident 67)

Findings include:

Clinical record review revealed that Resident 67 had diagnoses that included dementia, muscle weakness, and hemiplegia (weakness) and hemiparesis (paralysis) following cerebral infarction (stroke) affecting the right dominant side. The Minimum Data Set assessment dated May 2, 2022, indicated that the resident was cognitively impaired, required extensive staff assistance for most activities of daily living (including turning and positioning), was dependent on staff for transferring in and out of bed, and had one stage 2 pressure ulcer. There was a physician's order dated February 13, 2022, for heel boots to both heels at all times for wound care and prevention. On April 22, 2022, the physician ordered that the resident continue the use of the boots at all times, that she use a black abductor between the knees when out of bed, and that she should go back to bed between meals for off-loading for wound management and be propped in a side-lying position. The care plan identified the resident as at risk for skin breakdown/pressure ulcers related to decreased mobility and incontinence and that a stage two buttock wound was present. Interventions included try to keep off of right side as much as possible.

Observation of Resident 67 on May 25, 2022, from 12:14 p.m. through 1:21 p.m. revealed that the resident was out of bed and seated in her chair with no abductor cushion and no heel boots in place. During an interview on May 27, 2022, at 10:44 a.m., the lead therapist (OT 1) confirmed that the abductor cushion was used to avoid feet on feet contact and to prevent a pressure area.

Observation of Resident 67 on May 26, 2022, revealed that the resident was seated in her broda chair finishing her breakfast in the dining area at 10:21 a.m. Following breakfast, she remained in the same position and was wheeled in the same chair to the activities area at 10:40 a.m. She remained in the same chair and position at 11:59 a.m. when she was wheeled back to the dining area for lunch. The resident was not taken back to bed as ordered by the physician and was not repositioned in her chair during the observation.

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







 Plan of Correction - To be completed: 07/11/2022

1. The incidents were corrected upon notification. Abductor cushion and Heel Boots were offered to the resident and utilized as per orders.

2. All residents with Abductor cushions and Heel Boot orders were audited for the entire facility to ensure that staff were in compliant in offering pressure relieving as per physician orders.

3. Education was offered to nursing staff in making sure that all residents with Abductor cushions and Heel Boot orders are utilized and offered to residents as per physician orders.

4. Audits will be completed on 6 residents daily to ensure that Abductor cushions and Heel Boots are in place and utilized and discussed at QAPI with the inter-disciplinary team. Daily audits will be completed to ensure compliance for 4 weeks and then weekly for 4 weeks and randomly thereafter.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on facility policy review, clinical record review, and staff interview it was determined that the facility failed to monitor nutrition per policy for two of 18 sampled residents. (Residents 59, 234)

Findings include:

Review of the facility policy entitled, "Weight Monitoring and Management," dated May 18, 2022, revealed that staff was to confirm any weight change of more than five pounds with a re-weight within 24 hours, and document it into the electronic chart.

Clinical record review revealed that Resident 59 had diagnosis that included osteomyelitis (bone infection), diabetes, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS) assessment dated May 3, 2022, revealed the resident had cognitive impairment and required supervision with eating. Review of the current care plan revealed Resident 59 had a nutritional problem related to diabetes, and was to be weighed per facility policy. On January 31, 2022, the resident weighed 174.4 pounds (lbs). On February 7, 2022, she weighed 182 lbs, a difference of 7.6 lbs. On February 14, 2022, she weighed 177 lbs, a difference of five lbs from her February 7, 2022 weight. On March 7, 2022, Resident 59 weighed 184.4 lbs. On March 28, 2022, she weighed 178.4 lbs, a difference of six lbs. On April 18, 2022, Resident 59 weighed 179.6 lbs and on April 25, 2022, she weighed 170.8 lbs, a difference of 8.8 lbs. On May 2, 2022, Resident 59 weighed 171.2 lbs. On May 9, 2022 she weighed 166 lbs, a difference of 5.2 lbs. There was no documented evidence that Resident 59 was reweighed per facility policy.

Clinical record review revealed that Resident 234 was admitted to the facility on May 10, 2022 with diagnoses that included a right knee infection, gastroesophageal reflux disease, and diabetes. Review of the MDS assessment dated May 17, 2022, revealed that Resident 234 had no cognitive impairments and was independent with eating. Review of the current care plan revealed that the resident was at increased nutrition risk related to diabetes. On May 10, 2022, Resident 234 weighed 242.6 lbs. On May 11, 2022, the resident weighed 247.6 lbs, a difference of five pounds. On May 15, 2022, the resident weighed 237.8 lbs, a difference of 9.8 lbs from his May 11, 2022 weight. On May 22, 2022, Resident 234 weighed 227.8 lbs, a 10 lb difference from his May 15, 2022 weight. There was no documented evidence that Resident 234 was reweighed per facility policy.

In an interview on May 27, 2022, at 10:12 a.m., the Director of Nursing confirmed the reweights were not completed per facility policy.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.




 Plan of Correction - To be completed: 07/11/2022

1. The incidents could not be retroactively rectified; however, nursing staff and dietitian were educated in ensuring that triggered weights requires reweights as per policy.

2. Dietitian audited all residents for triggered weights and ensured any missing reweights were acquired and documented.

3. Education was offered to licensed nursing and dietitian in making sure that all residents with weight triggers should be reweighed as per policy.

4. Audits will be completed on all residents daily who trigger for weights protocol to ensure that the reweighs are captured and discussed at QAPI with the inter-disciplinary team. Daily audits will be completed to ensure compliance for 4 weeks and then weekly for 4 weeks and randomly thereafter.


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