Nursing Investigation Results -

Pennsylvania Department of Health
RESTORE HEALTH AT UNIVERSITY CITY
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RESTORE HEALTH AT UNIVERSITY CITY
Inspection Results For:

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RESTORE HEALTH AT UNIVERSITY CITY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an Abbreviated Survey in response to a complaint completed on February 20, 2020, it was determined that Restore Health at University City was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.





 Plan of Correction:


483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a facility-initiated emergency transfer for one of one eight records reviewed (Resident R1).

Findings include:

Clinical record review for Resident R1 revealed that resident was admitted to the facility on January 15, 2016, with diagnoses including diabetes (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose), cerebrovascular disease (damage to the brain from interruption of its blood supply), hemiplegia (paralysis on one side of the body), and atrial fibrillation (irregular and rapid heartbeat). The resident had a gastrostomy procedure (surgical construction of an opening into the abdomen for inserting a tube into the stomach) and a feeding tube was inserted to provide supplemental nutrition to the resident.

Review for Resident R1's progress notes, dated January 13, 2020, at 11:00 p.m. revealed that licensed nursing staff observed that the feeding tube for Resident R1 was leaking excessively. The primary care physician (PCP) was notified. The PCP instructed the nurse to attempt to replace the feeding tube. The attempt was unsuccessful and the resident was sent to the emergency department of an acute care hospital for evaluation per physician orders. There was no further documentation available in the resident's clinical record to indicated that the Long-Term Care Ombudsman was notified of the facility-initiated emergency transfer for Resident R1.

Interview on February 20, 2020 at approximately 11:00 a.m. with Employee E2, Director of Nursing, confirmed that the Long-Term Care Ombudsman was not informed of the above transfer via the monthly list transmitted by the facility to Pennsylvania State Office of the Long-Term Care Ombudsman.

The facility failed to notify the Office of the State Long-Term Care Ombudsman of a facility-initiated emergency transfer.









 Plan of Correction - To be completed: 03/11/2020

Facility will notify the Office of the State Long-Term Care Ombudsman about R1's January 15 discharge.
Social services was educated about the need to Notify Office of the State Long-Term Care Ombudsman for every unplanned discharge.
Administrator or designee will audit the unplanned discharge notification to the Office of the State Long-Term Care Ombudsman for 3 weeks.
Unplanned discharge list will be added to QUAPPI to ensure proper compliance is being met.



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