Pennsylvania Department of Health
RIVERSIDE HEALTH & REHAB CENTER
Patient Care Inspection Results

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RIVERSIDE HEALTH & REHAB CENTER
Inspection Results For:

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RIVERSIDE HEALTH & REHAB CENTER - 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 April 4, 2024, it was determined that Riverview Health and Rehab 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:


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(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 review of facility policy, facility documents, clinical records, and staff interview, it was determined that the facility failed to identify and investigate incidents of possible neglect and abuse for two of three residents (Residents R1 and R2).

Findings include:

Review of the facility policy" Abuse/ Neglect", last reviewed on 1/2/24, with a previous review date of 4/21/23, indicated that it is the facility's policy to investigate all allegations, suspicions and incidents of abuse, neglect, exploitation, etc. Facility staff must immediately report all such allegations to the Administrator. The Administrator will immediately begin an investigation and notify the applicable local and state agencies in accordance with the procedures in this policy.

Review of the facility "Event Summary Report", dated from 1/1/24 through 3/31/24, indicated Resident R1 had a fall while receiving care when Resident R1 rolled out of bed with no injuries identified on 2/21/24.

Review of the incident report dated 2/21/24, indicated Resident R1 "kept rolling" during incontinence care and slid onto the fall mat.

Review of the Minimum Data Set (MDS- periodic assessment of care needs) dated 2/13/24 indicated Resident R1 , indicated that Resident R1 had diagnoses that included a bacterial intestinal infection, arthritis, anxiety disorder, post traumatic stress disorder, muscle wasting. Section G0110 indicated Resident R1 required assistance of two for bed mobility and transfers. Section GG 0170 indicated dependent for rolling left and right while in bed.

During an interview on 4/4/24, at 1:15 p.m., the Director of Nursing (DON) stated that she was notified of the allegations made by Resident R1 but did not complete an investigation and/or report the incident as neglect as required.

Review of a facility " Concern Form" dated 1/19/24, indicated Resident R2 had alleged neglect when he stated he had "sat in his own urine" for four hours on 1/18/24. Resident R2 stated he "yelled out for staff and had the call bell on for two and a half hours". The form had been filled out by the Social Worker and the DON had documented that she had spoken to Resident R2.

During an interview on 4/4/24, at 1:15 p.m., the DON stated that she had spoken to Resident R2 and did not identify the incident as neglect and did not complete an investigation and /or report the incident as required.

28 Pa.Code: 201.14 (a) (c) (e) Responsibility of licensee.

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


 Plan of Correction - To be completed: 05/01/2024

Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under the state and federal laws.

Resident R1 was interviewed by the Director of Nursing/Designee regarding the allegation of neglect for rolling out of bed.

An investigation of Resident R1 incident was completed by the Director of Nursing.

A reportable event report was filed to the Department of Health along with a PB22 report on involved employee by the Director of Nursing.

The employee was re-educated on the use of the care plan to determine the need for a 2 person assist with bed mobility by the Director of Nursing or designee.

Resident R2 no longer resides in the facility.

A reportable event report was filed to the Department of Health regarding the allegation by the Director of Nursing.

Facility nursing staff will be educated on the use of the care plan to determine assistance needed for bed mobility and the facility's abuse and neglect policy by the Director of Nursing/designee.

The Administrator will educate facility department heads on the facility's grievance policy.

Audits will be conducted by the Director of Nursing/designee on incidents/accidents and concerns weekly for 4 weeks, biweekly for 2 weeks and monthly for 2 months. Audit findings will be reviewed at the facility's monthly QAPI meeting.


483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:
Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of four residents (Resident R3).

Findings include:

A review of the facility policy "Medication Administration" last reviewed on 1/2/24, with a previous review date of 4/21/23, indicated to administer medications as prescribed by the provider.

A review of the clinical record indicated that Resident R3 was admitted to the facility on 2/8/2024, with diagnoses that included syncope, muscle weakness and rheumatoid arthritis (the body's immune system attacks its own tissue, mainly in the hands and feet).

A review of the MDS(Minimum Data Set - periodic assessment of resident care needs) dated 2/15/2024, indicated the diagnoses remain current.

A review of a physician order dated 2/14/2024, indicated to give Hydroxychloroquine (immunosuppressive) oral tablet 200 mg (milligrams) one tablet by mouth every twelve hours at 07:00 (7:00 a.m.) and 21:00 (9:00 p.m.).

A review of the Medication Administration Record (MAR) log dated 2/8/2024, through 2/19/2024, indicated the Hydroxychloroquine was not given to resident R3 for the dates 2/14/2024, through 2/19/2024.

Review of a progress note dated 2/14/2024, indicated that the order had been sent to the pharmacy via fax after the order was obtained.

Review of a progress note dated 2/17/2024 indicated that the medication continued to not be available and that the Nursing Supervisor had been made aware.

During an interview on 4/4/2024, at 1:40 p.m., the Assistant Director of Nursing (ADON) Employee E1 confirmed that the facility failed to make certain Resident R3 was provided medications per a physician order which caused a significant medication error as the medication was for Resident R3's immunosuppressive disorder.

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

28 Pa. Code:211.9(e)(f)(g)(h) Pharmacy services.

28 Pa. Code: 211.10(c) Resident care policies.


 Plan of Correction - To be completed: 05/01/2024

Resident R3 no longer resides in the facility.

Medication error form completed by the Director of Nursing/designee and will be reviewed at the April 2024 QAPI meeting.

License nursing staff will receive education pertaining to missed medications and reasons. Education will include procedures in notifications and timelines to report to nursing administration along with documentation requirements. Education will be provided by the Director of Nursing/designee.

Medication administration records audits will be conducted by the Assistant Director of Nursing/designee to ensure medications are being administered as ordered weekly for 3 weeks and monthly for 2 months. Audit findings will be reviewed at the facility's monthly QAPI meeting.
211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight on 11 of 21 days (2/18/24, 2/21/24, 2/23/24, 2/24/24, 2/25/24, 2/26/24, 2/27/24, 2/28/24, 2/29/24, 3/1/24 and 3/8/24).

Findings include:

Review of facility census data indicated that on 2/18/24, the facility census was 88, which required 7.33 nursing assistants (NA's) during the evening shift.

Review of the nursing time schedule revealed 7.0 NA's provided care during the evening shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/21/24, the facility census was 88, which required 4.40 NA's during the night shift.

Review of the nursing time schedule revealed 4.0 NA's provided care during the night shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/23/24, the facility census was 89, which required 4.45 NA's during the night shift.

Review of the nursing time schedule revealed 4.0 NA's provided care during the night shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/24/24, the facility census was 87, which required 7.25 NA's during the daylight and evening shifts.

Review of the nursing time schedule revealed 6.81 NA's provided care during the daylight shift and 7.0 NA's provided care during the evening shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/25/24, the facility census was 87, which required 7.25 NA's during the evening shift and 4.35 NA's during the night shift.

Review of the nursing time schedule revealed 7.0 NA's provided care during the evening shift and 4.0 NA's provided care during the night shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/26/24, the facility census was 87, which required 7.25 NA's during the daylight and 4.35 NA's during the night shift.

Review of the nursing time schedule revealed 6.75 NA's provided care during the daylight shift and 4.0 NA's provided care during the night shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/27/24, the facility census was 86, which required 7.17 NA's during the daylight shift.

Review of the nursing time schedule revealed 7.0 NA's provided care during the daylight shift provided care during the daylight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/28/24, the facility census was 85, which required 4.25 NA's during the night shift.

Review of the nursing time schedule revealed 4.0 NA's provided care during the night shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/29/24, the facility census was 82, which required 4.10 NA's during the night shift.

Review of the nursing time schedule revealed 4.0 NA's provided care during the night shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/8/24, the facility census was 86, which required 4.30 NA's during the night shift.

Review of the nursing time schedule revealed 4.0 NA's provided care during the night shift. No additional excess higher level staff were available to compensate this deficiency.

During an interview on 4/4/24, at 2:30 p.m. the Director of Nursing confirmed the facility failed to provide a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight on 11 of 21 days (2/18/24, 2/21/24, 2/23/24, 2/24/24, 2/25/24, 2/26/24, 2/27/24, 2/28/24, 2/29/24, 3/1/24 and 3/8/24).


 Plan of Correction - To be completed: 05/01/2024

The center recognizes the requirement of nursing aide ratios of 1 to 12 on daylight and evening shifts and 1 to 20 on night shifts.

The Director of Nursing/designee will review the documentation for the following dates 2/18/24, 2/21/24, 2/23/24, 2/24/24, 2/25/24, 2/26/24, 2/27/24, 2/28/24, 3/1/24 and 3/8/24 to ensure no adverse events occurred.

To prevent recurrence the scheduler will be re-educated by the administrator on the PA state requirements for nursing ratios and HPPD. The center continues to interview and hire nursing staff on going.

The Administrator/Director of Nursing/designee and scheduler will meet to review staffing ratios for the day as well as staffing projections through the week and weekends. The Director of Nursing/designee is the backup for the scheduler.

To monitor and maintain ongoing compliance the Administrator will conduct weekly audits to ensure nursing aides ratios are met using the facility staffing tool. Findings of audits will be reviewed at the facility's monthly QAPI meeting.
211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:
Based on review of nursing time schedules and staff interviews it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 25 residents during the day shift and one LPN per 40 residents during the night shift on seven 21 days (2/18/24, 2/2/21/24, 2/23/24, 3/1/24, 3/3/24, 3/8/24 and 3/9/24).

Findings include:

Review of facility census data indicated that on 2/18/24 and 2/21/24, the facility census was 88, which required 2.20 LPN's during the night shift.

Review of nursing time schedules revealed two LPN's provided care the night shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 2/23/24, the facility census was 89, which required 2.23 LPN's during the night shift.

Review of nursing time schedules revealed two LPN's provided care the night shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/1/24, the facility census was 82, which required 2.03 LPN's during the night shift.

Review of nursing time schedules revealed two LPN's provided care the night shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/3/24, the facility census was 82, which required 3.16 LPN's during the daylight shift.

Review of nursing time schedules revealed three LPN's provided care the daylight shift. No additional excess higher level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/8/24 and 3/9/24, the facility census was 86, which required 2.03 LPN's during the night shift.

Review of nursing time schedules revealed two LPN's provided care the night shift. No additional excess higher level staff were available to compensate this deficiency.

During an interview on 4/4/24, at 2:30 p.m. the Director of Nursing confirmed the facility failed to provide a minimum of LPN per 25 residents during the day shift and one LPN per 40 residents during the night shift on seven 21 days (2/18/24, 2/2/21/24, 2/23/24, 3/1/24, 3/3/24, 3/8/24 and 3/9/24).



 Plan of Correction - To be completed: 05/01/2024

The center recognizes the requirement of LPN ratios of 1 to 25 on daylight and evening shifts and 1 to 40 on night shifts.

The Director of Nursing/designee will review the documentation for the following dates 2/18/24, 2/21/24, 3/1/24. 3/3/24, 3/8/24 and 3/9/24 to ensure no adverse events occurred.

To prevent recurrence the scheduler will be re-educated by the administrator on the PA state requirements for nursing ratios and HPPD. The center continues to interview and hire nursing staff on going.

The Administrator/Director of Nursing/designee and scheduler will meet to review staffing ratios for the day as well as the week and weekends. The Director of Nursing/designee is the backup for the scheduler.

To monitor and maintain ongoing compliance the Administrator will conduct weekly audits to ensure LPN ratios are met using the facility staffing tool. Findings of the audits will be reviewed at the facility's monthly QAPI meeting.

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