Nursing Investigation Results -

Pennsylvania Department of Health
SHENANDOAH MANOR NSG CTR
Patient Care Inspection Results

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SHENANDOAH MANOR NSG CTR
Inspection Results For:

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SHENANDOAH MANOR NSG CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on February 19, 2021, it was determined that Shenandoah Manor Nursing Center was not in compliance with the following requirements of 42 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(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:



Based on review of clinical records and staff interview, it was determined that the facility failed to timely consult with the physician and notify the resident's representative of significant weight losses for two residents out of five sampled (Resident 52, and 75).

Findings include:

A review of facility policy entitled "Notification in Change" last reviewed January 2021, revealed the nurse will notify the resident, resident's physician, and the resident representative for non-immediate changes of condition on the shift the change occurs unless otherwise directed by the physician. The facility will document the notification and record any new orders in the resident's medical record.

A review of the clinical record revealed that Resident 52 was admitted into the facility on June 23, 2020, and has diagnoses including cerebral infarction (stroke), dysphagia (difficulty swallowing), and hypertension.

A review of the resident's weight record revealed that the resident weighed 135.6 pounds on July 1, 2020. When the resident was weighed on August 5, 2020, it was noted that the resident's weight had decreased to 122 pounds. The resident had a 13.6 pound weight loss, which was a significant weight loss, of 10% loss of body weight in 30 days.

Nutrition/Dietary notes dated August 5, 2020, at 3:06 PM and August 11, 2020, at 1:04 PM identified the resident's weight loss, but there was no indication that the resident's representative was notified of the significant weight loss.

Further review of the resident's weight record revealed the resident weighed 117.6 pounds on November 12, 2020. The resident was weighed on November 25, 2020, and the resident's weight had further declined to 109 pounds. The resident had an 8.6 pound weight loss, which was a 7.31% weight loss in 2 weeks.

A Nutrition/Dietary note on November 25, 2020, at 2:02 PM, again noted the resident's weight loss, but there was no indication in this resident's clinical record that the resident's representative was notified of the weight loss.

Interview with the Nursing Home Administrator (NHA) on February 18, 2021, at approximately 3:00 PM confirmed that there was no documentation of notification of the resident's representative of the significant weight losses for Resident 52.

A review of the clinical record revealed that Resident 75 was admitted into the facility on May 3, 2019, with diagnoses that included Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves).

A review of the resident's clinical record indicated the resident weighed 126.4 pounds on December 2020. The resident was weighed on December 30, 2020 and was noted to weigh 118.8. lbs The resident had a 7.6 pound weight loss, which is 6 % in 30 days.

A review of the resident's clinical record revealed no documentation that the physician was notified of the resident's significant weight loss.

Interview with the NHA on February 18, 2021, at 12:30 PM confirmed that the facility failed to timely notify the physician of the resident' significant weight loss


28 Pa Code 211.12 (a)(c)(d)(3)(5)Nursing services






 Plan of Correction - To be completed: 03/30/2021

Resident 52 and 75 weights are stable. Their Representatives and Physician have been made aware of their significant changes in condition (weight loss).

Currents residents have been reviewed and significant changes in conditions, related to weight, have been reported to their Representatives and Physicians.

Appropriate staff have been made aware of the need to notify significant changes in condition related to weights. The facility Dietary Manager, along with oversight of the Dietician, will ensure weights are monitored closely and significant changes reported to the RN Supervisors so notification can be made.

The DON/Designee will audit changes in condition, related to weights, to ensure proper notification. Findings of the audits will be reviewed at QA meeting for review and recommendation.

483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 19 sampled (Residents 50, and 52).

Findings include:

A review of the clinical record revealed that Resident 50 was admitted to the facility on January 30, 2019, with diagnoses including Cerebral Infraction and Dementia.

Further review of Resident 50's clinical record revealed that the resident was currently receiving hospice services.

A review of Resident 50's quarterly MDS assessment dated January 14, 2021, revealed in Section O, Special Treatments K. Hospice Care, that the resident was not receiving Hospice Care.

An interview with the Director of Nursing on February 17, 2021 at approximately 1:00 PM confirmed that the resident was receiving Hospice Care during the period reviewed for the Quarterly MDS assessment dated January 14, 2021, and that the resident's MDS Assessment was inaccurate with respect to Hospice Care.

A review of the clinical record revealed that Resident 52 was admitted into the facility on June 23, 2020, and has diagnoses including cerebral infarction (stroke), dysphagia (difficulty swallowing), and hypertension.

A review of Resident 52's Quarterly MDS Assessment dated January 13, 2021, revealed in Section K0200 Height and Weight that Resident 52's weight in pounds in the last 30 days was 11 pounds.

Review of the resident's clinical record weight log, revealed on January 13, 2021, Resident 52 weighed 114.2 pounds.

Interview with the Director of Nursing on February 18, 2021, at approximately 1:00 PM confirmed that the above MDS assessment was inaccurate, and that Resident 52's weight had been inaccurately coded.


28 Pa. Code 211.5(g)(h) Clinical records.

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





 Plan of Correction - To be completed: 03/30/2021

Resident 50 and 52 MDS's were corrected to accurately reflect their status.

Current resident MDS's will be reviewed to ensure accurate reflection of status. Any coding errors will immediately be corrected.

Appropriate staff will be re-educated on the importance of the accurate assessments. The RNAC staff will be checking MDS daily for accuracy.

DON/Designee will audit MDS's for accuracy. Findings of the audits will be reviewed at the facilities QA meeting for review and recommendation.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:


Based on a review of clinical records and facility provided documentation and staff interview, it was determined that the facility failed to ensure that pharmacy recommendations were timely acted upon by the physician for one of 19 sampled residents (Resident 59).

Findings include:

Clinical record review revealed that Resident 59 was most recently admitted April 19, 2019 and had diagnoses, which included dementia (a group of thinking and social symptoms that interferes with daily function), psychotic disorder (a mental disorder characterized by a disconnection from reality), trichotillomania (a disorder that involves recurrent, irresistible urges to pull out body hair), anxiety, and depression.

Review of Resident 59's Medication Administration Record (MAR) for April 2020 and July 2020, revealed a physician order dated June 13, 2019, for Risperdal (an antipsychotic used for schizophrenia, and bipolar disorder)1 MG (milligrams) one mg by mouth two times a day (BID) for psychotic disorder.

A Pharmacy Consultant Medication Regimen Review (MRR) dated April 2, 2020, revealed a recommendation from the pharmacist to the physician to consider a trial dose reduction of Risperdal to 0.5 mg BID for psychosis. The physician did not respond to the pharmacist's recommendation until May 21, 2020, 49 days later, at which time the physician indicated that he disagreed with the GDR and provided rationale.

Review of Pharmacy Consultant MRR dated July 6, 2020, revealed a recommendation from the pharmacist to the physician suggest, consider a trial dose reduction to Risperdal to 0.5 mg BID for psychotic disorder with delusions. The physician did not respond to the pharmacist's recommendation until August 6, 2020, 31 days later, noting that he disagreed with the GDR with provided rationale.

Review of Resident 59's MAR for September 2020, revealed a physician order dated October 18, 2019, for Fluvoxamine (a medication to treat obsessive-compulsive disorder), 25 mg by mouth at bedtime for trichotillomania.

Review of Pharmacy Consultant MRR dated September 3, 2020, revealed a recommendation from the pharmacist to the physician to consider a trial dose reduction to Fluvoxamine 12.5 mg at bedtime. The resident did not respond to the pharmacist's recommendation until January 21, 2021, indicating that he disagreed with the GDR and provided rationale. The physician response was 140 days after the pharmacist recommendation date.

Interview with the Director of Nursing (DON) on February 17, 2021, at approximately 1:40 PM confirmed that the physician failed to timely act upon the pharmacist's identification of irregularities in the resident's drug regimen and recommendations to address these irregularities.

Interview with the Nursing Home Administrator (NHA) on February 19, 2021, at approximately 10:40 AM indicated that the physician's delayed response to the pharmacist's requests for gradual dose reductions was not the facility's expectation.

28 Pa. Code 211.9(a)(1)(k) Pharmacy services.

28 Pa. Code 211.2(a) Physician Services

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







 Plan of Correction - To be completed: 03/30/2021

Resident 59 'Pharmacy Consultant Regimen Review' has been reviewed and addressed by the Physician.

Current resident's 'Pharmacy Consultant Regimen Review' have been reviewed by their Physicians and recommendations have been timely addressed.

The facilities Attending Physicians have been re-educated on the regulation.

DON/Designee will audit 'Pharmacy Consultant Regiment Review's" monthly to ensure compliance. Findings of the audits will be reviewed at QA meeting for review and recommendation.


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