Nursing Investigation Results -

Pennsylvania Department of Health
SAINT MARY'S EAST
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SAINT MARY'S EAST
Inspection Results For:

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SAINT MARY'S EAST - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on March 19, 2021, it was determined that Saint Mary's East 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(f)(4)(ii)-(v) REQUIREMENT Right to Receive/Deny Visitors:This is a more serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(f)(4) The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.
(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time;
(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;
(iv) The facility must provide reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time; and
(v) The facility must have written policies and procedures regarding the visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction or limitation, when such limitations may apply consistent with the requirements of this subpart, that the facility may need to place on such rights and the reasons for the clinical or safety restriction or limitation.
Observations:

Based on review of clinical records and facility policy and staff and family interviews, it was determined that the facility failed to allow visitors for compassionate care visits (special visitation such as an end-of-life situation) as identified in Centers for Medicare and Medicaid Services (CMS) regulatory guidance, and based on the use of reasonable person concept (as defined by CMS - how a reasonable person in the recipient's position would be impacted by the noncompliance) resulted in psychosocial harm for seven of 10 residents reviewed (Residents R12, R13, R14, R15, R16, R17 and R18).

Findings include:

A CMS Memo "Nursing Home Vitiation-COVID-19" QSO-20-39-NH, updated September 17, 2020, provided guidance for reasonable ways a nursing home can safely facilitate in-person vitiation to address the psychosocial needs of residents. This visitation addressed compassionate care visits that included end-of-life situations. The memo also identified that even for counties with a high positivity rate, compassionate care visitation should continue to occur. Also, in addition to family members, compassionate care visits could be conducted by any individual that can meet the resident's needs, such as clergy or lay persons offering religious and spiritual support.

Nursing progress notes for Resident R12 documented the following: On 12/21/2020, the resident tested positive for the COVID-19 virus. On 12/23/2020, the resident began having difficulties breathing with low oxygen levels. Notes from 12/24/2020, through 12/28/2020, documented the resident's rapid decline in condition including difficulties breathing, less responsive and unable to communicate and unable to swallow fluids and pain with movement. On the morning of 12/26/2020, the physician placed the resident on end-of-life comfort measures, discontinued all medications, including the medication used to treat breathing difficulties and ordered Morphine (pain medicine) to be given frequently to keep the resident pain free and comfortable. On 12/28/2020, the resident ceased to breathe (CTB).

During an interview on 3/1/2021, at 8:32 a.m. the Nursing Home Administrator disclosed that the facility did not permit any visitation to the facility's COVID unit, including compassionate care or end-of-life visits.

During an interview on 3/5/2021, at 12:55 p.m. Resident R12's family and responsible party revealed that they requested to visit the resident during the resident's time of declining health but that the facility refused to allow them to enter the facility for any compassionate care visits during this time and they were not with the resident at the time of their death.

Further investigation revealed that six additional residents CTB while residing on the facility's COVID unit, the following was documented in the clinical record progress notes:

Resident R13 was found to be COVID positive on 12/8/2020, and was moved to the facility's COVID unit, the resident later CTB on 12/19/2020.

Resident R14 was found to be COVID positive on 12/8/2020, and was moved to the facility's COVID unit, the resident later CTB on 12/17/2020.

Resident R15 was found to be COVID positive on 12/10/2020, and was moved to the facility's COVID unit, the resident later CTB on 12/20/2020.

Resident R16 was found to be COVID positive on 12/11/2020, and was moved to the facility's COVID unit, the resident later CTB on 12/28/2020.

Resident R17 was found to be COVID positive on 12/12/2020, and was moved to the facility's COVID unit, the resident later CTB on 12/31/2020.

Resident R18 was found to be COVID positive on 12/14/2020, and was contained in the facility's COVID unit, the resident later CTB on 1/1/21/2021.

The clinical record progress notes also revealed that for at least six days prior to each resident's demise, documentation disclosed a steady, continual decline in physical condition leading up to the resident's death.

There was no documentation that the family members of these residents were offered or afforded compassionate care end-of-life visits prior to death for each of these six residents.

During an interview on 3/17/2021, at 5:40 p.m. the Director of Nursing (DON) confirmed that no family members of the above seven residents were offered or permitted any end-of-life compassionate care visits as their physical condition declined or while they were in the process of dying. During the same interview, the DON also verified that Residents R12, R13, R16 and R17 had family visits prior to their placement on the facility's COVID unit.

The facility's failure to follow the requirement to permit compassionate care visitation for end-of-life situation and declining health with ultimate death, based on the use of the reasonable person concept caused psychosocial harm to Residents R12, R13, R14, R15, R16, R17, and R18.


28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18 (b)(2) Management

28 Pa. Code 201.29 9 9 (i) (j) Resident Rights








 Plan of Correction - To be completed: 04/14/2021

a. This plan does not constitute an admission that this citation either legally or factually correct
b. As of February 26th, compassionate care visits are permitted for residents throughout the facility including the red zone.
c. The facility has revised its visitation policy to include compassionate / end of life family visitation for all zones.
d. Education will be provided to clinical staff on the policy revisions permitting compassionate care visits in all zones.
e. Residents on hospice or with end of life care needs will be audited weekly by the Director of Nursing or designee to ensure that compassionate care visits have been appropriately offered.
f. The Administrator, Director of Nursing or designee will monitor for compliance and report findings to the facility QA/PI committee monthly x 3 then quarterly.


483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:

Based on clinical record review, staff and family interviews, it was determined that the facility failed to fully inform and discuss the change of treatments for the medical management of a resident's clinical status and/or discuss alternate treatment options preferred by the resident's representative in advance of these changes for one of six residents reviewed (Resident R12).

Findings include:

Resident R12's clinical record revealed diagnoses that included dementia (confusion and an inability to make sound decisions), depression, diabetes, high blood pressure and dry eye syndrome.

A Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 12/26/2020, documented that Resident R12 was too confused to answer questions for a mental status assessment.

Nursing progress notes for Resident R12 documented the following:

On 12/21/2020, the resident's responsible party was notified that the resident tested positive for the COVID-19 virus but displayed no symptoms of the illness. On 12/23/20, the resident began having difficulties breathing and was ordered medication by the physician to treat breathing difficulties and inflammation from the virus. Notes from 12/24/2020 through 12/26/2020, revealed that the resident continued to have difficulties breathing, became less responsive, had trouble communicating and was observed to have pain with movement. On the morning of 12/26/2020, the physician discontinued all medications, including the medication used to treat breathing difficulties and inflammation, and ordered Morphine (pain medication) to be given frequently as needed. No other medications were ordered to treat the resident's viral symptoms.

There was no documentation to indicate that the decision to stop all Resident R12's treatments and not to try other treatments was discussed with the resident's responsible party.

A physician's note dated 2/26/2021, revealed that on the afternoon of 12/27/2020, Resident R12's representative became aware that all treatments had been stopped and wanted to speak with the physcian who then called the representative to explain that the decision to stop treating the resident had already been made by the physician.

During an interview on 3/1/2021, at 10:37 a.m. the Director of Nursing confirmed that there was no documentation to indicate that Resident R12's responsible party was involved with the decision to end treatments for the resident.

During an interview on 3/5/2021, at 12:45 p.m. Resident R12's representative confirmed that the treatment options were not communicated with him/her in advance so they could be part of the decision process.

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

28 Pa. Code 201.14(a) Responsibility of licensee







 Plan of Correction - To be completed: 04/14/2021

a. Resident R12 no longer resides in the facility.
b. The Director of Nursing or designee will monitor the 24 hour report daily for resident with significant changes , including those with discontinuation of medications at the end of life, to ensure that legal decision makers have been fully informed of treatment orders. Goals of care, as included in the residents advanced directives and physician orders, will be reviewed with end of life care treatments.
c. The Director of Nursing or designee will provide education to nursing staff and medical directors, to ensure that communications with residents and / or legal decision makers regarding end of life goals of care are documented in the clinical record.
d. The Administrator, Director of Nursing or designee will audit resident with significant changes and/or endo of life care needs for documentation of notification. Findings will be reported to the facility QA/PI committee monthly x3, then quarterly.


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