Nursing Investigation Results -

Pennsylvania Department of Health
CARING HEART REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CARING HEART REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  130 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
CARING HEART REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to three complaints completed on December 16, 2019, it was determined that Caring Heart Rehabilitation and Nursing 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 related to the health portion of the survey process.





 Plan of Correction:


483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
483.24(c) Activities.
483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on observation, resident and staff interviews, and facility activity documentation, it was determined that the facility failed to provide an ongoing program of meaningful activities designed to meet the individual interests and the physical, mental and psychosocial well-being for all residents on two of seven nursing units (second and third floor Cliveden).

Findings include:

During the initial tour of the third floor Cliveden memory care nursing unit on December 11, 2019, at 10:17 a.m., Resident R309's family representative stated that the facility staff does not try to engage her father in activities. She further stated that he usually just sits in his chair.

Observation on December 11, 2019, at 10:30 a.m. of the third floor Cliveden activities / dining room revealed there were 22 residents in the room. The television was on and seven residents were seated with their backs to the television. None of the 22 residents were watching the television and the 22 residents were observed staring off into space.

Further observation on December 11, 2019, at 11:10 a.m. of the third floor Cliveden activities / dining room revealed there were 31 residents in the room. The television was on and 11 residents were seated with their backs to the television. None of the 31 residents were watching the television and the 31 residents were observed staring into space.

Observation on December 11, 2019, at 10:00 a.m. of the second floor Cliveden activities/ dining room revealed 15 residents sitting in the room with one facility staff. The television was on and most residents were facing the television, several were facing away from the television and five appeared to be asleep. No activities were taking place at this time and no engaging conversations were occurring.

Observation on December 13, 2019, at 1:40 p.m. of the third floor Cliveden activities/ dining room revealed there were 27 residents in the room. The television was on and none of the 27 residents were watching the television. The 27 residents were observed staring into space.

Observation on December 13, 2019, at 1:55 p.m. of the third floor Cliveden activities / dining room revealed there were 27 residents in the room. The television was on and none of the 27 residents were watching the television. The 27 residents were staring into space.

Observation on the second floor nursing unit dining room on December 12, 2019 at approximately 9:50 a.m. 15 residents were in the dining room in the same seats that they ate breakfast in with a television on. Four of the 15 residents were seated with their backs away from the televison and staring off in the opposite direction. There was one nursing aide in the dining room during this time who was sitting in the back of the dining room.

Review of the activity calendar for short term rehablitation, 2nd floor (Cliveden) and 4th floor (Cliveden) revealed weekend activities every Sunday that consisted of church services at 10:00 a.m. and church servcies at 2:30 p.m.

Review of the activity calendar for short term rehablitation, 2nd floor (Cliveden) and 4th floor (Cliveden) revealed weekend activities every Saturday that consisted of church services at 10:00 a.m. and Bingo at 2:00 p.m.

The facility failed to provide an ongoing program of meaningful activities designed to meet the individual interests and the physical, mental and psychosocial well-being for all residents


28 Pa. Code 211.10 (d) resident care policies
Previously cited 12/28/18












 Plan of Correction - To be completed: 01/27/2020

1.R309 has been discharged from the facility. The facility has reassessed the residents on second and third floor Cliveden dining/activities areas to assure that an ongoing program of meaningful activities was provided to meet the individual interests and promote their physical, mental, and psychosocial well-being.
2.All resident dining/activities areas will be reviewed by Activities director/designee to assure that an on-going program of meaningful resident-centered activities is provided to meet the physical, mental, and psychosocial well-being of all residents occurring for all residents.
3.Activities staff and Nursing staff will be educated by Staff Development/designee on the importance of providing meaningful resident-centered activities to promote resident's physical, mental, and psychosocial well-being.
4.Random audits will be conducted by Activities Director/designee to ensure that an on-going program of meaningful resident-centered activities is occurring in all dining/activities areas on units for residents. Audits will be done weekly x4, then monthly x3, then quarterly until compliance is achieved. Findings will be reported to QAPI committee.
5.Compliance date is January 27, 2020.

483.25 REQUIREMENT Quality of Care: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 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 observations, interviews and clinical record review, it was determined that that the facility failed
to obtain and/or follow physician orders for three of 35 residents reviewed (Resident R44, R186, and R80).

Findings:

Review of the clinical record for Resident R44 revealed that the resident was admitted to facility on September 23, 2013, with diagnoses included, but not limited to, coronary artery disease (CAD-narrowing of the blood vessels which supply the heart with blood and oxygen), hypertension (elevated blood pressure) and bilateral upper extremity contractures.

Observation on December 11, 2019 at 9:53 AM revealed that the resident was receiving oxygen at 3 liter with tubing attached directly to the nozzle on oxygen concentrator, without a humidifier. Further observation on December 13, 2019 at 8:53 AM, revealed that oxygen was being administered to resident R44 at 3 liter without a humidifier.

Review of physician's orders for Resident R44 dated December 2019, revealed an order for Continuous oxygen at 2 liters per min,via nasal cannula with humidifier every shift.

On December 13, 2019 at 12:45 PM Employee E4, social worker, acknowledged that the oxygen was not set at 2 liters, as ordered and that the oxygen concentrator did not have a humidifier.

Review of Resident R186's clinical record revealed that the resident was admitted to the facility on May 16, 2019. with diagnoses included, but not limited to, myocardial infarction (heart attack), diabetes mellitus (DM-failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment) and hypertension (high blood pressure). Review of physician's " Order Summary Report" (compilation of orders since May 16, 2019) and Medication Administration Record for October and November, 2019, revealed that Humalog insulin was ordered to be administered before meals according to the blood glucose readings schedule for 7 AM, 11:30 AM and 5 PM.

Review of "Medication Administration Record" for October, 2019 revealed that Humalog insulin was
administered an hour and half after the schedule times on two occassions. On October 3, 2019 the scheduled time for insulin administration was 4 PM; the administration time was 5:59 PM. On October 4, 2019 the scheduled time for insulin administration was 4 PM; the administration time was 6:17 PM.

Review of "Medication Administration Record" for November, 2019 revealed that Humalog insulin was
administer an hour and half after the schedule times on eight occassions.
On November 02, 2019 insulin was schedule at 11 AM; the administration time was 2:59 PM.
On November 02, 2019 insulin was schedule at 4 PM; the administration time was 6:19 PM.
On November 18, 2019 insulin was schedule at 11:30 AM; the administration time was 1:48 PM.
On November 22, 2019 insulin was schedule at 11:30 AM; the administration time was 1:02 PM.
On November 23, 2019 insulin was schedule at 5 PM; the administration time was 6:46 PM.
On November 24, 2019 insulin was schedule at 11:30 AM; the administration time was 1:19 PM.
On November 26, 2019 the 11:30 AM dose of insulin was administered at 2:02 PM; the 5 PM dose of insulin was administered early at 4:20 PM.

These findings were verified by Assistant Director of Nursing, Employee E7 on December 16, 2019 at approximately 12:30 PM.

Clinical record review for Resident R80 revealed the resident was admitted to the facility on October 14, 2017 with diagnoses including seizure disorder (a disorder in which nerve cell activity in the brain is disturbed), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), hypertension (high blood pressure) and intracranial injury (occurs when an external force injures the brain).

Observation of Resident R80 on December 11, 2019 at 12:15 pm sitting in the dining area, revealed the resident wearing a protective, soft helmet. Observation of Resident R80 on December 13, 2019 at 12:00pm sitting in the dining area, revealed the resident wearing a protective, soft helmet.

Review of Resident R80's physician orders, dated last reviewed, November 21, 2019, revealed that Resident R80 did not have a physician's order for the resident to wear a helmet.

Interview with Employee E5, Unit Manager, on December 12, 2019 at 12:15 pm confirmed that the resident did not have a physician's order for the use of a helmet.


The facility failed to obtain and/or follow physician's orders for three residents.

CFR 483.25 Quality of care
Previously cited 9/13/19

28 Pa Code 201.18 (b) (1) Management
Previously cited 5/15/19

28 Pa Code 211.12 (d) (5) Nursing services
Previously cited 9/13/19 and 12/28/18












 Plan of Correction - To be completed: 01/27/2020

1.R44 is discharged from the facility. R186 insulin orders were reviewed to assure that staff administered insulin per physician orders. R80 was reassessed by therapy to assess the continued need for a helmet and a physician order was obtained.
2.All residents with oxygen, insulin, and helmets were reviewed by DON/designee to assure that a physician's order was present and that staff followed orders.
3.Licensed nurses will be educated by Staff development/designee related to obtaining and following physician orders for oxygen, insulin, and helmets.
4.Audits will be done of physician's orders and staff compliance with following orders for oxygen, insulin and helmets. Audits will be done weekly x4, then monthly x3, then quarterly until compliance is achieved. Findings will be reported to QAPI committee.
5.Compliance date is January 27, 2020.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on review of clinical records and facility policies and procedures and interviews with staff, it was determined that the facility failed to ensure that the resident's instructions for Advance Directive (one's wishes on life-sustaining medical or surgical treatment), were accurately reflected in the clinical record for two of 15 clinical records reviewed (Residents R179 and R85).

Findings include:

Review of facility policy, "Policy: Advanced Directives," dated adopted July, 2008, stated that the facility "will ensure that a resident's choices concerning the development of an Advance Directive relative to his or her medical care requests and /or refusal of medial treatment are followed in accordance with the facility's Advance Directive policy and procedure and current State and Federal laws. The same policy also stated that " a physician's order will be written to state the resident's and/or health care representative regarding Advance Directive."

Review of the clinical record for Resident R179 revealed that the resident was admitted to the facility on August 9, 2019 with diagnoses including pressure ulcer of sacral region, multiple sclerosis, diabetes mellitus and chronic pain, dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform every day activities) and chronic obstructive lung disease (COPD - disease process that causes decreased ability of the lungs to perform). Review of a POLST (Pennsylvania Orders for Life Saving Treatment) form, signed and dated by the resident's son on October 31, 2018, indicated DNR (Do Not Resuscitate - do not perform chest compressions to keep heart beating) and Limited Additional Interventions - Do not use intubation, advanced airway interventions, or mechanical ventilation. Review of the physician's orders for September, 2019 and October, 2019 did not indicate that the Advance Directives for the resident was DNR (Do Not Resuscitate - do not perform chest compressions to keep the heart beating) and DNI (Do not use intubation, advanced airway interventions, or mechanical ventilation).(code status - level of emergency medial interventions one wishes if breathing or the heart stops beating). Further review of Resident R14's clinical record revealed a written physician's order dated November 15, 2019, which stated that Resident R14 was DNR (Do Not Resuscitate - do not perform chest compressions to keep the heart beating).

Interview with the Director of Nursing on November 20, 2019, at approximately 1:00 p.m., confirmed that the physician's order for Resident R14 did not accurately reflect the wishes of the resident/responsible party as indicated by POLST (Pennsylvania Orders for Life Saving Treatment) of DNR (Do Not Resuscitate - do not perform chest compressions to keep hear beating) and Limited Additional Interventions - do not use intubation, advanced airway interventions, or mechanical ventilation).

Review of the nursing notes for Resident R85 indicated that the resident was admitted into the facility on October 2, 2019, with diagnoses that included, but not limited to, heart failure (heart failure-a progressive heart disease that affects pumping action of the heart muscles); chronic obstructive pulmonary disease, and visual impairment.

Review of the resident's POLST form that was signed and dated by the resident's sister and the attending physician at the facility on October 5, 2018, indicated DNR and Limited Additional Interventions.

Review of the physician orders for December 2019 revealed a physician's order which started on October 3, 2018, and monthly thereafter for DNR/DNI.

Further review of Resident R85's clinical record indicated revealed a POLST that was signed and dated by Resident R85 and the attending physician at the facility on November 21, 2018 which indicated "CPR/Attempt Resuscitation" (CPR-a medical technique for reviving someone whose heart has stopped beating by pressing on their chest and breathing into their mouth).

Review of an interdisciplinary note dated November 13, 2019 from a social services staff member stated in reference to Resident R85, "She remains a full code and is here for LTC."

The facility failed to ensure that residents' wishes for resuscitation upon life-threatening medical conditions were accurately reflected in the resident's clinical record.

28 Pa. Code 201.18(b)(1) Management
Previously cited 5/15/19

28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(c) Resident care policies
Previously cited 9/13/19, 1/28/19 and 12/28/18

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(2) Nursing services











 Plan of Correction - To be completed: 01/27/2020

1.R179 and R85 were reassessed to ensure that their wishes for advanced directives are accurately reflected in the clinical record.
2.All Residents will be reviewed quarterly by IDT to ensure that their wishes for advanced directives are accurately reflected in the clinical record.
3.The interdisciplinary team will be educated by Staff Development/Designee related to the importance of accurately reflecting resident's wishes for advanced directives in the clinical record.
4.Random audits will be conducted by DON/designee to ensure that resident's wishes for advanced directives are accurately reflected in the clinical record. Audits will be done weekly x4, then monthly x3, then quarterly until compliance is achieved. Findings will be reported to QAPI committee.
5.Compliance date is January 27, 2020.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide a skilled nursing facility advanced beneficiary notice (SNF-ABN) to the resident or the resident's representative following the end of their Medicare coverage for one of three sampled residents who were discontinued from Medicare Part A with benefit days remaining (Resident R146).

Findings include:

Clinical record review revealed that Resident R146 received Medicare Part A services from October 11, 2019, with an end date of November 10, 2019. According to the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by the facility, Resident R146 was discontinued from Medicare Part A with benefit days remaining and the termination of skilled services was initiated by the facility. There was no documented evidence that the resident or the resident's representative was provided the required SNF-Advance Beneficiary Notice of Non-coverage form (a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case).

In an interview conducted on December 16, 2019, at 8:50 a.m., with Employee E3, Social Worker, where she confirmed that the facility had not issued an SNF-ABN notice to Resident R146 or to the residents' representative.

28 Pa. Code 201.18 (e) (1) Management
Previously cited 12/28/18










 Plan of Correction - To be completed: 01/27/2020

1.R146 was provided the skilled nursing facility advanced beneficiary notice (SNF-ABN) of Non-coverage form.
2.Residents or their representative will be provided by Social work/designee a SNF-ABN form following the end of their Medicare coverage and documented evidence will reflect this.
3.Social services will be educated by the NHA/designee on providing and documenting that a SNF-ABN form was given to each resident or representative following the end of their Medicare coverage.
4.Random audits will be conducted by Director of Social Services/designee to ensure that each resident or representative is provided a SNF-ABN following the end of their Medicare coverage. Audits will be done weekly x4, then monthly x3, then quarterly until compliance is achieved. Findings will be reported to QAPI committee.
5.Compliance date is January 27, 2020

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on observation, review of clinical records and interviews with staff, it was determined that the facility failed to ensure that comprehensive person-centered care plans were developed to reflect the individual needs, for four of 35 resident records reviewed (Residents R67, R37, R85 and R59)

Findings include:

Review of the clinical record for Resident R67 revealed that the resident was admitted to the facility on July 14, 2016, with a diagnoses to include Epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing seizures). Continued review of Resident R 67's clinical record revealed no comprehensive care plan had been been developed related to the resident having a seizure disorder.

Interview on December 13, 2019, at 12:35 p.m., with the DON (Director of Nursing), where she confirmed that Resident R67'S diagnosis included epilepsy and further confirmed that no comprehensive care plan had been been developed related to the resident having a seizure disorder.

Review of Resident R37's clinical record revealed that the resident was admitted to the facility on November 27, 2019. Diagnoses included but not limited to, Chronic Kidney Disease Stage 4 (A person with stage 4 chronic kidney disease has advanced kidney damage and will need dialysis or a kidney transplant in the near future) and an Acquired Arteriovenous Fistula (AV fistula) (An AV fistula is a connection, made by a vascular surgeon, of an artery to a vein, without this kind of access, regular hemodialysis sessions would not be possible).

Review of physician order for Resident R37 dated November 27, 2019 indicated an order to keep catheter clamp at bedside at all time. It also ordered to monitor dialysis site every shift. Physician order also indicated dialysis on a Monday- Wednesday-Friday schedule.

Review of the care plan for Resident R37 on December 16, approximately at 10:05 a.m., revealed that Chronic Kidney Disease Stage 4, and Acquired Arteriovenous Fistula were not identified as the diagnosed problems in the comprehensive care plan, and there were no interventions and outcomes(Goals) care planned for these problems.

On December 16, approximately at 11:24 a.m., the Assistant Director of Nursing confirmed that the findings regarding the comprehensive care plan for R37 were accurate.

Review of the nursing notes for Resident R85 indicated that the resident was admitted into the facility on October 2, 2019 with diagnoses that included, but not limited to heart failure (heart failure-a progressive heart disease that affects pumping action of the heart muscles); chronic obstructive pulmonary disease (COPD-a disease that causes decreases the ability of lungs to perform), and visual impairment.

Review of the resident's interdisciplinary notes from the facility psychiatrist revealed that the resident was being seen by the psychiatrist and a psychologist for behavioral services related to depression, anxiety, adjustment issues related to her visual impairments, and not being able to be as independent as she was prior to the onset of her blindness.

Review of Resident R85's interdisciplinary notes from December 3, 2018 through the November 25, 2019, revealed that Resident R85 was evaluated and treated by the psychiatrist a total of nine times during the above referenced time period, and evaluated and treated by a psychologist three times during this time period, for behavioral health services related to depression, anxiety and adjustment issues related to Resident R85's loss of independence, as a result of her visual impairment.

Review of Resident R85's person-centered plan of care did not include any objectives, interventions or time frames regarding Resident R85's mental and psychosocial needs to ensure that Resident R85 attained or maintained her highest practical mental and social well-being.

During a discussion with the Director of Social Services (Employee E3) on December 16, 2019 at approximately 10:05 a.m. Resident R85's person-centered plan of care was discussed. During this time, the Director of Social Services confirmed that Resident R85 is being see by the psychiatrist and psychologist for depression. When Employee E3 reviewed Resident R85's person-centered plan of care during the above-referenced discussion, Employee E3 reported that the person-center plan of care for the resident did not include a care plan to address the resident's behavioral health needs.

Review of Resident R59's clinical record revealed the resident was admitted to the facility on August 20, 2019, with a diagnosis including, but not limited to, dementia (A group of thinking and social symptoms that interferes with daily functioning).

Review of Resident R59's clinical record revealed a psychiatry note dated October 7, 2019, which revealed " ... Nursing-the pt has been urinating all over the unit. He cannot be redirected. When I see the pt today he is alert,pleasant,verbal. He does not recall urinating in inappropriate places. Gives illogical responses ... "

Further review of the resident's clinical record revealed no care plan was developed with measurable goals and interventions to address the care and treatment for dementia.

The facility failed to ensure that a comprehensive person-centered care plan was developed for four residents.

28 Pa. Code 211.5 (f) Clinical records
Previously cited 12/28/18

28 Pa. Code 211.11 (c) Resident care plan
Previously cited 11/27/18

28 Pa. Code 211.12(d) (1) (5) Nursing services
Previously cited 9/13/19, 5/15/19, 1/28/19 and 12/28/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 5/15/19, 1/28/19 and 12/28/18










 Plan of Correction - To be completed: 01/27/2020

1.R67, R37, R85 and R59s Care Plans were reviewed and revised to reflect a comprehensive patient centered care plan to meet the resident's individualized needs.
2.Resident care plan goals and interventions related to seizure disorders, chronic kidney disease, behavioral health needs, and dementia will be reviewed on admission, quarterly and with any significant change to assure that a comprehensive person-centered plan of care was initiated.
3.The interdisciplinary team will be educated by the Staff Development/designee on the importance of developing/revising and implementing a comprehensive person centered care plan to meet the individualized needs of the residents.
4.Random audits will be conducted by DON/designee to ensure that comprehensive care plans have been developed related to seizure disorders, chronic kidney disease, behavioral health needs, and dementia. Audits will be done weekly x4, then monthly x3, then quarterly until compliance is achieved. Findings will be reported to QAPI committee.
5.Compliance date is January 27, 2020.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on observation, staff interviews and clinical record review, it was determined that the facility failed to provide palm guards to prevent injury to the palms of hands and to provide comfort to one of thirty-five residents reviewed. (Resident R44)

Findings include:

On December 12, 2019 at 9:55 AM and 12:55 PM, Resident R44 was observed in bed with contractures of both hands at the wrist and all fingers were closed tightly. The resident was not wearing any devices on hands.
Additionally, on December 13, 2019 at 08 :53 AM and at 12:22 PM, Resident R44 was observed in bed without any devices on hands.

Review of the clinical record revealed that the resident was admitted to facility on September 23, 2013.
Diagnoses included, but not limited to, coronary artery disease (CAD-narrowing of the blood vessels which supply the heart with blood and oxygen), hypertension (elevated blood pressure) and bilateral upper extremity contractures. The quarterly Minimum Data Set (MDS- a periodic assessment of the resident's needs) dated October 20, 2019 indicated that the resident's was impaired in both upper and lower extremities on both sides. The resident's functional status for all activities of daily living was total dependance with two person assistance for bed mobility, transfers, dressing, toileting, personal hygiene and full bath/shower. Further review of the MDS revealed the section: "Restorative Nursing Program" which indicated that no restorative nursing program including passive range of motion and splint assistance was being implemented.

Continue review of the clinical record revealed that bilateral palm guards were ordered by the physician. The "Treatment Administration Record" for December 2019 indicated that the palm guard were applied daily at 9 AM. The resident's care plan last reviewed on November 25, 2019 specified that restorative nursing program for range of motion exercises, bilateral wrist/hand splint and palm guards are needed.

Review of "Restorative Nursing Program evaluation dated December 11, 2019 state the resident will wear bilateral multi-podus boots on bilateral lower extremities; the resident will participate in passive range of motion exercises of bilateral upper extremities 7 days a week. There was no mention of palm guards.
The same information with the exact wording was documented in the clinical record for the months of September, October and November 2019.

On December 13, 2019 at 1:00 PM, the Unit Manager, Employee E 4 verified that the resident was not wearing palm guards and after searching the resident's closet and dresser drawers stated that the resident did not have the palm guards.

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

28 Pa. Code 211.10 (d) Resident care policies
previously cited 12/28/18

28 Pa. Code: 211.12 (d) (5) Nursing services
Previously cited 9/13/19 and 12/28/18











 Plan of Correction - To be completed: 01/27/2020

1.R44 is discharged from the facility.
2.All residents with palm guards will be monitored to assure that palm guards are applied per physician order to prevent injury and promote comfort.
3.Nursing staff will be educated by the Staff Development/designee on providing palm guards as ordered to prevent injury and provide comfort.
4.Random audits will be conducted by DON/designee to ensure that palm guards are provided as ordered to prevent injury and provide comfort. Audits will be done weekly x4, then monthly x3, then quarterly until compliance is achieved. Findings will be reported to QAPI committee.
5.Compliance date is January 27, 2020.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 staff interviews, review of clinical record, and facility documentation, it was determined that the facility failed to provide appropriate assistance with bathing for one of 35 residents reviewed (R44).

Findings include:

Review of the clinical record for Resident R44 revealed that the resident was admitted to facility on September 23, 2013, with diagnoses including, but not limited to, coronary artery disease (CAD-narrowing of the blood vessels which supply the heart with blood and oxygen), hypertension (elevated blood pressure) and bilateral upper extremity contractures. The quarterly Minimum Data Set (MDS- a periodic assessment of the resident's needs) dated August 27, 2019 indicated that the resident's was impaired in both upper and lower extremities on both sides. The resident's functional status for all activities of daily living is total dependance with two person assistance for bed mobility, transfers, dressing, toileting, personal hygiene and full bath/shower. Additionally, the resident's cognitive skills were assessed as severely impaired.

Review of the resident care plan reviewed on September 3, 2019 and November 25, 2019
indicated that the Resident R44 was totally dependent with two person assistance with bed mobility, personal care and bathing.

Review of the nurse's progress note written on October 7, 2019 revealed that at 10:20 AM, she was called by the care nurse while giving morning care. " Resident was found on the floor matt, noted hematoma (collection of blood underneath the tissue) of the forehead." "Staff said resident was on his side, and rolled to the floor. "

Review of the facility's fall investigation dated October 11, 2019 and the care nurse statement. The care
nurse stated the resident was in bed, on his side. The care nurse was giving care, the resident leaned
over too far and fell on the floor.

The facility failed to ensure that one resident received adequate assistance with bathing.

CFR 483.25(d)(2) Accidents
Previously cited 12/28/18

28 Pa. Code 201.18 (b) (1) Management
Previously cited 5/15/19 and 12/28/18

28 Pa. Code 211.12 (d) (5) Nursing services
Previously cited 5/15/19















 Plan of Correction - To be completed: 01/27/2020

1.R44 is discharged from the facility.
2.All residents will be reviewed on admission, quarterly and with any significant change to assure that assistance is provided during bathing activities so that residents are free from accident/hazards.
3.Nursing staff will be educated by Staff development/designee on the importance of providing assistance during bathing activities to assure that residents are free from accidents/hazards.
4.Random audits will be done by DON/designee of residents that require assistance during bathing activities to assure that residents are free of accidents/hazards; audits will be done weekly x4, then monthly x3, then quarterly or when compliance is achieved. Findings will be reported to QAPI committee.
5.Compliance date is January 27, 2020.


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