Nursing Investigation Results -

Pennsylvania Department of Health
SOUTH HILLS REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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SOUTH HILLS REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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SOUTH HILLS REHABILITATION AND WELLNESS 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, and Civil Rights Compliance Survey completed on January 30, 2020, it was determined that South Hills Rehabilitation and Wellness Center was not in compliance with the 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:
Based on observation, staff interview and policy review, it was determined that the facility failed to properly label and store food products in a manner to prevent foodborne illness in the main kitchen.

Findings include:

A review of facility policy titled "Food Storage" dated 01/07/2020, indicated that food will be stored in a safe manner.

During an observation on 01/27/2020, at 9:04 a.m. of the walk-in freezer the following were taken out of the original boxes and not labeled: two coconut cream pies, one bag of chopped spinach, one bag of green beans, one bag of red skin potatoes, two bags of hash browns,

During an observation on 01/27/2020, at 9:09 a.m. of the walk-in milk cooler Lyons raspberry desert syrup was undated with a visible fuzzy green substance on the pull-top lid.

During an interview on 01/27/2020, at 9:12 a.m. Registered Dietitian Employee E2 confined that the facility failed to store food products in a manner to prevent foodbourne illness.

28 Pa. Code 201.18 (b) (1) Management.

28 Pa. Code 211.6 (c) Dietary services.


 Plan of Correction - To be completed: 02/21/2020

F 812 Food Procurement, Store/Prepare/Serve-sanitary

1. The 2 coconut cream pies, 1 bag of chopped spinach, 1 bag of green beans, 1 bag of red skinned potatoes, 2 bags of hash browns, and 1 Lyons raspberry dessert syrup were immediately discarded upon discovery.
2. The Certified Dietary Manager will re-educate the dietary staff on labeling and dating.
3. The Certified Dietary Manager / designee will audit the kitchen daily for two weeks, weekly for two weeks, and monthly for three months for labeling and dating.
4. Results of the audits will be presented to the Quality Assurance Process Improvement team for review and further recommendations.
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 review of facility policy and clinical records and staff interviews, it was determined that the facility failed to make certain the facility developed and implemented a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for two of 24 residents (Resident R12 and R52 )

Findings include:

A review of the facility policy "MDS/RAI/Care Planning" dated 1/6/20, indicated that residents will have an individualized written plan of care that identifies the resident's problems and needs.

A review of the clinical record reveled that Resident R12 was admitted to the facility on 10/30/19, with diagnoses that include diabetes, bipolar disorder (a mental condition marked by alternating periods of elation and depression), and homelessness.

A review of a smoking screening assessment dated 10/30/19, indicated Resident R12 smokes 10 cigarettes a day.

A review of a nurse progress note dated 11/12/19, indicated Resident R12 was "bumming cigarettes."

A review of the care plan dated 11/7/19, did not include smoking for Resident R12

A review of a nurse progress not dated 12/1/19, indicated Resident R12 had a deep tissue injury (DTI) noted to the right heel.
A review of the non-pressure skin condition record, dated 1/7/20, indicated DTI to right heel with no changes.

A review of a physician order dated 1/8/20, indicated to apply skin prep (a protective barrier) to right heel daily.

A review of the care plan initiated 11/7/19, did not include the DTI to the right heel for Resident R12.

During an interview on 1/30/20 at 1:30 p.m., the Director of Nursing confirmed the above findings and that the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for smoking and injury to the right heel for Resident R12.

A review of the clinical record indicated that Resident R52 was admitted to the facility on 5/8/19, and Minimum Data Set (MDS-periodic assessment of care needs) dated 12/7/19, revealed diagnoses that included hypertension (high blood pressure), dwarfism (short stature of less than 4 feet 10 inches and can also be characterized by short limbs and/or short torso) lymphedema (localized swelling caused by a compromised lymphatic system which is responsible for returning fluid within organs or tissues to the bloodstream), diabetes (a chronic condition resulting in too much sugar in the blood), morbid obesity (body fat that increases the risk of health problems), and difficulty walking.

A review of the physical therapy delivery ticket dated 9/26/19, confirmed delivery of a loaner electric wheelchair for trial use for Resident R52.

A review of the physician order dated 10/30/19, indicated out of bed to loaner power wheelchair with bilateral non-elevating leg rests and tilt function.

During observations of the survey from 1/27/20 through 1/30/20, revealed Resident R52 seated in a tilted back power electric wheelchair with a seatbelt.

During an interview on 1/27/19, at 10:45 a.m. Resident R52 indicated that the seatbelt is for support in the wheelchair and that he can release it.

A review of the care plan last updated on 12/7/19, did not include use of a power electric wheelchair with seatbelt for support.

During an interview on 1/30/20, at 12:14 p. m. the Director of Nursing confirmed that the facility failed to to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs for wheelchair positioning and safety for Resident R52.

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







 Plan of Correction - To be completed: 02/21/2020

F656 Develop/Implement Comprehensive Care Plan

1. Resident R12 careplan has been updated to include smoking and the deep tissue injury to the right heel. Resident R 52 careplan has been updated to include the power wheelchair and the seatbelt used for support that he can self release.
2. The DON/designee will audit current resident care plans for residents who smoke, have skin impairment, and positioning devices to ensure that comprehensive, person centered care plans are in place for those residents.
3. The DON/designee will educate the nursing staff on developing and updating resident care plans to ensure they are comprehensive, person centered, with measureable objectives.
4. The DON/designee will audit 5 care plans a week x 2 weeks then monthly x 2 months to ensure that residents care plans have been updated to reflect the resident's current medical, physical, and psychosocial needs. The results of these audits will be reported to the monthly Quality Performance Improvement Committee for review
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on review of facility policies and clinical records and staff interview, it was determined that the facility failed to limit an as needed (PRN) psychoactive drug (any drug that affects the brain activities associated with mental processes and behavior including antianxiety drugs) to 14 days of use for two of 24 residents (Resident R4 and R9).

Findings include:

A review of facility "Antipsychotic Drugs" policy reviewed on 12/18/18, and 1/6/2020, indicated that residents are not given drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents who use antipsychotic drugs receive behavioral interventions in an effort to discontinue the drug.

A review of facility "Unnecessary Medications" policy reviewed on 12/18/18, and 1/6/2020, indicated resident's drug regimen will be free from unnecessary drugs. Unnecessary drugs is any drug used without adequate indications for its use.

A review of facility Admission Record indicated that Resident R4 was admitted to the facility on 10/28/19, with the diagnosis of depression, urinary tract infection, pneumonia, pain, and anxiety.

A review of the physician orders dated 11/3/19, indicated Resident R4 was prescribed Ativan (an Antianxiety drug) .5 milligrams (mg) every eight hours as needed (PRN). The order did not indicate a discontinue date for the medication or a rationale by the physician for it's use.

A review of Resident R4's Medication Administration Record for January 2020, revealed that Resident R4 received Ativan 0.5 mg 13 times.

During an interview on 1/30/2020, at 10:56 a.m. the Director of Nursing confirmed that Resident R4's physican order for PRN Ativan had not been reviewed by the physician since November 2019, and that the facility failed to limit the PRN psychotropic to 14 days of use unless evaluated by the attending physician.

A review of facility Admission Record indicated that Resident R9 was readmitted to the facility on 7/23/19, with the diagnosis of high blood pressure, heart failure, and depression.

A review of the physician orders dated 12/16/19, indicated that Resident R9 was prescribed Ativan 0.5 milligrams (mg) every eight hours as needed (PRN). The order did not indicate a discontinue date for the medication or a rationale by the physician for it's use.

A review of Resident R9's Medication Administration Record for January 2020, revealed that Resident R9 received Ativan 0.5 mg 16 times.

During an interview on 1/30/2020, at 10:56 a.m. the Director of Nursing confirmed that Resident R9's physican order for PRN Ativan had not been reviewed by the physician since November 2019, and that the facility failed to limit the PRN psychotropic to 14 days of use unless evaluated by the attending physician.



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

28 Pa code: 211.2(a) Physician services.

28 Pa code: 211.9(a)(1)(k) Pharmacy services.











 Plan of Correction - To be completed: 02/21/2020

F758 Free from Unnecessary Psychotropic Meds/PRN use
1. Resident R 4 and R9 prn Ativan orders have been reviewed by the physician to assess necessity and rationale for use.
2. The DON/designee will audit all current residents for any prn psychotropic medications, and ensure that any prn psychotropic medications have a 14 day limit.
3. The DON/designee will educate the nursing staff on the need for 14 day limits on psychotropic prn orders, physician documentation requirements, and the need for gradual dose reductions.
4. The DON/designee will review 5 residents on psychotropic medications a week x 2 weeks, then the results of these audits will be reported to the monthly Quality Performance Improvement Committee for review x 2 months to ensure all prn orders are limited to 14 days, physician reviews are documented, and gradual dose reductions have been addressed.
201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:
Based on review of facility infection control policies and procedures, quality assurance surveillance, and staff interview, it was determined that the facility failed to comply with the following requirement of MCARE Act 403(a)(1), for three of four quarterly Infection Control Committee meetings (January, July and October 2019).

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:
(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

A review of the facility infection control surveillance (tracking of all infections within the facility to identify trends or to prevent further infections from developing) for calendar year 2019, revealed no evidence that the facility had a community member at three of the four quarterly Infection Control Committee meetings (January, July and October) during the period of January through October 2019.

During an interview on 1/29/20, at 12:35 p.m. Registered Nurse Employee E1 confirmed that the facility was unable to provide evidence that the facility complied with the requirements of MCARE Act 403(a)(1).

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


 Plan of Correction - To be completed: 02/21/2020


P400 Responsibility of Licensee
1. The facility cannot retroactively correct the lack of a community member at the infection control meeting for the 3 quarters in 2019.
2. The Infection Control committee will be re-educated on the attendance requirements for the meeting by the NHA/designee.
3. The NHA/designee will ensure that there is community representation at the Infection Control meeting quarterly.
4. The NHA/designee will audit the attendance at the Infection Control Meeting to ensure the required members are in attendance. The results of these audits will be reported to the monthly Quality Performance Improvement Committee for review

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