Nursing Investigation Results -

Pennsylvania Department of Health
PROMEDICA TOTAL REHAB + (PHILADELPHIA)
Patient Care Inspection Results

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PROMEDICA TOTAL REHAB + (PHILADELPHIA)
Inspection Results For:

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PROMEDICA TOTAL REHAB + (PHILADELPHIA) - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated Survey in response to three complaints, completed on June 16, 2022, it was determined that Promedica Total Rehab Plus Philadelphia, 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 related to the health portion of the survey process.














 Plan of Correction:


483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on a resident group meeting, resident and staff interview, review of facility policy and procedures, it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents on four of four nursing units (Second, Third, Four and Fifth Floors).

Findings include:

A review of the facility policy and procedure, titled, "Grievances" stated "Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing, the right to file grievance anonymously the contact information of the grievance official with whom a grievance can be filed, that is his or her name, business address (mailing and email) and business phone number; a reasonably expected time frame for completing the review of the grievance."

During a resident group meeting on June 15, 2022, at 10:30 am., Residents R6, R7, R16, R22, R55, R67, and R94 were identified as being alert and oriented, revealed that the residents were unaware of where the grievance forms were located. The residents were unaware of any location of grievance/concern submission boxes to submit an anonymous grievance. Residents also were not aware of who is grievance officer at the facility.

Interview on June 15, 2022, at 11:05 a.m. with Nursing Home Administrator confirmed that grievance forms were not available to residents. The Nursing Home Administrator further reported, "grievance forms only available electronically to staff, residents make a call to any staff or call the front desk and guest service will interview the resident".

A tour was conducted with the Nursing Home Administrator of the Second, Third, Four and Fifth Floor and it was confirmed there was no grievance procedure nor contact name, or telephone number of the grievance officer posted on all nursing units.

28 Pa. Code 201.14(a)Responsibility of licensee

28 Pa. Code 201.18(b)(3) Management

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

28 Pa. Code 201.29(a)(d)(i) Resident rights








 Plan of Correction - To be completed: 08/09/2022

F-0585
Residents R6, R7, R16, R22, R55, R67, and R94 have been notified where the grievance forms are located.
Current residents will be notified of the grievance forms and how to submit them anonymously upon admission.
Facility staff have been educated on grievance forms and how pts can submit them anonymously by ADON/GSD/designee. Guest services will check that concern forms are accessible on each unit on an ongoing basis. Guest services will interview 5 patients weekly x4 weeks to ensure that they are aware of the grievance forms and how to submit them anonymously.
A review of the findings of the Grievance audit will be brought to Quality Assurance committee monthly. The committee will determine the need for further audits.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on facility policy, resident interviews, observations, and a review of pest control documentation, it was determined that the facility failed to maintain an effective pest control program on two out of four nursing units (Second and Fifth Floor).

Findings include:

A review of the facility policy "Pest Control" dated 11/2020, indicated that "Preventing pests' access to the kitchen, eliminating harborage condition, along with staff awareness of the importance of prompt action on sightings helps to keep the center free from pests."

On June 14, 2022, at 10:30 a.m. interview Resident R16 reported every night a mouse comes to visit her at night to see if she has left any food for him. She further reported that mice issues continue to be a problem.

On June 14, 2022, at 11:54 a.m. interview Resident R5 revealed that she killed a roach yesterday inside her bathroom with a broom. Resident's R5 bathroom observation at the time of the interview revealed a live large roach running inside of a Resident's bathroom. It was further observed a toilet was slightly elevated from the ground which allowed for the pest to come.

On June 14, 2022, at 11:43 a.m. an interview with Employee E11, Maintenance staff reported that he is the only one in the maintenance department and the maintenance director has been gone since last month. He has a pest control company come and inspect the building on weekly bases. He has also bought some sticky traps for mice and roaches to improve. He has raised a concern with the Administrator to get the pest company more frequently but the company had a lack of staff so they could do only weekly visits.

Pest Control logs for the 3rd floor was reviewed for the past 6 months and indicated that pest reporting of mice and pest infestation is an ongoing issue.

During a resident council meeting on June 15, 2022, at 10:30 am., seven residents, (Residents R6, R7, R16, R22, R55, R67, and R94) were identified as being alert and oriented, revealed that the facility has mice and roaches problems. Resident R94 saw a live mouse yesterday and Resident R22 reported "I saw mice today when it came out of my closed ran under the door and into the hallway.

On June 15, 2022, at 1:53 p.m. an observation on Resident R5's bathroom with Employee E11 Maintenance staff and Employee E12 Maintenance Regional Director showed a sealed opening between the toilet and floor, and observations were made of 3 small roaches running around the bathroom. Employee E12 reported that "they lifted a toilet and found a roaches nest and cleaned it up and sealed the opening and he's not sure how the 3 roaches got into the bathroom,"

An interview with Resident R517, on June 14, 2022, at 11:00 a.m. revealed that he has seen mice in his room on the past two night. He has seen them go into the heater system.

interview with licensed nurse, Employee E19 and nursing assistant, Employee E9 on June 14, 2022, at 11:30 a.m. revealed that they have seen mice in the building.

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

28 Pa. Code 207.2 Administrator's responsibility.






 Plan of Correction - To be completed: 08/09/2022

F0925
Resident R16 no longer reports having issues with pests.
A review of rooms in the facility will be conducted by Maintenance Director/Designee to ensure that rooms with any pest issues are treated by the exterminator
Education on reporting pest sightings will be provided to facility staff and patients to ensure that exterminator is treating areas by NHA /MD/designee
A random weekly audit of patient rooms and exterminator log will be completed to ensure that exterminator is out 3 times per week and treating areas with identified pest issues by the Maintenance Director/Designee The findings of the audit will be brought to Quality Assurance committee. The QAA committee will determine the need for further audits.


483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to complete a Quarterly MDS assessment at least every three months as required for one of 34 residents reviewed (Resident R2).

Findings include:

Review of Resident R2's MDS (Minimum Data Set - a mandatory periodic assessment) assessments revealed that the resident had an Admission MDS assessment completed on October 20, 2021, and a Quarterly MDS assessment completed on January 20, 2022. Continued review revealed that no further MDS assessments had been completed for Resident R2 since January 20, 2022.

Interview on June 16, 2022, at 11:04 a.m. Employee E23, Registered Nurse Assessment Coordinator, confirmed that Resident R2 still resided at the facility and that Resident R2 should have had a Quarterly MDS assessment completed in April 2022. Employee E23 confirmed that Resident R2's last MDS assessment was completed on January 20, 2022, and that the resident was overdue to have an assessment completed.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.5(h) Clinical records



 Plan of Correction - To be completed: 08/09/2022

F-0638
Review of Resident R2's MDS (Minimum Data Set - a mandatory periodic assessment) assessment has been completed
A review of resident MDS assessments was completed and current esidents have updated MDS assessments by RNAC
RNAC's and interdisciplinary team have been educated on completing MDS's on current patients quarterly, annually and with each significant change by DON/ADON/Designee
An audit of 5 patients will be conducted weekly x4 weeks by the RNAC to ensure that assessments are completed quarterly, annually and with each significant change by RNAC/designee.
The findings of the MDS audit will be brought to Quality Assurance committee monthly. The QAA committee will determine the need for further audits.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:
Based on clinical record review, staff, interviews and review of facility policy, it was determined that the facility failed to complete fall investigations for two out of four residents reviewed.
(Resident R108 and 109.)

Findings include:

A review of the facility abuse policy titled "Patient Protection, " dated October 2021, revealed that the resident has the right to be free from abuse, neglect, misappropriation, of the residents property, an exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint requires to treat the residents medical symptoms.

A review of the facilities "Fall Practice Guide" policy dated December 2011, revealed that the purpose of the fall practice guide is to focus on minimizing fall risk factors and falls related injuries while continuing to promote the patient's quality of life. Further review revealed when a resident has a fall an investigation should be conducted, an electronic incident report should be done and witness statements should be collected. And document the finding in the clinical record.

A review of Resident R109's closed clinical record revealed that the resident was admitted to the facility on October 14, 2021, and discharged to hospital on October 17, 2021.

Review of the admission evaluation dated October 14, 2021, revealed that the resident had a history of falls. The interventions listed included to encourage to transfer and change position slowly, evaluate medication if they cause a change in mental status, have commonly used item within reach, provide assist to transfer and ambulate as needed, and reinforce need to call for assistance..

A review of nurse's note dated October 14, 2021, at 11:35 p.m. revealed that the received was resident in bed, confused to time and place, "status post fall from day shift. Bed in low position, bed alarm in place and fall mats at both sides of bed. Will continue to monitor and maintain safety. Doctor made aware of fall."

Review of physician note dated October 14, 2021, revealed that the resident had a fall without injury, and did not hit head.

A fall investigation for the fall on October 14, 2021 was requested, in an interview with the Director of Nursing on June 15, at 12:30 p.m. revealed that no fall investigation was completed by the facility for the fall sustained by Resident 109 on October 14, 2021.

A review of Resident R108's closed clinical record revealed that the resident was admitted to the facility on April 27, 2022, and discharged May 20, 2022. The resident was admitted with the diagnoses of respiratory failure, anemia, pulmonary embolism, anxiety, and renal insufficiency.

A review of a physican note for Resident R108, dated April 29, 2022, revealed that the resident was being see for a fall that occurred the day before. "He stated he was sitting on the toilet and did not see the water on the floor and slipped. He hit left side of face land broke some teeth from dentures."

Review of a nurse's note dated April 29, 2022, revealed that an x-ray was ordered of face and jaw.

A review of the facial x-ray taken on April 29, 2022, facial bones demonstrate no apparent displaced fracture. The visualized skull is unremarkable with normal bone mineralizations and no linear or depressed fracture.

A request for the fall investigation for Resident R108, revealed no fall investigation was done for the residents fall on April 28, 2022, this was confirmed in an interview with the Director of Nursing on June 15, 2022 at 11:45 a.m.

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.10(d) Resident care policies

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





 Plan of Correction - To be completed: 08/09/2022

F-0842
R109 and R108 are no longer residing in the facility
A review of patients with falls in the last 30 days will be conducted to ensure that the investigation for the falls were completed
Education on falls investigation will be provided to nursing staff by the DON/ADON/Designee
A weekly random audit of patients falls will be conducted to ensure that investigations are completed on the fall by DON/ADON/Designee The findings of the audit will be reviewed in Quality Assurance committee. The QAA committee will determine the need for further audits.

483.70(g)(1)(2) REQUIREMENT Use of Outside Resources: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.
483.70(g) Use of outside resources.
483.70(g)(1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (g)(2) of this section.

483.70(g)(2) Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for-
(i) Obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and
(ii) The timeliness of the services.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to provide provision of professional services by an outside provider for one of 34 residents reviewed. (Resident R71)

Findings include:


Review of Resident R71's admission's MDS dated May 25, 2022 revealed the resident was cognitively intact. The resident diagnoses included high blood pressure and renal insufficiency. The same MDS indicated the resident was independent and needed some supervision with his activities of daily living.

Certified Registered Nurse Practioner (CRNP) admission note, dated May 22, 2022 referenced Resident R71's hospital from May 15, 2022 to May 22, 2022 and noted the resident having occasional memory loss, a tremor in his right arm and the concern for Parkinson's disease. The note further stated, "Refer to neuro (neurology) as OP (outpatient).

Review of Resident R71's hospital records revealed that the resident was admitted to the hospital on May 15, 2022 initially with lower back pain, and decreased weakness in his lower extremities. During the hospital stay Neurology was consulted to evaluate the resident's tremors and noted that it was concerning for possible Parkinson's disease. Instructions at discharge instructed the resident to follow-up with neurology within one week.

CRNP note, dated May 27, 2022, again indicated to follow-up with neurology but a scheduled appointment could not be found in the resident's physician orders and/or clinical records.

On June 16, 2022 at 9:23 a.m. the Director of Nursing confirmed the facility failed to order a neurology appointment for Resident R71.

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

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





 Plan of Correction - To be completed: 08/09/2022

F-0840
Patients R71 no longer resides in the facility.
Current residents with recommendations for neurology will be conducted to ensure that appointment for neurology is made.
Education to licensed nursing staff regarding the scheduling of recommendations for neurology consults will be completed by DON/ADON or designee
A random weekly audit of patients with recommendations for neurology will be conducted to ensure that appointments are made by the DON/ADON/Designee The findings of the audit will be reviewed at the Quality Assurance committee monthly x4 weeks.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Bassed on observations, resident interviews, a temperature test tray and review of dietary service standards, it was determined that the food offered to the residents was not served at the prefer temperature and not pleasant to the taste.

Findings include:

A review of the dietary service standards form, supplied by Dietary Account Manager, Employee E21, on June 15, 2022 at 12:30 p.m. revealed the prefer temperatures to serve food, are as followed: soup and hot beverages-above 150 degrees Fahrenheit, Hot entrees above 130 degrees farenheit, all cold foods and beverages- below 45 degrees Fahrenheit.

Interviews with Resident Resident R5 stated in an interview on June 14, 2022, at 11:54 am. that the food was not good and either too salty or too much pepper. The meats are too chewy, and the vegetables too over cooked.

A temperature test tray, was completed on June 15, 2022, at 12:30 p.m. revealed the following foods offered for lunch consisted of sausage pizza , potatoes soup, cole slaw, coffee and juice.

The temperatures of the food was taken at the time of the observation and revealed that the potatoes soup was 120 degrees Fahrenheit, the cole slaw was 59.9 degrees Fahrenheit, and the juice 56 degrees.

A taste test of the lunch time meal on June 15, 2022 at 12:30 p.m. revealed that the potatoes soup had an overly peeper taste and was not served hot, the cole slaw and the juice was not cold,.

28 Pa. Code 201.14 (a) Responsibility of licensee










 Plan of Correction - To be completed: 08/09/2022

F- 0804
Food will be served to residents at a palatable temperature and taste.
Education will be provided to dietary staff regarding holding temperatures.
A random weekly audit of meals will be completed to ensure palatable temperature and taste by the Dietary Manager or designee
The findings of the audit will be brought to Quality Assurance committee monthly. The QAA committee will determine the need for further audits

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on clinical record review, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that licensed nursing staff received skills competency training related to wound vacs for two of two residents reviewed with wound vacs (Residents R33 and R459).

Findings include:

Interview on June 14, 2022, at 11:03 a.m. Resident R33 stated that he was not receiving proper wound care to his right foot and that he felt that some of the nurses did not know how to properly change his wound vac (wound treatment that applies continuous negative pressure to promote wound healing).

Review of Medication Administration Records (MARs) for Resident R33 revealed a physician's order, initiated on May 27, 2022, for a wound vac to the right lateral (side) foot and to change the dressing every Monday, Wednesday and Friday during the night shift. Continued review revealed that Employee E14, licensed nurse, signed the MAR indicating that she changed the wound vac dressing on May 27 and June 3, 2022. Further review revealed that Employee E15, licensed nurse, signed the MAR indicating that she changed the wound vac dressing on June 8, 2022.

Interview on June 14, 2022, at 11:58 a.m. Resident R459 stated that she recently had hip surgery. Observation, at the time of the interview, Resident R459 revealed that she had a wound vac to her right hip

Review of MARs for Resident R459 revealed a physician's order, initiated June 13, 2022, for a wound vac to surgical incision and to change the dressing every Monday, Wednesday and Friday during the day shift. Continued review revealed that Employee E17, licensed nurse, signed that MAR indicating that she changed the wound vac dressing on June 13, 2022.

Review of facility documentation Program Attendance Records revealed that an educational in-service was provided on May 18 and 20, 2022, related to wound vacs. Further review revealed that Employees E14, E15 and E17 were not listed on the attendance records.

Interview on June 14, 2022, at 1:31 p.m. with Employee E4, staff educator, revealed that the above attendance records were the only documentation available related to wound vac education for nursing staff. Employee E4 stated that if a nurse was assigned to a resident who had a wound vac and they did not have training, that another nurse who had received training would be expected to provide assistance with the dressing change.

28 Pa Code 201.19 Personnel policies and procedures

28 Pa Code 201.20(b) Staff development






 Plan of Correction - To be completed: 08/09/2022

F0726
Resident R33 has been discharged from the facility. Resident R459 receives wound vac treatment to surgical incision to change the dressing every Monday wed and Friday during day shift
A review of current residents in the facility with wound vac orders was conducted to ensure that patients were receiving treatments as ordered by DON/ADON/designee
Education and competencies regarding wound vac treatments will be provided to licensed nursing staff by ADON/DON/designee
A random weekly audit of residents with wound vac orders will be conducted to ensure that patients are receiving treatments as ordered by DON/ADON/designee. The findings of the audits will be brought to Quality Assurance committee. The QAA committee will determine the need for further audits.

483.25 REQUIREMENT Quality of Care: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 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 observation, review of a clinical record, and staff interviews, it was determined that the facility failed to ensure that physician orders were clarified and/or obtained for two of 34 residents reviewed (Resident R18, R25, and R71).

Findings include:

Review of Resident R18 Admission's Minimum Data Set (MDS- assessment of resident's care needs), dated April 19, 2022 revealed the resident was cognitively intact. Further review of the MDS revealed that the resident was diagnosed with Congestive Heart Failure (CHF, the heart does not pump sufficiently causing signs of weight gain) and required the assistance of two people with bed mobility, dressing, bathing, hygiene, and toileting. The resident was assessed incontinent of bowel and bladder.

Review of Resident R18's physician order dated April 18, 2022, revealed that the resident required daily monitoring of weights due to the diagnosis of CHF. The was no evidence that the facility clarify with the resident's physician the need for the order to include parameters in which to notify the doctor.

Review of Resident R18's clinical record revealed that daily weights were not obtained as ordered by the physician. Interview with the Director of Nursing on June 16, 2022 at 1:45 p.m. revealed that the resident normally refused to get weighted. Review of the residen't clinical record revealed no evidence that the resident was educated in the need to have weights obtained due to the diagnosis of Congesive Hearth Failure.


Review of Resident R25's physician orders on April 15, 2022, and continuing to present, indicated " no straws" per the physician.

On June 14, 2022, at 10:29 a.m., and on June 15, 2022, at 12:46 p.m. an interview was held with Resident R25 who was observed to have a straw in his cup at both times.

On June 16, 2022, at 10:20 a.m. licensed nurse, Employee E13 Unit Manager confirmed the observation that the resident had a straw in the milk container. Employee E13 responded, "is he not supposed to have it?".

On June 16, 2022, at 12:29 p.m. an interview was held with Employee E26 and E27 Speech therapists who reported that the resident should not drink his liquids with a straw because of the aspiration issues. She further reviewed the speech discharge on May 4, 2022, which also stated "In order to reduce risk of aspiration with the intake of thin liquids pt. (patient) will utilize single-cup sips with no overt s/s (signs and symptoms) aspiration in > (more than) 90%of opportunities given min verbal cues". This order continues to be active for the resident not to drink his liquids from straws.



28 Pa. Code 201.14(a) Responsibility of licensee

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

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






 Plan of Correction - To be completed: 08/09/2022

F-0684
Resident R18 continues with daily weight orders.
A review of current residents with an order for daily weights will be conducted to ensure that residents are having their weights obtained daily or documenting any refusals by DON/ADON/designee
Education regarding daily weight documentation will be provided to nursing staff by the ADON/DON
A random weekly audit of patients on daily weights will be conducted to ensure compliance of documentation by the Dietitian to ensure completion and follow up. A review of the findings of the weekly audit will be reviewed in Quality Assurance committee. The QAA committee will determine in the need for further audits.
Resident R25 no longer resides in the facility.
A review of current residents with an order for "no straws" was conducted by DON/ADON/designee to ensure that residents are not receiving straws with orders.
Education regarding "no straws" will be provided to nursing staff and dietary to ensure that orders are followed and that no straws are provided to those patients by ADON/DON/Designee
A random weekly audit on patients with "no straws" ordered will be conducted to ensure that no straws orders are followed by the nursing supervisor by DON/ADON/designee. A review of the findings of the weekly audit will be reviewed in Quality Assurance committee. The QAA committee will determine the need for further audits.


483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record review, observations, resident and staff interviews and review of facility policy, it was determined that the facility failed to maintain adequate personal hygiene and grooming of residents dependent on staff for assistance for one of 34 residents reviewed (Resident R25).

Findings include:

A review of the facility policy and procedure, titled "Shaving" states " to provide for personal hygiene and grooming needs and remove unwanted facial hair."

On June 14, 2022, at 10:29 a.m. an interview was held with Resident R25 who was observed to have facial hair on his chin and reported: "yes I would like to be shaved, I haven't seen myself in ages and I don't know how I look like."

Review of Resident R25's recent quarterly Minimum Data Set (MDS- standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment) dated April 21, 2022, revealed that the resident as totally dependent on one person's physical assistance for his activities of daily living. The resident's (BIMS - Brief Interview for Mental Status - a screen used to assist with identifying a resident's current cognition) indicated Resident R25 had intact cognition.

On June 14, 2022, at 10:32 a.m. an interview with licensed nurse, Employee E32 who was overseeing the resident confirmed Resident R25 was unshaved. Resident R25 reported that he wanted to have a haircut as well.

On June 16, 2022 at 10:20 a.m. an observation with licensed nurse, Employee E13 for Resident R25 confirmed Resident 25 was still not shaved. Resident R25 reported the last time he got a shave was a week ago. Resident 25 further reported "Yesterday the hairdresser promised to shave me but did not, but only shampooed his hair and cut his hair. Then the night shift CNA (nursing assistant) reported to him that she was brought from the second floor to cover the shift and she was unable to shave him.

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

28 Pa. Code 211.12(d)(3)Nursing services

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





 Plan of Correction - To be completed: 08/09/2022

F0677
Resident R25 has been shaved.
A review of current residents with facial hair will be conducted and shaving will be offered.
Nursing staff will be educated on ensuring that shaving is offered and completed daily with daily hygiene and care of patients by DON/ADON/Designee
A random interview/audit of 5 patients will be conducted weekly x4 weeks by the nursing supervisor to ensure that residents are adequately shaved by DON/ADON/designee. A review of the findings of the audit will be reviewed in the Quality Assurance committee. The QAA committee will determine the need for further audits.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:


Based on clinical record review and interview with staff, it was determined that the facility did not accurately and completely give appropriate discharge instruction for wound care for one out of four residents reviewed. (Resident 107)

Findings include:

A review of Resident 107's clinical record revealed that the resident was admitted to the facility on May 4, 2022, and discharged to home on May 17, 2022. The resident admitting diagnosis included an abdominal wound with 16 sutures and right lower leg venous wound.

A review of May 2022 physcian orders dated May 4, 2022, revealed an order for an abdominal wound to be cleaned with normal saline and apply a clean dry dressing. The resident right lower leg venous wound, was to be cleaned with normal saline apply hydrogel and cover with a dry dressing.

A review of Resident R107's "transition to home discharge form," dated May 17, 2022, revealed that the section titled "wounds" the response was "Not Applicable." No wound care discharge instructions were provided to the resident upon her discharge from the facility.

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




 Plan of Correction - To be completed: 08/09/2022

F-0661
Resident 107 was provided telephone instructions and offered wound supplies as needed by facility and homecare
A review of current residents preparing for discharge that require wound care discharge instructions will receive them upon dc of the facility.
Licensed nursing staff will be educated on discharge instructions to residents upon discharge by the NPE/DON/designee
A random audit current patients requiring wound care discharge instructions will be conducted weekly x4 weeks to ensure that they will receive the instructions upon discharge or prior to discharge by the Unit manager/designee The findings of the audit will be reviewed by the Quality Assurance committee monthly x4 weeks. The QAA committee will determine the need for further audits.

483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on observations, clinical record reviews and interviews with residents and staff, it was determined that the facility failed to develop a baseline care plan, including the minimum healthcare information necessary to properly care for a resident within 48 hours of admission, for one of 34 residents reviewed (Resident R459).

Findings include:

Interview on June 14, 2022, at 11:58 a.m. Resident R459 stated that she recently had hip surgery and that she had a lot of pain. Observation, at the time of the interview, Resident R459 revealed that she had a wound vac (wound treatment that applies continuous negative pressure to promote wound healing) to her right hip as well as an intravenous (IV) catheter to receive antibiotics.

Review of Resident R459's Admission Evaluation, dated June 10, 2022, at 5:32 p.m. revealed that the resident was admitted to the facility on June 10, 2022, from the hospital.

Continued review of the Admission Evaluation revealed that the resident reported her pain level to be an eight on a scale of zero to ten, indicative of severe pain. The pain was reported to be at the right hip, that the pain occurred almost constantly and that medication was needed for pain relief. Further review of the assessment revealed that no baseline care plan was developed at the time of the assessment related to Resident R459's need for pain management.

Continued review of the Admission Evaluation revealed that the resident had a midline IV catheter in her right arm that measured 39 inches in length. Further review of the assessment revealed that no baseline care plan was developed at the time of the assessment related to Resident R459's need for IV catheter care.

Continued review of the Admission Evaluation revealed that the resident had a surgical incision site near her groin. Further review of the assessment revealed that no baseline care plan was developed at the time of the assessment related to Resident R459's need for surgical wound care.

Review of Medications Administration Records (MARs) for June 2022, revealed that Resident R459 had active physician orders for wound vac treatments to her surgical incision site, Vancomycin (an antibiotic) IV infusions every twelve hours and IV catheter care including line flushing and assessments. Continued review of MARs revealed that Resident R459 was prescribed several pain medications, including lidocaine patches, celecoxib, acetaminophen, gabapentin and oxycodone.

Review of Resident R459's care plan, dated as initiated June 10, 2022, revealed focus areas related to activities, discharge potential, nutrition and occupational therapy interventions for activities of daily living.

Continued review of Resident R459 ' s care plan revealed that there was no care plan developed related to the resident's need for pain management, need for surgical wound care and wound vac treatments and the resident's need for IV catheter care and IV antibiotic therapy.

Interview on June 15, 2022, at 2:04 p.m. the Director of Nursing (DON) confirmed that no baseline care plan had developed for Resident R459 related to her pain, surgical wound or IV antibiotic therapy. The DON stated that the baseline care plan should have been developed at the time the admission assessment was completed.

28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.11(d) Resident care plan






 Plan of Correction - To be completed: 08/09/2022

F655
Resident R459's care plan has been updated to include pain management, need for surgical wound care, wound vac treatments, IV catheter/antibiotic therapy.
A review of current resident's careplans will be conducted in the facility to ensure that baseline care plans are developed by the DON/ADON/designee
Licensed nursing staff will be educated on the initiation of baseline careplans upon admission by the DON/NPE
A weekly random sample audit of new admission careplans will be conducted by the DON or designee weekly x4 weeks to ensure that resident baseline careplans are completed timely. The findings of the audit will be reviewed in Quality Assurance committee. The committee will determine the need for further audits.

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.20(f) Automated data processing requirement-
483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to transmit an MDS assessment within the required timeframe for one of 34 residents reviewed (Resident R2).

Findings include:

Review of Resident R2's Quarterly MDS (Minimum Data Set - a mandatory periodic assessment) dated January 20, 2022, revealed that the assessment was not signed as completed until March 3, 2022. Continued review revealed that the assessment was transmitted on March 3, 2022.

Interview on June 16, 2022, at 11:04 a.m. Employee E23, Registered Nurse Assessment Coordinator, confirmed that Resident R2's Quarterly assessment was not transmitted within the required timeframe.

28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.5(h) Clinical records



 Plan of Correction - To be completed: 08/09/2022

I hereby acknowledge the CMS 2567-A, issued to PROMEDICA TOTAL REHAB + (PHILADELPHIA) for the survey ending 06/16/2022, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
F-0640
The facility failed has transmitted an MDS assessment for Resident R2
A review of current resident assessments for timely transmission will be completed by the RNAC to ensure that assessments are up to date.
RNACs will be educated on completing and transmitting MDS assessments timely on current residents by the DON/ADON
An audit of 5 patients will be conducted weekly x4 weeks by the RNAC to ensure that assessments are transmitted timely by RNAC/designee
The findings of the audit will be brought to Quality Assurance committee monthly. The QAA committee will determine the need for further audits.


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