Pennsylvania Department of Health
TWINBROOK HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TWINBROOK HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are 118 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.


TWINBROOK HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey and an Abbreviated Complaint Survey completed on May 17, 2024, it was determined that Twinbrook Healthcare and Rehabilitation Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

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.

§483.21(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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Plan of Correction - To be completed: 07/02/2024

1. Facility has a comprehensive care plan in place for residents R19, R51, R54, and R66.

2. The DON provided an in-service and education to IDT on resident-specific individualized care planning. All resident care plans will be reviewed for accuracy and updated as needed.

3. DON or designee will conduct audits of the completion and appropriateness of individualized comprehensive care plans. Audits will be completed weekly for 4 weeks then monthly for 3 months. Monitoring will be ongoing and will be checking for the completeness and appropriateness of individualized comprehensive care plans.

4. Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and prevent the potential spread of infection regarding respiratory care equipment according to physician's orders for six of 20 residents (Residents R4, R19, R51, R54, R58, and R66).

Findings:

A facility policy entitled "Oxygen Administration" dated 4/26/24, indicated: oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences; infection control measures included, a. clean/rinse oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe) filter weekly, change as needed; b. change oxygen tubing (lightweight tube used to delivery supplemental oxygen) and mask/cannula weekly and as needed if it becomes soiled of contaminated; c. clean humidifier bottle when empty, change weekly, use only sterile water for humidification; d. keep delivery devices covered in plastic bags when not in use.

Resident R19's clinical record revealed an admission date of 8/16/22, with diagnoses that included heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea (occurs when the throat muscles relax and block the airway). A physician's order dated 12/05/23, revealed to change oxygen tubing and canister, and clean oxygen concentrator filter on night shift every Tuesday.

Observation on 5/14/24, at 1:18 p.m. revealed Resident R19's oxygen tubing was dated 4/24/24, and hanging over the handle of his/her bedside stand, the humidifier bottle was dated 5/01/24. The humidifier tubing was not attached to the concentrator, the water canister was almost empty, and the concentrator filters were covered with a white, fluffy substance.

During an interview at that time, Resident R19 stated "not sure how long the humidifier tubing had been disconnected." Additional observation on 5/14/24, at 3:15 p.m. (during medication administration), revealed that Resident R19 reported to medication nurse that "the surveyor was 'looking' at the humidifier bottle earlier," and the medication nurse reconnected the humidifier bottle tubing to the concentrator.

Resident R51's clinical record revealed an admission date of 1/31/22, with diagnoses that included long-term respiratory failure, high blood pressure, bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and adjustment disorder. A physician's order dated 12/05/23, revealed to change oxygen tubing and canister, and clean oxygen concentrator filter on night shift every Tuesday.

Observation on 5/14/24, at 1:39 p.m. revealed Resident R51's oxygen tubing was dated 4/24/24, and the concentrator filters were covered with a white, fluffy substance.

Resident R54's clinical record revealed an admission date of 12/20/23, with diagnoses that included heart disease, respiratory failure, chronic obstructive pulmonary disease (COPD- chronic inflammatory lung disease that causes obstructed airflow from the lungs), high blood pressure, and bipolar disorder. A physician's order dated 12/21/23, revealed to change oxygen tubing and canister, and clean oxygen concentrator filter on night shift every Tuesday.

Observation on 5/14/24, at 1:34 p.m. revealed Resident R54's oxygen tubing was dated 4/24/24, and the concentrator filters were covered with a white, fluffy substance.

Resident R66's clinical record revealed an admission date of 3/18/23, with diagnoses that included COPD, end-stage renal disease, aorta bypass graft (procedure done to treat a blockage or narrowing of one or more of the coronary arteries), and heart failure. A physician's order dated 3/22/24, revealed to change oxygen tubing and canister, and clean oxygen concentrator filter on night shift every Tuesday.

Observation on 5/14/24, at 1:45 p.m. revealed Resident R66's oxygen tubing was dated 5/01/24, and the concentrator filters were covered with a white, fluffy substance.

Resident R4's clinical record revealed an admission date of 1/31/22, with diagnosis that included obstructive sleep apnea (a sleeping disorder where a person's breathing repeatedly stops and starts while sleeping), Hypertension (high blood pressure), diabetes, and hyperlipidemia (high cholesterol).

Review of Resident R4's physician orders revealed an order that Resident R4" Must wear continuous positive airway pressure (CPAP) every night."

Observation on 5/14/24, at 1:35 p.m. revealed Resident R4's CPAP machine (a machine that prevents breathing interruptions caused by sleep apnea) with the tubing and face mask attached to the machine. The face mask was laying on the floor with no barrier between the face mask and the floor. Further observation on 5/14/24, at 3:40 p.m. revealed Resident R4's CPAP mask continued to lay on the floor without a barrier between the mask and floor.

Resident R58's clinical record revealed an admission date of 3/9/22, with diagnoses that included COPD, hypertension, and anxiety.

Observation on 5/14/24, at 1:30 p.m. revealed oxygen tubing was dated 5/1/24, humification bottle was dated 4/24/24, and filters to bilateral sides of the oxygen concentrator were covered with a white, fluffy substance.

During an interview on 5/14/24, at 3:43 p.m. the Director of Nursing confirmed the dates on Residents R19, R51, R54, R58, and R66's oxygen tubing, humidifier bottles, and that the concentrator filters were "dirty" and Resident R4's CPAP mask was laying on the floor with no barrier between the mask and floor. He/she also confirmed that oxygen tubing, humidifier bottles and concentrator filters should be changed/cleaned per physician orders and the CPAP mask should have not been laying on the floor.

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

Plan of Correction - To be completed: 07/02/2024

1. the oxygen tubing and humidifier bottle were changed immediately for residents R19, R51, R54, R66, and R58. Resident R4's face mask for their CPAP machine was picked up from the floor after the DON was alerted to the issue.

2. The Director of Nursing and/or designee will educate all professional licensed nursing staff on the importance of promoting cleanliness with respiratory equipment and changing the appropriate equipment prior to expiration dates. An audit of all residents with oxygen will be completed to ensure cleanliness of respiratory equipment and that appropriate equipment is being changed prior to expiration dates; this includes oxygen tubing, humidifier bottles, and ensuring concentrator filters are clean. Audits will be ongoing, and the Director of Nursing or designee will continue to monitor weekly to ensure ongoing compliance.

3. The Director of Nursing and/or designee will audit all residents on oxygen weekly for 4 weeks, then monthly for 3 months to ensure all oxygen tubing, humidifier bottles, and concentrator filters are clean and within an appropriate date range. This audit will also include a detailed inspection of the residents' floors to ensure no respiratory equipment is present on the room floors.

4. Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans to reflect the current care and services for three of 20 residents reviewed (Residents R4, R20, and R58).

Findings include:

Review of facility policy entitled "Care Plan Revision Upon Status Change" dated 4/26/24, indicated that "The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change."

Resident R4's clinical record revealed an admission date of 1/31/22, with diagnoses that included obstructive sleep apnea (a sleeping disorder where a person's breathing repeatedly stops and starts while sleeping), hypertension (high blood pressure), diabetes, and hyperlipidemia (high cholesterol).

Review of care plan meeting documentation for Resident R4 revealed a care plan meeting was completed on 3/14/24.

Review of Resident R4's clinical record revealed a physician order dated 12/5/23, for continuous positive airway pressure (CPAP), must wear every night. Review of Resident R4's care plans lacked evidence of a care plan to address the CPAP.

Resident R20's clinical record revealed an admission date of 8/16/22, with diagnoses that included diabetes, hypertension, and chronic kidney disease (a disease that affects the kidney's ability to filter waste products and extra fluid from the body).

Review of care plan meeting documentation for Resident R20 revealed a care plan meeting was completed on 4/9/24.

Review of Resident R20's care plans revealed a care plan to address pain with a target date (a date that the care plan is to be updated by) of 4/9/24.

Resident R58's clinical record revealed an admission date of 3/9/22, with diagnoses that included chronic obstructive pulmonary disease (when your lungs do not have adequate air flow), hypertension, and anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone).

Review of care plan meeting documentation for Resident R58 revealed a care plan meeting was completed on 3/14/24.

Review of Resident R58's physician orders revealed an order for oxygen at four liters per minute dated 1/5/24. Review of Resident R58's care plans to address respiratory care revealed under interventions for oxygen at two liters per minute with a revision date of 3/28/24.

During an interview on 5/16/24, at 1:25 p.m. the Director of Nursing confirmed the care plans for Residents R4, R20 and R58 were not reviewed/revised to reflect current resident care and services. He/she also confirmed that care plans should be reviewed and revised as required.

28 Pa. Code 211.10(c)(d) Resident care policies

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

Plan of Correction - To be completed: 07/02/2024

1. The care plans for residents R4, R20, and R58 have been reviewed for accuracy and revised to reflect the residents' current care and services. the Director of Nursing or designee will educate the staff, including the therapy staff, that care plans need to be updated with changes in residents' needs and physician orders.

2. All resident care plans will be reviewed to ensure everyone reflects the current care and services being received by the residents.

3. Care plans will be updated weekly to reflect changes in residents' needs and physician orders. The RNAC or designee will audit 10 resident care plans weekly for 4 weeks, then monthly for 3 months to ensure care plans are being updated as changes occur. If no further errors are identified audits will be done for one additional quarter.

4. Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Plan of Correction - To be completed: 07/02/2024

1. Residents R8 and R69 had their catheter bags covered at the time of the survey to provide dignity and privacy.

2. The Director of Nursing and/or designee will educate the nursing staff on the facility policy that catheter bags of residents should be covered for dignity and privacy. Also, all nursing staff will be educated that any resident admitted with a catheter should be assessed for need of privacy cover, and if the new admission needs one, they will have one placed. An audit of all residents with a foley catheter present will be completed to ensure all residents have a privacy cover in place. If any are identified as not having privacy covers in place, they will have one placed. Checking for privacy covers will be something added to the admission checklist to address on admission; these admissions are reviewed for accuracy by the DON or designee, and this will be added to monitor for having a foley catheter when arriving from the hospital.

3. The Director of Nursing and/or designee will audit and monitor all residents with catheters to ensure they are covered to provide dignity and privacy for the resident. Audits will be completed daily for 2 weeks and weekly for 1 month.

4. Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to ensure that a pharmacist's recommendation was reviewed and acted upon for one of 20 residents reviewed (Resident R19).

Findings:

A facility policy entitled "Medication Regimen Review" dated 4/26/24, indicated that facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Resident R19's clinical record revealed an admission date of 8/16/22, with diagnoses that included heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea (occurs when the throat muscles relax and block the airway).

Resident R19's departmental progress notes revealed that on 1/27/24, the consultant pharmacist identified irregularities with Resident R19's medication regimen and referred to see the report.

Resident R19's clinical record lacked evidence of a pharmacy recommendation report for January 2024 addressing the irregularities.

During an interview on 5/16/24, at 2:00 p.m. the Director of Nursing confirmed there was no evidence that Resident R19's clinical record contained a pharmacy recommendation report for the irregularities identified 1/27/24.

28 Pa. Code 211.5(f)(x) Medical records

28 Pa. Code 211.10 (c) Resident care policies

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

Plan of Correction - To be completed: 07/02/2024

1.A copy of the pharmacy recommendation signed by the physician was obtained from Pharmerica and was placed into R19's clinical record.

2.Recommendations that are not addressed in a month are then added to a report for the following month stating that there was a lack of response. The DON will verify with the pharmacy that there are no outstanding recommendations that have not been addressed by the physician for all residents of the building. An audit of the last 3 months of recommendations will be completed to ensure all recommendations are addressed and a copy of the recommendations is provided in each resident's electronic or paper chart.

3.Moving forward, the Director of Nursing and/or designee will use the executive report to verify that all of the recommendations for the month that were passed out to providers were addressed by Physician and sent back to the pharmacy. The recommendations that are faxed to the pharmacy will be checked off after verifying they have been received back in the DON office. The Director of Nursing and/or designee will also provide medical records of copies to scan into patient's electronic medical record. The DON will then retain the original pharmacy recommendation in a binder in the DON office. Education will be provided to all nursing staff that all pharmacy recommendations need to be addressed in a timely manner and returned to the pharmacy via fax.

4.The Director of Nursing and/or designee will audit all pharmacist recommendations that are passed out to providers as well as all recommendations that are faxed to the pharmacy weekly for 4 weeks, bi-weekly for 2 weeks, and then monthly for 2 months; the Director of Nursing or designee will then continue to monitor these audits on a monthly basis.

5.Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on a review of facility policy and clinical records, and staff interview, it was determined that the facility failed to implement procedures to promote accurate and safe disposition of controlled medication records for one of three closed records reviewed (Resident CR94).

Findings include:

Review of the facility policy, entitled "Disposal of Medications," dated 4/26/24, indicated, "Controlled Substances listed in Schedules II, III, IV, and V remaining in the nursing care center after the order has been discontinued are retained in the nursing care center in a securely double locked area with restricted access until destroyed as outlined by state regulation. For the State of Pennsylvania, these controlled substances shall be disposed of by the nursing care center in the presence of appropriately titled professionals two licensed nurses employed by the nursing center. A controlled medication disposition log, or equivalent form shall be used for documentation and shall be retained as per federal privacy and state regulations. This log shall contain the following information, Resident's name, Medication name and strength, Prescription number, Quantity/amount disposed, Date of disposition, and Signatures of the required witnesses."

Review of Resident CR94's closed clinical record revealed admission to the facility on 2/3/22. Resident CR94 ceased to breathe on 2/23/24.

Review of Resident CR94's closed clinical record revealed a lack of evidence that two licensed nurses were present and signed on 1/24/24, and 2/12/24, for the removal of and destruction of Resident CR94's Fentanyl 25 micrograms/hour (mcg/hr) patch (a controlled schedule II drug used for pain management) and lacked evidence of the destruction of or return to pharmacy for Resident CR94's 22 remaining does of Methadone HCL 10 (milligram) mg Tablets (a controlled schedule II drug used for pain management).

During an interview on 5/16/24, at 3:00 p.m. the Director of Nursing confirmed that Resident CR94's disposition of medications documentation lacked evidence that two licensed nurses were present and signed on 1/24/24, and 2/12/24, for the removal of and destruction of Resident CR94's Fentanyl 25 mcg/hr patch and lacked evidence of the destruction of or return to pharmacy for Resident CR94's 22 remaining does of Methadone HCL 10 mg tablets.

28 Pa. Code 211.9(a) Pharmacy services

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

Plan of Correction - To be completed: 07/02/2024

1.The medication records for patient R94 were updated by the nurses who were noted to have disposed of the patient's remaining methadone to accurately reflect that the medications were disposed via drug buster bottle.

2.An audit of the last 6 months of discharges (including those who ceased to breathe) will be completed to determine if there are any other records that may be missing appropriate documentation of medication disposition at discharge per facility policy.

3.All RNs and LPNs will be educated on the facility policy of proper documentation of medication disposition. They will also be educated on appropriate documentation of disposal of any controlled substances, including needing 2 signatures for fentanyl patches or any controlled substance medication patches.

4.All documentation of controlled medication disposition will be reviewed and verified as complete and correct by DON or designee with every controlled substance. These audits will be completed daily for 2 weeks, weekly x 2 weeks and biweekly for 4 weeks. These audits will then become ongoing, completed every month going forward.

5.Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on review of manufacturer's recommendations, facility policy, and clinical records, and staff interviews it was determined that the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one of 20 residents reviewed (Resident R19).

Findings include:

Review of manufacturer's recommendations for administering acetaminophen (Tylenol) included not to exceed six tablets in 24 hours.

A facility policy entitled "Medication Administration" dated 4/26/24, indicated that medications will be administered as ordered and in accordance with manufacturer's specifications.

Resident R19's clinical record revealed an admission date of 8/16/22, with diagnoses that included heart disease, irregular heartbeat, heart failure, and obstructive sleep apnea (condition that occurs when the throat muscles relax and block the airway).

A physician's order dated 4/12/24, instructed staff to administer two acetaminophen 500 milligram (mg) tablets every four hours as needed for pain to Resident R19 (or up to 12 tablets 24 hours).

Resident R19's clinical record revealed that he/she was administered acetaminophen 1,000 mg on 4/24/24, at 4:54 p.m. and 5:03 p.m., and on 4/25/24, at 4:46 p.m. and 5:22 p.m.

During an interview on 5/16/24, at 1:50 p.m. the Director of Nursing confirmed that the physician's order for two acetaminophen 500 mg tablets every four hours exceeded the manufacturer's recommendations and staff incorrectly administered 1,000 mg of acetaminophen on 4/24/24, at 4:54 p.m. and 5:03 p.m., and on 4/25/24, at 4:46 p.m. and 5:22 p.m.

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

Plan of Correction - To be completed: 07/02/2024

1. Resident R19s orders for Acetaminophen were changed to follow manufacturer's recommendations.

2. An audit of all acetaminophen orders in the facility will be done to ensure that there are no other orders not following the manufacturer's recommendations.

3. The Director of Nursing and/or designee will run a report of all the new orders weekly and will check that there are no acetaminophen orders that do not follow manufacturer's recommendations. The Director of Nursing or designee will provide education to all nursing staff regarding ensuring that all orders entered are following manufacturer's recommendations. This includes any medicine, which includes tylenol. Also, the verbiage "not to exceed 3g/24hours" will be included with each order to remind the staff of the manufacturer's recommended dosages.

4.The Director of Nursing and/or designee will audit all new orders weekly for 4 weeks, bi-weekly for 2 weeks, and then monthly for 2 months. These audits will be ongoing, with the Director of Nursing or designee continuing to monitor weekly to ensure ongoing compliance.

5.Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§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 review of facility policy and clinical record, and staff interview, it was determined that the facility failed to provide a written summary of the baseline care plan and order summary to the resident and/or representative for one of 20 residents reviewed (Resident R60).

Findings include:

A facility policy entitled, "Baseline Care Plan" dated 4/26/24, revealed "A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include at a minimum the following:

a.The initial goals of the resident.
b.A summary of the resident's medications and dietary instructions.
c.Any services and treatments to be administered by the facility and personnel acting on behalf of the facility."

Resident R60's clinical record revealed an admission date of 3/14/24, with diagnoses that included chronic respiratory failure, pneumonia (an infection in the lungs), and epileptic seizures (a sudden uncontrolled electric disturbance in the brain that can cause changes in behaviors and movements).

R60's clinical record lacked evidence that a written summary of the baseline care plan and order summary was provided to Resident R60 and/or his/her representative.

During an interview on 5/16/24, at 2:20 p.m. the Director of Nursing confirmed that the clinical record for Resident R60 lacked evidence that a written summary of the baseline care plan and order summary was provided to the resident and/or his/her representative upon admission to the facility.

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

Plan of Correction - To be completed: 07/02/2024

1. Resident R60 had no negative outcome, and a written summary of the baseline care plan and order summary was provided to the resident.

2. Licensed nurses will be educated on providing a written summary of the baseline care plan and order summary within 48 hours of admission and presenting it to resident or resident representative.

3. DON or designee will audit new admissions to determine if a written summary of the baseline care plans and order summaries were offered to new residents. An audit of the past 3 months will be done to ensure that a copy of baseline care plans was received on admission by the resident or their representative.

4. DON or designee will conduct an audit of new admissions to ensure a written summary of baseline care plans and order summaries have been offered to new residents, weekly for 4 weeks then monthly for 3 months. Monitoring will be ongoing and will be checked for all residents having received a copy of their baseline care plan, and this will be checked when checking all new admissions. If anyone is identified, a copy of their baseline care plan will be provided to them.

5. Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

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 review of the Long-Term Care Resident Assessment Instrument (RAI - provides instructions and guidelines for the completion of Minimum Data Sets [MDS - federally mandated standardized assessments of resident abilities and care, conducted at specific intervals to plan resident care] User's Manual and clinical records and staff interview, it was determined that the facility failed to transmit MDS's to the required electronic system within the mandated time frame for two of 20 residents reviewed (Resident R5 and R39).

Findings include:

The RAI User's Manual indicated that Entry, Death and Facility and Discharge tracking MDS's must be completed and transmitted within 14 days of the event date.

Review of Resident R5's closed clinical record revealed an admission date of 11/22/23, with diagnoses that included infection following a procedure and high blood pressure.

Resident R5's clinical record progress note dated 1/8/24, indicated Resident R5 was discharged from the facility to the hospital.

Review of Resident R5's submitted MDS's included an entry MDS dated 1/8/24, and a state optional / admission MDS dated 1/8/24. The records lacked evidence that a Discharge, Return Not Anticipated MDS was submitted within 14-days of Resident R5's discharge on 1/8/24.

Review of Resident R39's closed clinical record revealed an admission date of 1/5/24, with diagnoses that included malignant neoplasm (cancer) of the prostate and high blood pressure.

Resident R39's clinical record progress note dated 1/21/24, indicated Resident R39 was discharged from the facility to the hospital.

Review of Resident R39's submitted MDS's included an entry MDS dated 1/8/24, and a state optional / admission MDS dated 1/8/24. The records lacked evidence that a Discharge, Return Not Anticipated MDS was submitted within 14-days of Resident R39's discharge on 1/21/24.

During an interview on 5/18/24, at approximately 11:30 a.m. the Director of Nursing confirmed that Resident R39's and R39 Discharge, Return Not Anticipated MDS was not submitted within the required timeframe.

28 Pa. Code 211.5(d) Medical records

Plan of Correction - To be completed: 07/02/2024

I hereby acknowledge the CMS 2567-A, issued to TWINBROOK HEALTHCARE AND REHABILITATION CENTER for the survey ending 05/17/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to accurately code the Minimum Data Set (MDS-periodic assessment of resident care needs) for one of 20 residents reviewed (Resident R4).

Findings include:

Review of facility policy entitled "RAI Policy" dated 4/26/24, revealed "Policy Statement ... This includes coding the MDS with accuracy ..."

Resident R4's clinical record revealed an admission date of 1/31/22, with diagnoses that included obstructive sleep apnea (a sleeping disorder where a person's breathing repeatedly stops and starts while sleeping), hypertension (high blood pressure), diabetes, and hyperlipidemia (high cholesterol).

Review of the MDS dated 2/22/24, under section Special Treatments, Procedures, and Programs section O0110 revealed to "check all of the following treatments, procedures, and programs that were performed during the last 14 days." Documentation on the MDS for section O0110 while a resident under G1 Non-Invasive Mechanical Ventilator revealed it was answered "no."

Review of Resident R4's clinical record revealed a physician's order dated 12/5/23, that indicated resident must wear continuous positive airway pressure (CPAP) every night.

Review Resident R4's Medication Administration Record (MAR) documentation for the month of February 2024, revealed that Resident R4 wore his/her CPAP during the lookback period for the MDS target date of 2/22/24.

During an interview on 5/16/24, at 1:25 p.m. the Director of Nursing confirmed that the resident had a physician's order to wear his/her CPAP nightly and that Section O0110 G1 of the MDS dated 2/22/24, was incorrectly coded for Resident R4 regarding receiving Non-Invasive Mechanical Ventilator and the use of the CPAP.

28 Pa. Code 211.5(f)(viii) Medical records

28 Pa. Code 201.14 (a) Responsibility of Licensee

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to include the discharge summary in the closed record for one of three closed records reviewed (Closed Record Resident CR96).

Findings include:

Review of Resident CR96's closed clinical record revealed an admission date of 8/2/23, with diagnoses that included myocardial infarction (heart attack), heart failure, and atrial fibrillation (irregular heartbeat).

Review of Resident CR96's closed clinical record revealed that Resident CR96 was discharged to the hospital on 3/10/24 and ceased to breath at the hospital.

Review of Resident CR96's closed clinical record revealed there was no discharge summary included in the record.

During an interview on 5/17/24, at 9:43 a.m. the Director of Nursing confirmed that the closed record for Resident R96 did not have a discharge summary included in the clinical record as required.

Plan of Correction - To be completed: 07/02/2024

1.Resident R96's chart was updated to include a discharge summary completed by the physician.

2.An audit of the last 6 months of discharges from the facility (including those who went to the hospital and ceased to breathe there) was completed to identify those resident's that lacked a discharge summary from the physician and the physician will update those charts to include a discharge summary.

3.The Medical records clerk or designee will track the discharges and ensure that all discharges have a discharge summary completed by the physician at time of discharge.

4.The Director of Nursing or designee will monitor all discharges to ensure a discharge summary is included in the documentation for all discharges. These audits will be completed once weekly for 4 weeks and then bi-weekly indefinitely to ensure compliance.

5.Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of facility nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide (NA) per 12 residents on the evening shift, and one NA per 20 residents on the overnight shift, for four of 21 days reviewed for staffing ratio (5/10/24, 5/11/24, 5/12/24 and 5/15/24).

Findings include:

Review of facility census on the following shifts revealed that the facility failed to meet the minimum required NA ratio.

Review of 21 days of nursing staffing documentation for the evening shift revealed:

5/10/24, facility census of 92 residents, 6.77 NA worked and 7.67 were required.

5/11/24, facility census of 93 residents, 6.37 NA worked and 7.75 were required.

5/12/24, facility census of 92 residents, 5.73 NA worked and 7.67 were required.

Review of 21 days of nursing staffing documentation for the overnight shift revealed:

5/15/24, facility census of 92 residents, 4.57 NA worked and 4.60 were required.

During an interview on 5/17/24, at 9:55 a.m. the Scheduler Employee E1 confirmed that the facility failed to meet the minimum NA ratio requirements on the above shifts and dates.

Plan of Correction - To be completed: 07/02/2024

1. A daily staffing meeting including the Nursing Home Administrator, Director of Nursing, Staffing Coordinator, Human Resources, or designees, is in place to monitor projected staffing ratios, with staffing coordinator offering bonuses for vacant shifts to staff as well as reaching out to PRN staff and agencies to fill shifts for call offs. The facility will continue the practice of not accepting admissions when staffing is projected to be below state minimum. The facility will continue to actively recruit and advertise to new and former employees.

2. The Staffing Coordinator will monitor in-house resident census by shift to verify accuracy. The Staffing Coordinator will be educated by the Nursing Home Administrator on documenting all efforts in procuring sufficient staff. The Staffing Coordinator will continue to ensure that the nursing staff ratios of Certified Nursing Assistants are as follows:

1:12 for Day Shift/1:12 for Evening Shift/1:20 for Night Shift.

3. Audits of nursing staff ratios will be conducted by the Director of Nursing or designee daily for 2 weeks, weekly for 4 weeks, and monthly for 3 months; these audits will then be completed monthly on an ongoing basis to ensure compliance is sustained.

4. Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

§ 211.12(f.1)(5) LICENSURE Nursing services. :

(5) Effective July 1, 2023, a minimum of 1 RN per 250 residents during all shifts.

Observations:

Based on review of nursing staffing documents and staff interview, it was determined that the facility failed to ensure a minimum of one Registered Nurse (RN) per 250 residents on the evening and overnight shifts for four of 21 days reviewed (5/10/24, 5/11/24, 5/12/24, and 5/15/24).

Findings include:

Review of facility census on the following shifts revealed that the facility failed to meet the minimum required RN ratio.

Review of 21 days of nursing staffing documentation for the evening shift revealed:

5/11/24, facility census of 93 residents, 0.57 RN worked, and one was required.

5/12/24, facility census of 92 residents, 0.03 RN worked, and one was required.

5/15/24, facility census of 92 residents, 0.07 RN worked, and one was required.

Review of 21 days of nursing staffing documentation for the overnight shift revealed:

5/10/24, facility census of 92 residents, 0.53 RN worked, and one was required.

5/11/24, facility census of 92 residents, zero RN worked, and one was required.

During an interview on 5/17/24, at 9:55 a.m. the Scheduler Employee E1 confirmed that the facility failed to meet the minimum RN ratio requirements on the above shifts and dates.

Plan of Correction - To be completed: 07/02/2024

1. A daily staffing meeting including the Nursing Home Administrator, Director of Nursing, Staffing Coordinator, Human Resources, or designees, is in place to monitor projected staffing ratios, with staffing coordinator offering bonuses for vacant shifts to staff as well as reaching out to PRN staff and agencies to fill shifts for call offs. The facility will continue the practice of not accepting admissions when staffing is projected to be below state minimum. The facility will continue to actively recruit and advertise to new and former employees.

2. The Staffing Coordinator will monitor in-house resident census by shift to verify accuracy. The Staffing Coordinator will be educated by the Nursing Home Administrator on documenting all efforts in procuring sufficient staff. The Staffing Coordinator will continue to ensure that the nursing staff ratios of Registered Nurses are as followed:

1 RN:250 Residents for All Shifts.

3. Audits of nursing staff ratios will be conducted by the Director of Nursing or designee daily for 2 weeks, weekly for 4 weeks, and monthly for 3 months; these audits will then be completed monthly on an ongoing basis to ensure compliance is sustained.

4. Audits will be submitted to the Quality Assurance Performance Improvement Committee for review and suggestions at the monthly meetings.

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