Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on February 12, 2020, it was determined that Broad Mountain Health and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address the dementia-related behavioral symptoms displayed by one resident out of five residents sampled (Resident 4 ).

Findings include:

A review of the clinical record revealed that Resident 4 had a diagnosis of dementia. A review of the resident's admission MDS Assess (minimum data set - a federally mandated assessment process completed at intervals to plan resident care) dated February 4, 2020, revealed the resident was severely cognitively impaired with a BIMS score (brief interview for mental status - a tool for assessment of cognition, a score of 0-7 indicates severe cognitive impairment) of 99, which indicated the resident was not able to participate in the assessment.

According to nursing documentation dated January 2020, the resident displayed intrusive behaviors, which included wandering on the nursing units and into other resident rooms, uninvited. Staff documented that the resident was resistive, and at times, combative with redirection.

According to review of the resident's clinical record the resident wandered into other resident rooms and went through or removed their belongings on January 2, 6, 18, 22, 27, 2020 and February 9, 2020. The resident attempted to get onto the elevator without staff supervision/assistance on January 13, 2020.

On January 1, 2020, the resident's family came to the facility to visit the resident and found, and subsequently returned, the personal items of other residents, located in Resident 4's room. The resident's family was upset that the resident's blanket was in another resident's room. The facility staff explained that the resident had likely taken the blanket and placed it on the other resident herself. Staff also documented that the resident was dragging a geri chair behind her, and was punching and pushing the nurse when the nurse attempted to retrieve the chair from the resident.

On January 18, 2020, nursing noted that the resident was observed feeding her roommate cookies and hard textured foods, which were not compatible with the roommate's prescribed therapeutic diet.

A review of the resident's clinical record revealed that the resident wandered into the room of a resident on another nursing unit of February 11, 2020, at 9:34 AM. Various staff members attempted to get the resident to leave the room, but were not successful. The resident's daughter was contacted and intervened and the resident did leave the other resident's room.
Staff documented on February 11, 2020, at 12:27 AM that the resident was wandering in and out of other resident rooms.

Interview with Resident 1, a cognitively intact resident, on February 12, 2020, revealed that the resident reported that Resident 4 frequently wandered, uninvited into her room and touched her personal belongings. Resident 1 frequently the staff has difficulty redirecting Resident 4 r out of her room as well as those of other residents.

During an interview with Resident 4's son on February 12, 2020, at 11:40 a.m. he confirmed that his mother frequently wandered the halls of the facility and into other resident rooms. He stated that she frequently took her own personal belongings and money with her when she wandered and gave these items out to other residents.

A review of Resident 4's comprehensive plan of care, which was last reviewed by the facility on February 5, 2020, revealed that the planned interventions to address the resident's behavioral symptoms were to involve the resident in activities of choice or small group activities and having the resident interact with a specific peer who resided across the hall. However, a review of a list of residents currently residing in the facility revealed that this identified resident no longer resided there,

The activities, which were planned to divert the resident's attention were not specified on the resident's care plan. There was no evidence of resident-centered individualized preferred activities or diversions, which had been attempted and proven to be successful or identification of those that were unsuccessful. The remaining interventions consisted of providing ordered medications, one to one for support, redirection as needed, emotional support and reassurance.

The facility staff was aware, and documented, the resident's intrusive behaviors, and tendency to wander. Staff also documented that the resident was not easily redirected. The facility staff was also aware that redirection caused the resident's behaviors to escalate, but there was no evidence that the facility had devised a person-centered individualized care plan reflective of the resident's cognitive abilities and dementia diagnosis to address and support the resident's dementia care needs.

The facility had not developed and implemented an individualized activities program, which attempted to provide meaningful interaction, resident specific diversional activities and resident preferred individualized activities as approaches to deter the resident's intrusive wandering behavior. The facility failed to identify and include the resident's specific preferences, past habits, personal history and/or daily routines that may be incorporated into meaningful and/or diversional activities for the resident.

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

28 Pa Code 211.11(d) Resident care Plan.

 Plan of Correction - To be completed: 03/12/2020

1. Resident R4 care plan has been updated with resident specific activities and diversions to address intrusive and wandering behaviors.

2. Resident with dementia or residents with intrusive and wandering behaviors will have care plans reviewed to ensure appropriate/effective activity programs are included.

3. DON/designee will re-educate activity department, social service department and nursing staff on ensuring care plans reflect resident's current status, which will include effective and specific interventions to address demonstrated behavior.

4. RNAC/designee will conduct random audits of care plans to ensure they are resident centered weekly x4 and monthly x 2. Results of audits will be reviewed by the monthly QAPI committee for further recommendations.

5. 03/12/2020

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