Nursing Investigation Results -

Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LUZERNE
Patient Care Inspection Results

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KADIMA REHABILITATION & NURSING AT LUZERNE
Inspection Results For:

There are  62 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT LUZERNE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on November 9, 2021, it was determined that Kadima Rehabilitation & Nursing at Luzerne 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:


483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:
Based on a review of clinical records and select facility policy and staff and resident interviews it was revealed that the facility failed to implement abuse prohibition procedures for screening perspective residents to determine whether the facility has the capability and capacity to provide the necessary care and services for each resident admitted to the facility for one resident out of four sampled residents (Resident CR2).

Findings include:

A review of the facility Admission Policy last reviewed September 6, 2021, revealed that a resident who is a registered sex offender will not be admitted to the facility unless it is deemed advisable by the interdisciplinary team due to deterioration of condition.

A review of the clinical record revealed that Resident CR2 was admitted to the facility on July 21, 2021, to a private room with diagnoses, which included a left femur (thigh bone) fracture.

A social services note dated July 26, 2021, at 10:07 AM indicated the resident and family contacted the social services director regarding a transfer to another facility as soon as possible. The entry noted that "Discharge started."

A social services note dated July 26, 2021, at 12:08 PM noted the potential receiving facility called back and indicated that they will not offer the resident a bed at their facility.

A nurses note dated July 26, 2021 at 8:14 PM noted the resident continued on 1:1 observation at this time.

A social services note dated July 27, 2021, at 9:24 AM noted that the resident will discharge home today via transportation company which is set up. A primary care physician appointment was scheduled. The note indicated that home health will be provided.

A nurses note July 27, 2021 at 10:31 AM noted that the physician and responsible party were aware of the resident's discharge to home with home health.

A discharge note dated July 27, 2021 noted the resident was discharged to home from the facility on July 27, 2021 at 3:45 PM.

Interview with the social services director (SSD) on November 9, 2021 at approximately 12:00 PM confirmed that she was made aware Resident CR2 was a registered sex offender by the other facility which she contacted on July 26, 2021 to potentially accept the resident for admission. The SSD stated that Resident CR2 was placed on 1:1 supervision because of that notification from the other facility that he was a registered sex offender.

Interview with the administrator on November 9, 2021 at approximately 1:00 PM confirmed that all residents are to be screened prior to admission to ensure that they are not a registered sex offender. The administrator confirmed that the facility had completed Resident CR2's screening prior to admission according to the facility's admission policy.


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

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

28 Pa. Code 201.29(a)(c)(d) Resident Rights

28 PA. Code 211.12(a)(c)(5) Nursing Services.




 Plan of Correction - To be completed: 12/03/2021

1. Resident CR2 is no longer a resident of the facility.
2. A Megan's Law search was completed on current facility residents.
3. The Admissions Director was re-educated on completing sex offender screening prior to admission. The search documentation will be uploaded into the resident's medical record.
4. The NHA or designee will complete an audit of new admissions weekly x 4 weeks then monthly x 2 months to ensure Megan's Law search documentation is uploaded into the resident's medical record. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
483.15(c) Transfer and discharge-
483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with 483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:

Based on a review of the clinical record of a resident whose discharge was initiated by the facility and select facility incident/accident reports, and staff interview, it was revealed that the facility failed to assure the presence of required documentation in the resident's medical record of the necessity of pursing a resident's discharge for one (resident CR1) out of two discharged residents reviewed.

Findings include:

A review of the clinical record revealed that Resident CR1 was admitted to the facility on October 21, 2021, with diagnoses, which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).

Review of Resident CR1's admission nursing assessment dated October 21, 2021, which included an elopement risk assessment, indicated that the resident was ambulatory and at risk for elopement [the total score (low risk score 0-4; moderate risk score 5-10; high risk score 11 plus) of the elopement risk was not calculated].

Review of a facility incident/accident report dated October 26, 2021, at 6:30 AM revealed that Resident CR1 eloped through the window in her room. The location of the resident's room and window directly faced the highway and industrial park where a hotel was located (an approximate 0.3 mile distance, an approximate 6-minute walk from the facility).

A late entry nurses note dated October 26, 2021, at 7:00 AM, entered by Employee 1, the RN supervisor dayshift 7:00AM to 3:00 PM, on October 26, 2021 at 12:00 PM, indicated that Resident CR1 was not in the facility. The director of nursing was notified. The resident was picked up at the police barracks and returned to the facility. Window were screwed closed to prevent further escapes. The responsible party was notified. A skin check was completed, and no injuries were noted to the resident. Resident checked frequently.

Review of a statement by the administrator dated, October 26, 2021, at 8:30 AM revealed that Resident CR1 relayed to the facility staff that she took a folding chair (kept in the room for staff/visitors to use) from her closet, put the chair next to the window, unfolded the chair, and climbed out the window. The resident demonstrated how she was able to unsecure child proof window locking mechanisms to disengage the lock. The resident noted that after she climbed out the window and closed the window and screen most of the way so that they wouldn't know that she left. The resident stated that she walked across the street at the traffic light and went to the hotel across the road to call a cab to take back to the city where she lived prior to being admitted. The statement noted a social work referral was placed for follow-up to transfer the resident to a secured unit with a wanderguard system (doors lock and alarm when someone wearing a wanderguard bracelet approaches).

A social services note dated October 26, 2021, at 10:34 AM indicated that the facility contacted 10 local nursing homes looking for a locked unit for the resident. The social service note indicated the facility was awaiting call back, noting that either no beds were available, or they do not have a locked unit. The social service note indicated "Will keep attempting."

A social services note dated October 28, 2021 at 3:37 PM noted the responsible party okayed the resident's transfer to another facility tomorrow, which was a sister facility located approximately two hours from this current facility.

A nurses note dated October 29, 2021 at 10:35 AM noted the resident was aware of planned transfer to another facility.

A nurses note dated November 2, 2021 at 9:33 AM noted the resident aware of transfer later today. The entry noted that the resident was "Expressing feelings of sadness, emotional support offered. Message left for responsible party regarding transfer today. Continue to check on resident."

A nurses note dated November 2, 2021 at 1:35 PM noted the resident was transferred to another facility via medical transport. The resident was tearful upon reviewing discharge instructions, emotional support given. Medications and all belongings sent with the resident.

Further review of the clinical record revealed there was no documentation in the resident's clinical record from the facility's interdisciplinary team and the resident's attending physician regarding the specific needs that could not be met in this skilled nursing facility to demonstrate the necessity of the resident's transfer to another skilled nursing facility for the resident's welfare.

Interview with the nursing home administrator (NHA) on November 9, 2021 at approximately 2:00 PM revealed the resident was discharged to another facility, which had a wanderguard system (doors lock and alarm sounds when someone wearing a wanderguard bracelet approaches). The NHA confirmed that adequate staff supervision is to be provided at the facility for all residents including residents at risk for elopement to ensure resident safety. The NHA verified that the facility failed to provide required documentation in the resident's clinical record from the facility's interdisciplinary team and the resident's attending physician regarding the specific needs that could not be met to demonstrate the necessity of the resident's transfer for the resident's welfare.

Refer to F689

28 Pa. Code 211.12(a) Physician's Services.

28 Pa. Code 211.5 (f)(g)(h) Clinical Records.

28 Pa. Code 201.29(f)(g) Resident Rights.







 Plan of Correction - To be completed: 12/03/2021

1. Resident CR1's RP asked for a transfer to a facility that was equipped with a Wander Guard system.
2. There were no other residents impacted by this deficient practice.
3. The SW was re-educated on the required documentation (including MD note) in the resident's clinical record regarding the specific needs that could not be met by the facility. The NHA will conduct a review of scheduled discharges for appropriateness.
4. The NHA or designee will conduct an audit of discharged residents weekly x 4 weeks then monthly x 2 months to ensure appropriate documentation is present in the medical record. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on observations, a review of clinical records and resident incident/accident reports, and staff interviews, it was determined that the facility failed to provide adequate staff supervision and monitor a resident at risk for elopement to prevent an elopement from the facility for one of four residents sampled (Resident CR1).

Findings included:

A review of the clinical record revealed that Resident CR1 was admitted to the facility on October 21, 2021, with diagnoses which included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Review of the clinical record revealed the resident was admitted to a private room.

Review of Resident CR1's admission nursing assessment dated October 21, 2021, which included an elopement risk assessment, indicated that the resident was ambulatory and at risk for elopement [the total score (low risk score 0-4; moderate risk score 5-10; high risk score 11 plus) of the elopement risk was not calculated].

The elopement risk assessment noted the resident was disoriented x 3 spheres (person, place, and time), forgetful/short attention span, affected by environment noise levels, expresses desire to go home, wanders aimlessly, ambulates with the assist of one, and has a history of wandering.

An elopement/wandering care plan was implemented with interventions, which included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, toileting, walking inside and outside, and reorientation strategies which including signs, pictures, and memory boxes.

A late entry nurses note dated October 26, 2021, at 7:00 AM entered by Employee 1, RN supervisor dayshift 7:00 AM to 3:00 PM, on October 26, 2021 at 12:00 PM, indicated that "upon arriving that Resident CR1 was out of the facility. The director of nursing was notified. The resident was picked up at the police barracks and returned to the facility. Window were screwed closed to prevent further escapes. The responsible party was notified. A skin check was completed, and no injuries were noted to the resident. Resident checked frequently. "

Review of a facility incident/accident report dated October 26, 2021, at 6:30 AM indicated that at 6:00 AM during a medication pass, a lab technician reported to Employee 2 (LPN) that Resident CR1 was not in her room. An immediate full house sweep was completed by all staff members present. The resident was reportedly last seen by Employee 3 (nurse aide) at 5:20 AM. The resident was noted to be awake and stated to Employee 3 that she was okay. The resident was noted to be pleasant and not stressed or irritated. A phone call was received from the local police at 6:35 AM stating that they had the resident at the police station with them. The police retrieved the resident from the hotel lobby located across the street from the facility. The investigation noted a new intervention was to secure the window with locking mechanism which cannot be disengaged.

Further review of the investigation revealed that Resident CR1 eloped through the window in her room. The location of the resident's room and window directly faced the highway and industrial park where the hotel was located (an approximate 0.3 mile distance, an approximate 6-minute walk from the facility).

Review of a statement from the administrator dated, October 26, 2021, at 8:30 AM revealed that Resident CR1 described that she took a folding chair (kept in the room for staff/visitors to use) from her closet, put the chair next to the window, unfolded the chair, and climbed out the window. The resident demonstrated how she was able to unsecure the child proof window locking mechanisms to disengage the lock. The resident stated that after she climbed out the window, she closed the window and screen most of the way so that they wouldn't know that she left. The resident stated that she walked across the street at the traffic light and went to the hotel across the road to call a cab to take her back to the city where she lived prior to being admitted to the facility. The statement noted that a social work referral was placed for follow-up to transfer the resident to a secured unit with a wanderguard system (doors lock and an alarm sounds when someone wearing a wanderguard bracelet approaches).

A facility wide audit was completed, and all windows were checked by maintenance. Screws/brackets were placed in all windows to ensure they could not be opened greater than six inches.

A nurses note dated, November 2, 2021 at 1:35 PM indicated that Resident CR1 was transferred to another skilled nursing facility.

Observation of Room 2, the room from which the resident had eloped and windows throughout the facility on November 9, 2021, at approximately 10:00 AM revealed that all windows were secured and could not be opened greater than six inches.

Observation also revealed that all doors on the nursing unit required a password to exit off the nursing unit.

At the time of the survey there were no residents identified as being an elopement risk residing at the facility.

Interview with the administrator on November 9, 2021 at approximately 1:00 PM confirmed that Resident CR1 was transferred on November 2, 2021, to a facility that had a wanderguard system. The NHA also confirmed that the facility failed to provide adequate staff supervision to prevent the resident's elopement and the facility initiated the resident's transfer to another skilled nursing facility.

Refer to F622

28 Pa. Code: 211.12(a)(c)(d)(3)(5) Nursing Services





 Plan of Correction - To be completed: 12/03/2021

1. Resident CR1's window was immediately re-secured with a locking mechanism that could not be disengaged.
2. Facility windows were re-secured with locking mechanisms that could not be disengaged.
3. The Maintenance Director was re-educated on ensuring window locking mechanisms could not be disengaged. The Maintenance Director will complete monthly checks of facility windows.
4. The NHA or designee will conduct an audit of 25% of facility windows weekly x 4 weeks then monthly x 2 months to ensure locking mechanisms cannot be disengaged. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

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