Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

There are  87 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.
KADIMA REHABILITATION & NURSING AT LAKESIDE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on January 5, 2024, it was determined that the facility was not in compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

211.5(f)(i)-(xi) LICENSURE Medical records.:State only Deficiency.
(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.


Based on a review of clinical record and interviews with facility staff, it was determined the facility failed to ensure that a resident's medical record contained sufficient nursing documentation noting observations, clinical findings and sufficiently detailed progress notes to accurately reflect a resident's status and condition for two residents out of 12 sampled (Resident CR1 and Resident 1).

Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient ' s EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care:
Clinical problems
Communications with other health care professionals regarding
the patient
Communication with and education of the patient, family, and the patient ' s designated support person and other third parties.

A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on December 5, 2023, with diagnosis to include post surgical care. The resident had an indwelling Foley urinary catheter for overactive bladder and a sphincter implant to his scrotum to manage incontinence (treatment for moderate to severe stress urinary incontinence that allows you to control your bladder with a hand-operated pump to compress and release a cuff around the urethra).

An interview with Employee 3, a nurse aide, on January 5, 2024 at approximately 11:30 AM revealed she recalled caring for Resident CR1 around December 16, 2023, and had noticed that the resident's catheter appeared to be causing a split to the top of the head of his penis. She stated she placed warm compresses on it to relieve any discomfort and stated she told a nurse about the resident's penis. Employee 3 stated that licensed nursing staff told her that the resident had a consult with urology but no treatments were ordered.

A review of the resident's medical record, conducted during the survey ending January 5, 2024, revealed no nursing documentation regarding a split to the head of the resident's penis, application of warm compresses or any other concerns regarding the condition of this area.

Interview with the director of nursing (DON) on January 5, 2024, at 1:00 PM revealed she was aware of the concern regarding the split in the resident's penis. She stated she was told on the night shift of December 16, 2023. When asked about the location of the nursing documentation of this finding she stated her shift was over at 7:00 AM and she instructed the oncoming nurse (no name provided) to note it in the resident's medical record. The DON confirmed that she did not enter any nursing documentation into the resident's medical record to reflect the condition of this resident's penis. She stated her shift was over she had to leave. The DON confirmed that neither she nor any other nursing staff documented this finding in the resident's medical record.

The resident was discharged on December 23, 2023, with scrotal swelling and did not return to the facility.

Review of Resident 1s clinical record revealed admission to the facility on November 6, 2023, and was identified to be at high risk for pressure sores.

Documentation completed by the facility's contracted outside wound care provider dated December 19, 2023, indicated that the resident had a Stage III pressure area to her coccyx measuring 0.9 cm x 0.5 cm x 0.2 cm with light serous drainage and 90% of slough. Wound documentation from the wound management team dated January 2, 2024, indicated that the resident's wound was debrided to remove slough/dead tissue and measured 1 cm x 0.5 cm x 0.2 cm with 30% slough remaining.

The facility staff were to apply a treatment of medihoney with border gauze to the resident's coccyx was to be applied every day and evening shifts.

The facility's licensed and professional nursing staff did not document the status, condition and healing progress of the resident's Stage III pressure sore, to include a description of the area in the week between the visit from the contracted wound care provider.

Nursing documentation dated December 27, 2023, revealed that the resident had a small pressure ulcer on her sacrum and nursing documentation dated January 3, 2024, indicated that the resident had a small open pressure area on her coccyx. These nursing entries did not describe the appearance or measures for these pressure areas.

The DON stated during interview at the time of the survey ending January 5, 2024, that the facility's nursing staff are not allowed to stage residents' pressure areas and that assessment task and documention is left up to the contracted outside wound care team.

The wound care team was in on December 19, 2023, but not again until January 2, 2024, and in the interim the facility's licensed and professional nursing staff failed to document an assessment of the resident's pressure areas for two weeks until the wound care team came in on January 2, 2024. Facility documentation only indicated the resident had a small pressure area and received the treatment of medihoney with gauze to her coccyx every morning and evening.

An observation of this resident on January 5, 2024 at approximately 12:45 PM revealed the resident did not have a dressing on her coccyx area and no open area was observed at the time of the observation. The resident stated during interview at that time, that the pressure area "comes and goes."

The facility's nursing staff failed to document timely and sufficiently detailed assessment and monitoring of the resident's skin impairments to accurately track status, condition and healing progress.

 Plan of Correction - To be completed: 02/06/2024

1. The facility is unable to retroactively document on resident CR1. Resident 1's clinical documentation matches her current status and condition.
2. A facility wide body audit was completed to identify skin integrity concerns on facility residents. Skin integrity was documented in the resident's medical records.
3. Licensed Nursing Staff will be re-educated that resident's medical records must contain sufficient nursing documentation noting observations, clinical findings and sufficiently detailed progress notes to accurately reflect a resident's status and condition. The IDT will review the 24-hour report on facility residents at morning meeting to ensure that the clinical record accurately reflects the resident's status and condition. Facility leadership will hold Town Hall Meetings to allow a venue for staff to voice concerns. Licensed Nursing Staff were re-educated on skin integrity, the facility's skin policy, shower day skin checks, weekly would evaluation flow sheets, wound staging and documentation. The DON will complete random body audits to ensure that the clinical record reflects skin integrity concerns of residents.
4. The DON or designee will complete a body audit of 25% of facility residents weekly x 4 weeks then monthly x 2 months to ensure that the clinical documentation reflects accurate and complete assessments of facility residents. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.

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