Nursing Investigation Results -

Pennsylvania Department of Health
ELM TERRACE GARDENS
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ELM TERRACE GARDENS
Inspection Results For:

There are  42 surveys for this facility. Please select a date to view the survey results.

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ELM TERRACE GARDENS - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed January 10, 2020, it was determined that Elm Terrace Gardens, 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:


483.25(k) REQUIREMENT Pain Management: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.
483.25(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 facility policy review, staff interview and clinical record review, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis and failed to ensure that pain management was consistent with professional standards of practice for three of 17 residents. (Residents 28, 32, 49)

Findings include:

Review of the facility policy entitled, "Pain Management," dated September 12, 2019, revealed that the nursing staff was to assess the resident's level of pain using a scale of one to ten. The scale was to be divided accordingly: one to four would be associated with mild pain, five to seven would be associated with moderate pain and eight to ten would be associated with severe pain. The staff was to medicate the resident with the appropriate medication based on the resident's pain level and the physician's order.

Clinical record review revealed that Resident 28 had diagnoses that included back pain. On June 19, 2018, a physician ordered for staff to administer an as needed pain medication (Tylenol) every six hours for mild pain. On November 16, 2018, a physician ordered for staff to administer an as needed pain medication (tramadol) every eight hours for moderate pain. On December 20, 2019, a physician also ordered an as needed pain medication (Percocet) every six hours for pain. Review of the Medication Administration Record (MAR) revealed the resident received pain medication 21 times in December 2019, and seven times in January 2020. There was no documentation to support that prior to administering the pain medications staff attempted non-pharmacological interventions 24 times in December and January. There was no documentation to support that staff identified the resident's level of pain as mild, moderate, or severe to ensure that the correct pain medication was administered.

Clinical record review revealed that Resident 32 had diagnoses that included a right hip fracture. On November 20, 2019, a physician ordered for staff to administer an as needed pain medication (oxycodone) every fours hours for unspecified pain. On November 20, 2019, a physician also ordered an as needed pain medication (Tylenol) every six hours as needed for mild pain. Review of the MAR revealed the resident received pain medication one time in November 2019, 28 times in December 2019, and one time in January 2020. There was no documentation to support that prior to administering the pain medications staff attempted non-pharmacological interventions 26 times in December and January. There was no documentation to support that staff identified the resident's level of pain as mild, moderate, or severe to ensure that the correct pain medication was administered.

Clinical record review revealed that Resident 49 had diagnoses that included Alzheimer's disease (a disease that causes progressive cognitive impairment, including memory loss), anxiety disorder, osteoporosis, right shoulder fracture, and a history of various bone fractures. On December 7, 2019, the physician ordered for staff to administer pain medication (tramadol) every six hours as needed for mild to moderate pain and on December 12, 2019, to administer pain medication (morphine sulfate solution) every 4 hours as needed for severe pain. Review of the December 2019, MAR revealed that the resident received as needed pain medication on 11 of 13 occasions with no evidence that staff attempted non-pharmacological interventions prior to administration of the medication. In addition, based on policy review, the facility failed to provide the correct medication for assessed pain level on three of 13 occasions.

During an interview on January 10, 2020, at 12:44 p.m., the Director of Nursing confirmed that there was no documentation to support that staff was attempting non-pharmacological interventions consistently or that staff was identifying the resident's level of pain and administering the correct pain medication based on doctor order and facility policy.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 1/4/19



 Plan of Correction - To be completed: 03/02/2020

Resident 28, 32 and 49 has non-pharmacological interventions documented prior to administering pain medications.
Other residents with PRN pain medication have been reviewed and are receiving non-pharmacological interventions prior to receiving pain medication.
Nurse Educator will re-educate nurses on policy for non-pharmacological interventions. Unit Manager / designee will conduct audits weekly random for 3 months to ensure compliance.
DON / designee will review compliance and present finding to QAPI monthly.


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 clinical record review and facility incident report review, it was determined that the facility failed to implement necessary interventions to prevent accidents for one of 17 sampled residents. (Resident 49)

Findings include:

Clinical record review revealed that Resident 49 had diagnoses that included Alzheimer's disease (a disease that causes progressive cognitive impairment, including memory loss), anxiety disorder, osteoporosis (a disease that causes bones to become porous, increasing the risk of fractures), a history of multiple fractures, and a history of falling. The Minimum Data Set assessment, dated November 22, 2019, indicated that the resident had memory problems and required extensive staff assistance for activities of daily living such as transferring between surfaces and walking.

Review of the facility incident report, dated August 4, 2019, at 6:30 a.m., revealed that Resident 49 experienced an unwitnessed fall and was found sitting on the floor next to her bed, stating "I just had to get up and I got up and I fell." It was determined that, just prior to the fall, the resident had been taken to the toilet, dressed, and put back to bed by the nurse aide. As a result of the fall, an additional intervention was added to the resident's care plan on August 4, 2019, that directed staff to take the resident to the nurses' station after care.

Review of the facility incident report, dated December 5, 2019, at 7:45 a.m., revealed that Resident 49 experienced an unwitnessed fall and was found lying on the floor next to the bed. It was noted that the resident was attempting to get out of bed without assistance after being provided with care, dressed by staff, and left in bed at 6:00 a.m. The facility failed to ensure that the resident was taken to the nurses' station after care, putting the resident at risk for falling.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 1/4/19







 Plan of Correction - To be completed: 03/02/2020

Resident 49 care plan has been updated. Intervention to be offered to come to nurses' station and or activities after care is provided.
Other residents with intervention to bring to nurses' station for oversight will have their care plan reviewed and updated to say offer activities or common area for observation is accepted by resident.
Nurse Educator / designee will re-educate nursing staff on specific care plan for observation after care. Unit Manager / designee will conduct weekly random audits for 3 months to ensure compliance.
DON / designee will review compliance and present finding to QAPI monthly.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to indicate the duration and provide non-pharmacological interventions prior to administering a psychotropic medication prescribed to be given as needed for one of 17 sampled residents. (Resident 49)

Findings include:

Clinical record review revealed that Resident 49 had diagnoses that included Alzheimer's disease, anxiety disorder, depression, and insomnia. The resident was ordered by the physician on December 6, 2019, to receive lorazepam .5 milligrams (mg) every 24 hours as needed (PRN) for anxiety. The facility failed to indicate the duration of the PRN lorazepam order and it was administered on five occasions, including January 2, 2020, January 4, 2020, and January 5, 2020; a duration exceeding 14 days. In addition, there was a lack of documentation to support that non-pharmacological interventions were provided to Resident 49 prior to the administration of the PRN psychotropic medication in accordance with the plan of care.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 1/4/19

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






 Plan of Correction - To be completed: 03/02/2020

Resident 49 has duration on PRN psychotropic medications and non-pharmacological interventions documented prior to receiving medication.
Other residents with PRN psychotropic medication have a duration and non-pharmacological intervention documented prior to receiving medication.
Nurse Educator / designee will re-educate nurses on policy for PRN medication duration and non-pharmacological interventions. Unit manager / designee will conduct weekly random audits for 3 months to ensure compliance.
DON / designee will review compliance and present finding to QAPI monthly.


483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify residents and residents' representatives of transfers and the reasons for the moves in writing upon transfer from the facility for one of 17 sampled residents. (Resident 48)

Findings include:

Clinical record review revealed that Resident 48 was transferred and admitted to the hospital on September 10, 2019, after a change in condition. There was no documented evidence that the resident and the resident's responsible party was provided written information regarding the resident's transfer to the hospital.

In an interview conducted on January 10, 2020, at 12:47 p.m., the Director of Nursing confirmed that no written transfer notices were given to the resident or the residents' representatives when transferred out of the facility.







 Plan of Correction - To be completed: 03/02/2020

Elm Terrace Gardens will develop a letter of notification for transfers from the facility to the hospital to be submitted to the residents and / or residents' representatives with information regarding the transfer to the hospital.
Residents will receive this notification at time of transfer.
Nurse Educator / designee will in-service nursing staff on policy of notification of transfer. Unit managers / designee will conduct weekly random audits for 3 months to ensure compliance.
DON / designee will review compliance and present findings to QAPI monthly.


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