Nursing Investigation Results -

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

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HILLVIEW HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  117 surveys for this facility. Please select a date to view the survey results.

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HILLVIEW HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey and incident survey completed on December 17, 2019, it was determined that Hillview 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:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of seven residents reviewed (Resident 2).

Findings include:

The facility's abuse policy, dated November 2018, indicated that a resident had the right to be free from abuse and that abuse was the willful infliction of injury.

A diagnosis record for Resident 2, dated December 2, 2019, revealed that the resident had diagnoses that included dementia with behaviors, adjustment disorder, alcohol-induced mood disorder and anxiety. The resident's care plan, dated June 12, 2019, included interventions to address inappropriate behaviors toward staff and physical agitation/aggression due to changes in routine. The interventions included to respect the resident's personal space, and if the resident was safe and behavioral interventions were not working, the staff were to leave the resident and reapproach later.

Information submitted by the facility revealed that on December 7, 2019, there was an altercation between Resident 2 and Activity Aide 3. The description of the incident indicated that the resident took a soda from the counter and Activity Aide 3 went to grab it from the resident. The resident became physical with grabbing and slapping the activity aide. Activity Aide 3 slapped the resident and left visible redness on the right side of her face and neck "which appeared to be finger marks on her right cheek."

Interview with the Assistant Director of Nursing on December 17, 2019, at 3:06 p.m. confirmed that the facility's investigation revealed that Activity Aide 3, whose employment was terminated following the incident, physically abused Resident 2.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 8/29/19, 5/2/19.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 5/2/19.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 5/2/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/29/19, 8/13/19, 5/2/19.









 Plan of Correction - To be completed: 01/22/2020

Resident #2 suffered no ill effect from the event that occurred. Employee is no longer with the facility.

A facility-wide audit (physical skin checks) of residents were completed by nursing for signs of bruising. Social services interviewed residents with focus questions asking residents if they have any concerns.

Facility staff including agency staff have been educated on the facilities Abuse Policy and mandatory reporting. Education to staff with a focus on recognizing burnout, various types of abuse and steps to reduce stress and burnout. Post-test performed. Training for new staff and new agency staff will be conducted accordingly and we are developing an "education binder" with updated educational needs for agency staff that will be job specific and will be conducted by the facility Nurse Educator.

Facility will perform 10 random observations/interviews per week. Audits will be conducted by nursing and social services to identify any concerns abuse. Audits will be performed weekly for four (4) weeks then monthly for two (2) months. Results will be reported and trended through the facility's Quality Assurance Committee for follow up as results indicate.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of the Older Adults Protective Services Act and clinical records, as well as staff interviews, it was determined that the facility failed to report an injury of unknown origin as required for one of seven residents reviewed (Resident 2).

Findings include:

The Older Adults Protective Services Act, 1997-13, Section 701, indicated that it was mandatory to report any reasonable cause to suspect that a resident was a victim of abuse to the Protective Services agency.

A diagnosis record for Resident 2, dated December 2, 2019, revealed that the resident had diagnoses that included dementia with behaviors, adjustment disorder, alcohol-induced mood disorder and anxiety. A nursing note dated December 15, 2019, revealed that when the resident returned from the emergency room she had bruises on her hand (right wrist area) that looked to be from "a hand holding her arm down" and the bruises appeared to be "finger marks."

There was no documented evidence that the facility reported the injury from possible abuse to the Protective Services agency.

Interview with the Assistant Director of Nursing on December 17, 2019, at 2:28 p.m. confirmed that Resident 2's bruises were possibly from being held down and were not reported to the Protective Services agency.

42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations.
Previously cited 5/2/19.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 8/29/19, 5/2/19.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 5/2/19.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/29/19, 8/13/19, 5/2/19.






 Plan of Correction - To be completed: 01/22/2020

Resident #2 suffered no ill effects from event that occurred.

Through contact with the hospital the etiology of the bruise was identified. No further actions were required.

Facility licensed staff including licensed agency staff was educated on completion of incident reports with a focus of recognizing potential abuse, appropriate actions to be taken and investigation of any bruising upon admission for appropriate reporting if necessary. In addition, training for new licensed staff and new agency staff will be conducted.

Incidents will be audited weekly by the interdisciplinary care team to ensure thoroughly investigated to rule out abuse was completed. Audits will be performed weekly for four (4) weeks then monthly for two (2) months. Trending reports will be reviewed and presented to the facility's Quality Assurance Committee for follow up.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that a thorough investigation was completed for an injury of unknown origin, to rule out that abuse and/or neglect were involved for one of seven residents reviewed (Resident 1).

Findings include:

The facility's policy regarding abuse and neglect, dated November 2018, indicated that the facility would immediately investigate all allegations of mistreatment, neglect or abuse, including injuries of unknown origin.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 11, 2019, revealed that the resident was understood, could understand, and required extensive assistance from staff for daily care tasks.

A nursing note for Resident 1, dated December 2, 2019, at 8:43 a.m. revealed that the nurse was called to assess the resident for a noted change to his left, upper extremity/shoulder area. There was maroon-colored bruising to the left upper shoulder and upper chest that extended downward onto the bicep, where it turned to a deep purple/blue tone and extended to the wrist area and encircled the entire forearm, elbow, and bicep area. The resident denied any injury and when asked if he was hurt by anyone or hit by anything he denied any type of injury.

An undated witness statement regarding Resident 1's bruising by Nurse Aide 1 revealed that she came in on Saturday morning (November 30, 2019) at 3:00 a.m. and when she went to do a.m. care at 5:30 a.m., she took the resident's shirt off, found the bruising, and reported it to the charge nurse.

An undated witness statement regarding Resident 1's bruising by Licensed Practical Nurse 2 revealed that on Monday, December 2, 2019, Nurse Aide 1 told her that she found the bruise on Resident 1 at 3:00 a.m. on Saturday morning (November 30, 2019). Licensed Practical Nurse 2 told the charge nurse who was here on that shift. She completed the incident report on December 2, 2019, because it was not done yet.

There was no documented evidence that the facility's investigation was expanded to include interviews with all staff who had potential contact with Resident 1 in and around the time that the bruising was first noted on November 30, 2019.

Interview with the Director of Nursing on December 17, 2019, at 2:45 p.m. confirmed that the investigation was not expanded to include interviews with all staff who had potential contact with Resident 1 in and around the time that the bruising was first noted on November 30, 2019.

42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation.
Previously cited 5/2/19.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 8/29/19, 5/2/19.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 5/2/19.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 5/2/19.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 8/13/19, 5/2/19.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/29/19, 8/13/19, 5/2/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/29/19, 8/13/19, 5/2/19.






 Plan of Correction - To be completed: 01/22/2020

Resident #1 suffered no ill effects from event that occurred.

Resident with skin incidents for the past seven (7) days have been completed to validate the root cause and ensure interventions are in place.

Facility licensed staff including licensed agency staff were educated by the Director of Nursing/designee on completion of incident reports with a focus of recognizing, investigation for root cause and reporting. New staff as well as new agency staff will be educated upon orientation to the facility.

Random audit will be conducted on incident reports relating to skin conditions to ensure a thorough investigation was conducted. Audits will be completed on 10 residents for four (4) weeks then monthly for two (2) months by the interdisciplinary care team to validate corrective actions and interventions are being taken. Results will be presented to quality assurance committee for follow up as results indicate.

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


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of two of seven residents reviewed (Residents 1, 6).

Findings include:

The facility's policy regarding care plans, dated November 2018, revealed that a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs would be developed and implemented for each resident.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 11, 2019, revealed that the resident received an anticoagulant medication (a medication that thins the blood to prevent clots). The resident's Medication Administration Records (MAR's) for October, November and December 2019 revealed that the resident received Coumadin (an anticoagulant medication) on October 4 through 27, 30 and 31, 2019; November 1 through 30, 2019; and December 1 through 3, 2019.

There was no documented evidence that a care plan was developed to address Resident 1's specific and individualized care needs related to receiving an anticoagulant medication.


An admission MDS assessment for Resident 6, dated November 22, 2019, revealed that the resident received dialysis (a procedure used to cleanse the blood when the kidneys do not function properly). Physician's orders, dated November 15, 2019, included an order for the resident to receive dialysis every Monday, Wednesday and Friday at 10:30 a.m.

There was no documented evidence that a care plan was developed to address Resident 6's specific and individualized care needs related to receiving dialysis.

Interview with the Assistant Director of Nursing on December 17, 2019, at 2:28 p.m. confirmed that individualized care plans and interventions were not developed related to Resident 1 receiving anticoagulant medication and Resident 6 receiving dialysis.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 8/29/19, 5/2/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/29/19, 8/13/19, 5/2/19.




 Plan of Correction - To be completed: 01/22/2020

Care plans for both residents #1 and #6 were reviewed and updated to ensure they contain specific and individualized interventions for care.

An audit of residents on dialysis and anticoagulant therapy was conducted and care plans were update to ensure specific and individualized interventions are in place.

Director of Nursing/designee will educate licensed staff, agency staff and any new staff (facility and agency) on responsibilities to care plan specific individualized interventions for residents on dialysis or anticoagulants.

The Interdisciplinary Care Team will review care plans on admission and quarterly to ensure the resident's comprehensive care needs are met and up to date. Nursing will update the care plans accordingly. The Registered Nurse Assessment Coordinator will be responsible for monitoring and reviewing with the quarterly and yearly Minimum Data Set submission The minimum data set is a key tool in the process of assessing the functional capabilities of residents.

The Director of Nursing/designee will complete 5 random audits of resident careplans on dialysis and anticoagulants. Audits will be completed for four (4) weeks then monthly for two (2) months. Results will be reported and trended through the facility's Quality Assurance Committee.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse completed a timely assessment following a change in condition and obtained orders for treatment in a timely manner for one of seven residents reviewed (Resident 1).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 11, 2019, revealed that the resident was understood, could understand, required extensive assistance from staff for daily care tasks, including transfers and bed mobility, and had a indwelling urinary catheter (a tube inserted and held in the bladder to drain urine).

A nursing note for Resident 1, dated October 25, 2019, at 7:02 p.m. and completed by a licensed practical nurse (LPN), indicated that the nurse aide got the nurse to look at the resident's penis, which appeared to have red, irritated, blistered area. The nurse aide pulled the foreskin back, cleansed the area with warm soapy water, and applied Enzol cream (a barrier cream). The LPN reported the area to the registered nurse supervisor.

There was no documented evidence that a registered (professional) nurse assessed this change in Resident 1's condition.

Physician's orders for Resident 1, dated October 27, 2019, included an order to cleanse the tip of the penis and apply a thin layer of Enzol cream to the urinary meatus (the opening of the urethra) each shift and as needed for soilage. There was no documented evidence that a physician's order for treatment of the area was obtained at the time the area was noted on October 25, 2019.

Interview with the Assistant Director of Nursing on December 17, 2019, at 3:00 p.m. confirmed that there was no documented evidence that a registered (professional) nurse assessed Resident 1's change in condition on October 25, 2019, and she was not sure why staff did not get an order for treatment until October 27, 2019.

42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 8/13/19.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 8/13/19, 5/2/19.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/29/19, 8/13/19, 5/2/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/29/19, 8/13/19, 5/2/19.




 Plan of Correction - To be completed: 01/22/2020

Resident #1 resides in the facility and suffers no ill effects for the issue.

Registered nurse assessment was completed and documented.

Licensed staff including agency staff was educated by Director Nursing/designee on proper notification process for change in condition. Any new staff (both facility and agency staff) will be educated on the proper notification process for changes in condition as part of the orientation to the facility.

No system change for notification of change in conditions has been made. Nursing Administration will review changes in condition during daily reading/review of the 24 hour report.

Facility will audit 5 random residents with a change in condition for four (4) weeks then monthly for two (2) months to validate notification. Results will be reported and trended through the facility's Quality Assurance Committee.

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results: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.
483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that laboratory testing was completed as ordered by the physician for one of seven residents reviewed (Resident 1).

Findings include:

The facility's lab and diagnostic testing policy, dated March 20, 2019, revealed that the physician would identify and order diagnostic and laboratory testing, and the staff would arrange for the tests. The facility would then notify the attending physician or physician extender about laboratory results in accordance with the physician's order.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 11, 2019, revealed that the resident received an anticoagulant medication (a medication that thins the blood to prevent clots).

A nursing note for Resident 1, dated November 1, 2019, revealed that lab results were reviewed by the certified registered nurse practitioner (CRNP - a registered nurse with advanced training) and a prothrombin time and international normalized ratio (PT/INR - tests that help evaluate the ability to form blood clots and determine the effects of anticoagulants) was to be rechecked in two weeks (November 15, 2019). Orders dated November 1, 2019, included an order for the resident to have a PT/INR collected on November 15, 2019.

There was no documented evidence that Resident 1's PT/INR was drawn on November 15, 2019, as ordered by the CRNP.

Interview with the Assistant Director of Nursing on December 17, 2019, at 3:00 p.m. confirmed that Resident 1's PT/INR was not completed as ordered by the CRNP on November 15, 2019.

42 CFR 483.50(a)(2)(i)(ii) Lab Services Physician Order/Notify of Results.
Previously cited 8/29/19.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 8/29/19, 5/2/19.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/29/19, 8/13/19, 5/2/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/29/19, 8/13/19, 5/2/19.




 Plan of Correction - To be completed: 01/22/2020

Resident #1 resides in facility and suffered no ill effects.

An audit of residents receiving Coumadin was performed to validate lab was obtained per physician order. Random lab audits on various other orders were conducted to ensure compliance.

Licensed staff including agency staff was educated on the facility's "Guidelines for Lab Processing". Any new facility staff or agency staff will be educated on the facility's "Guidelines for Lab Processing" as part of the orientation to the facility.

A system change has taken place that includes the creation of new lab books for each nursing unit. The lab requisition forms are added to the book and are to be complete daily to reflect all new lab orders. Night shift nursing staff will then review all new lab orders and compare with the lab requisition sheets to ensure labs are scheduled per the physician order.

Facility will audit 10 residents receiving lab services to validate labs were completed as physician orders by the Director of Nursing/Designee for four (4) weeks then monthly for two (2) months to validate the lab orders are being followed as written. Results will be reported and trended through the facility's Quality Assurance Committee.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of seven residents reviewed (Resident 2).

Findings include:

The facility's policy regarding changes in condition, dated November 2018, indicated that the nurse was to record information relative to changes in the resident's medical/mental condition or status in the resident's medical record.

A diagnosis record for Resident 2, dated December 2, 2019, revealed that the resident had diagnoses that included dementia with behaviors, adjustment disorder, alcohol-induced mood disorder and anxiety.

Information submitted by the facility revealed that on December 7, 2019, there was an altercation between Resident 2 and Activity Aide 3. The description of the incident indicated that the resident took a soda from the counter and Activity Aide 3 went to grab it from the resident. The resident became physical with grabbing and slapping the activity aide. Activity Aide 3 slapped the resident and left visible redness on the right side of her face and neck, "which appeared to be finger marks on her right cheek."

Resident 2's medical record contained no documentation that this incident occurred.

Interview with the Assistant Director of Nursing on December 17, 2019, at 1:31 p.m. confirmed that the incident was not documented on Resident 2's medical record.

42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable Information.
Previously cited 8/13/19, 5/2/19.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 8/13/19, 5/2/19.






 Plan of Correction - To be completed: 01/22/2020

Resident #2 medical record was updated to reflect the incident.

Licensed staff as well as any agency staff will be educated by the Director of Nursing/designee on the facility's documentation requirements and their responsibilities on documenting in the medical record. New staff (including agency staff) coming to the facility will be educated on the facility's documentation requirements and their responsibilities on documenting in the medical record as part of their orientation to the facility.

No system changes made at this time. Incident reports are reviewed daily by Nursing Administration (Director of Nursing/Assistant Director of Nursing/Nurse Educator) to ensure accurate completion of the incident reports.

The daily incident report review does cross over into the clinical record for the nursing note. The Director of Nursing educated the nursing staff which included agency staff on the process of placing their note in the "action tab" of point click care so that it carries over automatically into the clinical record. The nursing administration team will review incident reports daily as part of this review will be monitoring that note is in the clinical record. New facility staff as well as agency staff will be educated on this process as part of the orientation to facility.

Facility will audit 5 charts to ensure to appropriate documentation requirements for four (4) weeks then monthly for two (2) months. Results will be reported and trended through the facility's Quality Assurance Committee.


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