Pennsylvania Department of Health
CAMP HILL SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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CAMP HILL SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

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CAMP HILL SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an abbreviated health survey completed on February 8, 2024, it was determined that Camp Hill Nursing 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:


483.20(g) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 24 residents reviewed (Residents 25, 54, and 65).

Findings include:

Review of Resident 25's clinical record on February 5, 2024, at approximately 1:00 PM, revealed diagnoses that included diabetes type II (decreased ability of the body to utilize insulin for the transport of glucose from the blood stream into the cells for nourishment) and hypertension (elevated/high blood pressure).

Review of Resident 25's Quarterly Minimum Data Set (MDS - standardized assessment tool utilized to identify a resident's physical, mental, and psychosocial needs), with an assessment reference date of December 17, 2023, revealed that section M - Skin Conditions, subsection M300 - Current Number of Pressure Ulcers/Injuries at Each Stage was coded to reflect Resident 25 had one stage II pressure ulcer (injury of the skin that is caused by pressure over a bony surface) and one unstageable pressure ulcer.

Review of Resident 25's clinical record revealed that Resident 25's stage II pressure ulcer was assessed as healed as of November 13, 2024.

In an electronic communication on February 8, 2024, at 8:39 AM, the Director of Nursing (DON) confirmed that Resident 25's stage II pressure ulcer was considered healed as of November 13, 2024.

During a staff interview on February 8, 2024, at approximately 12:30 PM, DON revealed that Resident 25's December 17, 2023, Quarterly MDS was coded incorrectly and should not have included the stage II pressure ulcer.

Review of Resident 54's clinical record revealed diagnoses that included bipolar disorder (a lifelong mood disorder and mental health condition that causes intense shifts in mood, energy levels, thinking patterns, and behaviors), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and hypertension.

Review of Resident 54's Annual MDS, with the assessment reference date of April 27, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period.

Review of Resident 54's Quarterly MDS with the assessment reference date of May 4, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period.

Review of Resident 54's Quarterly MDS with the assessment reference date of August 4, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period.

Review of Resident 54's Quarterly MDS with the assessment reference date of August 31, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period.

Review of Resident 54's Quarterly MDS with the assessment reference date of November 23, 2023, revealed in Section I. Diagnoses that Resident 54's anxiety disorder was not coded; although, they were coded in Section N. Medications as receiving an antianxiety medication for all seven days of the assessment period.

During an interview with the Nursing Home Administrator (NHA) and DON on February 7, 2024, at 11:07 AM, the DON indicated that she had spoken to the Registered Nurse Assessment Coordinator and that they indicated that they did not code the anxiety disorder diagnosis because they felt the bipolar diagnosis covered the anxiety diagnosis.

Further review of Resident 54's Quarterly MDS with the assessment reference date of November 23, 2023, revealed in Section N. Medications revealed that Resident 54's physician had documented that a gradual dose reduction of their antipsychotic medication was clinically contraindicated on July 6, 2023.

Review of Resident 54's Quarterly MDS with the assessment reference date of December 22, 2023, also revealed in Section N. Medications revealed that Resident 54's physician had documented that a gradual dose reduction of their antipsychotic medication was clinically contraindicated on July 6, 2023.

Further review of Resident 54's clinical record revealed that their physician had documented on August 10, 2023, on a pharmacist recommendation report, that a gradual dose reduction of their antipsychotic medication
was clinically contraindicated.

During an interview with the NHA and DON on February 8, 2024, at 12:36 PM, the DON confirmed that the most recent date of Resident 54's physician documentation of a gradual dose reduction being clinically contraindicated was not captured on Resident 54's quarterly MDS's with the assessment reference dates of November 23, 2023, and December 22, 2023.

Review of Resident 65's clinical record revealed diagnoses that included chronic kidney disease (CKD - kidneys are severely damaged and have stopped doing their job, to filter waste from your blood) and hypertension.

Review of Resident 65's clinical record medical diagnosis revealed Resident 65 has a current diagnosis of other specified depressive episodes, with a created date of February 8, 2022. Resident 65's clinical record also revealed a diagnosis of adjustment disorder with mixed anxiety and depressed mood, with a created date of March 3, 2020.

Review of Resident 65's current comprehensive person-centered care plan revealed a focus area indicating Resident 65 is at risk for changes in mood related to depression, with an initiation date of July 9, 2021.

Review of Resident 65's quarterly MDS dated January 16, 2024, under Section I Active Diagnosis, I5800. Depression was not coded, indicating Resident 65 does not have a depression diagnosis.

During an interview with the DON on February 8, 2024, at 12:30 PM, revealed Resident 65's Quarterly MDS dated January 16, 2024, was coded incorrectly and should have been marked Yes for depression.

28 Pa. Code 211.5(f) Clinical records


 Plan of Correction - To be completed: 03/12/2024

1. MDS correction was completed and submitted for resident 25 to reflect the number of pressure ulcers. MDS correction was completed and submitted for Resident 54 to reflect the diagnosis of Anxiety. MDS correction was completed and submitted for Resident 65 to reflect the most recent date of GDR contraindication. Resident 65's physician determined that diagnosis of Depression is no longer active, therefore MDS is correctly coded.
2. A comprehensive review of current residents with pressure ulcers, diagnosis of Anxiety, Depression, and most recent Gradual Dose Reductions, will be done to ensure they are coded correctly on the MDS.
3. The facility will take further steps to validate the problem does not reoccur by in-servicing the RNAC staff on FTAG 641 accuracy of assessments with focus on pressure ulcers, anxiety, depression, and Gradual Dose Reductions coding. Education will be completed by the Director of Nursing/Designee.
4. Compliance will be monitored by the Director of Nursing/Designee using the MDS Accuracy Audit through four MDS Assessment audits weekly x 2 weeks to validate that the MDS is coded accurately. Results will be reported to the QAA committee and the QAA committee will determine the need for further audits.
483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive 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, clinical record review, and staff interview, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication for one of one residents reviewed (Resident 51).

Findings Include:

Review of facility policy, titled "NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation", with a last review date of January 17, 2024, indicated, in part, "Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility. 1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record or the state required form and send with the patient to his/her HD facility visit. 2. Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient. 3. Upon return of the patient to the Center, a licensed nurse will: 3.1 Review the certified dialysis facility communication; 3.2 Evaluate/observe the patient; and 3.3 Complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form. 4. Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center. 4.1 Document notification of certified dialysis facility regarding return of form or other communication."

Review of Resident 51's clinical record revealed diagnoses that included end-stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis) and dependence on renal dialysis (external filtering of the blood performed by a machine by removing the blood and replacing it).

Review of Resident 51's physician orders revealed an order for Dialysis on Mondays and Fridays, dated December 14, 2023.

Further review of Resident 51's physician order history revealed they have been receiving renal dialysis since approximately August 6, 2021.

Review of Resident 51's hard chart failed to reveal completed hemodialysis communication forms for the following dates:
June 16, 2023, (the form did not have a Resident's name on the form; the facility section did not include a weight and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature)
July 7, 2023, (form had no resident name, no weight, no facility staff signature, and dialysis section was completely blank);
July 31, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
August 4, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
August 9, 2023, (facility section only had two questions completed, did not include vital signs and weight, and was not signed by a staff member and the dialysis section was completely blank);
September 18, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
September 25, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
October 6, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
October 16, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
October 20, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights and that an additional medication was given with no signature);
October 30, 2023, (facility section did not include vital signs, weight, or a staff signature);
November 6, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
November 13, 2023, (facility section did not include vital signs, weight, or a staff signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
November 22, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
November 27, 2023, (facility section did not include vital signs, weight, or a staff signature);
December 1, 2023, (form did not contain Resident's name and the facility section was blank);
December 4, 2023, (facility section was blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
December 8, 2023, (facility section did not include vital signs, weight, or a staff signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights and that an additional medication was given with no signature);
December 11, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
December 15, 2023, (facility section of form was completely blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
December 22, 2023, (facility section did not include vital signs, weight, or a staff signature and the dialysis section of the form was completed but no signature was present);
December 24, 2023, (facility section was partially completed, did not include weight, and was not signed and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
December 29, 2023, (the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
January 5, 2024, (form did not contain Resident's name and the facility section was blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
January 8, 2024, (form did not contain Resident's name and the facility section was blank and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
January 12, 2024, (facility section only contained vital signs and weight indicating it was from January 11th, 2024, and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights and that an additional medication was given with no signature);
January 15, 2024, (the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
January 22, 2024, (the facility section was completed but there was no staff signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature);
January 26, 2024, (the facility section was completed but indicated the weight was obtained on January 25, 2023, and there was no staff signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature); and
January 29, 2023, facility section only included vital signs and no signature and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature).

In addition, there were three dialysis communication forms located in Resident 51's chart that had no name or dates in which the facility section was completely blank, and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature.

There was also one dialysis communication forms located in Resident 51's chart that included the Resident's name with the facility section of form completely blank, and the dialysis section of the form only contained pre-dialysis and post-dialysis vital signs and weights with no signature.

During an interview with the Nursing Home Administrator and Director of Nursing (DON) on February 8, 2024, at 10:11 AM, the DON confirmed that the dialysis communication sheets should be completed in their entirety.

28 Pa Code 211.5(f) Clinical records
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services


 Plan of Correction - To be completed: 03/12/2024

1. Resident 51's Hemodialysis Communication Form will be completed.
2. A review of residents on hemodialysis will be completed by the Director of Nursing/Designee to ensure completion of the Hemodialysis Communication Form.
3. The facility will take further steps to ensure the problem does not recur by in-servicing the Licensed Nurses on Ftag 698 Dialysis and Hemodialysis Communication and Documentation policy.
4. Compliance will be monitored by the Director of Nursing/Designee through audits of the Hemodialysis Communication Forms weekly x 2 weeks, to ensure completion of the Hemodialysis Communication Form. Results will be reported to the QAA committee and the QAA committee will determine the need for further audits.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one of 24 residents reviewed (Resident 51).

Findings include:

Review of Resident 51's clinical record revealed diagnoses that included end-stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), dependence on renal dialysis (external filtering of the blood performed by a machine by removing the blood and replacing it), and adult failure to thrive (a past history of weight loss of more than five percent, decreased appetite, poor nutrition, and physical inactivity, often associated with dehydration, depression, immune dysfunction).

Review of Resident 51's physician orders revealed an order for daily weights, dated April 18, 2023.

Review of Resident 51's weights in their electronic health record revealed that their daily weights were not recorded as ordered on the following dates:
April 19 and 29, 2023;
May 27 and 28, 2023;
June 24, 28, and 29, 2023;
July 2, 22, and 26, 2023;
August 1, 4, 6, 17, and 19, 2023;
September 2, 3, 4, 12, and 20, 2023;
Oct 1, 10, 28, 29, and 31, 2023;
November 1, 2, 5, 6, 8, 11, 12, 25, 26, and 29, 2023;
December 9, 12, 13, 14, 20, 21, 26, and 29, 2023; and
January 1, 6, 7, 15, 17, 18, 20, 27, 28, and 29, 2024.

Review of Resident 51's Treatment Administration records revealed the following:
April 2023: the weight was signed as obtained on the 19th, and was not signed or coded as a reason for not obtaining on the 29th;
May 2023: the weight was signed as obtained on the 27th, and was not signed or coded as a reason for not obtaining on the 28th;
June 2023: the weight was signed as obtained on the 24th and 29th, and was coded as "other/see notes" on the 28th (the note indicated that the "aides were not able to check weight with hoyer");
July 2023: the weight was signed as obtained on the 2nd and 26th, and was not signed or coded as a reason for not obtaining on the 22nd;
August 2023: the weight was signed as obtained on the 1st, 4th, 6th, 17th, and 19th;
September 2023: the weight was signed as obtained on the 2nd and 12th, and was coded as "other/see notes" on the 3rd, 4th, and 20th (notes indicated that on the 3rd the Resident was "sleeping", on the 4th the Resident was "out at dialysis", and on the 20th "unable to take it passed on to next shift");
October 2023: was signed as obtained on the 10th, and was not signed or coded as a reason for not obtaining on the 1st, 28th, 29th, and 31st;
November 2023: was signed as obtained on the 2nd, 5th, 8th, 25th, and 29th, and was not signed or coded as a reason for not obtaining on the 1st, 6th, 11th, 12th, and 26th;
December 2023: was signed as obtained on the 12th, 13th, 14th, and 29th, and was not signed or coded as a reason for not obtaining on the 9th, 21st, and 26th, and was coded as "other/see notes" on the 20th (note indicated, in part, "hoyer unavailable MD aware"; and
January 2024: was signed as obtained on the 1st, 6th, 27th, and 28th, and was not signed or coded as a reason for not obtaining on the 7th, 15th, 17th, 18th, 20th, and 29th.

Further review of Resident 51's weight data revealed the following:
1) January 5, 2024, the Resident weighed 204.2 pounds;
2) no weights were documented as indicated above on January 6, 7, or 8, 2024;
3) January 9, 10, 11, 2024, the Resident weighed 158 pounds (a loss of 46.2 pounds);
4) no weight was documented as indicated above on January 12, 2024;
5) January 13, 2024, the Resident weighed 160.2 pounds;
6) no weights were documented as indicated above on January 14 or 15, 2024;
7) January 16, 2024, the Resident weighed 160.8 pounds; and
8) no weights were documented as indicated above on January 17 or 18, 2024.

Review of Resident 51's clinical record progress notes revealed a nutrition/weight progress note confirming Resident 51's weight dated January 5, 2024, at 12:20 PM, by the dietician, which indicated, in part, "Note Text: Weight Warning: Value: 204.2 Vital Date: 2024-01-05 11:43 AM ...Triggering for +22.8% weight gain 12/6 weight compared to 1/5 weight ... Weight remains in 203-206# range 12/19 to present. Unsure of etiology of large weight gain. May be prone to wt \ flux \ 2/2 \ fluid status/dialysis/diuretic. On daily weights."

Further review of Resident 51's clinical record progress notes revealed that there were no other weight/nutrition notes by the dietician from January 5, 2024, until January 18, 2024, at 1:53 PM, which indicated, in part, "Note Text: Weight Warning: Value: 160.8 Vital Date: 2024-01-16 14:59:00.0 \ ...Triggering for -21.8% weight loss 12/19 weight compared to 1/16 weight ...Unsure of etiology of large weight gain- was 160.7# \ 12/18, 205.6# \ 12/19 and has been in 200s 12/19 to 1/5 weights, now with weight loss. Weight has been in upper 150s and low 160s 1/9 to present ...Continues on daily weights. Will continue to observe weight pattern."

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on February 7, 2024, at 11:24 AM, the aforementioned concerns were shared and additional information was requested regarding daily weights not being completed as ordered, especially January 5-9, 2024, and follow-up regarding their weight loss.

During another interview with the NHA and DON on February 8, 2024, at 10:16 AM, the aforementioned concerns were again shared and additional information was requested regarding daily weights not being completed as ordered, especially January 5-9, 2024, and follow-up regarding their weight loss.

During a follow-up interview with the NHA and DON on February 8, 2024, at 12:39 PM, the DON confirmed that the daily weights should have been obtained as ordered or documentation present indicating why they were not obtained.

During a final interview with the NHA and DON on February 8, 2024, at 1:40 PM, the DON indicated that she had been reviewing Resident 51's weights and comparing them with what was entered on the dialysis sheets and that it did not appear they had weighed 200 pounds. Review of the sheets that she was reviewing revealed that most of these weights were being documented by the dialysis center. It was shared again that the dietician's documentation confirmed the weights and did not indicate that they were inaccurate. The DON confirmed that Resident 51's weight loss which was first noted on January 9, 2024, was not addressed by the dietician or nursing staff until January 18, 2024.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(a)(c) Resident care policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services


 Plan of Correction - To be completed: 03/12/2024

1. Resident 51's weight was retaken and trends reviewed with MD and dietitian.
2. A comprehensive review of residents with physician orders for daily weights will be completed by the Director of Nursing/Designee to ensure completion of daily weights. Residents on daily weights, experiencing a weight change of 5% or greater will be reviewed by the physician and dietitian for further recommendations.
3. The facility will take further steps to ensure the problem does not recur by in-servicing the Licensed Nurses on Ftag 684 Quality of Care and the Weights and Heights Procedure.
4. Compliance will be monitored by the Director of Nursing/Designee, using the Daily Weight Audit through a review of four random charts weekly x 2 weeks, to ensure daily completion of resident's weights. Results will be reported to the QAA committee and the QAA committee will determine the need for further audits.
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 25 residents reviewed (Residents 42, 55, and 73).

Findings include:

Review of Resident 42's clinical record revealed diagnoses that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and diabetes (a group of diseases that result in too much sugar in the blood [high blood glucose]).

Review of Resident 42's progress notes from January 22, 2024, at 11:09 AM, revealed a progress note written by Employee 3 (Physician), that revealed Resident 42 had dementia and the plan of care was to, "continue with supportive care".

Review of Resident 42's MDS (Minimum Data Set evaluation), dated December 29, 2023, revealed in section I4800 that Resident 42 has an active diagnosis of Non-Alzheimer's dementia, meaning that the condition required and received treatment within the previous seven days.

Review of Resident 42's care plan on February 5, 2024, failed to reveal any care planning for the Resident's dementia care.

During a staff interview with the Director of Nursing (DON) February 8, 2024, at 9:45 AM, revealed that a care plan was developed and added to Resident 42's plan of care. She also revealed that the care plan should have been developed previously.

Review of Resident 55's clinic record on February 6, 2024, at 1:05 PM, revealed diagnoses that included diabetes mellitus type 2 (DM II - body's inability to make/use insulin causing high blood sugar levels) and atrial fibrillation (fast irregular beats in the upper chambers of the heart).

Review of Resident 55's physician orders revealed the following orders: morphine sulfate (opioid pain medication) oral tablet 15 milligrams, give one tablet by mouth every 12 hours for pain; insulin glargine (long-acting insulin for controlling blood sugar) subcutaneous solution, inject 16 units subcutaneously two times a day for DM; insulin lispro (short-acting insulin for controlling blood sugar), inject eight units subcutaneously one time a day for DM II and inject six units subcutaneously two times a day for DM II; furosemide (diuretic to reduce extra fluid in the body) oral tablet 20 milligrams, give one tablet by mouth two times a day for diuretic; duloxetine HCl (increases the amount of mood-enhancing chemicals in the brain) oral capsule delayed release particles 30 milligrams, give one capsule by mouth one time a day for depression; and apixaban (used to thin blood) oral tablet five milligrams, give one tablet by mouth two times a day for prevent blood clots.

Review of Resident 55's comprehensive care plan revealed no care plan for the use of opioid pain medication, insulin, antidepressant medication, and anticoagulant medication.

During a staff interview on February 8, 2024, at 10:04 AM, the DON revealed it was the facility's expectation that Resident 55 would have a care plan developed for the use of opioid pain medication, insulin, antidepressant medication, and anticoagulant medication.

Review of Resident 73's clinic record on February 6, 2024, at 12:37 PM, revealed diagnoses that included depressive episodes (feeling sad, irritable, empty) and venous thrombosis (condition that occurs when a blood clot forms in a vein).

Review of Resident 73's physician orders revealed orders for the following: escitalopram oxalate (antidepressant) oral tablet 20 milligrams, give one tablet by mouth one time a day for depression; bupropion HCl (antidepressant) oral tablet 75 milligrams, give one tablet by mouth one time a day for depression; and apixaban (anticoagulant) oral tablet five milligrams, give one tablet by mouth two times a day for prevent blood clots.

Review of Resident 73's comprehensive care plan revealed no care plan for the use of antidepressant and anticoagulant medications.

During a staff interview on February 8, 2024, at 10:04 AM, the DON revealed it was the facility's expectation that Resident 73 would have a care plan developed for the use of antidepressant medication and anticoagulant medication.

28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services


 Plan of Correction - To be completed: 03/12/2024

1. Resident 42's care plan was updated to reflect Dementia Care. Resident 55's care plan was updated to reflect opioid pain medication, insulin, antidepressant medication, and anticoagulant medication. Resident 73's care plan was updated to reflect antidepressant and anticoagulant medications
2. A comprehensive review of current residents will be completed by the RNAC/designee to identify Care Area Assessments triggering for Dementia, opioid pain medications, Insulin, Antidepressant medications, and anticoagulant medications over the last 90 days will be reviewed to ensure development of plan of care.
3. The facility will take the further steps to ensure the problem does not reoccur by inservicing the Interdisciplinary care plan team on the development and implementation care plans and Focus on Ftag F656 by the DON/designee. The RNAC will bring to the eagle room the Care Area Assessment Summary Report for those residents that are due for care plan updates. The Interdisciplinary Care Plan (ICP) team will be responsible for updating the care plan to reflect the resident's current needs.
4. Compliance will be monitored by the Director of Nursing/designee through five audits of resident care plans weekly x2 weeks and monthly x2 to validate that Dementia Care, Opioid pain medications, antidepressant, and anticoagulant medications are appropriately care planned. Audit results will be reported to the QAA committee and the QAA committee will determine the need for further audits.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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.
§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on review of the clinical record, policy review, and staff interviews, it was determined that the facility failed to ensure that the clinical record accurately reflected the resident preference for code status for one of 24 residents reviewed (Resident 18).

Findings include:

Review of facility policy, titled "Health Care Decision Making", last revised January 8, 2024, revealed "purpose - to provide patient the opportunity and knowledge necessary to make his/her health care decisions known" and "to assure that patients' wishes concerning health care decisions are communicated to all staff so that patients' rights will be honored and their wishes will be executed at the appropriate time."

Review of Resident 18's clinical record revealed diagnoses that included dementia (progressive or persistent loss of intellectual functioning) and rhabdomyolysis (breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood).

Further review of Resident 18's clinical record on February 6, 2024, at 10:04 AM, revealed a POLST (Pennsylvania Orders for Life-Sustaining Treatment), signed by the Resident and physician, that indicated the Resident did want cardiopulmonary resuscitation (CPR)/attempt resuscitation. Resident 18 checked that he wanted full treatment.

Review of the current physician orders revealed that Resident 18 had an order dated November 22, 2023, for DNR (do not resuscitate), indicating that, in the event of a cardiac arrest, Resident 18 would not want CPR.

Email communication on February 8, 2024, at 9:22 AM, with the Director of Nursing (DON) revealed that Resident 18's son confirmed Resident 18 wishes were to receive CPR/full treatment.

During an interview with the DON on February 8, 2024, at 10:04 AM, she indicated it was the facility's expectation that Resident 18's physician ordered code status and POLST accurately reflect Resident 18's wishes for CPR/full treatment.

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


 Plan of Correction - To be completed: 03/12/2024

1.Resident 18's physician ordered Code Status and POLST accurately reflect patients wishes for CPR/Full treatment.
2.A Comprehensive review of current residents Code Status and POLST forms will be completed to ensure an accurate reflection of patients wishes in regards to Code Status.
3.The facility will take the further steps to ensure the problem does not reoccur by in-servicing Social Services and Licensed nursing staff on the Healthcare Decision Making Policy as well as FTag 578.
4.Compliance will be monitored by the Director of Nursing/designee through audits of physician ordered code status and POLST forms to ensure resident's wishes are accurately reflected. Five random audits will be completed weekly for 2 weeks with audit results being reported to the QAA committee to determine the need for further additional follow up / monitoring.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 24 residents reviewed (Residents 51 and 65).

Findings include:

Review of facility policy, titled "OPS416 Person-Centered Care Plan", dated November 28, 2016, with a last review date of January 17, 2024, revealed, in part, "7. Care plans will be: ...7.2. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals."

Review of Resident 51's clinical record revealed diagnoses that included end-stage renal disease (ESRD-condition in which a person's kidneys cease functioning on a permanent basis), peripheral vascular disease (disease of the vascular system that results in decreased blood flow to the extremities), and hypertension (high blood pressure).

Review of Resident 51's care plan revealed a care plan focus for a right heel pressure ulcer, with a last revision date of October 7, 2022.

Review of Resident 51's clinical record revealed that their pressure ulcer to the right heel resolved on December 20, 2023.

During an interview with the Nursing Home Administrator and Director of Nursing (DON) on February 7, 2024, at 11:25 AM, the aforementioned concern was shared. The DON indicated that this was a recurrent issue for Resident 51, and that she would review Resident 51's record to determine if the Resident currently had a wound or not.

In a follow-up email communication received from the DON on February 8, 2024, at 8:34 AM, she confirmed that Resident 51's wound had resolved on December 20, 2023, and that it should not have been currently care planned.

Review of Resident 65's clinical record revealed diagnoses that included chronic kidney disease (CKD - kidneys are severely damaged and have stopped doing their job, to filter waste from your blood) and hypertension.

Review of Resident 65's clinical record medical diagnosis revealed Resident 65 had a current diagnosis of other specified depressive episodes, with a created date of February 8, 2022. Resident 65's clinical record also revealed a diagnosis of adjustment disorder with mixed anxiety and depressed mood, with a created date of March 3, 2020.

Review of Resident 65's current physician orders revealed that Resident 65 is not prescribed any medication for depression.

Further review of Resident 65's clinical record revealed a discontinued order for Sertraline Hydrochloride Oral Tablet 25 milligram, with an end date of October 14, 2023.

Review of Resident 65's current comprehensive person-centered care plan revealed a care plan focus area that indicated Resident 65 is at risk for adverse effects related to use of antidepressant, with an initiation date of July 12, 2021.

During an interview with the DON on February 8, 2024, at 12:30 PM, revealed that they would have expected Resident 65's comprehensive person-centered care plan relating to their antidepressant use to have been updated.

42 CFR 483.21(b) Comprehensive Care Plans
28 Pa. Code 211.11(d)(e) Resident care plan
28 Pa. Code 211.12(d)(5) Nursing services


 Plan of Correction - To be completed: 03/12/2024

1. Resident 51's care has been updated to reflect resolved pressure ulcers. Resident 65's care plan has been updated to reflect no longer at risk for adverse effects related to antidepressant.
2. A comprehensive review of care plans for current residents with pressure ulcers and antidepressants will be completed by the Director of Nursing/Designee to ensure accuracy of the resident's comprehensive plan of care.
3. The facility will take the further steps to validate the problem does not reoccur by in-servicing the Unit Managers/Supervisors on FTAG 657 Care plan timing and revision with focus on Pressure Ulcers Care plans and Antidepressant Care plans.
4. Compliance will be monitored by the Director of Nursing/Designee, using the Care Plan Audit through a review of four care plans weekly x 2 weeks, to ensure accuracy of the resident's comprehensive plan of care. Results will be reported to the QAA committee and the QAA committee will determine the need for further audits.


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