Pennsylvania Department of Health
UNITED ZION RETIREMENT COMMUNITY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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UNITED ZION RETIREMENT COMMUNITY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on July 18, 2024, at United Zion Retirement Community, it was determined that the facility was not in compliance under the 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 as they relate to the Health portion of the survey process.

Plan of Correction:

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary:

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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.

Observations:

Based on a review of clinical records and interview with staff, it was determined that the facility failed to ensure a physician's discharge summary was completed prior to or at the time of discharge for one of two closed records (Resident 57).

Findings include:

Review of Resident 57's clinical record revealed that the resident was discharged from the facility on May 6, 2024.

Further review of Resident 57's clinical record failed to reveal evidence that the discharge summary was completed by the physician prior to or at the time of discharge.

Interview with the Nursing Home Administrator on July 18, 2024 at 11:00 a.m. confirmed that the discharge summary was not completed.

28 Pa Code 211.5(d) Clinical record

Plan of Correction - To be completed: 08/19/2024

1.Resident 57 discharge summary will be completed by the physician/designee and placed in the closed record chart.
2.Discharge Summary will be added to the license nurse worksheet check off list by ADON/Designee before the resident discharges home.
3.License nurses and MD/CRNP will be educated on the added a Discharge Summary to the discharge worksheet check list by the Medical Records Director/Designee.
4.New closed charts will be audited to ensure Discharge Summary completed timely, weekly audits will be conducted times four weeks and PRN to continue compliance of Discharge Summary.
5.This plan will be completed by 8/19/2024.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§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 records review and staff interview, it was determined that the facility failed to ensure non-pharmacological interventions were attempted, and documented indication was provided before administering as-needed anti-anxiety medication for one of 5 residents reviewed (Resident 14).

Findings include:

Review of Resident 14's physician's order dated June 14, 2024, revealed an order for Lorazepam (anti-anxiety medication) 0.5 mg (milligram) one tablet twice daily as needed for anxiety.

Review of Resident 14's June 2024, Medication Administration Records (MAR) from June 15, 2024, until June 26, 2024, Resident 14 was administered as-needed Lorazepam seven times without appropriate indication for use and was administered ten times without attempts to provide a non-pharmacological intervention before administering the medication.

Interview conducted with the Nursing Home Administrator on July 18, 2024, at 11:00 a.m., confirmed the facility failed to document evidence of non-pharmacological interventions provided before administering the medication and no appropriate indication for the drug.

The facility failed to ensure non-pharmacological interventions were attempted, and appropriate indications were present before administering Resident 14 with as-needed anti-anxiety medication.

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

28 Pa. Code: 211.12 (d)(1)(3) Nursing Services

Plan of Correction - To be completed: 08/19/2024

1 The facility will ensure nonpharmacological interventions prior to administration of PRN Lorazepam.
2.The DON/Designee will educate the specific nurses administering PRN Lorazepam to Resident 14 regarding the need for indications and/or non- drug interventions.
2.The Licensed nurses will be reeducated to provide documentation of indications for administration and use of non-drug interventions prior to administration of PRN medications by the DON/Designee.
3. Audits for residents having a PRN Lorazepam will be conducted by the DON/Designee beginning 8/19/2024 on 10 PRN medications to ensure indication and non-pharmacological interventions are documented to correspond with administration. These audits will occur weekly x4 weeks and PRN as needed.
4.This plan will be completed by 8/19/2024.

§ 211.5(d) LICENSURE Medical records.:

(d) Records of discharged residents shall be completed within 30 days of discharge. Medical information pertaining to a resident ' s stay shall be centralized in the resident ' s record.

Observations:

Based on a review of clinical records and interview with staff, it was determined that the facility failed to ensure a physician's discharge summary was completed within 30 days of discharge for one of two closed records (Resident 56).

Findings include:

Review of Resident 56's clinical record revealed that the resident expired in the facility on May 12, 2024. There was no evidence that the discharge summary was completed by the physician within 30 days of discharge.

Interview with the Nursing Home Administrator on July 18, 2024 at 11:00 a.m. confirmed that the discharge summary was not completed.

Plan of Correction - To be completed: 08/19/2024

1.Resident 56 discharge summary will be completed by the physician/designee and placed in the closed record chart.
2.Discharge Summary will be added to the license nurse Discharge worksheet check list by the ADON/Designee for residents being discharged.
3.License nurses and MD/CRNP will be educated on the added a Discharge Summary to the discharge worksheet check list by the Medical Records Director/Designee.
4.New closed charts will be audited to ensure Discharge Summary completed timely, weekly audits will be conducted times four weeks and PRN to continue compliance of Discharge Summary.
5.This plan will be completed by 8/19/2024.

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