Pennsylvania Department of Health
DELAWARE VALLEY SKILLED NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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DELAWARE VALLEY SKILLED NURSING & REHABILITATION CENTER
Inspection Results For:

There are  23 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
DELAWARE VALLEY SKILLED NURSING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on March 27, 2024, it was determined that Delaware Valley Skilled 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:


483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on a review of clinical records and medication records, and resident and staff interview it was determined that the facility failed to provide pharmacy services, routine drugs and pharmaceuticals, to ensure timely medication administration as prescribed for one resident out of 16 residents sampled (Resident 14).

Findings included:

A review of the clinical record revealed that Resident 14 was admitted to the facility on February 29, 2024, with diagnoses, of diabetes, hypertension, and H. pylori infection (Helicobacter pylori, bacteria that infects the stomach).

A review of the resident's March 2024 Medication Administration Record (MAR) revealed that on March 23, 2024, the resident was prescribed Bismuth Subsalicylate (an over-the-counter medication to treat diarrhea, heartburn, nausea, and upset stomach) 525 mg, two tablets every 6 hours for treatment of H. pylori for 14 days. The medication was scheduled for administration at 6 AM, 12 PM, 6 PM, and 12 AM.

There was no evidence that the medication was administered to the resident on March 23, 2024, at 12 AM or 6 AM, on March 25, 2024, at 12 PM or 6 PM, or on March 26, 2024, at 12 PM. According to documentation in the resident's March 2024 MAR, the medication was not available from pharmacy for administration to the resident.

A list of over-the-counter medications supplied by the facility was provided during the survey of on March 27, 2024, which revealed that Bismuth Subsalicylate 525 mg liquid was included on the list of available OTC medications.

There was no evidence that the resident's physician was consulted to ascertain if an alternate form of the medication, the liquid, may be adminstered to the resident instead of the tablets.

Interview with the Nursing Home Administrator on March 27, 2024, at 1 PM, confirmed that the licensed staff failed to administer the prescribed medication to Resident 14. The NHA further confirmed that the facility should have contacted the physician regarding the alternate form of the medication readily available in the facility for administration to the resident.


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

28 Pa. Code 211.9 (d)(j.1)(1)(2)(3)(5) Pharmacy services






 Plan of Correction - To be completed: 04/18/2024

1. Resident 14's Physician was made aware of medication not administered. This medication was finished on 4/5/24 and resident is currently not receiving this medication.

2.Director of Nursing or designee will complete an audit for the past 3 days to ensure that if a medication is unavailable the physician is notified and Medication Unavailability Procedure is followed.

3. Director of Nursing or Designee will complete an education on the Medication Unavailability Procedure including physician notification if medication is unable to be obtained.

4.Director of Nursing or designee will complete an audit daily times 5 days, 3 times weekly for 3 weeks and monthly for 2 months to ensure the Physician is notified if a medication is unavailable. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee. Committee will determine the need for further audit and/or recommendations.
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 clinical records, select facility policy and investigative reports, and staff interview, it was determined that the facility neglected to provide one resident with the necessary care and services to prevent injury and maintain physical health out of 16 sampled. (Resident 4).

Findings include:

A review of the facility's abuse prohibition policy provided on March 27, 2024, revealed that it the policy of the facility to protect their residents from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion.

A review of Resident 4's clinical record revealed admission to the facility on June 14, 2022, with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), osteoarthritis, and heart disease.

Resident 4's plan of care, last revised by the facility October 30, 2022, indicated that the resident has an ADL (activity of daily living) self-care performance deficit related to activity intolerance related to CHF (congestive heart failure). Planned interventions were to provide the assistance of two staff members to turn and reposition the resident in bed as necessary and that the resident requires a full mechanical lift and assist of two staff members for transfers.

A review of a facility investigation report dated February 5, 2024, at 3:30 PM revealed that Employee 3, a nurse aide, rolled the resident in bed, to put a new brief under him. Resident 4 then shifted his hips and rolled off the bed. Employee 3 tried to stop the resident from falling out of bed but was unable to prevent the resident's fall. Resident 4 sustained a large skin tear and abrasion to his head. The physician ordered the resident to be transported to the emergency room for evaluation. The resident returned to the facility with sutures to the right parietal (side) region of his head and right forearm.

A review of Employee 3's witness statement dated February 5, 2024, revealed that the employee was assigned to Resident 4 to provide care and services on the day of the fall. According to Employee 3's statement, when he was putting a new brief under the resident, the resident rolled his hip and fell off the bed. He fell onto the floor. Employee 3's statement did not indicate the presence of another staff member while repositioning the resident in bed to provide ADL care.

There was no evidence that another staff member was assisting with the resident's turning and repositioning in bed at the time of the resident's fall. The facility failed to ensure that two staff members were present while repositioning and turning the resident in bed, as care planned, and the resident rolled out of the bed onto the floor and sustained minor injuries.

A review of a Report Form for Investigation of Alleged Abuse, Neglect, or Misappropriation of Property (PB-22) submitted by the facility to the Pennsylvania Department of Health on February 5, 2024, revealed the facility completed their investigation and concluded that neglect was substantiated due to Employee 3's failure to follow the resident's plan of care which indicated that another staff member was required when assisting in the resident's bed repositioning.

An interview with the Nursing Home Administrator and Director of Nursing on March 27, 2024, at approximately 1:00 PM confirmed that the facility failed to ensure that Resident 4 was free from neglect.

This deficiency is cited as past non-compliance.

The facility's corrective action plan included the following:


1.Resident 4 was sent to emergency room post fall and returned to the facility in stable condition. Employee 3 was immediately suspended and after conclusion of the investigation was terminated.
2.The Director of Nursing or designee completed an audit of bed mobility status and transfers assist of two to ensure it was in place on the plan of care and Kardex for all residents.
3.The Director of Nursing or designee educated the nursing staff to follow plan of care and Kardex for resident's bed mobility status and transfers assist of two. Physician's orders will be put in place for residents with transfer and bed mobility assist of two.
4.The Director of Nursing or designee will complete random observational audits to ensure staff are following the plan of care and Kardex for resident's bed mobility status and transfers assist of two. Random audits will be completed daily times 5 days, weekly times 3 weeks and monthly times 2 months. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee The committee will determine the need for further audit and/or recommendations.

The facility's completion date for the above corrections was February 9, 2024, which was verified during the survey completed March 27, 2024.



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

28 Pa. Code 201.29 (a) Resident Rights

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





 Plan of Correction - To be completed: 04/23/2024

Past noncompliance: no plan of correction required.
483.12 REQUIREMENT Free from Misappropriation/Exploitation: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
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.
Observations:

Based on a review of select facility policy, select investigative reports, and clinical records, and staff interview, it was determined that the facility failed to ensure that one resident was free from misappropriation of resident property, narcotic opioid medications, for two residents out of 17 residents sampled (Resident 16 and 17).

Findings included:

A review of the facility's abuse prohibition policy provided on March 27, 2024, revealed that it the policy of the facility to protect their residents from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. Misappropriation is the deliberate misplacement, exploitation, or wrongful, (temporary or permanent) use of a residents' belongings or funds without the resident's consent.

A review of the clinical record revealed that Resident 16 was admitted to the facility on September 21, 2022, with diagnoses of hypertension and diabetes.

The resident had a physician order initially dated January 26, 2024, for Oxycodone (a narcotic opioid pain medication) 5 mg, two tablets by mouth two times a day for chronic pain.

A review of the clinical record revealed that Resident CR2 was admitted to the facility on February 8, 2024, with diagnoses which included a fracture of her right humerus (upper arm) and was admitted for surgical aftercare.

The resident had a physician order for Tylenol 325 mg, two tablets every 6 hours as needed for mild pain, Tylenol extra strength 500 mg, two tablets every 8 hours as needed for moderate pain, and Oxycodone 5 mg every 4 hours as needed for moderate pain.

According to a facility investigative report, on February 21, 2024, at approximately 6 PM the Nursing Home Administrator (NHA) was notified that a narcotic medication was taken from Resident 16 to administer to Resident CR2 during the 3 PM to 11 PM shift on February 8, 2024. According to the facility's investigation, Resident CR2's Oxycodone 5 mg had not been delivered from the pharmacy. The licensed nursing staff on duty were unable to obtain the medication from the facility's emergency supply (Cubix) because two nurses were not duty during the shift that had access to the system. The facility requires two nurses for verification to withdraw narcotic medication from the emergency supply.

Review of an employee witness statement dated February 19, 2024, received by the NHA on February 21, 2024, completed by Employee 1, registered nurse, indicated that on February 8, 2024, Resident CR2's Oxycodone 5 mg was not available from pharmacy and the resident requested the medication for pain. Employee 1 stated that she was not given access to the emergency pharmacy supply, therefore, the narcotic medication could not be obtained for administration to the resident while awaiting delivery from pharmacy. According to Employee 1, she was told by Employee 2, registered nurse, that she was instructed by the Director of Nursing to take the medication from another resident to administer to Resident CR2, to document the medication as "wasted" so that the medication count would remain correct.

Review of the control substance record for Resident 16 revealed that on February 8, 2024, at 6 PM, the resident received his scheduled dose of Oxycodone 5 mg and at 9 PM, a dose of Oxycodone 5 mg was signed out as "wasted" by Employee 2, RN.

Review of Resident CR2's Medication Administration Record dated February 2024, revealed that Oxycodone 5 mg was administered at 10:54 PM on February 8, 2024

Review of Resident 17's control substance record revealed that on February 9, 2024, at 2:30 AM, one Oxycodone 5 mg tablet was also "wasted" by Employee 1.

Review of Resident CR2's MAR revealed that she received Oxycodone 5 mg at 3:03 AM for complaints of pain on February 9, 2024.

Review of Resident CR2's control substance record revealed that Oxycodone 5 mg for Resident CR2 was not delivered from pharmacy until dayshift on February 9, 2024. According to the record, 24 tablets were delivered to the facility.

The facility's report noted that the pharmacy, physician, and the resident were made aware. The local police and the Area Agency on Aging were notified. The facility reimbursed the residents for the "borrowed" medication.

A review of a Report Form for Investigation of Alleged Abuse, Neglect, or Misappropriation of Property (PB-22) submitted by the facility to the Pennsylvania Department of Health on February 21, 2024, revealed the facility completed their investigation on February 26, 2024, and concluded that misappropriation of resident property was substantiated.

An interview with the Nursing Home Administrator and Director of Nursing on March 27, 2024, at approximately 1:00 PM confirmed the facility failed to ensure that Residents 16 and 17 were free from misappropriation of property. The NHA confirmed the roles the former Director of Nursing, Employee 1, and Employee 2's played in the misappropriation. The DON subsequently confessed to instructing licensed staff to "waste" narcotic medication dispensed for other residents to Resident CR2. The NHA stated during the survey the DON no longer works at the facility.

This deficiency is cited as past non-compliance.

The facility's corrective action plan included the following:

1.Resident 16 representative was notified regarding the misappropriate of one oxycodone. Resident 16 was reimbursed the cost of the medication. Employees 1 & 2 were suspended immediately on February 21, 2024, pending the outcome of the investigation. Internal investigation identified concern related to the Director of Nursing providing direction on obtaining unavailable medication. The DON subsequently resigned. Employees 1 and 2 were provided education prior to returning to work. Employees 1 and 2 were compensated for missed time during suspension. Employee 1 was provided access to the Cubex (emergency pharmacy supply).
2.The DON/designee completed an audit of narcotic sheets of all current narcotics to ensure there are no noted concerns. DON/designee completed an audit to ensure nursing staff have access to Cubex.
3.The DON/designee completed education to nursing staff on the procedure for unavailable medication, controlled substance prescriptions, emergency pharmacy services, and emergency kits, receiving controlled substances. All licensed staff will be provided access to Cubex on orientation.
4.The DON/designee will complete a random audit of residents with narcotics to ensure there are no discrepancies on sheet. Narcotic sheets will be audited daily times 5 days, weekly times 3 weeks and monthly times 2 months. Nursing staff access to Cubex will be audited weekly times 3 weeks and monthly times 2 months. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee. The committee will determine the need for further audit and/or recommendations.

This plan was completed by February 26, 2024, and verified as completed during survey ending March 27, 2024.


28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing services

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

28 Pa. Code 201.29 (a)(c) Resident rights




 Plan of Correction - To be completed: 04/23/2024

Past noncompliance: no plan of correction required.
483.25 REQUIREMENT Quality of Care: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 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 review of select facility policy and clinical records, and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate that licensed nurses fully evaluated a resident's status after an unwitnessed fall for one resident (Resident CR1) out of 14 residents reviewed.

Findings included:


According to the Title 49, Professional and Vocational Standards, Department of State, Chapter 21 State Board of Nursing Subsection 21.11 (a) The register nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. In carrying out this responsibility, the nurse performs all of following functions: (4) Carries out nursing care actions which promote, maintain, and restore the well-being of individuals (6)(b) The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and Subsection 21.18. (a)(5) document and maintain accurate records.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

A review of facility policy entitled "Neurological Checks Policy" last reviewed April 2023 indicated neurological checks are indicated to monitor for potential irregularities in neurological status in the event of known or unknown head trauma as a result of a resident event, change in resident condition, or physician's order.

A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on November 20, 2023, with diagnoses that included seizures and abnormal gait and mobility.

A progress note dated November 27, 2023, at 12:06 AM revealed that the resident was found lying on the floor by his bed. A large puddle of blood was observed by his wheelchair outside the bathroom in his room. A moderate amount of blood was coming from the resident's right temple area. The resident was transferred to the hospital.

Further review of the resident's clinical record, conducted during the survey ending March 27, 2024, revealed no documented evidence the facility nursing staff conducted a neurological assessment of the resident after the unwitnessed fall with visible injury to the resident's temple area.

During an interview on March 27, 2024, at approximately 1:45 PM, the Nursing Home Administrator verified that the facility's licensed and professional nursing failed to conduct neurological assessments after unwitnessed fall consistent with professional standards of practice.



28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services

28 Pa. Code 211.5 (f) Medical records




 Plan of Correction - To be completed: 04/18/2024

1. Resident 1 has been discharged from the facility.

2. Director of Nursing or designee will complete an audit of unwitnessed falls for the past 14 days to ensure Neurological assessment is completed as required.

3. Director of Nursing or Designee will complete education on facility neurological checks policy with Licensed Nursing Staff.

4. Director of Nursing or designee will complete an audit of unwitnessed falls daily times 5 days, 3 times weekly for 3 weeks and monthly for 2 months to ensure Neurological Checks are completed as required. Findings of audits will be summarized and reported to the Quality Assurance Performance Improvement Committee. Committee will determine the need for further audit and/or recommendations.


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