Nursing Investigation Results -

Pennsylvania Department of Health
PAPERMILL ROAD NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PAPERMILL ROAD NURSING AND REHABILITATION CENTER
Inspection Results For:

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PAPERMILL ROAD NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to two complaints completed on January 23, 2020, it was determined that Papermill Road 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:


483.21(b)(1) 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.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that care plan interventions were implemented for one of five sampled residents. (Resident 45)

Findings include:

Clinical record review revealed that Resident 45 had diagnosis that included a gastrointestinal bleed, difficulty swallowing, glaucoma (visual difficulty) and dementia. Resident 45's care plan was most recently reviewed on December 20, 2019, and discussed with the resident's Guardian on January 2, 2020. The care plan identified the resident at risk for falls, at risk for complications in gastrointestinal status and at nutritional risk.

On August 13, 2019, the resident had a fall. The care plan initiated on August 15, 2019, indicated that staff was apply a chair alarm and check the function of the alarm every shift. On January 23, 2020, at 10:00 a.m., 12:30 p.m., and 1:15 p.m., Resident 45 was observed seated in the wheelchair without the chair alarm activated. In an interview at 1:15 p.m. NA1 confirmed that the box that activated the chair sensor pad was not present. NA1 also confirmed that she had provided care to the resident in the morning and had assisted the resident to her chair that morning without checking that the chair alarm was activated. After further observations the box could not be found in the resident's room. The Director of Nursing had to obtain the activation alarm box from central supply.

On December 10, 2019, Resident 45 was admitted to the hospital with a gastrointestinal bleed. The care plan initiated on December 14, 2019, indicated that staff was to obtain and monitor laboratory work and diagnostic studies as ordered by the physician. On January 9, 2020, the physician ordered that staff obtain a bowel movement sample for occult blood. This test indicated the presence or absence of blood in the stool. Review of the resident's bowel documentation revealed that the resident had bowel movements almost daily. There was no evidence to support that staff had obtained the stool sample and tested it for occult blood. In an interview on January 23, 2020, at 3:12 p.m., the Director of Nursing confirmed that staff had not tested the resident's bowel movement for blood. The Director of Nursing further confirmed that staff could complete the test in the nursing facility.

On January 2, 2020, staff initiated a new care plan that identified the resident with a history of weight loss. There was another ongoing care plan since January 30, 2019, that identified the resident with unplanned weight loss. Both care plans indicated that staff was to weigh the resident at the same time of day and record the results. 0n December 13, 2019, the physician ordered that staff weigh the resident three times a week. Review of the resident's weight records revealed that there was no weight obtained on ten of the 17 scheduled days since the December 13, 2019, physician's order. Additionally, an intervention dated January 6, 2020, noted that staff was to provide a peanut butter sandwich at bedtime and a calorie count was to obtained to determine if the resident was meeting nutritional needs. There was no documentation to support that a calorie count was completed. Review of the snack documentation revealed that the resident did not receive the sandwich snack on January 16 and 21, 2020.

CFR 483.21(b)(1) Comprehensive Care Plans.
Previously cited July 18, 2019.

28 Pa. Code 211.12 (d)(1)(5) Nursing services.
Previously cited July 18, 2019.

28 Pa. Code 211.5 (f) Clinical records.







 Plan of Correction - To be completed: 03/04/2020

1.Resident 45 chair alarm box was placed on wheelchair.
Resident 45 Care Plan was updated to reflect non-compliance with chair alarm box.
Occult blood stool sample was discontinued by Physician.
Weight order was changed from three times a week to weekly by Physician.
Resident 45 calorie count cannot be corrected. The dietician assessed nutritional status and resident is stable.
The snack documentation cannot be corrected.
2. Care plans and documentation of chair alarm box, stool samples, weights,Calorie count and snack documentation were audited for completion.
3. RN's and LPN's will be in-serviced on protocol for orders for weights, chair alarms, calorie counts and stool samples. CNAs will be in serviced on snack documentation
4. Audits will be completed by DON/Designee for weights, chair alarms, stool samples, calorie count and snacks weekly x 4 weeks, and then monthly x 2 months. Audits will be reviewed at QAPI meeting.


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 clinical record review, and staff interview, it was determined that the facility failed to ensure that physician's orders for speciality consultations (cardiac and gastrointestinal) were scheduled and provided for one of five sampled residents. (Resident 45)

Finding include:

Clinical record review revealed that Resident 45 as readmitted to the facility with new diagnosis that included pleural effusion (a build up of fluids between the layers of tissue that line the lungs and the chest cavity) and post gastrointestinal bleed December 13, 2019. Upon hospital transfer there was a recommendation for the resident to be assessed by the cardiac and gastrointestinal physicans that had provided care in the hospital in one week. The nursing home physican agreed and on December 13, 2019, ordered that staff schedule both of the consulting physician appointments in one week. Twenty days later on January 2, 2020, the resident's physician documented that there were no reports from either consulting physician. On January 16, 2010, Resident 45 became short of breath and had abnormal vital signs. A chest x-ray completed that day noted that the resident had cardiomegaly (enlarged heart) with congestive heart failure. The physician documented that the resident needed the follow up assessment with the cardiac physician. On January 17, 2020, (34 days since readmission to the facility) the physician documented that the resident still needed the cardiac physician as soon as possible. The physician also documented that the gastrointestinal consultation was also still required. There was a lack of evidence to support that the speciality physican consultations were scheduled timely. In an interview on January 23, 2020, at 2:45 p.m., the Director of Nursing confirmed that the gastrointestinal consult had not been scheduled and that the cardiac consultation was just completed on January 20, 2020, and new recommendation for care and services were requested by that physician.

CFR 483.25 Quality of care.
Previously cited 7/18/19

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 7/18/19



 Plan of Correction - To be completed: 03/04/2020

1.Resident 45 consultations appointments for cardiac and GI have been scheduled
2.Resident Physician orders for consultations have been audited for scheduled/completion on admission and for new orders.
3.RN's and LPN's will be in-serviced on tracking appointment log, timely completion of consultation appointments and communication with the physician.
4.Audits will be completed by DON/Designee for consultation orders and completion weekly x 4 weeks, and then monthly x 2 months. Audits will be reviewed at QAPI meeting.


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