Pennsylvania Department of Health
GRANDVIEW NURSING AND REHABILITATION
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GRANDVIEW NURSING AND REHABILITATION
Inspection Results For:

There are 134 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.


GRANDVIEW NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit and abbreviated complaint survey completed on May 21, 2024, it was determined that Grandview Nursing and Rehabilitation failed to correct federal deficiencies cited during the surveys of February 12, 2024, and April 12, 2024, and continued to be out of 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:

483.25 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.

Plan of Correction - To be completed: 06/18/2024

1. Unable to retroactively correct medication administration times. No negative outcomes noted for any resident receiving their medications untimely.

2. An audit of the last 72 hours of medication administrations will be performed to identify any untimeliness. If untimely administration is identified then resident will be evaluated for any related negative effects.

3. Medication administration times reviewed and adjusted to meet the needs of the resident in order to assure medications are timely. The DON/designee will provide education to professional nursing staff on medication administration policy and facility medication administration time adjustments.

4. The DON/designee will audit medication administrations 3 times per week x 4, then 2 times per week x 4, then weekly X 4. Audits will be reported to QAPI until substantial compliance has been met.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely consult with the physician regarding significant changes in resident condition after a fall with injury, which precipitated an additional fall for one resident out of 15 sampled (Resident 4).

Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties.

A review of facility policy entitled "Notification of Changes" with a review date of January 2024 revealed that the purpose of this policy is to ensure that the facility promptly informs the resident, consults with the resident's physician, and notifies consistent with his or her authority, resident representative when there is a change requiring notification which may include a clinical complication or an acute condition. Documentation of notification will record the date of time, name of individual who received the notification and any pertinent response to the notice will be made in the clinical record of the resident's clinical record.

A review of a facility policy "Notification of Change in Condition" last reviewed by the facility on March 1, 2023, indicated that the Center was to promptly notify the Patient/Resident, the attending physician, and the Resident Representative (RP) when there is a change in the condition or status. The nurse is to notify the attending physician and RP when there is a significant change in the patient/resident's physical, mental, or psychosocial status and the nurse it to complete an evaluation of the patient/resident and document the evaluation in the medical record.

A review of Resident 4's clinical record revealed admission to the facility on July 15, 2020, with diagnoses of displaced spiral fracture of shaft of right tibia (type of broken leg that occurs along the length of the bone below the knee and above the ankle), sprain anterior cruciate ligament of right knee (a tear of the ligament in the knee causing pain and swelling, reducing leg movement), unsteadiness on feet, difficulty walking and muscle weakness.

A physician order dated August 3, 2023, at 8:24 AM was noted for the resident to receive Oxycodone HCL (opioid pain medication) 5 milligrams (mg) by mouth every eight hours as needed for moderate to severe pain (4-10) pain in chest and knee and Tylenol (Acetaminophen - non-narcotic pain medication) 325 mg, give two tablets by mouth every four hours as needed for mild pain (1-3 pain).

Progress notes dated May 20, 2024, at 5:00 AM revealed that the resident sustained fall and was crawling out of the resident's room yelling for help. Staff found the resident sitting on the floor, outside of the doorway to the resident's room, with the resident's back resting against the door frame both legs extended. Nursing noted that the resident had no complaints of pain or signs and symptoms of injury at this time. Range of motion within normal range, physician notified and emergency contact.

However, at 5:39 AM on May 20, 2024, the resident complained of severe pain to the right knee all non-pharmacological interventions were ineffective at this time. Nursing administered Oxycodone HCL 5 mg by mouth.

At 8:00 AM on May 20, 2024, nursing conducted a follow-up assessment to the pain medication given at 5:39 AM, which was noted as ineffective with a pain scale rating of seven (out of 10).

At 9:00 AM nursing applied a knee brace prior to the resident leaving for an appointment and noted that the resident's right knee was "very swollen," noting the tissue of the resident's knee was soft and puffy, as with an effusion (extra fluid buildup in a joint). At the base of the patella (knee), there was a large light ecchymotic (bruise) area. Resident denied much tenderness over the patella (kneecap) but had tenderness over the tibial and fibular heads. There was a large ecchymotic area noted below the resident's elbow of the right forearm.

At 9:38 AM a scheduled every shift pain assessment was conducted and revealed that the resident's knee brace was applied. Staff instructed the resident to keep it on for support especially since she reports knee pain and weakness.

At 12:20 PM on May 20, 2024, the resident returned from appointment without incident.
At 2:06 PM on May 20, 2024, staff administered another dose of Oxycodone 5 mg by mouth for right knee pain, rated as an eight out of ten.

There was no indication that the physician was consulted regarding the resident's increased pain and appearance of the resident's knee.

Following up to the administration of the pain medication at 2:06 PM, nursing conducted another pain assessment, at 9:14 PM, which revealed that at this time the resident was currently crying with pain. However, nursing noted that she did have relief for approximately five hours and was given Tylenol for pain at this time.

Nursing noted that at 9:18 PM the resident was crying in pain rated at an eight out of ten. The resident's next dose of Oxycodone was not due at this time, nursing repositioned the leg and ice was applied.

At 9:30 PM the resident requested to use a bedpan. At baseline, the resident walks with a walker and staff supervision to the bathroom. She began to complain of pain of the right lower leg and throughout the evening reported the pain was worsening. She had decreased range of motion active and passive. Previous notes described ecchymotic areas and swelling of the right lower leg both the ecchymosis and swelling had increased.

There was no evidence that nursing consulted with the physician at this time regarding the resident's continued pain and increased swelling.

At 10:10 PM the resident continued to complain of pain, but gained some relief with Tylenol was sleeping at this time.

A progress note dated May 21, 2024, at 1:00 AM revealed that the resident was found self-transferring to the bathroom, during which she fell to the floor. She state that her lower right leg buckled and she fell, right lower extremity from knee to ankle both looked swollen and bruised with purple color. The resident was complaining of pain at level of 10 out of 10. Hoyer (mechanical lift to transfer) lift was needed to transfer off the floor resident. The resident was complaining of her leg hurting too much to put weight on it and requested to go to the ER, new order to transfer to ER noted and 911 services called.

At 1:59 AM on May 21, 2024, nursing administered Oxycodone 5 mg by mouth for pain rated at 10 out of 10 of the right knee.

At 3:20 AM on May 21, 2024, the resident was transferred to the ER via stretcher.

At 5:50 AM it was reported to the facility that the resident was negative for any fractures (break) to extremities including the right ankle.

At 9:15 AM on May 21, 2024, the resident returned from the ER with bruising to both legs and arms the Certified Registered Nurse Practitioner (CRNP) was made aware.

At 12:14 PM the resident received Oxycodone 5 mg by mouth for pain rated at a 10 of 10 to the right knee.

There was no documented evidence at the time of the survey ending May 21, 2024, that the resident's physician was timely consulted regarding the resident's continued severe pain and swelling to the knee prior to the resident's request to go to the ER after the second fall on May 21, 2024 at 1 AM

This failure to timely consult with the physician regarding the potential need to alter treatment was confirmed during interview with the Director of Nursing (DON) on May 21, 2024, at 1:45 PM.

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

28 Pa. Code 211.10 (a)(d) Resident care policies

Plan of Correction - To be completed: 06/18/2024

1. Provider notified of change in condition for resident 4 on May 21, 2024.

2. An audit of last 7 days of nursing notes were reviewed to ensure changes in condition were reported timely.

3. The DON/designee educated licensed nurses on federal regulation of notification of change.

4. The DON/designee will audit nurses notes for change in condition with timely provider and resident representative notification 3 times per week x 4, then 2 times per week x 4, then weekly X 4. Audits will be reported to QAPI until substantial compliance has been met.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

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

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

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

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

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

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

Observations:

Based on a review of select facility policy and clinical records and staff interview it was determined the facility failed to maintain accurate and complete clinical records, according to professional standards of practice, by failing to record a registered nurse's assessment and communication with other members of interdisciplinary team for one resident out of 15 sampled (Resident 15).

Findings include:

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient record to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient, Communication with and education of the patient, family, and the patient's designated support person and other third parties.

A review of facility policy entitled "Notification of Changes" with a review date of January 2024 revealed that the purpose of this policy is to ensure that the facility promptly informs the resident, consults with the resident's physician and notifies consistent with his or her authority, resident representative when there is a change requiring notification which may include a clinical complication or an acute condition. Documentation of notification will record the date of time, name of individual who received the notification and any pertinent response to the notice will be made in the clinical record of the resident's clinical record.

A review of clinical record revealed Resident 15 was admitted to the facility on May 2, 2023, with diagnoses which included dementia (a disorder that affects memory, thinking and interferes with daily life) and muscle weakness.

A progress notes dated May 2, 2024, at 6:47 AM revealed that the Occupational Therapy (OT) noted that the resident displayed plus one (the grade or measure of how serious it is) edema (swelling) to the left lower leg. This information was documented and assessed by a Licensed Practical Nurse (LPN) and was reported to a Registered Nurse (RN).

There was no documentation of an assessment from a RN or that this finding was communicated to the resident's physician.

A progress noted dated May 3, 2024, at 2:18 AM written by an LPN noted the swelling of resident's Resident 15's left lower extremity.

A review of progress notes May 6, 2024, at 6:00 AM revealed an assessment performed by an RN after a fall on that date, but did not reference the swelling of the resident's left lower extremity as noted by the OT on May 2, 2024. The physician was notified of the resident's fall, however, the entry did not indicate that the physician was made aware of the lower extremity edema.

On May 8, 2024, at 2:30 the resident had another fall, and an assessment was documented by an RN, and did not reference any edema to the left lower extremity.

On May 11, 2024, at 10:07 PM an LPN documented that the resident continued to have plus one-non pitting (feels firm without indentation) edema to the left lower extremity. The resident denied pain and was able to move the extremity. The LPN noted that the resident's lower leg was normal color and positive pedal pulse. The LPN elevated the resident's foot and noted that that the RN supervisor was aware.

Nursing progress notes dated from May 11, 2024, until May 15, 2024, revealed documentation of assessments performed by an LPN of the resident's left lower extremity edema, but no documented assessments by a registered nurse.

There was no documentation of an RN assessment of the resident's left lower leg edema from May 2, 2024, when identified by OT until May 16, 2024, or that the presence of this edema had been communicated to the physician or physician extender.

On May 16, 2024, at 1:44 PM the clinical record reflected an assessment performed by the RN noting redness and edema of the left lower extremity of plus two edema not warm to touch, pedal pulse present and physician assistant (PA-C) made aware. At 2:44 PM the PA-C assessed the resident's left lower extremity and noted plus two edema, no redness or warmth. New orders were noted for a left lower extremity venous doppler study (non-invasive ultrasound procedure to evaluate blood flow in veins to identify any blockages or clots that can be a sign of deep vein thrombosis [a condition in which the blood clots form in veins located deep inside the body usually the lower legs, can cause swelling]).

On May 17, 2024, at 5:47 PM the results of the left lower extremity doppler were noted as suggestive of an acute (new onset) deep vein thrombosis and superficial thrombophlebitis (inflammation in a vein caused by a blood clot). A new order was noted to start Eliquis (anticoagulant medication [blood thinner]) 5 milligrams (mg) by mouth two times daily for seven days.

During an interview with the Director of Nursing (DON) on May 21, 2024, at 12:56 PM the DON stated that an RN and Physician Assistant (PA-C) had assessed the resident on May 8, 2024, (six days after the initial report by the OT) but did not document anything in the resident's medical record. At this time the DON printed a consultation from the EPIC (electronic hospital charting system used by the PA-C, CRNP, and physicians providing care in the facility and affiliated with a nearby hospital system) from this day that revealed the resident asked to be seen by staff for complaints of a fall. Review of systems revealed that the resident had lower extremity edema. The physical exam revealed that extremities have no excess edema or calf tenderness, and range of motion is intact in all extremities.

However, there was no documentation in the resident's medical record maintained by the facility that the physician or PA was made aware of the resident's left lower extremity edema or that the resident was assessed by professional nursing or medical staff in a timely manner.

An interview with the Nursing Home Administrator (NHA) and DON on May 21, 2024, at approximately 1:45 PM confirmed that the facility's nursing staff failed document assessments and monitoring of changes in resident's condition resulting in inaccurate and incomplete clinical records.

28 Pa. Code 211.5 (f) Medical records

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

Plan of Correction - To be completed: 06/18/2024

1. Provider note from May 8, 2024 was uploaded into resident 15 facility medical record EMR. A late entry note was entered by the RN for 5/2/24

2. A lookback of provider visits within the last 7 days were reviewed to ensure they were uploaded into resident facility EMAR. Concerns identified were corrected immediately.

3. Educated licensed staff about requirement to document all assessments and communication with providers in real time. Personnel responsible for uploading provider visits into resident EMR have been educated of the timely completion by NHA/designee.

4. The NHA/designee will audit provider visits and facility EMR record 3 times per week x 4, then 2 times per week x 4, then weekly X 4. Audits will be reported to QAPI until substantial compliance has been met.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum licensed practical nurse staff to resident ratio was provided on each shift for one shift out of 39 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum licensed practical nurse (LPN) staff of 1:40 on the night shift based on the facility's census.

May 8, 2024 - 2.63 LPNs on the night shift, versus the required 3.43 for a census of 137. There was no additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator on May 21, 2024, approximately 2:45 PM, confirmed the facility had not met the required LPN to resident ratios on the above dates.

Plan of Correction - To be completed: 06/18/2024

1. Facility cannot retroactively correct.

2. A 7 Day lookback was conducted to ensure required LPN ratio was met.

3. Facility will continue to use agency staff to fill in holes/call-offs, offer bonuses, continue to recruit for in-house staff and continue using social media advertising. NHA/designee will educate facility scheduling personnel on the required ratios for nursing staff.

4. The NHA/designee will audit to ensure facility is meeting LPN ratios 3 times per week x 4, then 2 times per week x 4, then weekly X 4. Audits will be reported to QAPI until substantial compliance has been met.

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