Nursing Investigation Results -

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

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GRANDVIEW NURSING AND REHABILITATION
Inspection Results For:

There are  107 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 an Abbreviated Complaint survey completed on May 25, 2022, it was determined that Grandview Nursing and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


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 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.
483.10(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 a 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 changes in condition with the potential need to alter treatment for two residents out of five sampled residents (Resident 105 and 136).

Findings include:

The facility policy entitled "Physician Notification", last reviewed by the facility on January 2020, indicated the goal of this policy is to have nursing identify the urgency of the situation and determine when to make the call to the physician. The Nurse will recognize the condition change, the types of condition which frequently arise, altered mental status, bleeding, chest pain, diarrhea, edema, emesis, falls, family concerns, gastrostomy tubes, medication error, pain (head, abdomen, and limb), pressure sores, seizures, shortness of breath, skin rash, vital signs, laboratory values, and administrative.

A review of the clinical record revealed that Resident 105 was admitted to the facility on April 21, 2022, with diagnoses to include chronic kidney disease, major depression, chronic obstructive pulmonary disease (COPD), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), gastro-esophageal reflux disease (GERD), diabetes, contusion (Blood or bleeding under the skin due to trauma) of the spleen, hallucinations, protein-calorie malnutrition, and multiple fractures of the ribs, pubis (bones forming the two sides of the pelvis - hips), thoracic vertebra (mid - back bone), nasal bone, lumbar vertebra (lower back bone) and zygomatic (cheekbone below and lateral to the orbit, or eye socket) bone.

An admission Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated April 23, 2022, indicated that the resident was severely cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 3 (0-7 represents severe cognitive impairment).

A review of Resident 105's clinical record, nurses note, dated May 7, 2022, at 3:34 PM, that indicated the resident was "alert and oriented (A&O), with increased confusion. Resident stripped of clothes x 3 this shift and removed oxygen tubing multiple times, unable to redirect. He refused morning meds. RN aware and family was made aware. Vitals stable, will continue to monitor."

There was no documented evidence that the facility had notified the resident's physician of the increased confusion, stripping of clothes (3 times), removing the oxygen tubing, and or refusing his medications and that he was unable to be redirected.

A nurse's note dated May 7, 2022, at 9:14 PM, indicated that the resident had fallen in the bathroom of the resident's room. The resident sustained a laceration above the right eye, bleeding minimally, right eye turning black and blue and swollen, ice applied. It was at this time that the resident's family and Physician Assistant were notified and new orders obtained for x-rays and neurologic checks and post fall vital signs.

A review of the clinical record revealed that Resident 136 was most recently admitted to the facility on April 18, 2022, with diagnoses to include fracture of left femur (long bone in leg), cerebral infarction (stroke), hypertension, dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), chronic kidney disease, psychotic disorder with delusions, hallucinations, major depression, anxiety, and gastro-esophageal reflux disease (GERD).

A quarterly Minimum Data Set assessment dated February 2, 2022, indicated that the resident was moderately cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 10 (8-12 represents moderate cognitive impairment).

A nurse's note dated April 8, 2022, at 3:33 PM, indicated that the resident had increased confusion today as well as weakness. Vitals stable this shift. Made RN aware, will continue to monitor.

There was no documented evidence that the facility had notified the resident's physician of the resident's increased confusion and weakness.

A nurse' note dated April 13, 2022, at 7:30 AM, indicated that the "resident had fallen, lying on her left side with blankets beneath her and call bell lying on floor next to her disconnected from wall."

A nurse's note, dated May 17, 2022, at 2:07 PM, indicated that the resident returned from the hospital at 9:12 AM today, alert and oriented with confusion. Resident noticeably agitated this shift, yelling out and yelling at staff. Resident was found to be self-transferring and ambulating without assistance in her room. Not easily redirected, she continues with Physical Therapy (PT) and Occupational Therapy (OT). Vitals stable. Will continue to monitor.

There was no documented evidence that the facility had notified the resident's physician of the confusion, noticeably agitated behavior, and the unsafe act of self-transferring, ambulating without assistance, and not being easily redirected.

A review of Resident 136's clinical record, nurses note, dated May 17, 2022, at 4:30 PM, indicated the nurse heard a noise and found the resident on the floor by her bed on her buttocks.

Interview with the Director of Nursing (DON) on May 25, 2022, at approximately 12:20 PM, confirmed the above information and was unable to provide any additional information.

Interview with the Nursing Home Administrator (NHA) on May 25, 2022, at approximately 12:50 PM, confirmed the facility failed to timely notify Resident 105 and 136's physician of the changes displayed by the residents.


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

28 Pa Code 201.29(a)(l)(2) Resident rights




 Plan of Correction - To be completed: 06/30/2022

1. The physician has been made aware of all changes regarding residents 105 and 136.
2. The facility will conduct an audit of the past 7 days and notify the physician with any appropriate changes displayed by the residents.
3. The DON/designee will educate the facility's nurses on notifying the patient's physician when a resident displays a change.
4. The facility will conduct an audit weekly x4 weeks and monthly x2 months to verify physicians are being notified timely of a change displayed by a resident. Results will be reviewed at QAPI.
5. 6/30/22

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(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 clinical records, facility provided documentation, and staff and resident interview, it was determined that the facility's licensed and professional nursing staff failed to maintain clinical records in accordance with professional standards and practices by failing to document complete, and accurate clinical documentation in the clinical records of three residents out of five sampled residents (Resident 105, 68 and 65).

Findings:

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's EHR (electronic health 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 the clinical record revealed that Resident 105 was admitted to the facility on April 21, 2022, with diagnoses to include chronic kidney disease, major depression, chronic obstructive pulmonary disease (COPD), dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), gastro-esophageal reflux disease (GERD), diabetes, contusion (Blood or bleeding under the skin due to trauma) of the spleen, hallucinations, protein-calorie malnutrition, and multiple fractures of the ribs, pubis (bones forming the two sides of the pelvis - hips), thoracic vertebra (mid - back bone), nasal bone, lumbar vertebra (lower back bone) and zygomatic (cheekbone below and lateral to the orbit, or eye socket) bone.

An admission Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated April 23, 2022, indicated that the resident was severely cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 3 (0-7 represents severe cognitive impairment).

A review of the resident's clinical record, nurses note, dated May 7, 2022, at 9:14 PM, indicated the resident had fallen in the bathroom. Nursing noted "vital signs BP 142/68 resp 20 pulse 70 pulse ox 96% room air temp 97.7. Laceration above the right eye, bleeding minimally, right eye turning black and blue and swollen, ice applied. resident states" I fell now get me up" no loss of conscience (LOC) answers questions appropriately assisted to feet and ambulated to bed with assist of one. Family and PA notified, new orders obtained for x-rays and neurologic checks and post fall vital signs."

A nurses note, dated May 9, 2022, at 12:40 PM, indicated "call to 911 to transfer resident to Hospital ER for hallucinations and altered mental status (AMS) changes."

A nurses note, dated May 9, 2022, at 2:41 PM, indicated that the resident was noted to have increased confusion and hallucinations today. Nursing noted "Resident refused meals and fluids. No complaints of pain noted, vitals stable. Physician Assistant (PA) made aware of residents decline, resident was sent to Hospital ER."

A RNP (restorative nursing program) Progress Note, dated May 11, 2022, at 1:44 PM, indicated "to discontinue (D/C) any previous Restorative Nursing Program's, resident was admitted to the hospital."

A COVID Assessment in the resident's clinical records, dated May 12, 2022, at 10:58 AM, indicated "LATE Entry, that the resident (who had been admitted to the hospital on May 9, 2022, and was not present in the facility at this time) was assessed and found to have; fever : no, cough: No, shortness of breath (sob): no, muscle aches : no, diarrhea : no, chills : no, headache : no, sore throat : no, vomiting : no, and loss of taste or smell : no."

COVID Assessments in the resident's clinical record dated May 13, 14, and 15, 2022, at 8:32 AM, indicated that the resident (who remained hospitalized on these dates) was assessed and found to have; fever : no, cough: No, shortness of breath (sob): no, muscle aches : no, diarrhea : no, chills : no, headache : no, sore throat : no, vomiting : no, and loss of taste or smell : no.

A nurses note dated May 18, 2022, at 10:32 AM noted "Late Entry, indicated resident returned from Hospital, orders confirmed with PA."

A review of facility provided Hospital documentation, entitled "ED to Hosp -Admission" and or "Discharge Summary", dated May 18, 2022, indicated the Resident 105 was admitted for inpatient hospital stay from May 9, 2022, until May 18, 2022.

Facility nursing staff documented that COVID assessments of the resident were conducted on the dates that the resident had been hospitalized and was not present in the facility.

A review of the clinical record revealed that Resident 65 was most recently admitted to the facility on May 6, 2022, with diagnoses to include dislocation of hip, dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Alzheimer's (A progressive disease that destroys memory and other important mental functions), chronic kidney disease, fracture of right femur (long bone in leg), and aphasia (a language disorder that affects a person's ability to communicate).

A Significant Change Minimum Data Set assessment dated May 12, 2022, indicated that the resident was severely cognitively impaired with a BIMS score of 3 (0-7 represents severe cognitive impairment).

A nurse's note dated April 12, 2022, at 3:43 AM, indicated "she continues to have increased difficulty with transfers (TR) with assist of two staff members. Seems to not want to put weight on left leg. 11-7 RN made aware. Patient complains of pain when TR but refuses pain med x 3."

A nurse's note, dated April 25, 2022, at 3:25 AM, indicated the resident "denies pain to left leg/hip "as long as I don't move it (left leg)". Left hip incision remains pink with no increased warm to area noted at this time. Afebrile (no fever)."

An appointment note dated April 27, 2022, at 1:46 PM, indicated "an appointment is made for May 2, 2022, at 1:15 PM at MRI clinic. Resident will be transported by stretcher/BLS at 1:00 PM. RN supervisor aware."

A nurses note dated May 3, 2022, at 10:00 AM, indicated "family updated with resident going to hospital ER for her left hip pain."

A nurses note dated May 3, 2022, at 11:09 AM, indicated "resident representative made them aware resident going back to ER related to MRI finding of left hip."

Nursing staff failed to document that the resident was out of the facility on May 2, 2022, for the appointment at the MRI clinic, and or that she had returned to the facility.

During an interview with the Director of Nursing (DON) on May 25, 2022, at approximately 12:20 PM, the DON confirmed there was no documented evidence in Resident 65's clinical record of the resident being out at the MRI clinic for diagnostic tests and or that she returned to the facility. She further confirmed that Resident 105 could not have been assessed for COVID, for 4 consecutive days, as indicated in the clinical record, because of the resident's admission to the hospital at that time.

During an interview with the Nursing Home Administrator (NHA) on May 25, 2022, at approximately 12:50 PM, confirmed the above documentation and the facility's expectation of complete and accurate clinical documentation in the residents' records.


A review of the clinical record revealed that Resident 68 was admitted to the facility on April 23, 2021, with diagnoses to include heart disease, chronic kidney disease, osteoarthritis, osteomyelitis of sacral area, pressure ulcer of the sacrum and muscle weakness.

An annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 28, 2022, revealed the Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, revealed that the resident scored a 15, which indicated that she was cognitively intact, (a score of 13-15 equates to being Cognitively Intact), and required extensive assistance by staff with bed mobility, transfer, toilet use, personal hygiene, and dressing.

A review of Resident 68's care plan initially dated April 23, 2021, and revised March 16, 2022, revealed that interventions were in place to prevent pressure sore development were to limit time in wheelchair (WC) to meals only OR have resident shift ST every 2 hours if refuses to get in bed, Turn and Reposition every 2 hours around the clock (ATC) side to side reposition while in bed (WIB), utilize protective/preventative skin creams, keep sheets clean dry and wrinkle free, full replacement low air loss mattress, Roho cushion to wheelchair with dycem below check every shift.

An outside wound consultant report dated March 22, 2022, revealed a wound evaluation and management for a Stage 4, full thickness pressure wound of the sacrum. The sacral wound measured (L x W x D) 5 x 3.5 x 3.5 centimeter (cm), with moderate serous exudate (fluid that has seeped out of blood vessels or an organ). The wound is 20 % slough (dead tissue separating from living tissue, a mass of dead tissue), and 80 % granulation tissue (tissue that will fill in a wound that is healing). Surgical excisional debridement was performed. Treatment is to continue, Dakins (1/2 strength) solution 0.25 % (Sodium Hypochlorite). Apply to Sacrum topically every evening and night shift for pressure area Irrigate wound daily with saline. apply zinc oxide to perimeter, loosely pack sacral wound with Dakins moistened kerlex, cover with bordered gauze until resolved.

An outside wound consultant report dated April 7, 2022, revealed a wound evaluation and management for Stage 4, full thickness pressure wound of the sacrum. The sacral wound measured 2 x 2.5 x 2.5 (cm), with moderate serous exudate. The wound is 20 % slough, and 80 % granulation tissue. Surgical excisional debridement was performed. Treatment is to continue, Dakins (1/2 strength) solution 0.25 % (Sodium Hypochlorite). Apply to Sacrum topically every evening and night shift for pressure area Irrigate wound daily with saline. apply zinc oxide to perimeter, loosely pack sacral wound with Dakins moistened kerlex, cover with bordered gauze until resolved.

An outside wound consultant report dated April 14, 2022, revealed a wound evaluation and management for a Stage 4, full thickness pressure wound of the sacrum. The sacral wound measured 4 x 2 x 2 (cm), with moderate serous exudate. The wound is 20 % slough, and 80 % granulation tissue. Surgical excisional debridement was performed. Treatment is to continue, Dakins (1/2 strength) solution 0.25 % (Sodium Hypochlorite). Apply to Sacrum topically every evening and night shift for pressure area Irrigate wound daily with saline. apply zinc oxide to perimeter, loosely pack sacral wound with Dakins moistened kerlex, cover with bordered gauze until resolved.

An outside wound consultant report dated April 21, 2022, revealed a wound evaluation and management for a Stage 4, full thickness pressure wound of the sacrum. The sacral wound measured 5 x 2.5 x 2 (cm), with moderate serous exudate. The wound is 20 % slough, 70 % granulation tissue, and 10 % bone. Surgical excisional debridement was performed. Treatment is to continue, Dakins (1/2 strength) solution 0.25 % (Sodium Hypochlorite). Apply to Sacrum topically every evening and night shift for pressure area Irrigate wound daily with saline. apply zinc oxide to perimeter, loosely pack sacral wound with Dakins moistened kerlex, cover with bordered gauze until resolved.

A further review of the clinical record at the time of the survey ending May 25, 2022, found the resident's wound remained mostly unchanged. The treatment was changed on May 23, 2022, to a Normal Saline Solution (NSS) every evening and night shift for Sacral pressure area pack w/ NSS soaked gauze, zinc to peri - wound, border gauze daily.

A review of facility provided Tracking documentation from April 1, 2022, to May 25, 2022, revealed that it was incomplete, with multiple blanks and areas noted as NA (Not Applicable). Interview with the Director of Nursing (DON) on May 25, 2022, at approximately 12:20 PM confirmed that "NA indicated not applicable" and blank spaces indicated that the tracking was not completed and or not documented by staff.

Review of the Documentation Survey Report (tasks completed for the resident), indicated turn and reposition every 2 hours around the clock side to side reposition while in bed (WIB), from April 1, 2022, to April 30, 2022, revealed that the resident had not been turned/repositioned for 2 consecutive hours on April 1, 2022, and 6 consecutive hours on April 10, 2022, and 8 consecutive hours on April 3, 4, and 23, 2022. On April 25, 2022 staff documented that the turning and repositioning program was not applicable (NA) for 2 consecutive hours, 4 consecutive hours on April 15, 19, and 6 consecutive hours on April 27, 2022. This lack of documented evidence of consistent turning and repositioning was confirmed by the DON during interview on May 25, 2022, at approximately 12:20 PM.

Review of the Documentation Survey Report indicated staff were to turn and reposition the resident every 2 hours around the clock, side to side reposition while in bed (WIB). The documentation of the completion of this task from May 1, 2022, to May 25, 2022, indicated that the resident had not been turned/repositioned for 2 consecutive hours on May 12, 21, 22, and 23, 2022, 6 consecutive hours on May 11, 2022, 8 consecutive hours on May 9, 12, 14, 19, and 16 consecutive hours on May 7, 2022. On May 14, and 19, 2022, staff documented that the program was not applicable for 2 consecutive hours and 4 consecutive hours on May 3, and 4, 2022, which was confirmed by the DON during interview on May 25, 2022, at approximately 12:20 PM.

Interview with alert and oriented Resident 68, on May 25, 2022, at approximately 2:20 PM, revealed that the resident stated that she is dependent on staff for transferring, and toileting. Resident 68 stated that almost, on a "daily basis" she waits for staff assistance (for toileting and transfers.) over 30 minutes and at times, over 45 minutes. She also stated that that many times, "they, (staff) don't make it in time."

Observation on May 25, 2022, at approximately 2:35 PM, of Resident 68's buttocks, sacrum, (with the Resident's permission) in the presence of the DON, revealed a clean, round, open area, approximately the size of a golf ball, on the resident's sacrum. The wound bed appeared red, white and soft, with minimal drainage without odor.

Interview with the DON on May 25, 2022, at approximately 12:20 PM confirmed at the time of the survey ending May 25, 2022, that the facility was unable to provide documented evidence of the consistent implementation of measures planned to promote healing of the resident's pressure sore.

Interview with the Nursing Home Administrator (NHA) on May 25, 2022, at approximately 12:50 PM, confirmed the information above, was unable to provide any additional information at the time the survey ended, and confirmed the facility failed to show documented evidence in the clinical records that the facility had consistently implement the identified interventions as planned for Resident 68's skin breakdown.


28 Pa. Code 211.5(f)(g)(h) Clinical records

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




 Plan of Correction - To be completed: 06/30/2022

1. The nurses competed late documentation to reflect corrected documentation for residents 105 and 65.
2. The facility will conduct an audit for the last 7 days to verify accurate documentation in the resident records.
3. The DON/designee will educate the facility's nurses on complete and accurate clinical documentation in the resident's records.
4. The facility will conduct an audit weekly x4 weeks and monthly x2 months to verify complete and accurate clinical documentation in resident records. Results will be reviewed at QAPI.
5. 6/30/22

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on a review of clinical records and select facility policy, and staff interviews it was determined that the facility failed to provide effective pain management and/or administer pain medication as prescribed by the physician, to alleviate pain for one of five residents sampled (Resident 65).

Findings include:

A review of the facility's policy, entitled "Pain Management" last revised August 4, 2020, indicated, each resident who experiences pain will have a comprehensive review of that pain and will have a treatment plan established to treat his or her pain. Resident preferences must be respected when deciding on methods to be used for pain management. Family members should be involved when appropriate. Use a pain scale when the resident describes his or her pain and amount of pain relief. For residents who cannot understand a numerical scale nonverbal, who may be non-communicative, or severely demented, a Simple Verbal Descriptive Pain Intensity Scale or Facial Pain Intensity Scale may be used. Residents who are non-verbal, non-communicative, or severely demented can also be reviewed for pain by monitoring other indicators that may indicate the presence of pain: Tense body language, restlessness, strained facial expressions, sad facial expressions or tearfulness. Whenever the results of a pain review reveal that a residents pain is not under control, the supervisor should notify the attending physician for further orders.

A review of the clinical record revealed that Resident 65 was readmitted to the facility May 6, 2022, with diagnoses to include fracture of the left acetabulum (hip joint), dislocation of hip, dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Alzheimer's (A progressive disease that destroys memory and other important mental functions), chronic kidney disease, right hip pain, fracture of right femur (long bone in leg), and aphasia (a language disorder that affects a person's ability to communicate).

A Significant Change Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated January 9, 2022, indicated that the resident was severely cognitively impaired with a BIMS (brief interview to assess cognitive status) score of 3 (0-7 represents severe cognitive impairment).

Resident 65's clinical record, indicated a Guardian / Resident Representative is listed as an emergency contact # 1, and a family member (niece) is listed as a care conference person.

Review of Resident 65's care plan initially dated December 14, 2020, and revised May 19, 2022, indicated that the resident has a history of right hip fracture, left hip fracture with a surgical wound, and possible left hip dislocation. It also indicated the resident has altered mental status, disorganized thinking, severely impaired cognition related to dementia and Alzheimer's. It further indicates the resident has pain, with interventions that included to reposition, pillow under the calves, and pain observation tool per policy.

A review of physician orders dated January 3, 2022, indicated Tylenol tablet (acetaminophen) 325 milligram (mg), give 2 tablets by mouth (PO) every 4 hours as needed for mild to moderate pain.

A nurses note dated April 11, 2022, at 6:34 AM, indicated that the resident was having increased difficulty ambulating this AM. Nursing noted "Right and left (bilateral) feet seem to be rotated inward thus having difficulty walking or bearing wt. (weight) Having increased pain when sitting on commode this AM. Resident not wanting to put weight on left hip area while in commode. 11-7 RN made aware."

A nurse's note dated April 11, 2022, at 6:43 AM, indicated that the resident refused pain medication x 3.

There was no documented evidence that the facility had attempted non-pharmacological measures in an attempt to alleviate the resident's pain.

A nurses note dated April 11, 2022, at 6:56 AM, indicated that the resident was turning both feet completely inward, facing toe to toe, during AM care. Nursing noted "Stated resident was resisting to sit on left hip and complaints of (c/o) left hip pain. Also, stated she was having difficulty ambulating. Will follow up with physician for evaluation and treatment. Resident currently sitting quietly in wheelchair, nonverbal."

A nurses note dated April 11, 2022, at 1:47 PM, indicated "x-ray report; right and left hip prostheses appear intact. Physician Assistant (PA) made aware. "

Restorative Nursing Program (RNP) progress note, dated April 11, 2022, at 1:52 PM, indicated that "resident having a decline with ambulation. Currently on Physical Therapy (PT) and Occupational Therapy (OT) case load. Therapy and nursing made aware."

A nurse's note dated April 11, 2022, at 2:14 PM, noted "resident secondary to increased difficulty transferring and ambulation, PA updated, and new orders received for left hip x-ray and pelvis. Result were unremarkable, PT made aware. Resident offered pain medication, but does not accept, unaware of previous fracture. Resting in bed at this time with no complaints."

A nurses note dated April 12, 2022, at 3:43 AM, indicated "she continues to have increased difficulty with transfers (TR) with assist of two staff members. Seems to not want to put weight on left leg. 11-7 RN made aware. Patient complains of pain when TR but refuses pain med x 3."

There was no documented evidence that the facility had attempted non-pharmacological measures to reduce the resident's pain in response to the resident's refusal of pain medications.

A nurse's note dated April 20, 2022, at 2:33 PM, indicated to "discontinue (DC) transfers Assist (A) x 1 staff member with / rolling walker (RW) and gait belt. RNP for transfer to continue to mobilize patient, mobility limited due to significant left lower extremity (LLE) pain. Nursing and physician staff aware."

An RNP note dated April 21, 2022, at 1:34 PM, indicated "implementation of RNP for transfers A x 1 w/ RW and gait belt, 7 x per week. Goal is to maintain A x 1. Verbal cues for pushing up from sitting surface and maintaining upright posture. Resident/family perceived goals."

A nurse's note, dated April 23, 2022, at 6:44 PM, indicated "Nursing Aide (NA), reports resident c/o pain in left hip and leg when standing. Left hip incision pink."

A nurse's note dated April 24, 2022, at 7:31 PM, indicated "a review of residents transfer and mobilization info. She is no longer independent with transfers and wheelchair (w/c), requiring maximum assist for all Activities of Daily Living (ADL's). There have been no exit seeking behaviors for greater than 6 months. Resident having a reaction to the wander guard band as noted. Will have Plan of Care (POC) review for possible D/C."

A nurses note dated April 25, 2022, at 3:25 AM, indicated "the resident denies pain to left leg/hip "as long as I don't move it (left leg)". Left hip incision remains pink with no increased warm to area noted at this time. Afebrile (no fever)."

A nurse's note dated April 25, 2022, at 1:15 PM, indicated resident "continues to have intermittent left hip pain and is not weight bearing. PA made aware, and resident to be seen by doctor."

There was no documented evidence that the facility was consistently implementing non-pharmacological interventions in an attempt to alleviate the resident's pain.

A nurses note dated April 26, 2022, at 12:53 PM, indicated "D/C RNP for Transfers A x 1 w/ RW and gait belt, 7 days per week. Patient continuing to have significant c/o pain. Back to demonstrating little to no weight bearing LLE. A x 2 for patient and staff safety. I would like to avoid use of hoyer due attempt fears of intolerance. Physician further assessing."

An appointment note dated April 27, 2022, at 1:46 PM, indicated "an appointment is made for May 2, 2022, at 1:15 PM at MRI clinic. Resident will be transported by stretcher/BLS at 1:00 PM. RN supervisor aware."

A nurses note, dated May 3, 2022, at 10:00 AM, indicated "family updated with resident going to hospital ER for her left hip pain."

A nurses note dated May 3, 2022, at 11:09 AM, indicated "telephone call to resident representative made them aware resident going back to ER related to MRI finding of left hip."

A nurses note, dated May 4, 2022, at 8:45 AM, indicated "telephone call to patient placement. Resident admitted to Hospital on May 3, at 6:28 PM with diagnoses (DX) fractured left acetabulum (Hip)."

A nurses note dated May 6, 2022, at 3:15 PM, "resident arrived via bls from Hospital. Resident is non - weight bearing at all on left hip. closed reduction done."

A physician order dated May 11, 2022, was noted for Acetaminophen extended release (ER) 650 mg tablet, give 1 tablet by mouth three (3) times a day for pain.

A review of the resident's April 2022, Medication Administration Record (MAR) revealed that staff administered Tylenol 325 mg, 2 tablets PO, on April 23, and 24, 2022, for a pain level of 10, and on April 27, 2022, for a pain level of 5.

A review of the resident's May 2022, MAR revealed that staff administered Tylenol 325 mg, 2 tablets PO, on May 3, 2022, for a pain level of 4.

There was no documented evidence that the facility timely and fully addressed the resident's increasing pain, with decreased functional ability. The facility failed to demonstrate a continuous, team approach for deciding on methods to be used for pain management, including, including involvement of family members and or resident representative, for Resident 65 who is identified as disorganized thinking, severely impaired cognition, with dementia - Alzheimer. The facility further failed to follow physician orders for administering the Tylenol 325 mg, 2 tablets prescribed for mild pain for a pain scale of 10.

Interview with the Director of Nursing (DON) on May 25, 2022, at approximately 12:20 PM, confirmed the above information, and that the facility failed to follow physician orders with administering the Tylenol for a pain scale of 10, and or that the facility failed to consistently develop and or implement comprehensive person-centered pain care plans.

During an interview on May 25, 2022, at approximately 12:50 PM, with the Nursing Home Administrator (NHA), she confirmed the facility failed to address the resident's increasing pain and failed to show evidence of a team approach for deciding on methods to be used for pain management, for a severely impaired resident and or that the facility failed to follow physician orders with administering the Tylenol prescribed for mild pain.



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

28 Pa. Code 211.2(a) Physician Services

28 Pa. Code 211.5(f)(g) Clinical records

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services



 Plan of Correction - To be completed: 06/30/2022

1. The facility in conjunction with resident 65's physician has reviewed the resident's plan of care regarding pain control.
2. The facility will audit the last 7 days of PRN pain medication administration to verify appropriate pain scale is followed.
3. The don/designee will education the facility nurses on following physician orders when administering pain medication and consistently developing and implementing comprehensive person-centered pain care plans.
4. The facility will conduct audits weekly x4 weeks and monthly x2 months to verify physician orders are followed when administering pain medications. Results will be reviewed at QAPI.
5. 6/30/22

483.80(i)(1)-(3)(i)-(x) REQUIREMENT COVID-19 Vaccination of Facility Staff:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.80(i)
COVID-19 Vaccination of facility staff. The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine.

483.80(i)(1) Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents:
(i) Facility employees;
(ii) Licensed practitioners;
(iii) Students, trainees, and volunteers; and
(iv) Individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.

483.80(i)(2) The policies and procedures of this section do not apply to the following facility staff:
(i) Staff who exclusively provide telehealth or telemedicine services outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section; and
(ii) Staff who provide support services for the facility that are performed exclusively outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section.

483.80(i)(3) The policies and procedures must include, at a minimum, the following components:
(i) A process for ensuring all staff specified in paragraph (i)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents;
(iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19;
(iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (i)(1) of this section;
(v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC;
(vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law;
(vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements;
(viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains:
(A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
(B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications;
(ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and
(x) Contingency plans for staff who are not fully vaccinated for COVID-19.

Effective 60 Days After Publication:
483.80(i)(3)(ii) A process for ensuring that all staff specified in paragraph (i)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations;
Observations:


Based on a review of the DEPARTMENT OF HEALTH & HUMAN SERVICES QSO 22-07-ALL memo dated December 28, 2021, select facility policy, staff observations and interviews, it was determined that the facility failed to fully develop and follow their policy for COVID-19 vaccination for staff.

Findings include:

A review of a DEPARTMENT OF HEALTH & HUMAN SERVICES, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group dated December 28, 2021, QSO 22-07-ALL memo stated that:

Within 60 days after the issuance of this memorandum 4, if the facility demonstrates that:

Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule; or Less than 100% of all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is noncompliant.

A review of the facility policy entitled "COVID-19 Vaccine Policies and Procedures", last reviewed/revised on February 1, 2022, indicated the purpose is to establish the process to comply with the Federal mandate that all staff are vaccinated against COVID - 19 unless they have a medical or religious exemption to help reduce the risk residents and staff have of contracting and spreading COVID -19. Additional precautions and contingency plans for unvaccinated staff: staff who receive an exemption to the COVID - 19 vaccine will be subject to additional precautions to mitigate the transmission and spread of COVID - 19, which includes: routine surveillance testing , in accordance with state, federal and / or CDC guidelines (testing twice a week), Personal protective equipment, as recommended by state, federal guidelines and or CDC guidelines (N95), assigned to work with fully vaccinated residents when possible. Any employee who has not been vaccinated in accordance with the facility COVID vaccination policy or as not submitted an acceptable exemption form will be terminated.

There was no documented evidence, at the time of the review during the survey of May 25, 2022, that the facility's policy for COVID-19 Vaccine Policies and Procedures included specific protocols defining the the personal protective equipment that is to be worn by by unvaccinated staff with qualifying exemptions, when it is required and the locations within the facility. There was no documented evidence, at the time of the review, on May 25, 2022, that the facility's policy specified when and where an "N95", is to be worn by unvaccinated staff.

Interview on May 25, 2022, at approximately 3:30 PM, with Employee 1, Licensed Practical Nurse (LPN), on the ground floor, indicated that she was granted a non-medical exemption. She was observed during this interview to be wearing a surgical mask, as confirmed by Employee 1.

At the time of the survey ending May 25, 2022, the facility had one (1) resident test positive for COVID 19, who tested positive during routine testing, and who was not hospitalized and or expired, in the past 4 weeks.

Review of National Healthcare Safety Network (NHSN) date for week ending May 15, 2022, revealed that the facility had 86.6 % of staff fully vaccinated.

Review of the facility provided, employee vaccination status - matrix, at the time survey ending May 25, 2022, revealed that 351 staff were fully vaccinated, with 2 partially vaccinated (new hire), and 53 granted exemptions, totaling 100% staff vaccination rate.

Interview with the Nursing Home Administrator (NHA) on May 25, 2022, at approximately 3:00 PM, confirmed that the facility's policy regarding COVID-19 vaccinations (additional precautions and contingency plans for unvaccinated staff) lacked specific mitigation procedures as stated above and failed to define when and where unvaccinated staff are required to wear N95 or additional PPE.



28 Pa. Code 201.14 (a) Responsibility of Licensee

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






 Plan of Correction - To be completed: 06/30/2022

1. The facility's COVID 19 policy regarding COVID-19 will be updated with when and where unvaccinated staff are required to wear an N95 or additional PPE. Employee 1 will be educated on the updated policy.
2. The facility will conduct an initial audit to verify unvaccinated staff are wearing appropriate PPE.
3. The DON/designee will educate unvaccinated staff on the updated COVID policy including the appropriate PPE.
4. The facility will conduct an audit weekly x4 weeks and monthly x2 months to verify unvaccinated staff are wearing the appropriate PPE. Results will be reviewed at QAPI.
5. 6/30/22


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