Pennsylvania Department of Health
ROBERT PACKER HOSPITAL SKILLED CARE AND REHABILITATIONCENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 54 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.


ROBERT PACKER HOSPITAL SKILLED CARE AND REHABILITATIONCENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, ans Civil Rights Compliance Survey, completed on March 8, 2024, it was determined that Robert Packer Hospital Skilled Care and Rehab Center 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:

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

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.

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on review of select facility policies and procedures, clinical record review, employee personnel records, and family and staff interview, it was determined that the facility failed to thoroughly investigate and report to the appropriate agencies incidents of potential resident neglect for two of four residents reviewed for accident concerns (Residents 4 and 48); and the facility failed to implement its abuse prohibition policy pertaining to newly hired employee training for two of five newly hired employees reviewed (Employees 4 and 5).

Findings include:

The facility policy entitled, "Resident Abuse and Neglect Prevention Program," last reviewed without changes on February 28, 2024, revealed that the facility has a plan in place to assure appropriate steps are taken to protect each resident from mistreatment, neglect, abuse, and misappropriation of property. Every complaint or allegation of resident abuse or neglect shall be promptly reported to the immediate supervisor of the area and the Administrator and/or his/her designee. Each report shall be treated promptly and with discretion with priorities that include the compliance with pertinent laws and regulations. The interpretation of the definition of neglect noted, "Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safe, adequate, and appropriate services, treatment and care, including but not limited to nutrition, medication, therapies, and activities of daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect." Section I, Abuse and Neglect Prevention included that employees are expected to immediately report any event, incident, or other concern that may be related to potential abuse or neglect. Negligence or willful inattention to resident needs or preferences as specified in the plan of care is unacceptable. Immediately upon discovery of an allegation of abuse or situation with the potential for abuse or harm, the facility will take all reasonable measures to separate the alleged perpetrator from access to the alleged victim. Upon receiving a report of abuse or alleged abuse, the registered nurse supervisor, Director or Nursing or assistant director of nursing or Administrator will begin the investigation. Any employee identified as the alleged perpetrator will be placed on immediate automatic suspension pending the outcome of the investigation. The facility will report alleged and substantiated incidents to the Pennsylvania Department of Health, additional state agencies and/or local authorities per federal and state requirements. Any report or allegation of abuse/neglect will be reported initially by the Administrator, Director of Nursing, assistant director of nursing, or delegated supervisor within 24-hours of knowledge of the event through the electronic event reporting system and use of the PB-22 (Provider Bulletin 22, document used to outline a facility's investigation of potential abuse/neglect, appropriate agency notifications, and corrective actions); Area Agency on Aging, and (if required) Protective Services, the local police, and the Pennsylvania Department of Aging. The investigative team's investigation will include interviews/statements from any witnesses to the incident, interview/statements from staff members having contact with the resident during the time of the alleged incident, and a review of all circumstances surrounding the incident. The Administrator or his/her designee will complete the PB-22 within five working days of the incident.

The Employee Abuse Prevention and Training procedure included that all new employees are required to attend an orientation program which includes a minimum of two hours of training related to Abuse and Neglect Prevention, Identification/Reporting of Abuse, and Techniques for Care for the Cognitively Impaired Resident. The employee signs a statement of receipt of education once completed, which is then maintained in the employee file.

Interview with Resident 4's daughter on March 5, 2024, at 2:12 PM, revealed that her mother was, "dropped," by staff during a shower on the Thursday before Christmas while one staff member attempted to provide care. Resident 4's daughter indicated that her mother was to have two staff present for care; however, only one staff was present when they attempted to transfer her. Resident 4's daughter stated that her mother sustained a large skin tear to her arm and that she struck her head which caused bruising and swelling.

Clinical record review for Resident 4 revealed physical therapy documentation dated January 21, 2022, that indicated an evaluation of surface transfers for safety. The documentation indicated that Resident 4 required a Hoyer lift (mechanical device used to move a resident from one surface to another via a sling requiring no participation or weight bearing by the resident) for all transfers. The documentation stipulated that Resident 4 could, transfer between surfaces in the "big bathroom" with the assistance of two staff.

Review of a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated July 25, 2023, continued to assess Resident 4 as dependent upon the extensive physical assistance of two staff for transfers and toileting.

An annual MDS assessment dated October 11, 2023, assessed Resident 4 as dependent (helper does all of the effort, the resident does none of the effort to complete the activity) for chair/bed-to-chair transfers and toileting hygiene. Tub/shower and toilet transfers were not attempted due to medical condition or safety concerns.

A quarterly MDS assessment dated December 27, 2023, assessed Resident 4 as dependent for transfers (toilet transfer, chair/bed-to-chair, tub/shower transfer), toileting hygiene, and shower/bathing.

Nursing documentation dated December 21, 2023, at 9:49 AM, revealed that the registered nurse was called to the "big bathroom" on Resident 4's nursing unit where she noted Resident 4 on the floor in front of her wheelchair. Resident 4 had a hematoma (swelling and discoloration caused by pooling of blood under the skin) to the middle of her forehead and a skin tear to her right forearm that measured 4.5 centimeters (cm) by 2 cm.

Nursing documentation dated December 24, 2023, at 7:47 AM, revealed that Resident 4 had moderate pain of her right forearm, which was red, warm, and swollen. The staff notified Resident 4's physician who provided orders for an x-ray and an antibiotic for cellulitis (skin infection) and UTI (urinary tract infection).

Nursing documentation dated December 27, 2023, at 1:57 PM, revealed that the physician assessed Resident 4's skin tear and provided new orders to culture the wound drainage (which was described as excessive and with an odor).

Review of the facility's Incident/Accident Report and Investigation of Resident 4's fall on December 21, 2023, identified that Resident 4's mobility status per her plan of care prior to the occurrence was, "Hoyer/2 (two) assist surface transfer in big BR (bathroom);" and that care plan interventions for transfer were not carried out as care planned. The report specifically noted, "only 1 (one) staff member assisting." Although the report indicated that Resident 4 was correctly transferred into a chair via a Hoyer lift before a nurse aide transferred her into the bathroom alone, the investigation did not include a statement or interview notes with a second staff person who was present during the Hoyer lift. The statement from the nurse aide present during the fall stipulated that she was assisting Resident 4 to stand to transfer her into her wheelchair from the shower chair when Resident 4 sat back down on the edge of the shower chair and slid off.

Interview with the Nursing Home Administrator on March 8, 2024, at 10:20 AM, confirmed that the facility did not identify Resident 4's fall as an incident of potential resident neglect although the required level of staff assistance was not present during the transfer. The facility submitted an event report to the Department and initiated a PB-22 report following the surveyor's questioning.

Review of Employee 4's (nurse aide) personnel record revealed that the facility hired her on January 2, 2024. Employee 4's time sheet revealed that she worked January 8, 9, 11, 15, 16, 18, 22, 23, 26, 29, and 31, 2024; and February 1, 2, 5, 6, and 7, 2024.

Review of Employee 5's (nurse aide) personnel record revealed that the facility hired her on January 3, 2024. Employee 5's time sheet revealed that she worked January 3, 5, 6, and 9, 2024.

Interview with Employee 2 (associate vice president) and Employee 3 (regulatory specialist) on March 7, 2024, at 12:23 PM, revealed that a review of Employee 4's and Employee 5's personnel records provided no evidence that their orientation programs included the training related to abuse and neglect prevention.

Interview with the Director of Nursing on March 7, 2024, at 1:05 PM, revealed that Employee 4 completed abuse prevention training on February 7, 2024. The interview also confirmed that Employee 5 did not complete abuse prevention training until January 9, 2024. The interview confirmed that Employees 4 and 5 did not receive their abuse orientation training before their presence on the nursing units.

In an interview with Resident 48 and a family member of the resident on March 5, 2024, at 11:49 AM, the family member indicated they had been notified on a few occasions recently that Resident 48 required being lowered to the floor by staff.

Clinical record review for Resident 48 revealed a nursing noted dated December 2, 2023, at 6:27 PM noting the resident was being taken to the bathroom assisted by staff, needed to rest, just tried to sit, and staff assisted the resident to the floor.

Review of Resident 48's physician's orders revealed an order dated November 29, 2023, which indicated the resident may stand pivot transfer with one assist and rolling walker and was ambulatory with a rolling walker with two assist. This order was active at the time of the December 2, 2023, incident.

Review of facility documents investigating Resident 48's incident of being lowered to the floor on December 2, 2023, noted again the resident was walking to the bathroom with staff when she started to sit and the staff member lowered the resident to the floor, and Resident 48's mobility status was two assist with a rolling walker and only one staff member was assisting the resident and the staff member was not aware of the changed status for the resident.

An attached statement from employee 6, nurse aide, dated December 2, 2023, indicated she was walking the Resident 48 to the bathroom and was going by her paper as to what the resident's status was. The facility document also indicated the staff member was educated for resident changes in status.

Further clinical record review for Resident 48 revealed a nurse's note dated January 19, 2024, at 1:10 PM noting while staff was assisting the resident to the bathroom at 7:20 AM the resident's knees buckled and the resident was lowered to the floor in the bathroom.

A review of Resident 48's physician's order dated December 29, 2023, for Resident 48's transfer/ambulation status was to utilize a two wheeled walker and two assist. This order was active at the time of the January 19, 2024, incident.

Review of facility documents regarding Resident 48's incident on January 19, 2024, revealed staff assisted the resident to and from the bathroom with one assist, and the resident was ordered two assist for transfers/ambulation and noted staff education was completed.

An attached statement from employee 7, licensed practical nurse, dated January 19, 2024, noted employee 7 was walking Resident 48 to the restroom when she stated her legs were giving out and she lowered her to a safe seat on the floor.

Clinical record review for Resident 48 revealed a nurses note dated February 20, 2024, at 7:42 AM which noted again Resident 48 became weak during transfer and was assisted to the floor.

Review of physician orders for Resident 48 revealed an order dated February 3, 2024, for Resident to transfer with a two wheeled walker and two assist. This order was active at the time of the February 20, 2024, incident.

Review of Resident 48's care plan revealed the resident had an active plan of care for the potential for falls in which an intervention was added on December 12, 2023, which indicated the resident was to have a gait belt for transfers, and "transfers, ambulation with two assist and two wheeled walker" with "staff education 1/21/24 for fall," noted beside it.

Review of a facility document investigating Resident 48's incident on February 20, 2024, occurred at 5:30 AM and revealed the resident was assisted to the floor when she became weak during transfer from her bed to her recliner, and the resident was being transferred with one assist and her mobility plan of care was two assist with two wheeled walker and her transfer plan of care was two assist.

An attached statement from employee 8, nurse aide, indicated after assisting Resident 48 to the bathroom the resident sat in the recliner and then decided to go to bed and got weak and slid off the chucks while getting up. Another attached statement from employee 9, licensed practical nurse, noted the resident wanted to go from the bathroom to the recliner, to bed and became weak and "we" lowered her to the floor, although the facility document indicated staff education was to be completed to prevent reoccurrence as the resident to be assisted by two using a two wheeled walker. There was no other documentation to indicate a second staff member was present.

There was no evidence the incidents for Resident 48 that occurred on December 2, 2023, January 19, 2024, and February 20, 2024, all resulting in the resident being lowered to the floor during ambulation/transfer without the ordered/appropriate level of assistance were reported to the Department of Health event reporting system or investigated as alleged neglect for not following the resident's orders/plan of care resulting in falls for the resident. Resident 48 did not sustain any injuries from the incidents.

In an interview with the Nursing Home Administrator and Director of Nursing on March 8, 2024, the above findings were reviewed for Resident 48. The Director of Nursing confirmed the incidents were not reviewed or investigated as potential neglect.

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

28 Pa. Code 201.19(6)(8) Personnel policies and procedures

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

Plan of Correction - To be completed: 04/17/2024

Resident 4 and 48 transfer orders clarified and updated in EMR. Staff education on transfer status of Resident 4 and 48.
Full house audit completed to identify any other potentially affected residents.
Education to all staff provided on transfer/ambulation status and following plan of care.
Education provided to DON and RN supervisors on reports of potential abuse/neglect.
All staff education provided on neglect/abuse policy and procedure.
Audits to be completed weekly by DON or Designee x 4 weeks, then Monthly x 5 months
All audits to be reviewed monthly in QAPI.

Employees 4 and 5 have completed abuse training.
Audits complete of all staff to identify any other potential employees.
Education provided to HR/DON on requirement for abuse training.
Audits to be completed weekly x4 weeks, then monthly x 5 months
All audits to be reviewed monthly in QAPI.

483.10(f)(10)(iii) REQUIREMENT Accounting and Records of Personal Funds:

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(f)(10)(iii) Accounting and Records.
(A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
(B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.
(C)The individual financial record must be available to the resident through quarterly statements and upon request.

Observations:

Based on review of resident personal fund accounting, clinical record review, and resident and staff interview, it was determined that the facility failed to provide a resident fund quarterly statement for one of two residents reviewed for personal fund concerns (Resident 40).

Findings include:

Clinical record review for Resident 40 revealed an MDS assessment (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 30, 2024, that assessed Resident 40 as able to make himself understood, had clear comprehension when understanding others, and had a BIMS (Brief Interview for Mental Status, an assessment tool to determine cognitive deficits) score of 15 (indicating no cognitive deficits).

Review of a, "Resident Trust Fund Authorization Form," (document that the facility utilized to obtain a resident/resident representative authorization to hold money for the resident) signed by Resident 40 on May 26, 2020, revealed that Resident 40 did not designate another person to manage his personal funds. The document stipulated that a, "...full and complete separate accounting of all financial transactions made on his/her behalf will be maintained and made available to the Resident and/or Power-of-Attorney/Guardian at least quarterly and upon request."

Interview with Resident 40 on March 5, 2024, at 10:20 AM, revealed that he did not receive any financial statements pertaining to his personal fund account. Resident 40 denied that he had any family or individuals who assisted him to manage his finances.

Interview with the Director of Nursing and the Nursing Home Administrator on March 7, 2024, at 2:19 PM, confirmed that the facility had no evidence that Resident 40 received a statement of his personal fund account at least quarterly.

483.10(f)(10)(iii) Accounting and Records
Previously cited deficiency 4/7/23

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(2)(3)(e)(1)(f) Management

28 Pa. Code 201.29(a) Resident rights

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

Plan of Correction - To be completed: 04/17/2024

Resident 40 designated another person to manage his funds.
Complete Audit to be completed of resident funds management to determine if any other residents have been affected.
Residents/residents rep will receive a signed copy of statements to acknowledge they have received or sent via certified mail.
Audits to be completed each quarter for the year 2024 by NHA or Designee
Audit results to be reported in QAPI.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:

§483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section.

§483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Observations:
Based on clinical record review and staff interview it was determined that the facility failed to provide the correct required notification to a resident whose payment coverage changed for two of three residents reviewed (Residents 18 and 60).

Findings include:

A review of the form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end.

A review of the "Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055" revealed that examples of the common reasons why an extended care stay, or services may not be covered under Medicare might include the beneficiary no longer requires daily skilled care for a medical condition but wants to continue residing in the skilled nursing facility (SNF). The SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. In the blank that follows "Beginning on ...," the skilled nursing facility enters the date on which the beneficiary may be responsible for paying for care that Medicare is not expected to cover. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice.

The SNF must issue this notice when there is a termination of all Medicare Part A services for coverage reasons. If after issuing the NOMNC, the SNF expects the beneficiary to remain in the facility in a non-covered stay, the SNFABN must be issued to inform the beneficiary of potential liability for the non-covered stay.

Clinical record review for Resident 18 revealed ADT (Admit, Discharge, Transfer) Event documentation that indicated Resident 18's care changed from skilled to non-skilled on November 23, 2023.

A review of a CMS-10123 form provided by the facility confirmed that Resident 18's last covered day of Medicare A services ended November 22, 2023.

The facility did not provide a CMS-10055 form for Resident 18 who remained in the facility for services that would not be covered by Medicare Part A.

The facility provided a CMS-R-131 (Advance Beneficiary Notice of Noncoverage (ABN) used to notify beneficiaries of the discontinuation of Medicare Part B services) form which was signed by Resident 18's Power-of-Attorney on November 21, 2023. There were no comments or information provided on the form to indicate a reason that the notice was not given at least two days before a change in Resident 18's payment source.

The graph on the CMS website (Beneficiary Notices Initiative) stipulates that the provider types for the CMS-R-131 form use include independent laboratories, home health agencies, hospices, physicians, practitioners, and providers paid under Medicare Part B. The same graph instructs that skilled nursing facilities are to use the CMS-10055 form.

Interview with the Nursing Home Administrator on March 8, 2024, at 10:21 AM, confirmed that the facility provided the incorrect Medicare notice to Resident 18's Power-of-Attorney which was dated less than two days from the date the payment source for her care changed.

Clinical record review for Resident 60 revealed that the coverage for his skilled nursing care ended December 9, 2023.

A review of a CMS-10123 form provided by the facility confirmed that Resident 60's last covered day of Medicare A services ended December 9, 2023.

The facility did not provide a CMS-10055 form for Resident 60 who remained in the facility for services that would not be covered by Medicare Part A.

The facility provided a CMS-R-131 form which was signed by Resident 60's daughter on December 5, 2023.

Interview with the Nursing Home Administrator on March 8, 2024, at 10:21 AM, confirmed that the facility provided the incorrect Medicare notice to Resident 60's representative when the payment source for his care changed.

483.10(g)(17)(18)(i)-(v) Medicaid/medicare Coverage/liability Notice
Previously cited deficiency 4/7/23

28 Pa. Code 201.18(b)(2)(e)(1) Management

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 04/17/2024

Residents 18 and 60 remain in the facility. Resident/resident reps 18 and 60 have received the corrected form.
Staff education on NOMNC/ABN forms and process
Audits completed for completion of NOMNC in required time frame.
Weekly Audits x4
Monthly audits x 5 All audits to be reviewed monthly in QAPI.

483.25 REQUIREMENT Quality of Care:

§ 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 resident and staff interview, it was determined that the facility failed to provide the highest practicable care related to physician ordered bowel management medications for one of 17 residents reviewed (Resident 26).

Findings include:

Interview with Resident 26 on March 5, 2024, at 12:08 PM, revealed that she needs MOM (Milk of Magnesia, liquid medication used to stimulate a bowel movement) or a suppository (Bisacodyl/Dulcolax, medication inserted into the rectum to stimulate a bowel movement) occasionally. Resident 26 believed that she had a bowel movement approximately every three days.

Clinical record review for Resident 26 revealed the following active physician ordered bowel protocol medications dated as initiated on November 2, 2022:
Magnesium Hydroxide 400 mg (milligrams) per 5 ml (milliliters) oral suspension (Milk of Magnesia, MOM) 30 ml daily as needed if no bowel movement every second and third day
Bisacodyl 10 mg rectal suppository daily as needed on the fourth day of no bowel movement
Fleet enema 7-19 gm (grams) per 118 ml daily as needed if suppository ineffective (liquid medication instilled through the rectum to stimulate a bowel movement)

Review of Resident 26's "Bowel Movement History" documentation (electronic documentation used by staff to record episodes and descriptions of residents' bowel movements) dated January and February 2024 revealed the following:
Did not have a bowel movement between January 2, 2024, at 2:51 PM, and January 8, 2024, at 2:26 PM
Did not have a bowel movement between January 14, 2024, at 6:57 AM and January 19, 2024, at 7:09 AM.
Did not have a bowel movement between January 30, 2024, at 1:40 PM and February 4, 2024, at 10:53 PM.

Review of Resident 26's MAR (Medication Administration Record, electronic system used by staff to document the administration of medications) dated January and February 2024 revealed that staff administered the MOM medication on the following dates:
January 5, 2024, at 6:46 AM
January 8, 2024, at 1:33 AM
January 17, 2024, at 9:46 PM
February 3, 2024, at 7:21 AM

Resident 26's clinical record did not contain evidence that staff attempted to administer the bowel management medications as ordered per the following:
MOM medication on January 4, 2024; the Dulcolax on January 6, 2024; or the Fleet enema following an ineffective suppository after January 6, 2024.
MOM medication on January 16, 2024, or the Dulcolax on January 18, 2024
MOM medication on February 1 or 2, 2024

The surveyor reviewed the above findings during an interview with the Nursing Home Administrator on March 8, 2024, at 9:35 AM.

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

Plan of Correction - To be completed: 04/17/2024

Resident 26 has had regular Bowel Movements
Audit completed to identify any other potential residents.
Bowel Management policy updated.
Staff education provided on bowel management policy and procedures.
Audits to be completed weekly x4 weeks, then monthly x 5 months
All audits to be reviewed monthly in QAPI.

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia:

§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of three residents reviewed (Resident 29).

Findings include:

Clinical record review for Resident 29 revealed the facility admitted her on May 12, 2023, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 29's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated May 18, 2023, indicated that the facility assessed Resident 29 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.

A review of Resident 29's care plan dated May 25, 2023 revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss, which should reflect family involvement in development. The facility indicated that Resident 29's goal would be for Resident 29 to return to her previous cognitive status which would be impossible.

The findings were reviewed with the Administrator and Director of Nursing on March 6, 2024, at 1:15 PM, and confirmed that Resident 29 did not have an individualized care plan for dementia and cognitive loss.

483.40(b)(3) Dementia Treatment and Services
Previously cited 4/7/23

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

Plan of Correction - To be completed: 04/17/2024

Resident 29 plan of care updated to include a person-centered care plan that addresses dementia and cognitive loss.
Facility wide audit completed to identify any other potential residents without person centered dementia/ cognitive loss care plan.
Staff education on development of person-centered care plan
Audits to be completed weekly by RN supervisor/DON for 4 weeks, then monthly x 5
All audits to be reviewed monthly in QAPI.

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

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on clinical record review, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents reviewed (Resident 29).

Findings include:

Review of Resident 29's clinical record revealed a physician order dated January 15, 2024, for staff to administer Haldol (typical used to treat schizophrenia or Tourette's syndrome) .5 mg (milligrams) every four hours as needed for behaviors. The facility stopped and restarted the same Haldol order on January 25, 2024, February 7, 2024, February 23, 2024, February 29, 2024, and March 8, 2024, making it a continuous as needed order. The most recent physician order for Haldol dated March 8, 2024, continues until April 7, 2024, making it almost a month of as needed usage for Resident 29.

There was no documented evidence in Resident 29's clinical record to justify the continued use of the as needed Haldol for almost a four-month period.

A pharmacy recommendation dated January 20, 2024, indicated that the pharmacist identified that Resident 29's as needed Haldol order did not have a 14 day stop date. The pharmacist recommended that Resident 29's physician provide the stop date for her Haldol usage. There was no response from Resident 29's physician to indicate a stop date or a rationale for using the Haldol as needed past 14 days.

Interview with the Director of Nursing on March 8, 2024, at 12:40 PM, confirmed the above findings for Resident 29.

28 Pa. Code 211.9(k) Pharmacy services

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

Plan of Correction - To be completed: 04/17/2024

Resident 29 physician order for Haldol has been updated by MD to include justification for the continued use of the need of Haldol.
Staff education including MD on use of PRN psychotropic medication, and documentation.
Full house audit to identify any potential other residents and the use of unnecessary psychotropic meds.
Audits to be completed weekly by DON or Designee x 4 weeks, then Monthly x 5 months
All audits to be reviewed monthly in QAPI.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to monitor antibiotic use for one of three residents reviewed for antibiotics (Resident 48).

Findings include:

Clinical record review for Resident 48 revealed a nurse's note dated February 21, 2024, at 1:09 PM noting Resident 48 had a new order for Cipro, (Ciprofloxacin, a medication used to treat bacterial infections in many different parts of the body), 500 milligrams for 10 days, and that a urinalysis with culture and sensitivity was ordered, also noting the resident had thick, tan, purulent urine.

Further review of Resident 48's clinical record revealed Resident 48 did have a physician's order to start Ciprofloxacin HCL 500 mg twice a day to start February 21 and end on March 1, 2024, as indicated for a urinary tract infection.

Review of Resident 48's lab reports revealed a urine specimen was collected on February 22, 2024, and resulted the same day showing greater than 100,000 CFU/mL, (colony forming unit per milliliter), normal urogenital flora and no further workup was needed.

A review of Resident 48's medication administration record revealed the resident was administered the Ciprofloxacin twice a day from February 21 through March 1, 2024, as ordered.

There was no evidence Resident 48's physician was contacted to review the use of the antibiotic after the urinalysis revealed no need for a culture and sensitivity workup or any physician documentation indicating an explanation as to why the antibiotic was ordered prior to urinalysis results, or as to why it continued after the urinalysis results were available.

In an interview with the Nursing Home Administrator, Director of Nursing, and employee 1, infection control, on March 8, 2024, at 12:49 PM it was confirmed an antibiotic was started on Resident 48 for a urinary tract infection prior to the urinalysis being completed, the antibiotic continued after no culture and sensitivity was indicated, and there was no evidence of communication with the physician regarding the continued antibiotic use or documentation to indicate as to why the antibiotic continued to be administered until March 1, 2024 as ordered.

28 Pa. Code 211.10(d) Resident care policies

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

Plan of Correction - To be completed: 04/17/2024

Resident 48 urine culture reviewed with MD. Explanation obtained as to why antibiotics continued.
Staff education including Physicians on reviewing culture and sensitivity and appropriate documentation.
Full house audit to identify any potential other residents with cultures completed.
Audits to be completed weekly by DON or Designee x 4 weeks, then Monthly x 5 months
All audits to be reviewed monthly in QAPI.

§ 201.18(b)(2) LICENSURE Management.:

(2) Protection of personal and property rights of the residents, while in the facility, and upon discharge or after death, including the return of any personal property remaining at the facility within 30 days after discharge or death.

Observations:
Based on clinical record review and staff interview, it was determined that there was no evidence that identified the disposition of a resident's personal belongings following discharge from the facility for two of three closed records reviewed (Residents 68 and 70).

Findings include:

A closed clinical record review for Resident 68 revealed the resident was discharged to home on December 11, 2023.

A review of Resident 68's personal belongings inventory form revealed that it was not signed by the resident/responsible party upon discharge from the facility. Further review of the resident's closed clinical record revealed no documentation to indicate the disposition of Resident 68's personal belongings.

Interview with the Nursing Home Administrator on March 8, 2024, at 12:29 PM confirmed the above noted findings related to the disposition of Resident 68's personal belongings.

Closed clinical record review for Resident 70 revealed that the resident expired at the facility on January 16, 2024.

Review of an Inventory of Personal Effects form (document that the facility utilized to account for resident property on admission and again on discharge) contained in Resident 70's clinical record revealed no disposition of his property following his death on January 16, 2024.

Interview with the Nursing Home Administrator on March 8, 2024, at 9:58 AM, and the Director of Nursing on March 8, 2024, at 11:26 AM, revealed that the facility had no additional evidence of the disposition of Resident 70's property following his death on January 16, 2024.

Plan of Correction - To be completed: 04/17/2024

Resident 68 and 70 have been discharged from the facility.
Staff education on procedure for disposition of resident belongs at discharge.
Audit completed to identify any other potential incomplete resident belongings disposition.
Audits to be completed weekly x4 weeks, then monthly x 5 months
All audits to be reviewed monthly in QAPI.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement