Nursing Investigation Results -

Pennsylvania Department of Health
PROMEDICA SKILLED NURSING AND REHABILITATION (BETHLEHEM NORT
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PROMEDICA SKILLED NURSING AND REHABILITATION (BETHLEHEM NORT
Inspection Results For:

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PROMEDICA SKILLED NURSING AND REHABILITATION (BETHLEHEM NORT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on April 21, 2022, it was determined that Promedica Skilled Nursing and Rehabilitation (Bethlehem North) 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) 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 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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on policy review, observation, and staff interview, it was determined the facility failed to store food under sanitary conditions.

Review of the facility policy entitled, "Sanitation and Infection Control: Labeling and Dating," dated March 30, 2022, revealed that all food items were to be labeled, dated, use-by dates monitored and followed, and prepared foods were to be removed from cold storage after five days and discarded.

Observations during the kitchen tour on April 19, 2022, at 9:30 a.m., with the dietary manager revealed that in refrigerator 2 there was a container of green gelatin not dated and a container of fruit cocktail that was dated April 12, 2022. In freezer 3, there was a pizza with torn plastic wrapping that was open to air, two bags of french fries, two bags of pierogies, four banana cream pies and an open bag of sliced garlic bread. All the items were removed from the original packaging and were not dated.

In an interview on April 19, 2022, at 10:00 a.m., the Dietary Manager confirmed that the fruit cocktail should have been discarded, the pizza should have been wrapped securely and that the other food items should have been dated.

28 Pa. Code 201.18(b) (3) Management.

28 Pa. Code 211.6 (c) Dietary services.







 Plan of Correction - To be completed: 05/26/2022

1.All expired and improperly labeled food has been removed and discarded and no residents were affected by the deficient practice.

2.Current residents and new admissions have the potential to be affected by the deficient practice. Utilizing the "Kitchen Food Services" QAPI tool, a comprehensive audit of food items will be completed to ensure proper labeling and storage.

3.To ensure the deficient practice does not re-occur the Food Service Manager/designee will educate dietary staff on "focus Ftag 812", labeling food and date marking on or before the date of compliance.

4.Utilizing the "Kitchen Sanitation Quick Checklist" Sodexo Tool, the Food Service Director will audit food for proper labeling and dating daily for 4 weeks. Any trends will be reported to the QAPI Committee for further action planning.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide meal service in a manner to promote dignity in dining for two of 22 sampled residents. (Residents 111, 125)

Findings include:

Clinical record review revealed that Resident 111 had diagnoses that included dementia and adult failure to thrive. The Minimum Data Set (MDS) assessment dated March 19, 2022, indicated that he was cognitively impaired, was usually understood, usually understood others, and required extensive staff assistance with eating. Observation during lunch in the third floor dining room on April 20, 2022, revealed that the first food cart arrived at 11:43 a.m. and four of eight tables were served and the residents began eating. While watching others eat, Resident 111 called out, "Help me with food. Yo, what about me? Over here." The second cart arrived at 11:53 a.m. and two additional tables were served. The third cart arrived on the nursing unit at 12:05 p.m. and the final two tables were served. Resident 111 did not receive his meal until 12:05 p.m.

Clinical record review revealed that Resident 125 had diagnoses that included dementia. The MDS assessment dated March 24, 2022, indicated that he was cognitively impaired, understood others, and required supervision and set-up with eating. Observation during lunch in the second floor dining room on April 20, 2022, revealed that the first meal cart, containing the trays for the dining room, arrived on the unit at 12:28 p.m. Resident 125 was seated at a small table with Resident 61 in the center of the dining room with residents at tables surrounding him. All dining room meal trays contained in the first cart were served by 12:35 p.m. Resident 125 did not receive his lunch from the first cart and sat with the other residents while they ate including Resident 61 who was seated at his table. Resident 125 did not receive lunch until the third meal cart arrived on the unit with his tray at 12:52 p.m. During an interview on April 20, 2022, at 12:43 p.m., the registered nurse (RN 1) confirmed that Resident 125 had eaten in the dining room during previous meals.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 211.6(c) Dietary services.









 Plan of Correction - To be completed: 05/26/2022

1. The cited residents (R111 and R125) were updated in E-Kardex for their meal tray to arrive on dining room food cart. All seating charts updated for dining room.

2. Current residents and new admissions have the potential to be affected by the deficient practice. Utilizing the "Dining Room Seating Charts" Food Service Manager/designee will update E-Kardex to validate meal tickets are in proper order.

3. To ensure the deficient practice does not re-occur the NHA/designee will educate center staff utilizing the "Focus on Ftag 550" on or before the date of compliance.

4. Utilizing the "Dining Room Monitoring Tool" the NHA/designee will audit all dining rooms weekly for 4 weeks to validate that appropriate residents are in the dining rooms and meal trays are arriving on proper meal cart. Any trends will be reported to the QAPI committee for further action planning if needed.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(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 attempt non-pharmacological interventions prior to administration of as needed psychoactive medication for one of 32 sampled residents. (Resident 140)

Findings include:

Clinical record review revealed that Resident 140 had diagnoses that included anxiety and depression. The Minimum Data Set assessment dated April 12, 2022, indicated that the resident was alert and oriented. A physician order dated April 8, 2022, directed staff to administer an anti-anxiety medication (lorazepam) as needed for anxiety and sleep. Review of the medication administration record revealed that staff administered the lorazepam on eleven occasions in April 2022. There was no documented evidence that staff offered non-pharmacological interventions prior to the administration of the as needed psychoactive medication.

In an interview on April 21, 2022 at 1:10 p.m., the Director of Nursing confirmed that there was no documented evidence of attempts to offer non-pharmacological interventions prior to administration of lorazepam.

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





 Plan of Correction - To be completed: 05/26/2022

1.R140 discharged on 4/21/2022

2.Current residents and new admissions have the potential to be affected by the deficient practice. Social Services/designee will complete a comprehensive audit of all residents with PRN Psychotropic medications.

3.To ensure the deficient practice does not reoccur, DON/designee will educate nursing staff utilizing the "Focus on Ftag 758" on or before the date of compliance.

4.Utilizing the "Psychotropic Medications" audit tool, Social Services/designee will audit 7 residents per week for 4 weeks to validate that NPI's are being provided prior to giving PRN Psychotropic medication. Any trends will be reported to the QAPI committee for further action planning if needed.

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 clinical record review and staff interview, it was determined that the facility failed to ensure pain management included the attempt to provide non-pharmacological interventions to alleviate pain prior to or in conjunction with the administration of pain medication prescribed on an as needed basis for one of 32 sampled residents. (Resident 140)

Findings include:

Clinical record review revealed that Resident 140 had diagnoses that included fibromyalgia (a disorder that affects muscle and soft tissue). A physician's order dated April 9, 2022, directed staff to provide the resident an as needed pain medication, tramadol, every six hours. The care plan included that staff were to offer non-pharmacological interventions such as warm/cool compress, massage, and positioning to assist with pain. Review of the medication administration record revealed that the resident received the as needed pain medication on eleven occasions in April 2022. There was a lack of documentation to support that non-pharmacological interventions were offered to address the pain when the as needed pain medication was administered.

In an interview on April 21, 2022, at 1:10 p.m., the Director of Nursing confirmed that there was a lack of documentation to support that non-pharmacological interventions were offered to Resident 140 prior to or in conjunction with the administration of the as needed pain medication.

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





 Plan of Correction - To be completed: 05/26/2022

1.R140 discharged on 4/21/2022

2.Current residents and new admissions have the potential to be affected by the deficient practice. Current residents and new admissions who are prescribed PRN pain medications will be identified. Facilities will validate patients with current Pain Medication will have NPI's care-planned.

3.To ensure the deficient practice does not reoccur, the DON/designee will educate nursing staff utilizing the "Focus on Ftag 697" on or before the date of compliance.

4.Utilizing the "Pain" audit tool, the DON/designee will audit 10 residents per week for 4 weeks to validate NPI's are being offered prior to giving PRN pain medication. Any trends will be reported to the QAPI committee for further action planning if needed.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on clinical record review and observation, it was determined that the facility failed to ensure that catheter care was provided in accordance with the plan of care for one of 32 sampled residents. (Resident 64)

Findings include:

Clinical record review revealed that Resident 64 was admitted to the facility on December 16, 2021, with diagnoses that included chronic kidney disease and malignant neoplasm (cancerous tumor). Review of the Minimum Data Set assessment dated February 20, 2022, revealed that the resident had cognitive impairments, and required extensive assistance from staff for activities of daily living and had an indwelling urinary catheter. Review of the current care plan revealed that the resident had an indwelling catheter due to urinary retention with an intervention for staff to maintain the drainage bag below bladder level. On April 20, 2022, from 10:20 a.m. through 1:00 p.m., Resident 64 was observed in a reclining wheelchair with his catheter drainage bag containing urine on the chair seat between his left knee and the armrest and level with his bladder.

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




 Plan of Correction - To be completed: 05/26/2022

1.R64 was not affected negatively by the deficient practice.

2.Current residents and new admissions have the potential to be affected by the deficient practice. Utilizing the "Incontinence/Catheters" QAPI tool, a comprehensive audit of residents who have a catheter/SP Catheter will be completed.

3.To ensure the deficient practice does not reoccur, the DON/designee will educate center staff utilizing the "Focus on Ftag 690" on or before the date of compliance.

4.Utilizing the "Incontinence/Catheter" QAPI tool, the DON/designee will audit 3 residents per week for 4 weeks to validate catheters are below bladder level. Any trends will be reported to the QAPI committee for further action planning if needed.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop a care plan and interventions to address an identified problem area for one of 32 sampled residents. (Resident 52)

Findings include:

Clinical record review revealed that Resident 52 had diagnoses that included Alzheimer's disease, benign prostatic hyperplasia (condition in which the flow of urine is blocked due to the enlargement of prostate gland), anxiety, and depression. Review of the Minimum Data Set (MDS) assessment dated May 16, 2022, revealed that the resident had a communication impairment and that his primary language was Russian. The Care Area Assessment (CAA) for this MDS assessment indicated that communication was a problem that need to be included on the plan of care. Review of the current care plan did not include any interventions to address Resident 52's communication impairment or primary language.

In an interview on April 21, 2022, at 2:45 p.m., the Director of Nursing confirmed that there had been no care plan developed to address the resident's communication needs.

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




 Plan of Correction - To be completed: 05/26/2022

1.R52 was provided with Russian language cards and care plan updated to show that Russian language is primary.

2.Current residents and new admissions have the potential to be affected by the deficient practice. Utilizing the "Language List Report" Social Services/designee will run report to ensure all residents with a different primary language are care planned.

3.To ensure the deficient practice does not reoccur, the DON/designee will educate center staff utilizing the "Focus on Ftag 656" on or before the date of compliance.

4.Utilizing the "Language" audit tool, Social Services/designee will audit 4 residents weekly for 4 weeks to validate that their language care plan is updated. Any trends will be reported to the QAPI committee for further action planning.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on facility policy review, facility incident report review, clinical record review, and staff interview, it was determined the facility failed to immediately report an allegation of abuse or injury of unknown origin to the Administrator/Abuse Prevention Coordinator of the facility for two of 22 sampled residents. (Residents 17, 91)

Findings include:

Review of the facility policy entitled, "Patient Protection, Abuse, Neglect, Mistreatment, and Misappropriation Prevention," dated March 30, 2022, revealed the directive that the facility must not use verbal, mental, sexual, or physical abuse. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator of the facility.

Clinical record review revealed that Resident 17 had diagnoses that included anxiety disorder, depression, psychosis (a severe mental disorder), and muscle weakness. The Minimum Data Set (MDS) assessment dated January 25, 2022, indicated that the resident was cognitively impaired; but, was able to state the correct year and recall items after cueing. She required extensive staff assistance for bed mobility, transferring between surfaces, dressing, and personal hygiene. Review of facility witness statements revealed that Resident 17 made an allegation of sexual abuse by a staff member to a nurse aide (NA 1) on February 10, 2022. There was a lack of evidence to support that the facility Administrator (Abuse Prevention Coordinator) was notified within two hours of the allegation or that an investigation had been started until February 11, at 11:00 a.m. Documentation reflected that the Administrator was not notified until February 11, 2022, at 11:30 a.m. During an interview on April 21, 2022, at 1:54 p.m., the Administrator confirmed that Resident 17 made the allegation of sexual abuse during the 3:00 p.m. to 11:00 p.m. nursing shift on February 10, 2022, and that she was not notified until February 11, 2022, at 11:30 a.m.

Clinical record review revealed that Resident 91 had diagnoses that included Parkinson's disease (a chronic and progressive movement disorder) and other symptoms and signs involving cognitive functions and awareness. The MDS assessment dated February 28, 2022, indicated that the resident was cognitively impaired, required supervision for transferring and walking, and required staff assistance for dressing, personal hygiene, and using the toilet. Review of facility witness statements revealed that a nurse aide (NA 2) saw a bruise on the right side of the resident's chest during the night shift on February 8, 2022. When asked by the nurse aide about the bruise the resident stated he did not know what happened. Documentation by the nurse practitioner on February 9, 2022, at 9:30 a.m. indicated that the resident was observed with a contusion and ecchymosis of the right humerus/shoulder, right posterior shoulder, and right anterior upper chest of unknown cause or onset. The facility incident report dated February 9, 2022, at 11:57 a.m., indicated that the injury was identified by the nurse practitioner. There was a lack of evidence to support that the Administrator was immediately notified within two hours regarding the injury of unknown origin. During an interview on April 21, 2022, at 1:54 p.m., the Administrator confirmed that she was not notified of the injury within two hours and was informed following assessment by the nurse practitioner.

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






 Plan of Correction - To be completed: 05/26/2022

1.Residents R17 & R91 were not adversely affected by the deficient practice.

2.Current residents and new admissions have the potential to be affected by the deficient practice. Utilizing the "Patient Protection Practice Guide" all current employees, including agency staff will sign that they received abuse training and reporting education.

3.To ensure the deficient practice does not reoccur, the NHA/designee will educate center staff utilizing "Focus on Ftag 609" on or before the date of compliance.

4.Utilizing the "Abuse Prevention" QAPI tool, the NHA/designee will audit 7 employees weekly for 4 weeks to validate that they understand the reporting requirements for abuse/alleged violations. Any trends will be reported to the QAPI committee for further action planning if needed.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on facility policy review, clinical record review, observation and staff interview, it was determined the facility failed to assess residents for physical restraints and conduct an on-going assessment of a restraint for two of 32 sampled residents. (Residents 52, 103)

Findings include:

Review of the facility policy entitled "Restraint Guidelines," dated March 30, 2022, revealed that prior to the use of a restraint, the resident would be evaluated by the interdisciplinary team. The continued use of and need for a restraint was to be evaluated by the interdisciplinary team with scheduled assessments and with any change in condition.

Clinical record review revealed that Resident 52 had diagnoses that included Alzheimer's disease, benign prostatic hyperplasia (condition in which the flow of urine is blocked due to the enlargement of prostate gland), anxiety, and depression. Review of the Minimum Data Set (MDS) assessment dated February 16, 2022, revealed that the resident had cognitive impairments, and required extensive assistance with dressing and toileting. Review of the current care plan revealed Resident 52 was at risk for behavior symptoms due to Alzheimer's disease with an intervention to wear a jump suit. Observations on April 20, 2022 from 10:28 a.m. through 1:00 p.m., and on April 21, 2022 at 8:37 a.m., revealed Resident 52 dressed for the day wearing a one piece jump suit that zipped down the back. The jump suit limited his normal access to his own body and staff assistance was required to put on and take off the jump suit.

Clinical record review revealed that Resident 103 had diagnoses that included senile degeneration of the brain, anxiety, depression, and adjustment disorder. Review of the MDS assessment dated March 14, 2022, revealed that the resident had cognitive impairments, and required extensive assistance with dressing and toileting. Review of the current care plan revealed Resident 103 was at risk for behavior symptoms due to Alzheimer's with an intervention to dress in body suits. Observations on April 19, 2022 from 10:27 a.m. through 1:30 p.m., and on April 20, 2022 from 10:29 a.m. through 1:00 p.m., revealed Resident 103 dressed for the day wearing a one piece jump suit that zipped down the back. The jump suit limited his normal access to his own body and staff was required to put on and take off the jumpsuit.

There was no documented evidence that the facility did an initial restraint evaluation or continued restraint assessments for either Resident 52 or 103 to determine if the restraints were needed in accordance with facility policy.

In an interview on April 21, 2022, at 12:35 p.m., the Nursing Home Administrator confirmed the facility did not conduct any restraint evaluations for the use of the jump suits.

28 Pa. Code 211.8(e)(f) Use of Restraints.

28 Pa. Code 201.12(d)(1) Nursing services.





 Plan of Correction - To be completed: 05/26/2022

1.The cited residents (R52 and R103) had jumpsuits discontinued.

2.Current residents and new admissions have the potential to be affected by the deficient practice. Facility will validate MDS in section "P" to ensure no current resident is utilizing Physical restraints. If Physical Restraint is utilized, facility will complete restraint assessment and identify for appropriateness.

3.To ensure the deficient practice does not reoccur, the DON/designee will educate center staff utilizing the "Focus on Ftag 604", on or before the date of compliance.

4.Utilizing the "behaviors" eagle room tool, the DON/designee will audit 6 behaviors per week for 4 weeks to validate that physical restraints aren't being utilized for behaviors. Any trends will be reported to the QAPI committee for further action planning if needed.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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, facility documentation review, and staff interview, it was determined that the facility failed to provide a skilled nursing facility advanced beneficiary notice (SNF-ABN) and/or a Notice to Medicare Provider Non-coverage (NOMNC) forms to the resident or the resident's representative following the end of their Medicare coverage for two of three sampled residents who were discontinued from Medicare Part A with benefit days remaining. (Residents 66, 142)

Findings include:

Clinical record review revealed that Resident 66 had diagnoses that included schizophrenia. The Minimum Data Set assessment (MDS) dated February 23, 2022, indicated that the resident had some memory problems. Resident 66 received Medicare Part A services from February 9, 2022, through March 4, 2022. According to the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by the facility, he was discontinued from Medicare Part A with benefit days remaining and the termination of skilled services was initiated by the facility. Review of the clinical record revealed that there was no documented evidence that the resident's representative was notified in writing and provided the required SNF-ABN form (a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case) or NOMNC form (form that conveys the right to a review of the service termination).

Clinical record review revealed that Resident 142 had diagnoses that included heart failure. The MDS assessment dated March 8, 2022, indicated that the resident had some memory problems. Resident 142 received Medicare Part A services from March 5, 2022 through April 18, 2022. According to the SNF Beneficiary Protection Notification Review form completed by the facility, she was discontinued from Medicare Part A with benefit days remaining and the termination of skilled services was initiated by the facility. Review of the clinical record revealed that there was no documented evidence that the resident's representative was notified in writing and provided the required SNF-ABN form or NOMNC form.

In an interview conducted on April 21, 2022, at 11:09 a.m., the Social Work Director confirmed that there was no documentation to support that written SNF-ABN and NOMNC notice was provided to the residents' representatives.

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








 Plan of Correction - To be completed: 05/26/2022

1.The cited residents (R66 & R142) were not affected negatively by the deficient practice.

2.Current residents and new admissions have the potential to be affected by the deficient practice. All upcoming NOMNCs will be reviewed weekly to ensure RP was notified.

3.To ensure the deficient practice does not reoccur, the NHA/designee will educate Social Services/Business Office on the "focus Ftag 582" on or before the date of compliance.

4.Utilizing the "SNF Beneficiary Notification Review" QAPI tool, Social Services/designee will audit 3 NOMNCS per week for 4 weeks to validate that RP notifications were documented. Any trends will be reported to the QAPI committee for further action planning if needed.

201.20(c) LICENSURE Staff development.:State only Deficiency.
(c) There shall be at least annual inservice training which includes at least infection prevention and control, fire prevention and safety, accident prevention, disaster preparedness, resident confidential information, resident psychosocial needs, restorative nursing techniques and resident rights, including personal property rights, privacy, preservation of dignity and the prevention and reporting of resident abuse.
Observations:

Based on a review of annual mandatory trainings and staff interview, it was determined that the facility failed to ensure that staff received the required inservice training for two of seven sampled employees.(Employee 1, 2)

Findings include:

A review of the annual training records for Employee 1 and Employee 2 revealed that they did not include infection prevention and control, fire prevention and safety, accident prevention, disaster preparedness, resident psychosocial needs, resident rights, including personal property, confidential information and privacy, preservation of dignity, and the prevention and reporting of resident abuse.

In an interview on April 19, 2022, at 2:00 p.m., the Director of Human Resources confirmed that annual in-service trainings for Employee 1 and Employee 2 had not been completed.
















 Plan of Correction - To be completed: 05/26/2022

1.No like residents

2.Current residents and new admissions have the potential to be affected by the deficient practice. Utilizing "Relias Training", employee transcripts will be checked weekly to ensure all mandatory in services are being completed.

3.To ensure the deficient practice does not re-occur the HRD/designee will educate center staff to complete all mandatory in-services by deadline date on Relias training on or before the date of compliance.

4.Utilizing "employee transcripts" on Relias, the Human Resources Director will audit to ensure all current employees and new hires are completing mandatory in-services. Any trends will be reported to the QAPI committee for further action planning.


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