Nursing Investigation Results -

Pennsylvania Department of Health
TWIN LAKES REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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TWIN LAKES REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  173 surveys for this facility. Please select a date to view the survey results.

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TWIN LAKES REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on December 7, 2021, it was determined that Twin lakes Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's attending physician was notified timely about a change in condition for one of five residents reviewed (Resident 2), resulting in a delay in treatment.

Findings include:

The facility's policy regarding changes in a resident's condition or status, dated December 23, 2020, revealed that the nurse was to notify the resident's attending physician or the physician on call when there was a significant change in the resident's physical, emotional or mental condition, or a need to alter the resident's medical treatment significantly.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 16, 2021, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, and had diagnoses that included a severe intellectual disability. A nursing note dated October 4, 2021, at 7:18 p.m. revealed that the resident was on the floor next to her wheelchair at the nursing station. The resident was unable to explain what happened, had no signs of pain, had no pain with active range of motion (joint movement) to her extremities, and the physician and the resident's family member were notified. A nursing note dated October 5, 2021, at 5:35 p.m. revealed that the resident was moving all of her extremities without difficulty and there were no signs/symptoms of pain.

A nursing note for Resident 2, dated October 6, 2021, at 10:31 p.m., and completed by a licensed practical nurse, revealed that the resident was unable to hold her right leg/foot up when being transported by the nurse aide in her wheelchair. The resident was assisted to transfer into bed, and she would not assist with the transfer. Upon assessment, the resident's right leg was swollen and the resident complained of pain. The Registered Nurse Supervisor was notified and assessed the resident's right leg.

There was no documented evidence that the resident's physician was notified about this change in Resident 2's condition.

A nursing note for Resident 2, dated October 7, 2021, at 10:12 a.m. revealed that the resident was complaining of right knee and leg pain. The right distal femur (the large bone of the upper part of the leg) was edematous (swollen) compared to her left leg, there was mild discoloration noted on the patella (knee cap), and the physician was notified and ordered an x-ray of the resident's right hip, femur, and knee. A nursing note dated October 7, 2021, at 4:03 p.m. revealed that the x-ray results showed a fractured right femur, the physician was notified, and an order was received to send the resident to the emergency room. A social service note for Resident 2, dated October 20, 2021, at 12:09 p.m. revealed that the resident had surgery on October 8, 2021.

Interview with the Director of Nursing on December 7, 2021, at 11:15 a.m. confirmed that there was no documented evidence that Resident 2's physician was notified regarding the change in the resident's condition on October 6, 2021, and was not notified until the next day, October 7, 2021.

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





 Plan of Correction - To be completed: 01/13/2022

1. The facility notified the physician on October 7, 2021, at 10:12 am that Resident 2 had a change of condition at 10:31 pm on October 6, 2021.
2. 24-hour report will be reviewed in clinical meeting to ensure changes in condition of residents had the appropriate physician and family notification completed. If a notification was not completed, it will be done immediately following meeting. An afternoon clinical wrap up meeting to ensure items identified in morning meeting are followed up on.
3. Director of Education or designee will educate licensed nurses and agency licensed nurses on changes in condition and need to notify physician at the time of the change. System change includes the implementation of the afternoon clinical wrap up meeting.
4. Director of Nursing or designee will audit documentation of 5 residents for physician notification weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month.
5. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

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 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.
483.20(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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of five residents reviewed (Resident 2).

Findings include:

The facility's policy regarding a change in a resident's condition or status, dated December 23, 2020, revealed that the nurse was to record information relative to changes in the resident's medical/mental condition or status in the resident's medical record.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated September 16, 2021, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, and had diagnoses that included severe intellectual disability. A nursing note for Resident 2, dated October 6, 2021, at 10:31 p.m. and completed by a licensed practical nurse, revealed that the resident was unable to hold her right leg/foot up when being transported by the nurse aide in her wheelchair. The resident's right leg was swollen and the resident complained of pain. The Registered Nurse Supervisor was notified and assessed the resident's right leg.

There was no documented evidence in Resident 2's clinical record regarding the registered nurse supervisor's assessment of the resident's right leg.

Interview with the Director of Nursing on December 7, 2021, at 11:15 a.m. confirmed that the registered nurse supervisor's assessment of Resident 2's right leg was not documented in the resident's clinical record.

28 Pa. Code 211.5(f) Clinical records.

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




 Plan of Correction - To be completed: 01/13/2022

1. The facility cannot retroactively correct the missed documentation for Resident 2 on October 6, 2021.
2. The Interdisciplinary Team in clinical meeting will review the 24-hour report and nurse documentation in the electronic medical record for completeness. Items identified as needing documented will be noted for correction.
3. Director of Education or designee will educate the nursing staff and agency staff on documentation requirements. System change includes the implementation of the afternoon clinical wrap up meeting to ensure items are complete.
4. Director of Nursing or designee will audit documentation of up to 5 residents for change in condition assessment weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month.
5. Results will be reviewed by the Quality Assurance Performance Improvement Committee for any systematic changes, if needed, to maintain regulatory compliance.


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