Nursing Investigation Results -

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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TWIN LAKES REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:
There are 179 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.


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 May 26, 2022, 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:

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

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.

The facility must ensure that its-
�483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on a review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of 12 residents reviewed (Resident 2).

Findings include:

The facility's policy for reconciliation of medications, dated February 17, 2022, indicated that the facility was to ensure the medication's safety by accurately accounting for the resident's medications, routes, and dosages upon admission/readmission to the facility. The information to reconcile the medication list should include the discharge summary from the referring facility, all prescription and supplemental information obtained from the resident/family during the medication history, and the most recent medication administration record (MAR). A medication reconciliation was to be performed by listing all medications from the medication history, the discharge summary, the previous MAR, and the admitting orders. The list was to be reviewed carefully and if the dosage on the discharge summary does not match the dosage on the resident's previous MAR, the nurse or physician from the referring facility and/or the admitting/attending physician was to be contacted.

A discharge summary from the hospital for Resident 2, dated May 9, 2022, indicated that he had a NON-ST elevated MI ( heart attack), chest pain, and baseline left bundle branch block (abnormal heart rhythm) with coronary artery disease resulting in the need to wear a life vest (a vest that can deliver a shock treatment to restore the heart to a normal rhythm when a life threatening arrhythmia occurs).

The hospital physician's discharge summary for Resident 2, dated May 9, 2022, at 3:29 p.m. indicated that he was on 3.125 milligrams (mg) of Carvedilol (Coreg), one tablet two times a day after meals. However, there was also documentation on the physician's summary in enlarged print that revealed the resident's Coreg had been increased to 6.25 mg two times day. A physician's order, obtained verbally from the facility's attending physician on May 9, 2022, included an order for 3.125 mg of Coreg 3.125 twice a day.

An inpatient summary, titled "inpatient discharge instructions" for Resident 2, dated May 9, 2022, at 4:21 p.m. indicated that his Coreg dosage was "changed" and that he was on 6.25 mg of Coreg twice each day after meals. The summary provided documentation of when the resident's medications were last administered while at the hospital. It indicated that the last dose of Coreg administered at the hospital was 6.25 mg on May 9, 2022, and the next dosage was due on May 10, 2022. This record indicated that it was checked by the nurse on May 10, 2022, at
3:44 a.m. as a 24-hour check. There was no documented evidence that the physician was contacted for clarification of Resident 2's Coreg dosage at this time.

A nursing note for Resident 2, dated May 12, 2022, indicated that the resident was transferred to the hospital due to a change in condition. The hospital discharge summary for Resident 2, dated May 12, 2022, indicated that the medications to be continued included 6.25 mg of Coreg twice a day. There was no documented evidence that the physician was contacted for a clarification of his Coreg dosage at this time.

The medication administration record (MAR) for May 2022 indicated that Resident 2 received 3.125 mg of Coreg twice a day from May 10-19, 2022 a.m.

The cardiologist's consult report for May 12, 2022, and dated as received on May 18, 2022, at 11:40 a.m., indicated that the resident's medications included 6.25 mg of Coreg twice a day after meals. There was no documented evidence that the physician was notified to clarify the dosage of the Coreg until May 19, 2022.

A nursing note for Resident 2, dated May 19, 2022, at 10:39 a.m. indicated that the facility called the resident's cardiologist for clarification regarding the resident's Coreg dosage, and they were informed that the dosage was to be 6.25 mg twice a day.

A physician's order for Resident 2, dated May 19, 2022, indicated that the dosage of Coreg was changed to
6.25 mg twice a day.

Interview with the Nursing Home Administrator on May 26, 2022, at 4:30 p.m. confirmed that there were discrepancies on the clinical record for the dosage of Coreg, which was clarified on May 19, 2022.

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

Plan of Correction - To be completed: 07/06/2022

1.) Resident 2 no longer resides at the facility.
2.) Baseline audit will be completed for new admissions/hospital returns since 6/9/22.
3.) Admission orders are reviewed on night shift for each resident by the supervising nurse. The facility will implement a new admission/readmission checklist which will include review of medication listing and discharge summary. This review will be completed with the interdisciplinary team during morning clinical meeting. The Director of Nursing/Designee will educate the interdisciplinary team and nursing supervisors to include agency if applicable on the regulation, admission/readmission checklist, and their responsibility to review the discharge summary and clarify with physician if necessary.
4.) The Director of Nursing/Designee will audit admission/readmission checklist and medication orders. This audit will be completed weekly x 4 weeks, every 2 weeks x 1 month, then monthly x 1 month.
5.) Results of this audit will be reviewed by the Quality Assurance Performance Improvement Committee for additional interventions as necessary.

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 review of policies, clinical records and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address care needs related to a life vest for one of 12 residents reviewed (Resident 2).

Findings include:

The facility's policy for comprehensive, person-centered care plans, dated February 17, 2022, indicated that the care plan would include the services that are to be furnished to attain and maintain the resident's highest practical physical, mental, and psychosocial well being. The care plan would incorporate risk factors associated with identified problems.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 16, 2022, indicated that he was alert and oriented, required extensive assist of one for bed mobility, and extensive assistance of two for transfers.

A discharge summary from the hospital, dated May 9, 2022, indicated that Resident 2 had a NON-ST elevated MI (heart attack), chest pain, and a baseline left bundle branch block (abnormal heart rhythm) with coronary artery disease resulting in the need for him to wear a life vest (a vest that is worn and is capable of delivering a shock treatment to restore the heart to a normal rhythm when a life threatening arrhythmia occurs).

Physician's order for Resident 2, dated May 10, 2022, indicated that staff were to check the function of the life vest every shift for monitoring.

There was no documented evidence that a comprehensive, person-centered care plan was developed for the use and monitoring of Resident 2's life vest.

Interview with the Director of Nursing on May 25, 2022, at 4:25 p.m. indicated that Resident 2 was alert and oriented and fully responsible for the care and use of his life vest and that the nurses had no responsibility for its use and therefore no need for a care plan.

28 Pa. Code 211.11(d) Resident care plans.

Plan of Correction - To be completed: 07/06/2022

1.) Resident 2 no longer resides at the facility.
2.) Baseline audit will be completed for current residents to ensure that any resident with a life vest is care planned to include interventions.
3.) Care plans are reviewed quarterly for each resident and updated daily with changes. The facility will implement a new admission/readmission checklist which will include initiating care plans and current interventions. This review will be completed with the interdisciplinary team during morning clinical meeting. The Director of Nursing/Designee will educate the interdisciplinary team on the regulation, admission/readmission checklist, and their responsibility to develop comprehensive care plans that include specific and individualized interventions.
4.) The Director of Nursing/Designee will audit that resident care plans are specific and individualized to address their care needs. This audit will be completed weekly x 4 weeks, then monthly x 2 months.
5.) Results of this audit will be reviewed by the Quality Assurance Performance Improvement Committee for additional interventions as necessary.

� 205.9(c) LICENSURE Corridors.:

(c) Areas used for corridor traffic may not be considered as areas for dining, storage, diversional or social activities.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that areas used for corridor traffic were not used for storage.

Findings include:

Observations on the Mellon Unit on May 26, 2022, at 11:12 a.m., 2:52 p.m., and 3:36 p.m. revealed that a mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) was stored in the corridor between resident room 100 and 101, a dirty laundry bin was stored in the corridor outside of resident room 102 and in the corridor between resident room 119 and 121, a cart containing incontinent wipes and linens was stored in the corridor between resident rooms 102 and 104 as well as in the corridor between resident rooms 116 and 117, and a standard wheelchair was stored in the corridor outside of resident room 104.

Interview with Registered Nurse 1 on May 26, 2022, at 3:41 p.m. confirmed that the above items should not be stored in the corridors when not being used by staff.

Observations on the Palmer unit on May 26, 2022, at 9:35 a.m. and 12:06 p.m. revealed that there was a cart containing a cooler of ice across from the nurses' station, a clean linen cart and bariatric wheelchair were stored between rooms 216 and 218, a black cart was stored between rooms 218 and 220, and a soiled linen cart was stored in the corridor outside of room 201.

Observations on the Palmer unit on May 26, 2022, at 2:12 p.m. revealed a cart containing a cooler of ice across from the nurses' station, a large blue linen bin with clean linens, a black cart with four collected lunch trays with left-over foods, and a clean linen cart stored between clinical resource and room 218.

Interview with Nurse Aide 2 on May 26, 2022, at 2:52 p.m. confirmed that all of the items were in the hallways, and that the linen and ice cart were always stored in the corridors when not being used by staff, and the large blue bin of clean linens was for night shift staff to organize.

Interview with the Nursing Home Administrator on May 26, 2022, at 5:54 p.m. confirmed that storage was at a premium, and the staff attempt to space out carts and bins in the hallway, as the physical structure does not allow for storage.

Plan of Correction - To be completed: 07/06/2022

1 & 2.) Facility unable to retroactively correct findings during the survey.
3.) Soiled laundry bins/trash bins, linen carts, and mechanical lifts are stored in the shower room when not in use. Coolers of ice are stored behind the nurses' station when not in use. The Director of Nursing/Designee will educate the nursing staff on the regulation and their responsibility to ensure soiled laundry bins/trash bins, linen carts, and mechanical lifts are stored in the shower room when not in use, as well as coolers of ice to be stored behind nurses' station when not in use.
4.) The Director of Nursing/Designee will audit that soiled laundry bins/trash bins, linen carts, mechanical lifts, and coolers of ice are properly stored when not in use. This audit will be completed weekly x 4 weeks, then monthly x 2 months.
5.) Results of this audit will be reviewed by the Quality Assurance Performance Improvement Committee for additional interventions as necessary.

� 205.28(c)(1)-(4) LICENSURE Nurses' station.:

(c) The nurses' station shall have facilities for:

(1) A nurses' call system.

(2) Charting and supplies.

(3) Medication storage and preparation, which may be within the clean workroom, if a self-
contained cabinet is provided. The medication storage cabinet shall be locked. Mechanical
ventilation shall be provided in this workroom. If a medication cart is used, provisions shall be made
to lock the cart or to place the cart when not in use in a safe area that can be locked. The cart may not
be stored in the corridor.

(4) A double-locked narcotic compartment within the medication area.

Observations:

Based on observations and staff interviews, it was determined that the facility failed to ensure that medication carts were not stored in the corridors when not in use.

Findings include:

Observations on the Mellon Unit on May 26, 2022, at 11:12 a.m., 2:47 p.m., and 3:36 p.m. revealed that the medication carts that were not in use were stored in the corridor outside of resident room 100 and outside of resident room 101.

Interview with Registered Nurse 1 on May 26, 2022, at 3:41 p.m. confirmed that the medication carts should not be stored in the corridors when not being used by staff.

Observations on the Palmer unit on May 26, 2022, at 9:35 a.m., 2:29 p.m, and 2:52 p.m. revealed that the medication cart that was not in use was stored in the corridor outside of the shower room.

Interview with Registered Nurse 3 on May 26, 2022, at 2:29 p.m. and 3:52 p.m. revealed that she was leaving the floor for her lunch break and that the medication cart can be stored anywhere on the floor when not in use as long as it remained locked and secure.

Interview with the Nursing Home Administrator on May 26, 2022, at 5:54 p.m. revealed that the medication carts should be stored in the nurses' station or medication room when not in use, but space was very limited.

Plan of Correction - To be completed: 07/06/2022

1 & 2.) Facility unable to retroactively correct findings during the survey.
3.) Medication carts are stored behind the nurses' station when not in use. The Director of Nursing/Designee will educate the nurses on the regulation on their responsibility to ensure medication carts are locked and stored behind the nurses' station when not in use.
4.) The Director of Nursing/Designee will audit that medication carts are properly locked and stored when not in use. This audit will be completed weekly x 4 weeks, then monthly x 2 months.
5.) Results of this audit will be reviewed by the Quality Assurance Performance Improvement Committee for additional interventions as necessary.

� 211.12(i) LICENSURE Nursing services.:

(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.

Observations:

Based on review of nursing staffing schedules, as well as staff interviews, it was determined that the facility failed to provide the required minimum number of nursing care hours of 2.7 hours of direct resident care for each resident for nine of 21 days reviewed.

Findings include:

The facility's nursing schedules for May 5, 2022, through May 25, 2022 revealed that the facility's nursing care hours per resident per day on May 7 was 2.37, May 8 was 2.41, May 9 was 2.44, May 10 was 2.61, May 12 was 2.28, May 13 was 2.58, May 14 was 2.03, May 15 was 2.68 , May 16 was 2.60.

Interview with the Nursing Home Adminstrator on May 31, 2022, at 8:55 a.m. confirmed that nursing care hours had been below the required 2.7 hours per resident per day due to staff call offs.

Plan of Correction - To be completed: 07/06/2022

1) Facility will staff the facility at the appropriate 2.7 staffing hours to meet the needs of the residents. Review of the staffing hours will occur daily.
2) Residents of the facility have the potential to be affected by the number of staffing hours. Staff will be assigned to the various units based on resident acuity.
3) Staffing will be monitored daily by the Nursing Home Administrator/Director of Nursing to ensure staffing hours per regulation are attained. Admissions will be adjusted to ensure the 2.7 staffing hours or higher are reached. Overtime and bonuses are available to encourage coverage of open shifts/call offs to achieve necessary staffing hours. Agency staff will be utilized to assist with the attaining the appropriate level of staffing. Nursing administration will work in direct care if needed.
4) Staffing hours audits will occur 3 days/week by the Nursing Home Administrator/designee for 1 month and the 1 day/week for 2 months, areas of opportunity will be addressed, and documentation of efforts taken to address staffing will be reviewed.
5) Results of the audits will be reviewed monthly at the Quality Assurance Performance Improvement meeting and adjustment made as deemed necessary.

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