Pennsylvania Department of Health
BROOKVIEW HEALTH CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BROOKVIEW HEALTH CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an incident survey completed on February 16, 2024, it was determined that Brookview Health Care 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:

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

This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. 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 policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported physical abuse in a timely manner, which allowed the staff member to return to the resident to be mentally abused for one of five residents reviewed (Resident 2) putting all of the residents in danger of being abused, resulting in Immediate Jeopardy to their physical and mental safety. This deficiency was cited as past non-compliance.

Findings include:

The facility's abuse policy, dated April 13, 2023, revealed that it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Training topics will include prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown cause. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to responding immediately to protect the alleged victim and integrity of the investigation.

An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated November 16, 2023, revealed that the resident was understood, understands, and had a diagnosis which included Parkinson's disease, anxiety, and depression.

A statement completed by Licensed Practical Nurse 1, dated January 29, 2024, at 2:00 p.m., revealed that on January 29, 2024, at 7:30 a.m. she was assisting Nurse Aide 2 with Resident 2. They were getting the resident out of bed by Hoyer lift (a mobile floor lift system that rolls on wheels and is intended to help lift, suspend, and transfer a medically-dependent person) and placing her in her wheelchair for breakfast. After the resident was safely placed in her wheelchair, Nurse Aide 2 put the footrests on the wheelchair and attempted to place the resident's feet onto the footrests. The resident then removed her feet, and in response to Nurse Aide 2 grabbed hold of the resident's ankles to place them back onto the footrests. Every time Nurse Aide 2 grabbed hold of the resident's ankles, the resident would holler out and place her feet back on the ground. Based on these actions the nurse knew that the resident did not want her feet on the footrests. Nurse Aide 2 attempted to place her feet on the footrests again. When Nurse Aide 2 was bent over grabbing hold of the resident's ankles again, the resident hit Nurse Aide 2 with her open hand on Nurse Aide 2's back. Nurse Aide 2 then stood up straight and opened handed slapped the resident on her left hand and then told the resident, "You are being an ass." Nurse Aide 2 then took the Hoyer lift out of the room and Licensed Practical Nurse 1 stayed in the room with the resident. Nurse Aide 2 returned back to the room to comb the resident's hair and stated to the resident, "I hope that did hurt," then walked back out of the room.

There was no evidence to indicate that Resident 2's initial physical and verbal abuse (that included grabbing her ankles and repeatedly placing them back on the footrests of the wheelchair, slapping the resident or calling her an asshole) by Nurse Aide 2 was immediately reported when it happened.

A statement completed by the Nursing Home Administrator (NHA), dated February 9, 2024, revealed that on January 29, 2024, she reviewed with Licensed Practical Nurse 1 her written statement regarding the incident with Resident 2. She reviewed with Licensed Practical Nurse 1 that Nurse Aide 2 should have been immediately sent off the unit to the staff lounge until the Director of Nursing or NHA could speak with her. The NHA also stated that Nurse Aide 2 should not have been allowed to come back into the resident's room to comb her hair.

Following the incident on January 29, 2024, the facility's corrective actions included:

Nurse Aide 2 was suspended of her duties, and after the investigation her employment with the facility was terminated.

An audit of residents was performed.

Licensed Practical Nurse 1 was re-educated regarding abuse.

Re-education regarding abuse to staff was started.

Daily random audits of residents were being completed.

On February 15, 2024, at 5:10 p.m. the Nursing Home Administrator and Director of Nursing were given the required Immediate Jeopardy Template due to the failure of the facility to ensure that Licensed Practical Nurse 1 immediately reported the witnessed abuse of Resident 2 by Nurse Aide 2, and to protect the resident by allowing Nurse Aide 2 to return to the resident's room.

On February 15, 2024, at 8:00 p.m. the facility submitted an immediate action plan that included:

The nurse aide was suspended at the time of the reported abuse and is no longer employed at the facility.

An in-house audit was performed on residents at the time of the incident, and assessments were completed along with interviews to confirm no other residents were identified.

In-house re-education was provided to staff on abuse and reporting of abuse. The facility will not allow an employee to work unless education has been completed prior to returning to work.

Daily random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings.

Facility staff were interviewed on February 16, 2024, and were knowledgeable of the facility's policy on abuse.

The facility alleged compliance on January 31, 2024.

The Immediate Jeopardy was lifted on February 16, 2024, at 12:03 p.m. when it was confirmed that the corrective action plans developed on January 29, 2024, were completed by January 31, 2024, and that Resident 2 and any other current residents were not physically/mentally abused since January 31, 2024.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

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

Plan of Correction - To be completed: 03/05/2024

Past noncompliance: no plan of correction required.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

§483.12 Freedom from Abuse, Neglect, and Exploitation
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)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from physical and mental abuse for one of five residents reviewed (Resident 2), resulting in Immediate Jeopardy to the resident's physical, mental health, and safety. This deficiency was cited as past non-compliance.

Findings include:

The facility's abuse policy, dated April 13, 2023, revealed that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property.

An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated November 16, 2023, revealed that the resident was understood, could understand, and had diagnoses that included Parkinson's disease, anxiety, and depression.

A statement completed by Licensed Practical Nurse 1, dated January 29, 2024, at 2:00 p.m., revealed that on January 29, 2024, at 7:30 a.m. she was assisting Nurse Aide 2 with Resident 2. They were getting the resident out of bed by Hoyer lift (a mobile floor lift system that rolls on wheels and is intended to help lift, suspend, and transfer a medically-dependent person) and placing her in her wheelchair for breakfast. After the resident was safely placed in her wheelchair, Nurse Aide 2 put the footrests on the wheelchair and attempted to place the resident's feet onto the footrests. The resident then removed her feet, and in response to this Nurse Aide 2 grabbed hold of the resident's ankles to place them back onto the footrests. Every time Nurse Aide 2 grabbed hold of the resident's ankles, the resident would holler out and place her feet back on the ground. Based on these actions the nurse knew that the resident did not want her feet on the footrests. Nurse Aide 2 attempted to place her feet on the footrests again. When Nurse Aide 2 was bent over grabbing hold of the resident's ankles again, the resident hit Nurse Aide 2 with her open hand on Nurse Aide 2's back. Nurse Aide 2 then stood up straight and opened handed slapped the resident on her left hand and then told the resident, "You are being an ass." Nurse Aide 2 then took the Hoyer lift out of the room and Licensed Practical Nurse 1 stayed in the room with the resident. Nurse Aide 2 returned back to the room to comb the resident's hair and stated to the resident, "I hope that did hurt," then walked back out of the room.

An undated statement completed by Student Practical Nurse 3 indicated that on the morning of January 29, 2024, the student nurse heard Nurse Aide 2 raise her voice with a resident. Student Practical Nurse 3 was sitting in the nurses' station working on school paperwork when Licensed Practical Nurse 1 went to Resident 2's room to assist Nurse Aide 2 with the Hoyer lift. Shortly after she left, Student Practical Nurse 3 heard Nurse Aide 2 raise her voice to Resident 2. Student Practical Nurse 3 did not hear all that was said but remembered her saying "this is ridiculous," "do not hit me," and some comment about Resident 2 sliding in her wheelchair. Student Practical Nurse 3 was able to hear her comments clearly from the nurses' station.

A social worker's interview with Resident 2, dated January 29, 2024, revealed that she spoke with Resident 2 regarding how she was treated that morning. The resident advised her that her caregiver this morning chose clothes that she did not want. The caregiver, whose name she could not remember, was "cussing" at her and even "hit" her, indicating her left wrist area, and stated "fresh this morning." Resident 2 said, "I hit her back."

A statement completed by the Director of Nursing revealed that on January 29, 2024, at 7:45 a.m., upon arriving on the Lehman House unit, she was updated that Licensed Practical Nurse 1 had witnessed an occurrence between Nurse Aide 2 and Resident 2. Licensed Practical Nurse 1 reported that while performing care for the resident Nurse Aide 2 open handed slapped the resident's left hand and she called the resident an "ass." Nurse Aide 2 also said to the resident, "I hope that hurt."

Interview with Licensed Practical Nurse 1 on February 15, 2024, at 2:55 p.m. revealed that she went in to help Nurse Aide 2 with the Hoyer lift because Resident 2 was a Hoyer lift. She indicated that when she went into the room, she could tell that the resident was "shaken up." They got the resident into her wheelchair and Nurse Aide 2 was insistent to place the resident's feet on the wheelchair footrests. She knew that the resident did not want her feet on the footrests. Nurse Aide 2 was bent over, and the resident slapped her on the back. Nurse Aide 2 then stood up and slapped the resident and called her an "asshole." Nurse Aide 2 then took the Hoyer lift out of the room. She then returned to comb the resident's hair and stated, "I hope that did hurt." She indicated that she remembered saying to Nurse Aide 2 that she can transfer herself and thought to herself that the resident slapped Nurse Aide 2 because it must have hurt. She indicated that she and the resident were near the resident's bed when Nurse Aide 2 came back in by the bathroom door and stated "I hope that did hurt," and after making the comment she turned around leaving the resident's room.

Following the incident on January 29, 2024, the facility's corrective actions included:

Nurse Aide 2 was suspended of her duties, and after the investigation her employment with the facility was terminated.

An audit of residents was performed.

Licensed Practical Nurse 1 was re-educated regarding abuse.

Re-education regarding abuse to staff was started.

Daily random audits of residents were being completed.

On February 15, 2024, at 5:10 p.m. the Nursing Home Administrator and Director of Nursing were given the required Immediate Jeopardy Template and informed that the physical/mental health and safety of Resident 2 had been placed in Immediate Jeopardy due to the failure of the facility to ensure that Resident 2 was not subjected to physical/mental abuse by Nurse Aide 2, who physically/mentally abused the resident.

On February 15, 2024, at 8:00 p.m. the facility submitted an immediate action plan that included:

The nurse aide was suspended at the time of the reported abuse and is no longer employed at the facility.

An in-house audit was performed on residents at the time of the incident, and assessments were completed along with interviews to confirm no other residents were identified.

In-house re-education was provided to staff on abuse and reporting of abuse. The facility will not allow an employee to work unless this education has been completed prior to returning to work.

Daily random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings.

Facility staff were interviewed on February 16, 2024, and were knowledgeable of the facility's policy on abuse.

The facility alleged compliance on January 31, 2024.

The Immediate Jeopardy was lifted on February 16, 2024, at 12:03 p.m. when it was confirmed that the corrective action plans developed on January 29, 2024, were completed by January 31, 2024, and that Resident 2 and any other current residents were not physically/mentally abused since January 31, 2024.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

28 Pa. Code 201.29(j) Resident Rights.

Plan of Correction - To be completed: 03/05/2024

Past noncompliance: no plan of correction required.

483.40(b)(2) REQUIREMENT No Behavior Difficulties Unless Unavoidable:

§483.40(b)(2) A resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma and/or post- traumatic stress disorder does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that development of such a pattern was unavoidable;

Observations:

Based on review of policies, clinical records, and personnel files, as well as staff interviews, it was determined that the facility failed to properly address a resident's behavior of repeatedly taking her feet off the wheelchair footrests and placing them on the ground for one of five residents reviewed (Resident 2), resulting in Immediate Jeopardy when the nurse aide continued to grab hold of the resident's ankles, causing her to yell out and place her feet back on the ground, which resulted in the resident hitting the nurse aide while the nurse aide was bent over to once again grab the resident's ankles to place the her feet back on the wheelchair footrests. In response, the nurse aide slapped the resident's hand and called the resident an "asshole."

Findings include:

The facility's policy regarding behaviors, dated April 13, 2023, revealed that facility staff will attempt to implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions, to help meet behavioral health needs and may include, but are not limited to offering hydration and nutrition; exercise; pain relief; individualizing sleep and dining routines; considerations for restroom use, incontinence; adjusting the environment to be more individually preferred or homelike; consistent staffing to optimize familiarity; supporting the resident through meaningful activities that match his/her individualized abilities, interests and needs; assisting the resident with outdoors activity weather permitting; providing access to pets or animals for the resident who enjoys pets; assisting the resident to participate in activities that support their spiritual needs; focusing the resident on activities that decrease stress and increase awareness of actual surroundings, such as familiar activities; offering verbal reassurance, especially in terms of keeping the resident safe; and acknowledging that the resident's experience is real to her/him; utilizing techniques such as music, art, electronics/computer technology systems, reminiscing, and providing redirection.

A review of the personnel file for Nurse Aide 2 revealed that she was hired by the facility on October 13, 2003, received customer service training on January 23, 2023; received elder abuse training on May 2, 2023; received resident rights training on April 5, 2023; received hand-and-hand dementia module 1 training on June 5, 2023; hand-and-hand dementia module 2 training on July 5, 2023; received abuse, prevention, reporting and elder justice act training on August 29, 2023; and received behavioral health training on August 29, 2023. On December 10, 2017, she received disciplinary action regarding concerns that they had received multiple complaints about her poor attitude, being rude to other nurse aides, and speaking harshly and disrespectfully to residents.

An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated November 16, 2023, revealed that the resident was understood and could understand others, and had diagnoses that included Parkinson's disease, anxiety, and depression.

A nursing note for Resident 2, dated January 18, 2024, revealed that the nurse and the nurse aide attempted to get the resident into the bath multiple times. The resident refused and became combative and kept stating she will tomorrow, or she will let them know when she wants a shower.

A nursing note for Resident 2, dated January 21, 2024, revealed that the resident was hitting, pinching, and cursing at staff with morning care. Even with attempts of calming talk and redirecting, she was attempting to get out of bed by herself and did not want staff to assist her.

A statement completed by Licensed Practical Nurse 1, dated January 29, 2024, at 2:00 p.m., revealed that on January 29, 2024, at 7:30 a.m. she was assisting Nurse Aide 2 with Resident 2. They were getting the resident out of bed by Hoyer lift (a mobile floor lift system that rolls on wheels and is intended to help lift, suspend, and transfer a medically-dependent person) and placing her in her wheelchair for breakfast. After the resident was safely placed in her wheelchair, Nurse Aide 2 put the footrests on the wheelchair and attempted to place the resident's feet onto the footrests. The resident then removed her feet, and in response to this Nurse Aide 2 grabbed hold of the resident's ankles to place them back onto the footrests. Every time Nurse Aide 2 grabbed hold of the resident's ankles, the resident would holler out and place her feet back on the ground. Based on these actions the nurse knew that the resident did not want her feet on the footrests. Nurse Aide 2 attempted to place her feet on the footrests again. When Nurse Aide 2 was bent over grabbing hold of the resident's ankles again, the resident hit Nurse Aide 2 with her open hand on Nurse Aide 2's back. Nurse Aide 2 then stood up straight and opened handed slapped the resident on her left hand and then told the resident, "You are being an ass." Nurse Aide 2 then took the Hoyer lift out of the room and the nurse stayed in the room with the resident. Nurse Aide 2 returned back to the room to comb the resident's hair and stated to the resident, "I hope that did hurt," then walked back out of the room.

A statement completed by Nurse Aide 2, undated, revealed that while doing care on Resident 2, "she started hitting me. I told her to stop it. I put my hand in front of hers to stop her from hitting me. She then started to yell at me. She was yelling and hitting me while the nurse was just standing there. The resident then started kicking and would not keep her feet on the wheelchair footrests."

There was no documented evidence in Resident 2's clinical record to indicate that Nurse Aide 2 attempted a different approach with the resident or other interventions to prevent her behavior from escalating to the point of hitting Nurse Aide 2.

On February 15, 2024, at 5:10 p.m. the Nursing Home Administrator and Director of Nursing were given the Immediate Jeopardy Template due to the failure of the facility to properly address a resident's behavior of repeatedly taking her feet off the wheelchair footrests and placing them on the ground. The nurse aide continued to grab hold of the resident's ankles, causing her to yell out and place her feet back on the ground, which resulted in the resident hitting the nurse aide while the nurse aide was bent over to once again grab her ankles to place the her feet back on the wheelchair footrests. In response, the nurse aide slapped the resident's hand and called the resident an "asshole."

On February 15, 2024, at 9:31 p.m. the facility submitted an immediate action plan that included:

The nurse aide was suspended at the time of the reported abuse and is no longer employed at the facility.

Licensed Practical Nurse 1 was re-educated regarding abuse.

Resident 2's care plan was updated to identify the resident's behaviors.

Care plans will be established for residents that exhibit behaviors with individualized interventions.

In-house re-education was provided to staff on the facility's behavioral policy and how to manage behaviors. The facility will not allow an employee to work unless education has been completed prior to returning to work.

Daily random audits of care and interviews continue to ensure that no residents have been affected. The audits are going to be reviewed at Quality Assurance Performance Improvement (QAPI) meetings.

Interview with the Nursing Home Administrator on February 16, 2024, at 9:35 a.m. revealed that they felt Resident 2 did not have any behaviors for them to address at the time of the incident.

The facility acknowledged compliance on February 16, 2024.

The Immediate Jeopardy was lifted on February 16, 2024, at 12:03 p.m. when it was confirmed that the corrective action plans developed on February 15, 2024, were implemented. It was confirmed that Resident 2 and any other current residents did not exhibit any behaviors. The majority of staff were educated, and a plan for remaining staff to receive the education prior to the start of their next work shift was developed and implemented.

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

Plan of Correction - To be completed: 03/18/2024

F743
1. Care plan of resident #2 was reviewed and updated to reflect behavior of refusing taking her feet off of wheelchair leg rest
2. The facility has determined that all residents have the potential to be affected by the sighted deficient practice. An audit was conducted for current residents to identify residents with current behaviors of refusing care. The care plans were updated to reflect for the behavior of refusing care and interventions for managing behaviors.
3. Team members responsible for resident care and interactions will be re-educated on the facility's policy for resident behavior.
4. The Director of Nursing or designee will conduct audits of behaviors of refusing care for documentation of interventions to reduce/ deescalate behaviors. Audits will be conducted weekly x4 weeks, Biweekly x4 weeks, and monthly x1 month. A summary of the audits will be presented at the Quality Assurance and Performance Improvement meetings for 3 months for further review and recommendations.

483.70 REQUIREMENT Administration:

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.

§483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Observations:

Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free from abuse, for ensuring that staff reported abuse and protected the resident from further abuse, and for ensuring that staff properly address a resident's behavior.

Findings include:

The job description for the NHA, dated January 17, 2023, indicated that the primary function of this position was to
provide general oversight and direction to all services provided by the Brookview Health Care Center. Maintains compliance with the Department of Health, Welfare, Medicare, and Educational regulatory requirements. Supervision and coordination of services to include overseeing budget and corporate policies and procedures related to the care of all residents.

The job description for the DON, dated October 15, 2020, indicated that the primary function of this position was to organize, administrate, and supervise the total nursing service program in compliance with the regulatory process and operational guidelines, and modifies nursing care policies and/or procedures to maintain the highest practicable well-being of each resident.

The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.12 Freedom from Abuse, Neglect, and Exploitation (F600), revealed that the NHA and DON failed to fulfill their essential job duties for ensuring that the residents' environment remained free from abuse.

The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and 483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act (F607), revealed that the NHA and DON failed to fulfill their essential job duties for ensuring that staff timely reported abuse and allowing staff to return to the resident.

The deficiencies cited under the Code of Federal Regulatory Groups for Long-Term Care, 483.40(b)(2) A resident whose assessment did not reveal or who does not have a diagnosis of a mental or psychosocial adjustment difficulty or a documented history of trauma and/or post-traumatic stress disorder does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that development of such a pattern was unavoidable (F743), revealed that the NHA and DON failed to fulfill their essential job duties for ensuring that staff properly address a resident's behavior.

Refer to F600, F607 and F743.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

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

Plan of Correction - To be completed: 03/18/2024

1. Nurse Aide 2 was suspended immediately upon notification of the allegation of abuse and later the same day terminated. Licensed Practical Nurse 1 was re-educated on our abuse policy. Care plan of resident #2 was reviewed and updated to reflect behavior of refusing taking her feet off of wheelchair leg rest.
2. The facility has determined that residents residing in facility have the potential to be affected by the deficient practice. An audit was conducted for current residents on any allegations of abuse and to identify residents with current behaviors of refusing care. The care plans were updated to reflect the behavior of refusing care and interventions for managing behaviors.
3. Team members responsible for resident care and interactions will be re-educated on facility abuse policy facility policy for resident behavior.
4. The Administrator or designee will conduct random audits of care and interviews with residents. Audits will be conducted weekly x4 weeks, Biweekly x4 weeks, and monthly x1 month. A summary of the audits will be presented at the Quality Assurance and Performance Improvement meetings for 3 months for further review and recommendations.

The Director of Nursing or designee will conduct audits of behaviors of refusing care for documentation of interventions to reduce/ deescalate behaviors. Audits will be conducted weekly x4 weeks, Biweekly x4 weeks, and monthly x1 month. A summary of the audits will be presented at the Quality Assurance and Performance Improvement meetings for 3 months for further review and recommendations.

483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a baseline care plan included instructions regarding behaviors and the use of psychotropic medications for one of five residents reviewed (Resident 5) who was admitted after February 9, 2024.

Findings include:

A nursing note, dated February 9, 2024, at 11:14 a.m., revealed that the resident was admitted to the facility on this date. Physician's orders, dated February 9, 2024, included orders for 12.5 mg of Seroquel in the morning and 25 mg of Seroquel(antipsychotic) at bedtime for dementia with behaviors, 0.25 milliliters (mL) of lorazepam (anti-anxiety) three times a day for anxiety, and 10 mg of escitalopram (anti-depressant) in the morning for major depression.

A Certified Registered Nurse Practitioner (CRNP, a registered nurse who has advanced education and clinical training in a health care specialty area) note, dated February 9, 2024, revealed that the resident was agitated and anxious, refused to have her dressing changed, refused to have a skin evaluation, and refused her medications. New orders were received for 2.5 milligrams (mg) of Haldol (antipsychotic) one time, 0.5 mg of Ativan (anti-psychotic) three times a day for three days, and she was to continue her as-needed Ativan and 12.5 mg of Seroquel in the morning.

A nursing note, dated February 9, 2024, at 2:21 p.m., revealed that the resident's daughter informed the facility that Resident 5 had behaviors of hitting, spitting, kicking, and throwing objects if she was mad and did not want anything or did not like something. She refused to allow the nurse to assist her with the removal of her coat and accepted sips of water and gingerale at lunch time, then threw her cup of gingerale. She was offered a cup of hot tea, and the resident picked up the cup and threw it at the nurse. Staff attempted to do her admission assessment and allowed staff to assess her feet and left arm, but then she began to hit, kick and spit at the nurse, and was unable to be redirected even with the daughter's assistance.

Nursing notes for Resident 5, dated February 10, at 3:54 p.m., revealed that the resident was combative with morning medications, and on February 11, 2024, at 11:06 a.m. the resident was highly combative and hitting and spitting at staff.

A baseline care plan for Resident 5, dated February 9, 2024, did not include instructions regarding Resident 5's behaviors or use of psychotropic medications.

Interview with the Nursing Home Administrator on February 16, 2024, at 12:44 p.m. confirmed that Resident 5 had behaviors and used psychotropic medications, and the resident's baseline care plan should have included this information.

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

Plan of Correction - To be completed: 03/18/2024

655- baseline care plan
1. Resident # 5 has expired.
2. The facility determined that new admission residents have the potential to be affected by this alleged deficient practice. An audit was conducted for new admissions to the facility in the past 21 days. The audit too include review of the baseline care plan for psychotropic medications and interventions regarding behaviors. Baseline care plans were updated accordingly.
3. Director of nursing or designee will educate licensed nursing staff on Baseline Care Plan Policy to include care planning of physician orders. Baseline Care Plan Policy updated to include physician orders necessary to properly care for resident within 48 hours of admission.
4. The Director of Nursing or designee will conduct audits of baseline care plan for psychotropic medications and behavioral interventions of new admissions, weekly x4 weeks, Biweekly x4 weeks, and monthly x1 month. A summary of the audits will be presented at the Quality Assurance and Performance Improvement meetings for 3 months for further review and recommendations.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§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.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for one of five residents reviewed (Resident 2).

Findings include:

The facility's policy regarding behaviors, dated April 13, 2023, revealed that facility staff will attempt to implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions.

An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated November 16, 2023, revealed that the resident was understood, understands, and had a diagnosis which included Parkinson's disease, anxiety, and depression.

A nursing note for Resident 2, dated January 18, 2024, revealed that the nurse and the nurse aide attempted to get the resident into the bath multiple times. The resident refused and became combative and kept stating she will tomorrow, or she will let them know when she wants a shower.

A nursing note for Resident 2, dated January 21, 2024, revealed that the resident was hitting, pinching, and cursing at staff with morning care. Even with attempts of calming talk and redirecting, she was attempting to get out of bed by herself and did not want staff to assist her.

A statement completed by Licensed Practical Nurse 1, dated January 29, 2024, at 2:00 p.m., revealed that on January 29, 2024, at 7:30 a.m. she was assisting Nurse Aide 2 with Resident 2. They were getting the resident out of bed by Hoyer lift (a mobile floor lift system that rolls on wheels and is intended to help lift, suspend, and transfer a medically-dependent person) and placing her in her wheelchair for breakfast. After the resident was safely placed in her wheelchair, Nurse Aide 2 put the footrests on the wheelchair and attempted to place the resident's feet onto the footrests. The resident then removed her feet and in response to this Nurse Aide 2 grabbed hold of the resident's ankles to place them back onto the footrests. Every time Nurse Aide 2 continued to grab hold of the resident's ankles, the resident would holler out and place her feet back on the ground. Based on these actions the nurse knew that the resident did not want her feet on the footrests. Nurse Aide 2 attempted to place her feet on the footrests again. When Nurse Aide 2 was bent over grabbing hold of the resident's ankles again, the resident hit Nurse Aide 2 with her open hand on Nurse Aide 2's back.

A statement completed by Nurse Aide 2, undated, (referring to the incident of January 29, 2024, at 7:30 a.m.) revealed that while doing care on Resident 2, "she started hitting me. I told her to stop it. I put my hand in front of hers to stop her from hitting me. She then started to yell at me. She was yelling and hitting me while the nurse was just standing there. The resident then started kicking and would not keep her feet on the wheelchair footrests."

There was no documented evidence that a comprehensive care plan that included specific and individualized interventions was developed for Resident 2 regarding her behaviors until February 15, 2024.

Interview with the Nursing Home Administrator on February 16, 2024, at 9:35 a.m. revealed that they felt Resident 2 did not have any behaviors, so a care plan was not developed regarding behaviors until February 15, 2024.

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

Plan of Correction - To be completed: 03/18/2024

F656
1.ComprehensiveCare plan of the resident #2 was reviewed and updated to include behaviors, and interventions to manage behaviors.
2.The facility has determined that residents residing in the facility have the potential to be affected by the deficient practice. An audit was conducted of current residents comprehensive care plans to identify residents' current behaviors, and interventions for managing behaviors.
3.All interdisciplinary care plan team members responsible for writing behavior care plans will be re-educated on the facility's policy for Comprehensive Care Plans.
Team members responsible for providing care to residents will be re-educated on the facility policy for Behaviors.
4.The Director of Nursing or designee will conduct audits of comprehensive care plans for behaviors and interventions to manage behaviors weekly x4 weeks, Biweekly x4 weeks, and monthly x1 month. A summary of the audits will be presented at the Quality Assurance and Performance Improvement meetings for 3 months for further review and recommendations.

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