Pennsylvania Department of Health
 CARING HEIGHTS COMMUNITY CARE AND REHABILITATION CENTER
Patient Care Inspection Results

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CARING HEIGHTS COMMUNITY CARE AND REHABILITATION CENTER
Inspection Results For:

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CARING HEIGHTS COMMUNITY CARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on February 21, 2024, it was determined that Caring Heights Comminity Care and Rehab Center was not in compliance with the 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(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§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 review of facility policy, clinical record review, investigation documentation, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse for one of three sampled residents (Resident R1).

Findings include:

Review of facility policy "Abuse, Neglect, and Exploitation" dated 8/3/23, indicated it is the facility policy to investigate all suspicions and incidents of neglect and injuries of unknown source. It was indicated written statements must be obtained from the resident, if possible, the accused, and each witness. It was indicated if there are no direct witnesses, then the interviews may be expanded.

The facility policy "Fall Prevention and Management Policy" last reviewed 7/1/23, indicated all falls will be reviewed and investigated.

Review of the clinical record indicated that Resident R1's was admitted to the facility on 12/19/23.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/23, indicated diagnoses fall, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), generalized weakness.

Review of Resident R1's care plan dated 1/29/24, indicated the resident was at risk of falling.

Review of Resident R1's "Event Report" dated 2/5/24, entered by Registered Nurse, Employee E2 indicated Resident R1 had a fall with minor injury. It was indicated the resident had a "bump" on her head.

Review of the facility's "Post Fall Huddle (PFH) Form" that was not dated or signed, indicated Resident R1 had a fall on 2/5/24, at 12:45 a.m. It was indicated Registered Nurse (RN), Employee E1, RN, Employee E2, and Nurse Aide (NA), Employee E3 assisted the resident after the fall.

Review of Resident R1's investigation report failed to include NA, Employee E3's witness statement and a statement from the resident.

During an interview on 2/21/24, at 12:59 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to conduct a thorough investigation to rule out neglect and/or abuse as required for one of three residents (Resident R1).

28 Pa. Code: 201.14 (a)(c)(e) Responsibility of licensee.
28 Pa. Code: 201.18 (e)(1) Management.


 Plan of Correction - To be completed: 03/21/2024

I. DON/Designee will conduct a full investigation on R1's identified fall incidents to rule out neglect and/or abuse. R 1's fall incident has been investigated and E 3's statement has been obtained.
II.To identify other residents with the potential to be affected, NHA and DON will conduct a 30 day review of fall incidents to ensure a thorough investigation was completed to rule out abuse or neglect. Facility will conduct a 30 day look back on all fall incidents to ensure post assessments and orders are followed, documentation, resolution, and response was completed.
Moving forward, facility will thoroughly investigate, resolve and document all fall incidents.
III. To prevent this from reoccurring, DON/designee will educate Licensed staff on how to conduct an investigation at time of occurrence, to include staff statements. NHA/Designee will re-educate staff on investigating all fall incidents.
IV. Ongoing monitoring for compliance, NHA/Designee will audit ensure a thorough investigation was completed and to rule out any abuse or neglect incidents weekly x4 and monthly for 2 months.

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 review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included interventions needed to provide effective and person-centered care for one of three residents (Resident R1).

Findings include:

The facility policy "Interim/Baseline Care Planning Policy" last reviewed 7/1/23, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission.

Review of the admission record indicated Resident R1 was admitted to the facility on 12/19/23, with the diagnoses of diagnoses fall, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and COVID (a contagious respiratory virus).

Review of Resident R1's "Johns Hopkins Fall Risk" dated 12/19/23, indicated the resident was a high fall risk.

Review of Resident R1's clinical record from 12/19/23, through 12/21/23, failed to include a baseline care plan that was implemented. The to provide effective and person-centered care.

During an interview on 2/21/24, at 12:50 p.m. the Director of Nursing confirmed that the facility failed to implement a baseline care plan for one of three residents (Resident R1).

28 Pa. Code: 211.11 (a)(c)(d) Resident care plan.
28 Pa. Code: 211.12(d)(1)(5) Nursing services


 Plan of Correction - To be completed: 03/21/2024

I.R1 has had their care plans reviewed. RNAC or designee to audit admissions weekly x4 to ensure all baseline care plans are completed.
II. To identify other residents with the potential to be affected, RNAC/designee will conduct a 30 day look back to identify any trends regarding completion of baseline care plans. RNAC/designee be educated by NHA on baseline care planning.
III. To prevent this from reoccurring, RNAC/designee will educate Licensed nurses on initiating a baseline care plan. RNAC or designees to ensure all new admission baseline care plans are completed timely.
IV. Ongoing monitoring for compliance, RNAC/designee will audit new admissions 5 days a week x4 weeks and weekly for 2 months to ensure baseline care plans are completed.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to provide needed care and services to prevent falls, provide an ongoing assessment post fall, and follow physician orders for one of three residents (Resident R1).

Findings include:

The facility policy "Fall Prevention and Management Policy" last reviewed 7/1/23, indicated residents will be assessed for fall risks on admission, quarterly, after any fall, and as needed. It was indicated if risks are identified, preventive measures will be put in place and care planned. All falls will be reviewed and investigated.

The facility policy "Interim/Baseline Care Planning Policy" last reviewed 7/1/23, indicated a baseline care plan to meet the resident's immediate needs shall be developed within forty-eight hours of the resident's admission.

Review of the clinical record indicated that Resident R1's was admitted to the facility on 12/19/23.

Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/26/23, indicated diagnoses of history of falling, dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities), and generalized weakness.

Review of Resident R1's physician order dated 12/19/23, indicated administer 2.5 mg Eliquis (blood thinner) twice a day.

Review of Resident R1's "Johns Hopkins Fall Risk" assessment dated 12/19/23, indicated the resident was a high fall risk.

Review of Resident R1's clinical record from 12/19/23, through 1/28/24, failed to include a focus and interventions to prevent falls from occurring.

Review of Resident R1's care plan dated 1/25/24, indicated the resident is prescribed anticoagulant therapy (medications that prevent the blood from clotting as quickly which increases the risk of bleeding), and interventions indicated to protect the resident from injury and trauma. No further interventions to protect the resident from injuries or trauma was documented.

Review of the facility's fall report dated 11/21/23, through 2/21/23, indicated Resident R1 had a fall on 1/27/24, 2/2/24, and 2/5/24.

Review of Resident R1's progress note dated 1/27/24, entered at 4:15 p.m. by Licensed Practical Nurse (LPN), Employee E4 indicated
the resident was found sitting on the floor next to her bed, LPN called the RN to assess, no injuries noted. The family and physician were notified.

Review of Resident R1's "Johns Hopkins Fall Risk" assessment dated 1/29/24, indicated the resident was a high fall risk.

Review of Resident R1's care plan dated 1/29/24, indicated the resident was at risk of falling. Interventions included to wear non-skid footwear, give resident verbal reminders not to ambulate or transfer without assistance, and keep call light and personal items frequently used in reach at all times. No further interventions were implemented to prevent the resident from falling.

Review of Resident R1's progress note dated 2/2/24, entered at 5:24 p.m. by RN, Employee E5 indicated upon being notified by a visitor, staff found resident sitting on the floor in front of a chair in the day lounge. She was facing her wheelchair that was unlocked. Resident was unaware of what she was attempting to do. No injuries were observed. The resident's daughter and physician were notified. It was indicated a physical assessment was completed and neurological checks were initiated.

Review of Resident R1's "Neurological Checks" form dated 2/2/24, indicated a set of vital signs must be obtained with each neurological check (assess an individual ' s neurological functions, motor and sensory response, and level of consciousness) until the observation is completed. It was indicated to complete neurological checks every 15 minutes for one hour, then every 30 minutes for two hours, then hourly for four hours, then every four hours for 16 hours, then every eight hours for 56 hours. The facility staff failed to obtain vital signs and complete a neurological check after the first assessment.

During an interview on 2/21/24, at 9:42 a.m. LPN, Employee E6 indicated if a resident has an unwitnessed fall, neurological checks must be completed every 15 minutes, then half hour, then hourly, then every eight hours for 72 hours.

During an interview on 2/21/24, at 11:25 a.m. LPN, Employee E6 confirmed the facility failed to obtain Resident R1's vital signs and complete a neurological check after the first assessment on 2/2/24.

Review of Resident R1's "Johns Hopkins Fall Risk" assessment dated 2/2/24, indicated the resident was a moderate fall risk. The assessment indicated the resident did not have a fall within the previous six months and was on zero high risks medications. The facility failed to accurately complete Resident R1's fall risk assessment.

Review of Resident R1's "Event Report" dated 2/5/24, entered by Registered Nurse, Employee E2 indicated Resident R1 had a fall with minor injury. It was indicated the resident had a "bump" on her head.

Review of the facility's "Post Fall Huddle (PFH) Form" undated and unsigned, indicated Resident R1 had a fall on 2/5/24, at 12:45 a.m.

Review of the facility's "Focused Head to Toe Observation" dated 2/5/24, entered at 1:38 a.m. indicated the assessment was completed after the resident fell. It was indicated the resident did not have any alteration in skin such as bruises.

Review of Resident R1's progress notes on 2/5/24, failed to include documentation regarding the resident's fall.

Review of Resident R1's physician order dated 2/5/24, indicated to apply ice to the affected area of injury post fall for 20 minutes, four times a day, for three days. It indicated to monitor for significant injury, and notify the physician if severe swelling, bruising, or pain is present.

Review of Resident R1's weekly skin note dated 2/6/24, indicated the resident had an existing skin issue. It was documented the resident had left side head and face contusion. No further description was documented.

Review of Resident R1's clinical record failed to indicate a physician was notified of the resident's bruising to her left side head and face as ordered.

Review of Resident R1's late entry progress note entered by Nurse Practitioner, Employee E7 on 2/12/24, dated 2/9/24, indicated the resident was seen for a fall review and follow up. It stated the resident had a large hematoma (a solid swelling of clotted blood within the tissues) on the left side of her forehead that was tender to touch, and left periorbital (around the eye) ecchymosis (occurs when blood leaks from a broken capillary into surrounding tissue under the skin) and bruising.

During an interview on 2/21/24, at 12:59 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility provide needed care and services to prevent falls, provide an ongoing assessment post fall, and follow physician orders for one of three residents (Resident R1).

28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 03/21/2024

I. R1 was assessed and monitored. DON or designee will audit all post fall incidents weekly x4 to ensure accuracy and completion of documentation.
II. To identify others with the potential to be affected, NHA/DON will conduct a 30 day look back of residents with fall to review, ongoing assessments and any physician orders were followed to identify any concerns or trends. DON or designee will re-educate all licensed staff on following MD orders and on accuracy & completion of documentation
III. To prevent this from reoccurring, DON/designee will educate Licensed Nurses on addressing resident fall risk to attempt to prevent falls, to complete required ongoing assessments post fall and follow and physician orders provided post fall.
IV. To prevent this from reoccurring, DON or designee will audit residents with falls 5 X week for 4 weeks and monthly for 2 month to ensure needed care and services were provided to residents post fall. DON/designee will review new admissions that are a high risk for falls to ensure fall preventative measures are addressed. weekly for 4 ike residents for accuracy and completion of post fall documentation weekly x4.


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