Pennsylvania Department of Health
DARWAY HEALTHCARE AND REHABILITATION 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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DARWAY HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on February 23, 2024, it was determined that Darway Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

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.

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure an appropriate physician response to consultant pharmacist recommendations for three of five residents reviewed for potentially unnecessary medications (Residents 22, 41, and 46).

Findings include:

Clinical record review for Resident 22 revealed a consultant pharmacist recommendation dated July 28, 2023, that requested the physician evaluate a gradual dose reduction (GDR) of Resident 22's Quetiapine Fumarate (Seroquel, an antipsychotic medication used to treat mood/mental disorders).

The physician's response on August 7, 2023, declined to reduce Resident 22's Quetiapine medication with the rationale, "Pt (patient) hasn't tolerated GDR in the past currently stable on current meds."

Physician orders active at the time of the July 28, 2023, pharmacist recommendation instructed staff to administer Seroquel 200 mg by mouth at bedtime.

Resident 22's total daily intake of Seroquel was reduced from 250 mg to 225 mg on February 11, 2023.

Resident 22's total daily intake of Seroquel was reduced from 225 mg to 200 mg on June 28, 2023.

There was no evidence of an increase in Resident 22's problematic target behaviors between February 11, 2023, and August 7, 2023, when the physician indicated Resident 22 had failed a GDR in the past.

A consultant pharmacist recommendation dated January 23, 2024, again requested that the physician evaluate a possible GDR of the Quetiapine medication. The physician disagreed with the recommendation on February 11, 2024, with the rationale, "Benefits > (greater than) Risks." The physician did not provide a clinically significant rationale as the basis for declining the consultant pharmacist's recommendations.

Interview with the Director of Nursing on February 23, 2024, at 12:09 PM confirmed the above findings for Resident 22.

Clinical record review for Resident 41 revealed a consultant pharmacist recommendation dated June 23, 2023, that requested the physician evaluate Resident 41's Seroquel medication for a GDR. The physician disagreed on June 28, 2023, with the rationale, "Pt continues to have symptoms agitation, yelling, etc."

Social services quarterly assessment documentation dated April 25, 2023, at 7:58 AM stipulated that, "(Resident 41) had 0 (zero) days of adverse behaviors throughout the review period."

Review of interdisciplinary progress note documentation dated April 25, 2023, through June 28, 2023, revealed one entry (June 24, 2023, at 6:43 PM) when staff documented Resident 41 was easily agitated but was redirected and calmed, "after short while."

Interview with the Director of Nursing on February 23, 2024, at 12:09 PM revealed that the facility could not provide evidence of Resident 41's ongoing symptoms of agitation, yelling, etc., that the physician referred to in the June 28, 2023, response.

A consultant pharmacist recommendation dated December 19, 2023, again requested that the physician evaluate Resident 41's Seroquel medication for a GDR. The physician disagreed on December 31, 2023, with the rationale, "Benefits > (greater than) risk." The physician did not provide a clinically significant rationale as the basis for declining the consultant pharmacist's recommendations.

Clinical record review for Resident 46 revealed a consultant pharmacist recommendation dated April 27, 2023, that requested the physician evaluate a possible GDR of Resident 46's Seroquel dose. The physician disagreed on May 1, 2023, with the rationale, ""Pt is still agitated, combative..." There was additional handwriting following that statement; however, the surveyor, Director of Nursing, and the Nursing Home Administrator could not decipher the comment when reviewed on February 23, 2024, at 9:45 AM.

Review of interdisciplinary progress note documentation dated March 1, 2023, through May 1, 2023, revealed numerous entries that Resident 46 was kind, smiling, had no signs or symptoms of depression, was calm, cooperative, and pleasant.

Social services documentation dated March 30, 2023, at 9:25 AM revealed that Resident 46 had one day of physical behavior and one day of care rejection throughout the review period (one quarter, approximately three months).

Care plan interdisciplinary documentation dated April 5, 2023, at 1:49 PM reiterated that Resident 46 had one day of physical behavior and one day of care rejection throughout the review period.

Interview with the Director of Nursing on February 23, 2024, at 12:09 PM revealed that the facility could not provide evidence of Resident 46's ongoing episodes of agitation and combativeness that the physician referred to in the May 1, 2023, response.

A consultant pharmacist recommendation dated October 18, 2023, again requested the physician review Resident 46's Seroquel dose for a GDR. The physician's response dated October 23, 2023, indicated that Resident 46 continued to have behavioral symptoms, i.e., combative, yelling, etc.; and that the GDR was not advised.

Interdisciplinary documentation dated October 5, 2023, at 2:10 PM indicated that Resident 46 went to the common areas to socialize with other residents and staff, he participated in group activities, and that he had only one day of physical behaviors throughout the review period.

Review of interdisciplinary progress note documentation dated October 5, 2023, through October 23, 2023, revealed several entries that staff assessed no behaviors for Resident 46. One entry dated October 7, 2023, at 3:57 indicated Resident 46 yelled if another resident and went near him; however, there was no indication of a physically aggressive action.

Progress note documentation beginning October 17, 2023, at 6:48 AM revealed that Resident 46 began abnormal respiratory symptoms such as coughing and abnormal lung sounds.

Nursing documentation dated October 20, 2023, at 5:28 PM revealed that Resident 46's physician ordered antibiotic therapy for Resident 46. Although nursing documentation dated October 20, 2023, at 11:37 PM indicated that Resident 46 had physical behaviors noted only during care, Resident 46 was experiencing acute illness at that time.

Interview with the Director of Nursing on February 23, 2024, at 12:09 PM confirmed that the facility had no behavior tracking other than the above progress note documentation. The facility could not provide evidence of ongoing behavioral symptoms referred to by the physician in his October 23, 2023, declination of the consultant pharmacist's recommendation to GDR the antipsychotic medication.

28 Pa. Code 211.2(d)(3)(8)(9) Medical director

28 Pa. Code 211.9(k) Pharmacy services

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

Plan of Correction - To be completed: 04/04/2024

1. Resident 22, Resident 41, and Resident 46 GDR's will be re-evaluated by MD for Seroquel usage.

2. IDT team will do a whole house audit on GDR's for the month of February to ensure appropriate rationale for accepting or declining the GDR recommendation.

3. DON/Designee will educate MD on GDR process and appropriate rationale for accepting or declining the GDR recommendation.

4. DON/Designee will complete an audit of GDR responses monthly x 3 to ensure proper rationale for accepting or declining the GDR recommendation. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on a review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure residents' medication regime was free from potentially unnecessary medication for three of five residents reviewed for medication regime review (Residents 22, 41, and 46).

Findings include:

The facility policy entitled, "Tapering Medications and Gradual Drug Dose Reduction," last reviewed without changes on January 18, 2024, revealed that all medications will be considered for possible tapering. Tapering that is applicable to antipsychotic medications will be referred to as gradual dose reduction. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue these drugs. Periodically, the staff and practitioner will review the continued relevance of each resident's medications. The attending physician and staff will identify target symptoms for which a resident is receiving various medications. The staff will monitor for improvement in those target symptoms and provide the physician with that information. The staff and practitioner will consider tapering medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefitting the resident. The staff and practitioner will consider tapering under certain circumstances, including when:

The resident's clinical condition has improved or stabilized;
The underlying causes of the original target symptoms have resolved;
Non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms
The physician will review periodically whether current medications are still necessary in their current doses; for example, whether an individual's conditions or risk factors are sufficiently prominent or enduring that they require medication therapy to continue in the current dose, or whether those conditions and risks could potentially be equally well managed or controlled without certain medications, or with a lower dose. When a medication is tapered or stopped, the staff will closely monitor the resident and will inform the physician if there is a return or worsening of symptoms. When a medication is tapered or stopped, the staff and practitioner shall document the rationale for any decisions to restart a medication or reverse a dose reduction, for example, because of a return of clinically significant symptoms. Within the first year after a resident is admitted on an antipsychotic medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR (gradual dose reduction) in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated.

Clinical record review for Resident 22 revealed Resident 22's total daily intake of the antipsychotic, Seroquel, was reduced from 250 mg to 225 mg on February 11, 2023.

Resident 22's total daily intake of Seroquel was reduced from 225 mg to 200 mg on June 28, 2023.

Physician orders dated May 1, 2023, instructed staff to track verbally abusive behavior (threatening others, screaming/yelling at others, cursing/swearing), socially inappropriate or disruptive behavior (self-injury (scratch/hit), pacing/wandering, disrobing, sexual acts/comments, masturbation/self-stimulation, rummaging, stealing, fecal manipulation, screaming/yelling out), and refusal of care as needed and provide additional details as needed in progress notes.

Review of interdisciplinary progress note documentation dated June 28, 2023, through August 28, 2023, revealed no socially inappropriate, disruptive, or abusive behaviors that were not related to Resident 22's refusal of care.

Nursing documentation dated July 28, 2023, at 10:24 AM through August 4, 2023, at 8:38 PM revealed that Resident 22 received antibiotics for a right elbow skin infection.

A physician's order dated August 28, 2023, instructed staff to reverse Resident 22's Seroquel dose reduction and resume dosing at the increased 225 mg daily.

Resident 22's clinical record did not contain evidence that the staff and practitioner documented a rationale for the decisions to reverse the dose reduction (e.g., a return or worsening of clinically significant symptoms).

Interview with the Director of Nursing on February 23, 2024, at 12:09 PM confirmed that Resident 22 entered the facility in January 2018, with an antipsychotic medication; and that the facility had no evidence of a failed GDR that was evidenced by a return or worsening of target behaviors. The facility was unable to provide documentation of the clinically significant symptom that required the resumption of Resident 22's antipsychotic medication, Seroquel, at 225 mg daily. The interview confirmed that Resident 22's clinical record indicated that he tolerated a gradual dose reduction of the Seroquel medication February 11, 2023, through August 27, 2023, based on no evidence of an increase in his behaviors or a decline in his functioning.

Clinical record review for Resident 41 revealed that the facility admitted him on January 17, 2023. Admission physician orders for Resident 41 instructed staff to administer Seroquel 25 mg twice a daily (total 50 mg daily dose).

Physician orders dated May 1, 2023, instructed staff to track Resident 41's target behaviors as subsequently described as: socially inappropriate or disruptive behavior (i.e., self-injury (scratch/hit), pacing/wandering, disrobing, sexual acts/comments, masturbation/self-stimulation, rummaging, stealing, fecal manipulation, screaming/yelling out) and refusals of care. Staff were to track by occurrence as needed and provide any additional details as needed in Resident 41's progress notes.

Resident 41's clinical record did not contain any evidence that the facility attempted a gradual dose reduction of Resident 41's antipsychotic in two separate quarters (with at least one month between the attempts) during his first year in the facility.

Interview with the Director of Nursing on February 23, 2024, at 12:05 PM confirmed that the facility did not have behavior tracking to support that the staff monitored Resident 41 for improvement in target symptoms to find an optimal dose or determine whether continued use of the medication was benefitting Resident 41.

Clinical record review for Resident 46 revealed that the facility admitted him on March 22, 2022.

Physician orders dated June 4, 2022, instructed staff to administer Seroquel 25 mg during the day and 50 mg at bedtime.

Physician orders for Resident 46 continued the Seroquel medication at the total daily dose of 75 mg from June 4, 2022, through September 25, 2023.

There was no evidence in Resident 46's clinical record that the facility attempted a gradual dose reduction during the first year after Resident 46 started the antipsychotic medication.

Review of interdisciplinary progress note documentation dated March 1, 2023, through May 1, 2023, revealed numerous entries that Resident 46 was kind, smiling, had no signs or symptoms of depression, was calm, cooperative, and pleasant.

Social services documentation dated March 30, 2023, at 9:25 AM revealed that Resident 46 had one day of physical behavior and one day of care rejection throughout the review period (one quarter, approximately three months).

Care plan interdisciplinary documentation dated April 5, 2023, at 1:49 PM reiterated that Resident 46 had one day of physical behavior and one day of care rejection throughout the review period.

Social services documentation dated June 30, 2023, at 7:53 AM for a quarterly assessment, revealed that Resident 46 had two days of care refusal behavior throughout the review period.

Physician orders dated September 25, 2023, instructed staff to increase Resident 46's Seroquel dose to 50 mg twice daily (a total of 100 mg in a day).

Social services documentation dated October 2, 2023, at 7:35 AM for a quarterly assessment, revealed that Resident 46 had one day of physical behaviors throughout the review period.

Interdisciplinary documentation dated October 5, 2023, at 2:10 PM indicated that Resident 46 went to the common areas to socialize with other residents and staff, he participated in group activities, and that he had only one day of physical behaviors throughout the review period.

Review of interdisciplinary progress note documentation dated October 5, 2023, through October 23, 2023, revealed several entries that staff assessed no behaviors for Resident 46. One entry dated October 7, 2023, at 3:57 indicated Resident 46 yelled if another resident and went near him; however, there was no indication of a physically aggressive action.

Interview with the Director of Nursing on February 23, 2024, at 12:09 PM confirmed that the facility had no behavior tracking, other than interdisciplinary progress note documentation. The facility could not provide evidence that continuing the antipsychotic at the same dose from June 2022 to September 2023, benefitted the resident given no significant change in the frequency or severity of his target behaviors per the social services documentation above. The facility could not provide evidence of an increase in target behaviors before increasing Resident 46's Seroquel medication in September 2023.

28 Pa. Code 211.2(d)(3) Medical director

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

Plan of Correction - To be completed: 04/04/2024

1. Resident 22, Resident 41, and Resident 46 GDR's will be re-evaluated by MD for Seroquel usage.

2. IDT team will do a whole house audit of behavior tracking for one week to ensure behaviors have been captured when appropriate.

3. DON/Designee will educate nursing staff on ensuring documenting behaviors for each resident occurrence.

4. DON/Designee will audit behavior tracking 5 times per week x 4 weeks and then bi weekly x 4 weeks to ensure behaviors are captured when appropriate. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

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 select facility policies, clinical record review, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy that ensured a complete and thorough investigation of an incident involving the potential for neglect for one of 14 residents reviewed (Resident 24).

Findings include:

The facility policy entitled "Darway Rehabilitation Center Abuse Policy" last reviewed without changes on January 18, 2024, revealed that the facility residents will be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Abuse is "the willful infliction of injury, unreasonable confinement, intimidation, or corporal punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s) that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. The facility will report all alleged violations of abuse, neglect, exploitation or mistreatment and the results of all investigations of alleged violations.

Clinical record review for Resident 24 revealed nursing documentation dated August 9, 2023, at 9:32 PM that Resident 24 was "found sitting in front of her chair facing the nurse's station in the TV area. The chair alarm was not sounding when checked, it was not turned on."

Review of the facility's investigation dated August 9, 2023, confirmed that the alarm was turned off and that the facility had two staff complete statements, both of which indicated that they did not witness Resident 24's fall.

There was no investigation to determine who was the assigned staff member that failed to turn the alarm on at the time of placing Resident 24 in her chair, a statement from this staff member indicating if they did or did not turn the alarm on, and/or documentation which indicated that Resident 24 turns her alarms off on her own or is non-compliant with alarm usage.

There was also no documentation regarding the identification of potential neglect by the assigned staff member who failed to turn Resident 24's chair alarm on, reporting of this potential neglect to the appropriate state agencies, or completion of staff education regarding implementation of fall interventions, including ensuring chair alarms are turned on at the time of placement into the chair.

This information was reviewed during an interview with the Director of Nursing on February 23, 2024, at 12:12 PM.

28 Pa. Code 201.18(b)(1)(3) Management

28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 201.29(a) Resident rights

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

Plan of Correction - To be completed: 04/04/2024

1. Facility cannot retroactively correct

2. DON or designee will review incident reports from past 14 days to ensure no investigation or reporting issues are identified.

3. NHA/Designee will educate nursing staff on alarm check process when residents are moved to chairs to ensure alarms are turned on and sounding. NHA/Designee will educate RN/DON staff on investigation and reporting process for potential neglect incidents.

4. DON or designee will conduct review incidents reports daily x two weeks and then bi-weekly x 4 weeks to ensure proper investigation and/or reporting process is completed. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

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.

Plan of Correction - To be completed: 04/04/2024

1. Resident 32 care plan was adjusted to include applicable pacemaker information; including individualized treatment and services necessary to maintain the required pacemaker monitoring.

2. IDT team will complete a whole house audit of pacemaker care plans to ensure individualized treatment and services necessary to maintain the required pacemaker monitoring is included in residents with pacemakers.

3. DON/Designee will educate IDT team on pacemaker care plans and the need for individualized treatment and services necessary to maintain the required pacemaker monitoring to be included.

4. DON/Designee will audit care plan's for pacemakers weekly x 4 to ensure they are individualized and have necessary information included. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for two of two residents reviewed for hospitalizations (Residents 32 and 48).

Findings include:

Clinical record review for Resident 48 revealed that was transferred to the hospital on February 16, 2024, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital.

The surveyor reviewed the above information for during an interview with the Nursing Home Administrator and Director of Nursing on February 23, 2024, at 10:04 AM.

Clinical record review for Resident 32 revealed nursing documentation dated October 26, 2023, at 10:44 AM that nursing staff informed the physician of laboratory values and, the physician instructed staff to send Resident 32 to the hospital. An ambulance arrived and transported Resident 32 to the hospital.

Nursing documentation dated October 26, 2023, at 5:45 PM indicated that the hospital admitted Resident 32 with diagnoses that included a urinary tract infection, pneumonia (infection of the lungs), and CHF (congestive heart failure, the inability of the heart to pump sufficiently resulting in the retention of fluids in the lungs).

Resident 32's clinical record contained no evidence that the facility provided written notice to Resident 32's responsible party that specified the duration of the state bed-hold policy upon Resident 32's transfer to the hospital.

Interview with the Nursing Home Administrator on February 22, 2024, at 2:32 PM confirmed that the facility was not mailing the required bed-hold policy notice to residents' responsible parties. The facility could not provide evidence that Resident 32's responsible party received the required bed-hold notice upon his transfer to the hospital.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.29(f) Resident rights

Plan of Correction - To be completed: 04/04/2024

1. Facility cannot retroactively correct

2. Social Services will audit the past 14 days of bed-hold notices and mail hard copy of the notice to RP.

3. NHA/Designee will educate social services and IDT team that bed-hold notices must be mailed or hard copy given to RP after verbal confirmation.

4. IDT will audit bed-hold notices biweekly x 4 weeks to ensure physical copy is provided to RP. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital for two of two residents reviewed (Residents 32 and 48).

Findings include:

Clinical record review for Resident 48 revealed that they were transferred to the hospital on February 16, 2024, after a change in their condition. There was no documentation that the facility provided written notification to the resident or the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, contact and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

The surveyor reviewed the above information for during an interview with the Nursing Home Administrator and Director of Nursing on February 23, 2024, at 10:04 AM.

Clinical record review for Resident 32 revealed nursing documentation dated October 26, 2023, at 10:44 AM that nursing staff informed the physician of laboratory values and after the physician spoke to Resident 32's son, the physician instructed staff to send Resident 32 to the hospital. An ambulance arrived and transported Resident 32 to the hospital.

Nursing documentation dated October 26, 2023, at 5:45 PM indicated that the hospital admitted Resident 32 with diagnoses that included a urinary tract infection, pneumonia (infection of the lungs), and CHF (congestive heart failure, the inability of the heart to pump sufficiently resulting in the retention of fluids in the lungs).

Resident 32's clinical record contained no evidence that the facility provided written notice to Resident 32's responsible party of his transfer.

Interview with the Nursing Home Administrator on February 22, 2024, at 2:32 PM confirmed that the facility was not mailing the required transfer notices to residents' responsible parties. The facility could not provide evidence that Resident 32's responsible party received the required transfer notice.

28 Pa. Code 201.14 (a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 04/04/2024

1. Facility cannot retroactively correct

2. Social Services will audit the past 14 days of transfer notices and mail hard copy of the notice to RP.

3. NHA/Designee will educate social services and IDT team that transfer notices must be mailed or hard copy given to RP after verbal confirmation.

4. IDT will audit transfer notices biweekly x 4 weeks to ensure physical copy is provided to RP. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:

(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on closed clinical record review and staff interview it was determined that the facility failed to account for the disposition of medication upon discharge for one of three discharged residents reviewed (Resident 56).

Findings include:

Closed clinical record review for Resident 56 revealed nursing documentation dated December 24, 2023, at 3:30 AM that the nurse found Resident 56 without breaths or heartbeat. The nurse determined Resident 56 had died.

Nursing documentation dated December 24, 2023, at 4:45 AM revealed that funeral home staff transported Resident 56's body out of the facility.

Review of Resident 56's medication administration record dated December 2023 revealed medications prescribed for Resident 56 up to the time of his death included the following:

Carvedilol (medication used to treat high blood pressure) 3.125 mg (milligrams) twice daily
Levetiracetam (medication used to treat seizures/epilepsy) 500 mg twice daily
Seroquel (antipsychotic medication used to treat mental/mood disorders) 100 mg twice daily

Resident 56's closed clinical record did not include documentation regarding who disposed of the above three medications, the quantity remaining of the medications, or the method of disposition of the medications.

Interview with Employee 1 (registered nurse) on February 23, 2024, at 11:51 AM, confirmed the above findings for Resident 56.

Plan of Correction - To be completed: 04/04/2024

1. Facility cannot retroactively fix.

2. IDT team will audit closed charts from past 30 days to ensure completed disposition of medications are included.

3. DON/Designee will educate RN staff on disposition of medications process and completion.

4. DON/Designee will audit closed charts weekly x 6 weeks to ensure that completed disposition of medications is included. Results of the audit will be presented for review and recommendations at the monthly QAPI meeting.

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