Pennsylvania Department of Health
TUCKER HOUSE NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TUCKER HOUSE NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 153 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


TUCKER HOUSE NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey, and an Abbreviated Survey in response to 4 complaints, completed on January 31, 2024, it was determined that Tucker House Nursing and Rehabilitation 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 related to the health portion of the survey process.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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.

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and staff interviews it was determined that the facility failed to maintain resident care areas and personal belongings in a clean and homelike environment for three of three nursing units (2nd, 3rd, and 4th floor Nursing Units).

Findings Include:

Observations on January 26, 2024, at 11:50 a.m. in room 326 revealed the floors were sticky to touch and there was a red juice stain next to the window bed. Further observations revealed Resident R115's wheelchair was dirty with significant build-up of food/debris along the frame of the chair.

Observations on January 26, 2024, at 12:00 p.m. revealed residents seated in the 3rd floor dining room and lunch was about to start. The floors were observed to be dirty from breakfast with breakfast food spillage and wrappers on the floor. Further observations revealed a breakfast tray was left out on a table in the corner of the room.

Observations on January 29, 2024, at 11:15 a.m. in the 3rd floor dining room revealed spillage stains on the walls throughout the room and dining room chairs were soiled with stains. Further observations revealed a pile of stained sheets in the corner of the room.

During an observation on January 26, 2024 at 1:15 p.m. upon entering room 225, the floor felt "sticky" while walking on it, and made sounds indicating it was "sticky." Resident R164 was observed lying in his bed which is near the window. The resident's window was covered with a white blanket that had thumb tacks holding it up on the walls. There were no blinds or curtains observed behind the white blanket in room 225. A green chair was also observed on Resident R164's side of the room. The chair was observed to have several stains of an unknown substances on it. A pink basin was observed on the right side of the bed with what appeared to be a yellow unknown liquid substance inside of it with what appeared to be brown particles floating inside the unknown liquid substance that was in the pink basin. The unknown substance was later confirmed to be urine during an observation with Employee E20 on January 30, 2024 at 1:51 p.m. when the pink basin was observed still in the resident's room, filled with the above referenced substance, and sticking out from under the resident's bed. The floor inside the room were tile flooring and, and one tile on the right side of the resident's bed (when facing the front of the bed) was broken/chipped and needed to be repaired. The resident privacy curtains had stains of an unknown substance that were brown that could be seen on the outside of the curtains belonging to Resident R164 when entering the room.

Resident R71 who also residents in room 225 had two dressers drawers. Upon entering the room and looking to the left, you could see that both dressers were damaged with several scratches on the side of them with various parts of both dressers missing pieces of wood. A mouse trap was also observed on Resident R71's fall mat.

During an observation in room 230 on January 26, 2024 at 1: 23 p.m. upon entering room 230, the floor felt "sticky" while walking on it and made sounds indicating it was "sticky." Resident R150, was lying in his bed, and stated "these floors need to be cleaned, don't they?" Further observation revealed a big light brown stain under the bed of Resident R104, who is the roommate for Resident R150.

During an observation on January 26, 2024, at 1:27 p.m. Resident R120 was observed lying in his bed in room 231. A mousetrap was observed against the wall on the right side of his bed with two deceased bugs in it. Several blinds attached to the resident's windows were broken and/or missing. A green chair was also observed on Resident R28's side of the room, who shares a room with Resident R120. The chair was observed to have several stains of an unknown substance on it.

28 Pa. Code 211.10 (d) Resident care policies

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

Immediate Corrective Action: 

Room 326 floors were mopped, and juice stain cleaned up. R 115's wheelchair was cleaned.

3rd floor dining room floors were cleaned, and breakfast trays were removed. Stains on the walls were cleaned and dining room chairs were cleaned. Stained sheets were removed.

Room 225 floors were cleaned, and new blinds were hung. The chair on R164's side of the room was cleaned. Basin was removed. The privacy curtain was washed and replaced and the missing/broken tile on floor will be repaired.

R71's dresser was replaced, and mouse trap was removed from fall mat.

Room 230 floors were cleaned, and stain was removed.

Room 231 mouse trap was removed. Blinds were replaced and the chair was cleaned.

Housewide Corrective Action: 

-Dining room floors on each unit were audited to ensure floors were mopped and walls wiped down.

-Resident rooms were audited to ensure floors and chairs were cleaned and mouse traps were removed.

-Resident rooms were audited to ensure blinds/curtains were hanging appropriately.

-Resident rooms were audited to ensure tiles were intact and/or replaced if needed.

Education:

Housekeeping staff will be re-educated on room cleaning procedures.

Performance Monitoring: 

NHA or designee will conduct 5 random room rounds audits per week x 2 months to ensure rooms are cleaned, orderly and free of debris per policy. Results will be reviewed during facility's monthly QAPI meeting.

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:

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)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§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, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to report allegations of resident abuse to the state agency as required for two of four abuse allegations reviewed (Resident R22 and R32).

Findings Include:

Review of undated facility policy "Abuse" revealed allegations of abuse are reported per Federal and State Law. Further review of facility policy revealed the facility will ensure that all alleged violations involving abuse are reported to the administrator of the facility and to other officials, including to the State Survey Agency. If an allegation is considered reportable, the designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five working days.

Review of facility documentation revealed an incident report with a witness statement by Registered Nurse, Employee E14, dated May 24, 2023, that the 4th floor unit manager reported that Resident R22 alleged that a nurse hit him in the head. Further review of the incident report revealed that the perpetrator was identified as Registered Nurse, Employee E15, who was suspended pending investigation.

Review of the State Survey Agency event reporting system revealed allegations of abuse were not reported as required.

Interview on January 31, 2024, at 1:56 PM with the Assistant Administrator, Employee E3, confirmed allegations and results of the investigation were not reported to the state agency.

Continued review of the policy indicated that during the investigation of injuries of unknown origin or suspicious injuries must immediately investigated to rule out abuse. The policy also indicated that when an incident or suspected incident of "abuse" is reported, the administrator or designee investigation will include the following: investigating who was involved, obtaining witness statements, resident statements, resident roommate statements, in addition to other investigative areas.

Review of Resident R32's January 2024 physician orders included the following diagnosis: cerebral palsy (a group of disorders that affects an individual's movement, muscle tone, balance, and posture); adult failure to thrive, osteoporosis (a condition when an individual's bone strength weakens, making that individual susceptible to fractures), adult failure to thrive (occurs when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and dementia (a group of symptoms affecting memory, thinking and social abilities).

Review of the resident's Discharge Minimum Data Set that was completed due to a hospital admission, dated December 6, 2023 indicated that the resident was cognitively impaired.

Review of a nursing noted written by licensed nursing staff (Employee E16) dated January December 5, 2023 at 8:15 p.m. indicated that the resident complained to the nurse about her left lower leg, and when the nurse started to assess the resident and touched her left lower leg, Resident R32 began to scream.

Continued review of the nursing notes indicated that the physician was notified, an x-ray was obtained, and review of the nursing note dated December 6, 2023 4:11 p.m. indicated that the resident sustained an "acute hairline spiral fracture of the distal third of the tibial shaft (left leg fracture). Severe osteoporosis." Review of the "Radiology Results Reports" dated December 6, 2023, corroborated the above referenced nursing note.

Review of the events reported to the State Survey Agency for the months of December 2024, January 2024, and February 2024 did not show evidence that an event related to Resident R32's injury of unknown origin was reported to the State Survey Agency, as required, despite her diagnosis of osteoporosis.

During an interview with the Director of Nursing (DON) and the Regional Nurse (Employee E4) on January 31, 2024 at 11:40 a.m. it was confirmed with the Regional Nurse that the facility did not report the resident's injury of unknown origin to the State Survey Agency, as required.

28 Pa. Code 51.3 (f) Notification

28 Pa. Code 51.3 (g)(6) Notification

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

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

Immediate Corrective Action: 

R22 and R32 abuse allegation and injury of unknown were reported to state agency as required.

House wide Corrective Action: 

The facility will audit abuse allegations and injury of unknown origins over the last 60 days to ensure a report was made timely to the State Agency as required.

Education: 

IDCP Team educated on facility Abuse policy including to investigating and reporting allegation of abuse timely to the State Agency.

Performance Monitoring: 

The NHA/Designee will complete a weeky audit x 3 months to ensure the timeliness of reporting of allegations of abuse to the State Agency. Results will be reported during facility's monthly QAPI meeting.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§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 interviews, review of clinical records and facility documentation, it was determined that the facility failed to ensure a complete and through investigation to rule about abuse and/or neglect for an injury of an unknown origin for 1 out of 33 residents reviewed (Resident R32).

Findings include:

Review of the facility's undated "Abuse" policy indicated that during the investigation of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse. The policy also indicated that when an incident or suspected incident of "abuse" is reported, the administrator or designee investigation will include the following: investigating who was involved, obtaining witness statements, resident statements, resident roommate statements, in addition to other investigative areas.

Continued review of the policy indicated that during the investigation of injuries of unknown origin or suspicious injuries must immediately investigated to rule out abuse. The policy also indicated that when an incident or suspected incident of "abuse" is reported, the administrator or designee investigation will include the following: investigating who was involved, obtaining witness statements, resident statements, resident roommate statements, in addition to other investigative areas.

Review of Resident R32's January 2024 physician orders included the following diagnosis: cerebral palsy (a group of disorders that affects an individual's movement, muscle tone, balance, and posture); adult failure to thrive, osteoporosis (a condition when an individual's bone strength weakens, making that individual susceptible to fractures), adult failure to thrive (occurs when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), and dementia (a group of symptoms affecting memory, thinking and social abilities).

Review of the resident's Discharge Minimum Data Set that was completed due to a hospital admission, dated December 6, 2023 indicated that the resident was cognitively impaired.
Review of a nursing note written by licensed nursing staff (Employee E16) dated January December 5, 2023 at 8:15 p.m. indicated that the resident complained to the nurse about her left lower leg, and when the nurse started to assess the resident and touched her left lower leg, Resident R32 began to scream.

Continued review of the nursing notes on the above referenced date, indicated that the physician was notified, and an x-ray was obtained on December 6, 2023. Review of the nursing note dated December 6, 2023 4:11 p.m. indicated that the resident sustained an "acute hairline spiral fracture of the distal third of the tibial shaft (fracture of the left leg) Severe osteoporosis." Review of the "Radiology Results Reports" dated December 6, 2023, corroborated the above referenced nursing note.

Review of witness statements indicated the assigned nurse aides for December 3, 2024, December 4, 2023 and December 5, 2023 during the 7-3 a.m. shift (Employee E21 and E24) and the 3-11 p.m. (Employee E22 and Employee E23) were interviewed, in addition to the resident's roommate.

Employee E21 reported in her undated statement that "before care and after care" resident was lying on her back both days and reported to Employee E21 that her leg hurt. Employee E21 that she then told the nurse

Employee E24 reported in her statement that was obtained on December 11, 2023, 5 days after the results of the x-rays determined that the resident sustained a fracture of her left leg, that the resident complained about pain to her leg, explained how the resident had a sheet folded in between her knees, so she repositioned the resident. Employee E24 explained how the resident let the nurse know about her pain and that a "few days prior" Resident R32 was transferred to her Gerri chair.

Employee E22 reported in his undated statement that he was assigned to her, her bedside table was on the side of her, and that "a week ago he had her," he was told by the resident's roommate that she got up and out of her bed. "She was not in her pain and everything seems ok."

Employee E23, reported in her statement dated December 5, 2023 that the resident was lying down during her shift, and that the bedside table was across the resident as she was lying in her bed.

Resident R136 (resident's roommate) reported in her statement obtained on December 12, 2024, 6 days after results of the x-rays determined that the resident sustained a fracture of her left leg, that the resident does not get out of bed and that she gets out when they put her in her "blue chair." Resident R136 reported, "she didn't fall out of bed. She don't walk."

Review of the facility investigation did not include any interviews with nurse aides who were assigned to the resident on the following dates and times: Employee E25 December 3, 2023, 11 p.m. through 7:00 a.m. shift; Employee E26 assigned to the resident on December 4, 2023, 11:00 p.m. through 7:00 a.m. shift, and Employee E27 who was assigned to the resident on December 5, 2023, 11:00 through 7:00 a.m. shift. Continued review of facility documentation also did not show evidence of any interviews with any additional staff/ nursing staff members (e.g., nurses, nursing assistants, therapy staff) who may not have been assigned to resident, but may have helped with her care, to see if they may have witnessed something, observed something, or overheard something, or know of something that would have provided insight/information to rule out neglect, and find out if anything related to the resident's treatment, care and services, could have attributed to the fracture of her left leg, despite of the resident's diagnosis of osteoporosis.

During an interview with the Director of Nursing (DON) and the Regional Nurse (Employee E4) on January 31, 2024 at 11:40 a.m. it was confirmed with the Regional Nurse that the facility did not include statements from the above referenced nurse aides, in addition to other licensed nursing staff members and nurse aides who worked on various shifts.

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

28 Pa. Code 211.12(c) Nursing services

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

Immediate Corrective Action: 

Statements were obtained from employees that worked 72 hours prior to noted injury for R32.

Housewide Corrective Action: 

Facility will audit injuries of unknown origin over the last 60 days to ensure all statements were obtained and a thorough investigation was completed.

Education: 

Nursing staff will be re-educated on abuse policy, incident/accident policy and obtaining witness statements as part of a thorough investigation.

Performance Monitoring: 

DON or designee will complete a weekly audit of injuries of uknown origins to ensure all statements were obtained and a thorough investigation was completed x 3 months. Results will be reported during facility's monthly QAPI meeting.

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

§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 the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner, in writing and in a language and manner they understood after a selected resident was transferred to the hospital for two of 33 residents reviewed (Residents R22 and R471).

Findings include:

Review of Resident R22's clinical record revealed that the resident was transferred to the hospital on September 4, 2023, after a fall and October 28, 2023, due to lung cancer.

Further review of Resident R22's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to the Office of the State Long-Term Ombudsman.

Review of Resident R471's clinical record revealed that the resident was transferred to the hospital on November 4, 2023, January 3, 2024, and January 27, 2024, related to Resident R471 having Hematemesis (vomiting of blood).

Further review of Resident R471's clinical record failed to reveal documented evidence of a written hospital transfer notice provided by the facility to the Office of the State Long-Term Ombudsman.

Interview with the Assistant Nursing Home Administrator, Employee E3, on January 31, 2024, at 2:38 p.m. confirmed that Residents R22 and R471 didn't have transfer notices provided by the facility to the Office of the State Long-Term Ombudsman.

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights

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

Immediate Corrective Action: 

R22 and R471 RP made aware of transfers

Housewide Corrective Action: 

The facility will complete an audit to ensure all appropriate parties were notified of transfer for all current hospitalized residents.

The facility will notify the Ombudsman of transfers for the last 3 months.

Education: 

All licensed nurses will be re-educated on notifying MD and RP when residents are sent out to the hospital.

Social services will be re-educated on notifying the ombudsman monthly of transfers and discharges.

Performance Monitoring: 

DON or designee will complete weekly audits x 3 months to ensure proper parties were notified of transfers out. Results will be reported during facility's monthly QAPI meeting.

NHA or designee will complete a monthly audit x 3 months to ensure monthly notification to the ombudsman is completed.

483.25 REQUIREMENT Quality of Care:

§ 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 observations, review of facility policies, review of clinical records, and staff interviews, it was determined that the facility failed to ensure one resident had a physician order for a wander guard for one of 33 residents reviewed (Resident R62).

Findings Include:

Review of Resident R62's significant change Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated November 3, 2023, revealed the resident had a diagnosis of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). Further review of the MDS revealed Resident R62 had severe cognitive impairment and used a wheelchair for mobility.

Review of Resident R62's comprehensive nursing evaluation, Section 11. Elopement Risk, dated January 3, 2024, revealed the resident was not at risk for elopement.

Observations on January 29, 2024, at 2:10 p.m. with licensed nurse, Employee E13, revealed Resident R62 had a wander guard on the right wrist. Interview with licensed nurse, Employee E13, revealed the nurse was previously unaware Resident R62 had a wander guard and further confirmed there was no physician order or care plan to indicate the resident had a wander guard.

Email communication on January 30, 2024, at 11:30 a.m. with Regional Registered Nurse, Employee E4, revealed the facility does not have a specific wander guard policy.

Review of the facility elopement, pressure ulcer, and skin integrity policy revealed these policies do not address the use of wander guards.

Interview on January 30, 2024, at 12:00 p.m. with Regional Registered Nurse, Employee E4, revealed residents with a wander guard should have a physician order to check placement and function of wander guard at least daily. Registered Nurse, Employee E4, was unsure of facility protocol or policy regarding skin checks for a wander guard.

Follow-up interview on January 31, 2024, at 11:15 a.m. with Regional Registered Nurse, Employee E4, revealed the resident previously had a physician order for a wander guard to the right wrist that was discontinued April 24, 2023. Continued interview with Registered Nurse, Employee E4, revealed the employee was unsure if the wander guard was ever actually taken off Resident R62's wrist.

Observations on January 31, 2024, at 12:00 p.m. with licensed nurse, Employee E10, revealed Resident R62 still had the wander guard to her right wrist. Interview with licensed nurse, Employee E10, confirmed Resident R62 was non-ambulatory and used to be at risk for elopement but no longer is. Licensed nurse, Employee E10, reported Resident R62 did not need the wander guard.

Review of Resident R6's physician orders revealed no physician order for use of wander guard, checking for placement and function daily, or an order for skin checks surrounding the wander guard.

28 Pa. Code 211.10 (d) Resident care policies.

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

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

Immediate Corrective Action: 

R33 was re-assessed for elopement risk and it was determined that a wander guard was no longer needed. Wander guard was removed and care plan was updated.

Housewide Corrective Action: 

Current residents will be audited for wander guard placement and appropriate physicians' orders for wanderguard.

Education: 

Licensed nurses will be re-educated on obtaining a physician's order for wander guards and the proper orders related to wander guard checks/monitoring.

Performance Monitoring: 

DON or designee will complete a random weekly audit of 5 residents x 3 months to check for wander guard usage and appropriate orders related to wander guard checks/monitoring. Results will be reported during facility's monthly QAPI meeting.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility policy, review of facility documentation, observations, review of clinical records, and staff interviews it was determined that the facility failed to ensure residents received adequate supervision and were free from accidents and hazards related to smoking, mechanically altered diets, and resident safety (Resident R40, R105, and 162).

Findings include:

Review of facility policy "Smoking Safety", revised October 2022, revealed residents who smoke will be permitted to smoke in the designated outside smoking area. Residents must agree to and comply with the safe smoking practices and the conditions of the Smoking Safety Policy and Procedure. Residents will be assessed after admission by Nursing/ Social Services/designee and at a minimum, annually.

Further review of facility policy revealed noncompliance with the safe smoking practices could pose significant negative impact on the safety of all residents and staff. Violations include smoking in areas not designated for smoking.

Review of Resident R40's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 6, 2023, revealed the resident was admitted to the facility on June 28, 2023, and had diagnoses of hemiplegia (paralysis of one side of the body) affecting left nondominant side and mild cognitive impairment. Further review of the MDS revealed the resident had impaired vision and required use of corrective lenses.

Review of Resident R40's comprehensive care plan revised June 29, 2023, revealed the resident had an activities of daily living self-care performance deficit related to bilateral arm weakness/hemiplegia.

Continued review of Resident R40's comprehensive care plan revised January 24, 2024, revealed the resident was a smoker and violated the smoking policy.

Further review of Resident R40's comprehensive care plan revised January 21, 2024, revealed the resident had a behavior problem related to smoking cannabis and refusal to follow the facility smoking policy.

Review of Resident R40's clinical record revealed a nurses note dated November 22, 2023, that indicated Resident R40 was observed on November 21, 2022, smoking marijuana in the main dining room.

Review of Resident R40's quarterly smoking assessments dated September 21, 2023, and November 22, 2023, revealed assessments were incomplete. Review of the assessments revealed the rehabilitation and social screen sections were not completed.

Interview on January 30, 2024, at 12:10 p.m. with the Regional Registered Nurse, Employee E4, confirmed smoking assessments on September 21, 2023, and November 22, 2023, were incomplete.

Interview on January 29, 2024, at 12:15 p.m. with nurse aide, Employee E9, revealed a couple weeks ago there was a fire in the 3rd floor shower room because Resident R40 threw a cigarette into the trash can.

Further interview on January 30, 2024, at 12:10 p.m. with the Administrator, Employee E1, Director of Nursing, Employee E2, and Regional Registered Nurse, Employee E3, confirmed Resident R40 violated the smoking policy again on January 16, 2024, when the resident was found smoking in the 3rd floor shower room.

Review of facility incident report dated January 16, 2024, revealed Resident R40 was seen by staff smoking in the shower room. Further review of the incident report revealed a statement by the Director of Nursing, Employee E2, that there was smoke coming from the 3rd floor shower room and upon further observation there was a small fire with lots of smoke that was noted coming from the trash can. A fire extinguisher was used to contain the fire.

Review of Resident R40's comprehensive care plan revealed interventions dated January 17, 2024, that the resident's smoking privileges were revoked and resident was further placed on 1:1 supervision.

Review of facility diet manual revealed the facility followed the International Dysphagia Diet Standardization Initiative (IDDSI) Framework (provides a common terminology to describe food textures and drink thickness).

Review of the diet manual revealed "IDDSI Level 4 - Pureed Diet" is designed for individuals who have moderate to severe dysphagia (swallowing difficulty). Foods are pureed, which are of a smooth, homogenous, and cohesive consistency and keep their shape when on a spoon.

Review of the facility lunch menu for January 26, 2024, revealed garlic buttered fish, roasted potatoes, creamed spinach, and chilled peaches were being served.

Review of the diet extension sheets (a report that shows the breakdown of the menu items for each day and mealtime by diet type and consistency) for the lunch meal revealed the chilled peaches should be pureed for the IDDSI Level 4 - Pureed diet.

Review of Resident R105's physician order dated December 8, 2023, revealed the resident was ordered a "Pureed - Level 4" diet texture.

Observations on January 26, 2024, at 12:15 p.m. revealed facility staff pre-set the dining room tables for lunch with a cup of chilled, diced peaches at each place setting.

Further observations on January 26, 2024, at 12:26 p.m. revealed Resident R105 grabbed a cup of diced peaches (not pureed) and began to consume them. Observations were confirmed by nurse aide, Employee E7, who confiscated the peaches from the resident.

Review of Residents R162 clinical record revealed that resident R 162 has a behavior problem to potential for harming herself and others. There was incident reported occurred on November 15, 2023, reported that resident R162 was first hit and trying stab other resident with a fork.

Review of R162's care plan, created on November15, 2023, revealed that due to resident's behavior and incident, resident will use only plastic eating utensil for all meals and 1:1 supervision.

Observation in dining room at the 4th floor on January 26, 2024, at 12:13 PM, observed metal utensil was set on the table were resident R162 was sitting and didn't have nurse aide 1:1 supervision at her table.

Observation in dining room at the 4th floor on January 29, 2024, at 12:15 PM, observed metal utensil was set on the table where resident R162 was sitting and didn't have nurse aide 1:1 supervision at her table.

Interview with the Nursing Home Administrator, Employee E1, on January 4, 2024, at 12:20 PM in the dining room at the 4th floor about the resident's R162 behavior and clinical record says about resident using only plastic utensil and 1:1 supervision. Nursing Home Administrator, Employee E1 reported that he was not aware of the resident's behaviors and remove the metal utensil and give resident plastic utensil. Also asked her nurse aid to sit with her at the table.

211.10 (d) Resident care policies.

211.12 (d)(5) Nursing services.

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

Immediate Corrective Action: 

A new smoking assessment was completed for R40.

An incident report was completed for R105 and MD was made aware of the incident. Orders were given to monitor resident's condition post event.

R162 was given plastic utensils and 1:1 supervision for meal.

Housewide Corrective Action: 

New smoking assessments will be completed for current residents that smoke.

Education: 

Nursing, therapy and socials services were re-educated on completing smoking assessments and smoking policy.

CNAs were re-educated to ensure tables are not "pre-set" to ensure residents do not ingest food that is not at their current diet level.

Nursing staff on the 4th floor were re-educated on R162's plan of care.

Performance Monitoring: 

DON or designee will complete monthly audits x 6 months of smoking assessments for residents that smoke to ensure proper completion of assessment.

DON or designee will complete weekly audits x 3 months of dining room to ensure place settings are not "pre-set" with food.

DON or designee will complete random weekly audits x 3 months of R162 during mealtime to ensure resident is using plastic utensils and is under direct supervision. Results will be reviewed during facility's monthly QAPI meeting.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on clinical record review and observation, it was determined that the facility failed to ensure the proper care of indwelling urinary catheter and tubing for two of two residents observed with urinary catheters. (Residents R16 and Resident R59).

Findings include:

According to the facilities "Catheter Care, Urinary" policy, dated April 1, 2022, all 'catheter tubing and drainage bags are to be kept off the floor'.

Review of Resident R16's clinical record revealed an admission date of November 9, 2021, with diagnoses that included retention of urine. A physician order was obtained on April 24, 2023, for the use of an indwelling foley catheter.

Observation made on January 26, 2024, at 10:36 a.m. revealed that Resident R16's urinary catheter drainage bag and tubing extended out and lying directly on the floor underneath the bed.

Observation conducted of Resident R59 on January 26, 2024, at 10:45 a.m. revealed that Resident R59 was laying in bed with the urinary catheter drainage bag and tubing extended out and lying directly on the floor.

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

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

Immediate Corrective Action: 

R59 and R16 catheter drainage and bag were removed from the floor.

Housewide Corrective Action: 

Current residents with catheters were audited to ensure drainage bag/tubing were off the floor.

Education: 

Nursing staff will be re-educated on catheter care and keeping drainage bag and tubing off of the floor.

Performance Monitoring: 

DON or designee will complete weekly audits x 3 months of residents with catheters to ensure drainage bag and tubing are off the floor. Results will be reviewed during facility's monthly QAPI meeting.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on review of facility policy, review of clinical records, and staff interviews, it was determined the facility failed to ensure adequate monitoring to identify and apply relevant approaches to maintain acceptable parameters of nutritional status for one of six residents reviewed for nutrition (Resident R78).

Findings Include:

Review of facility policy "Weight Assessment and Intervention" revised February 15, 2022, revealed the nursing staff and Dietitian will cooperate to prevent, monitor, and intervene for undesirable weight loss for the residents. Review of facility policy indicated the registered dietitian will review monthly weights by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the registered dietitian whether or not the definition of significant weight change is met.

Continued review of facility policy revealed significant weight changes are defined as: more or less than 5% within 30 days; and more or less than 10% within 6 months. If a weight loss meets the definition of significant, the registered dietitian should discuss with the interdisciplinary team and make recommendations.

Review of Resident R78's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated December 14, 2023, revealed the resident had a diagnosis of dementia (affect the brain's ability to think, remember, and function normally) and was rarely/never understood. Continued review of the MDS revealed the resident had a loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen.

Review of Resident R78's comprehensive care plan revised September 7, 2023, revealed the resident had a nutritional problem related to significant weight loss. Interventions dated August 13, 2019, revealed the registered dietitian would evaluate and make diet change recommendations as needed.

Review of Resident R78's weight history revealed a documented weight on October 4, 2023, of 124 pounds and two documented weights on November 1, 2023, of 107.4 pounds and 107.2 pounds for confirmation. This would reflect a significant weight loss of 16.8 pounds and 13.5% in one month.

Review of Resident R78's clinical record revealed a nursing note dated November 3, 2023, by licensed nurse, Employee E11, that confirmed Resident R78 had a significant weight loss of 16.8 pounds in one month and indicated the Dietitian was aware and addressing. Continue review of the nursing note revealed Licensed nurse, Employee E11, initiated weekly weights and a 3-day calorie count for monitoring.

Review of Resident R78's physician orders confirmed the 3-day calorie count was ordered with a start date of November 4, 2023, and the weekly weights were ordered with a start date of November 6, 2023.

Review of Resident R78's entire clinical record revealed no evidence of the results or follow-up to the 3-day calorie count that was ordered. Further review of the clinical record revealed weekly weights were not completed as ordered.

Further review of Resident R78's clinical record revealed the weight loss was not addressed by the dietitian until December 14, 2023.

Review of the Resident R78's nutrition assessment dated December 14, 2023, by Nutrition and dietetic technician, registered (NDTR - trained in food and nutrition; work independently as team members under the supervision of Registered Dietitians), Employee E12, confirmed Resident R78 had a significant weight loss and met the criteria for malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets). NDTR, Employee E12, recommended weekly weights and the addition of a supplement four times per day.

Review of Resident R78's clinical record revealed no documented evidence the weekly weights or supplement were initiated as recommended.

Continued review of Resident R78's clinical record revealed no documented evidence the resident was weighed for the month of January.

Interview on January 30, 2024, at 2:15 p.m. with Registered Dietitian, Employee E6, confirmed there was no January weight for Resident R78 and further confirmed the November 1, 2023, significant weight loss was not addressed by a nutrition professional until December 14, 2023.

Follow-up interview on January 31, 2024, at 10:30 a.m. with Registered Dietitian, Employee E6, confirmed there was no follow-up to the 3-day calorie count ordered November 4, 2023, and the weekly weights from November were also not completed. Continued interview confirmed that the nutritional recommendations made by NDTR, Employee E12, on December 14, 2023, were also not implemented.

Further interview on January 31, 2024, at 10:30 a.m. with Registered Dietitian, Employee E6, revealed nursing staff obtained a weight for Resident R78 on January 31, 2024, of 104.5 pounds which would reflect a continued, undesirable, downward weight trend.

201.14 (a) Responsibility of licensee

201.18 (b)(1) Management

211.10 (d) Resident care policies

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

Immediate Corrective Action: 

R78 weight and weight loss were reviewed by the Physician and Dietician and interventions were put into place.

Housewide Corrective Action: 

Residents with a significant weight loss over the last 60 days were reviewed to ensure interventions were put into place and/or reassessed as needed.

Education: 

Nursing staff will be re-educated on the company's policy on "Weight Assessment and Intervention" and following dietician recommendations.

Performance Monitoring: 

Dietician or designee will complete weekly audits x 3 months of resident's that require a weekly weight and/or re-weight to ensure follow up is completed timely.

Dietician or designee will complete weekly audits x 3 months to ensure recommendations have been implemented/completed timely.

Results will be reviewed during facility's monthly QAPI meeting.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

§483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Observations:

Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure appropriate enteral feeding practices related to labeling for one of three residents reviewed for tube feedings (Resident R74).

Findings include:

Review of facility policy, "Enteral Feeding" dated last revised January 2, 2021, revealed that, "tube feeding formula will be labeled with residents name, date and time hung'. It also revealed that "syringes should be dated and labeled with the resident name."

Review of care plan for R74 revealed the use of tube feed related to dysphasia.

Observation on January 2, 2024, at 11:29 a.m. revealed Resident R74 resting in bed. Next to his bed hanging in a feeding pump was an opened, undated, unlabeled bottle of tube feed. On the bedside table, rested 3 opened, undated, unlabeled syringe bottles.

Interview, at the time of the observation, the Director of Nursing confirmed that it is the expectation of nurses to label, date and time all tube feed and supplies.

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

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

Immediate Corrective Action: 

A new bottle of feeding was hung and dated, and syringe bottles were replaced and dated for R74.

Housewide Corrective Action: 

Current residents with tube feedings were audited to ensure tube feeding bottles and supplies were properly dated.

Education: 

Licnesed nursing staff will be re-educated on facility's policy for Enteral Feeding.

Performance Monitoring: 

DON or designee will complete weekly audits x 3 months of residents with tube feedings to ensure feeding bottles and supplies are dated and labeled properly. Results will be reviewed during facilities monthly QAPI meeting.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on review of personnel files and staff interviews it was determined that the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents for one nursing staff reviewed (Employee E8)

Findings Include:

Review of nurse aide, Employee E8's, personnel file revealed the nurse aide was hired by the facility on October 10, 2023.

Further review of nurse aide, Employee E8's, personnel file revealed no competencies were available to ensure the nurse aide was competent in skills and techniques necessary to care for residents needs including activities of daily living such as personal hygiene, transfers, and mobility.

Interview with the Nursing Home Administrator, Employee E1, and Regional Registered Nurse, Employee E4 on January 31, 2024, at 1:30 p.m. confirmed that there was no documentation available to review to show that licensed nursing staff had been evaluated for competencies.

201.20 (b) Staff development.

201.20 (d) Staff development.

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

Immediate Corrective Action: 

Staff member E8 competencies were completed and placed in personal file.

Housewide Corrective Action: 

Current CNA personnel files were reviewed to ensure competencies were completed.

Education: 

HR and nursing management were re-educated on ensuring competencies are completed prior to being off probationary period for newly hired nurses and CNAs.

Performance Monitoring: 

DON or designee will complete monthly audits x 3 months of new nursing hires' personal files to ensure competency completion prior to end of 90-day probationary period. Results will be reviewed during faclity's monthly QAPI meeting.

483.40(d) REQUIREMENT Provision of Medically Related Social Service:

§483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.

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

Immediate Corrective Action: 

The facility will pursue guardianship for R120.

Housewide Corrective Action: 

The facility will audit current residents for the need of guardianship.

Education: 

NHA, social services and business office manager will be re-educated on pursing guardianship for residents in need.

Performance Monitoring: 

NHA or designee will complete monthly x 3 months audit of residents that are in need to ensure facility has started the process to obtain guardianship. Results will be reviewed during facility's monthly QAPI meeting.

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

§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 review of facility policy, review of clinical records, and staff interview it was determined that the facility failed to ensure that the physician documented that the pharmacist's identified irregularities were reviewed and failed to document the action taken or not taken to address the irregularities for one of five residents reviewed (Resident R14).

Findings Include:

Surveyor requested the policy regarding monthly medication reviews on January 31, 2024, at 12:45 p.m. Subsequently the facility provided the policy "Drug Regimen Free From Unnecessary Drugs", revised October 24, 2022.

Review of facility policy "Drug Regimen Free From Unnecessary Drugs" revealed the policy did not address the time frames for steps in medication regimen review or steps the pharmacist must take when an irregularity requires urgent action.

Review of Resident R14's clinical record revealed clinical notes by the consultant pharmacist dated 8/8/2023, 9/12/2023, 9/22/2023, and 10/10/2023 that the medication regimen was reviewed. Recommendations were made to prescriber and to see medication regimen review report.

Review of Resident R14's clinical record revealed recommendation reports from the consultant pharmacist were unavailable. No documented evidence that the reports were reviewed and addressed by the attending physician.

Interview on January 31, 2024, at 11:30 a.m. with Regional Nurse, Employee E4, confirmed the reports were not available for review as they were unable to be located.

211.9 (k) Pharmacy Services.

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

Immediate Corrective Action: 

R14s medication regimen recommendations for 8/8/23, 9/12/23, 9/22/23, 10/10/23 were reviewed with the provider.

Housewide Corrective Action: 

Medication regimen reviews over the last 60 days were reviewed to ensure recommendations were addressed appropriately.

Education: 

DON and nursing management were re-educated on timely follow up regarding medication regimen recommendations and reviewing and addressing with the providers.

Performance Monitoring: 

DON/designee will complete a monthly audit of 10 residents for completion of drug regimen reviews x 3 months. Results will be reviewed during facility's monthly QAPI meeting.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on interviews with staff and review of facility documentation, it was determined that the facility failed to ensure that resident electronic signatures on admission documents were safeguarded to prevent unauthorized use of the signatures for one out of two residents reviewed (Resident R121).

Findings include:

Review of the "Electronic Signature" policy dated April 1, 2022, indicted that this policy addressed the usage of electronic signatures for medical records and agreements throughout the operations of the facility.

Continued review of the policy indicated that when electronic signatures are used, safeguards to prevent unauthorized access, reconstruct information, and minimize fraud must be in place. The policy indicated that safeguards included but are not limited to (1) Verification of a person's identity before assigning the unique qualifier (2) System security roles to control what sections/areas individuals can access or enter data based on the individual's role, security role and unique identifier (3) A specific computer "lock out" time that is activated when there has been no activity (4) System security that prevents a record from being changed once it is electronically signed and requires any corrections to be entered as amendments to the record.

Review of the January 2024 physician orders for Resident R121 indicated that the resident was admitted into the facility on March 2, 2023 included the following diagnosis: heart disease (a broad term for various conditions that affect the heart's function and blood flow); heart failure (occurs when the heart muscle doesn't pump blood as well as it should); hypertension (high blood pressure); atrial fibrillation (a disease of the heart characterized by an irregular and often faster heartbeat); depression(a mood disorder that causes a persistent feeling of sadness and loss of interest); schizophrenia (a mental disorder that includes believing things that are not real or shared by other people, and seeing, hearing, feeling, or smelling something that does not exist, in addition to having disorganized thoughts, speech and behavior); alcohol use with intoxication; adjustment disorder; cocaine use; bipolar disorder (a mental illness that causes extreme mood swings, from high to low, that affect an individual's energy, thinking, and behavior).

Review of the resident's admission agreement dated March 2, 2023, included the following information that was reviewed by the Admission Director with resident upon his admission into the facility by the facility's admission department: visitation, payment for cost of care, medical care, discharges, transfers, beholds, arbitration agreements, the facility's smoking policy in addition to other information relevant to his stay at the facility.

Review of the resident's Admission Agreement made on the above referenced date indicated that admission agreement was reviewed by the resident, and acknowledged by the "electronic signature" of the resident using what resembled a "cursive signature font" on the Admission Agreement for Resident R121.

Continued review of the electronic signature documentation indicated that the electronic Admission Agreement utilized by the Admission Department did not include as a safeguard in obtaining electronic signatures from residents and or their responsible parties such as, but not limited to, assigned identifiers for residents and/ or their responsible party who are signing the agreements to minimize fraud, and to ensure that an entry could not be changed once entered by just anyone, with the exception of the identifier resident and/or responsible party for that resident who signed the electronic document, instead of the facility's current system in which the admission staff types in the resident and/or responsible party's signature, or even the resident typing in their own signature without any of the required safeguards in place.

During an interview with the Admission Director (Employee E17) on January 31, 2024 at 12:50 p.m. Employee E17 discussed the process of utilizing the computer system for the admission documents that she reviews with the resident confirmed that when reviewing the admission documents with resident and/or responsible party, she first logs into the system using her user name and password, reviews the admission documents with the resident and/or responsible party, and then types in the residents and/or responsible party's name, when obtaining their "electronic signature" of acknowledgement of the documents that were reviewed with the resident.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

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

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

Immediate Corrective Action: 

None

Housewide Corrective Action: 

Facility will ensure that residents are provided with the right to electronically sign their own admission document.

Education: 

Admissions director will be educated to ensure that residents are provided with the right to electronically sign their own admission document.

Performance Monitoring: 

NHA/designee will audit 3X weekly X4 then monthly X2 to ensure that residents we're provided with the right to electronically sign their own admission document. Results will be reviewed during the facility's monthly QAPI meeting.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright © 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement