Heritagespring Healthcare Center Of West Chester

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to ensure a resident was free from significant medication errors during the admission process. Upon admission from another skilled nursing facility, the resident's transfer documents were incomplete, with several pages missing from the faxed admission orders, including those listing current medications. The admitting nurse entered medication orders from the incomplete fax without noticing the missing pages, and the same incomplete set of orders was provided by the resident's family upon arrival. The missing documentation resulted in the omission of an order for apixaban, an anticoagulant medication that the resident had been receiving at the previous facility for atrial fibrillation. Multiple staff members, including the admitting nurse, a nurse practitioner, and a second nurse who double-checked the orders, failed to identify that the admission orders were incomplete and that the anticoagulant was missing from the medication list. The facility's process required verification of orders and confirmation that all pages were received, but this was not done. The resident's care plan included a diagnosis of atrial fibrillation but did not address anticoagulant therapy, and the medication administration record showed that apixaban was not administered during the resident's stay. The resident subsequently developed symptoms of shortness of breath and tachycardia, prompting transfer to a hospital where a diagnosis of pulmonary embolism was made. Hospital staff confirmed with the facility that the resident had not received apixaban since admission. Interviews with facility staff revealed that the error was not detected during the initial review or subsequent verification of orders, and the omission was only discovered after the resident's hospitalization.

Removal Plan

• Resident #148's medical record was reviewed by the DON, including a review of the medication list from admission and the admission orders transcribed into the EMR.
• CNE #200 conducted a review of Resident #148's medical record including physician orders, care plans, and administration records.
• Regional MDS Nurses #220, #230, #235, and #240 completed an audit of all residents admitted in the last 60 days to ensure admission orders were transcribed correctly into the medical record.
• Any concerns noted during the audit were reviewed with NP #360 and orders updated as needed by licensed nurses.
• Regional MDS Nurses #220, #230, #235, and #240 verified that all pages of admission orders from transferring facilities were received/present.
• The DON or designee completed an audit of current residents with atrial fibrillation diagnosis and residents receiving anticoagulant medications for appropriateness.
• NP #360 reviewed current residents with atrial fibrillation diagnosis and residents receiving anticoagulant medications for appropriateness.
• Nurse Educator #280 completed a medication administration observation.
• RN #15 and RN #16 were immediately provided education by the DON, including ensuring admitting orders are received and transcribed into the medical record, that all pages of the orders are received, and hard copy of the orders are received upon resident's arrival.
• Licensed nurses were provided with an additional in-service education by the DON and ADON #100, including ensuring admission medication orders are reviewed and transcribed into resident medical records, that all pages of the orders are received, and that a hard copy of orders is received upon resident's arrival.
• A performance improvement (PI) audit worksheet was implemented to verify residents' admitting orders are transcribed completely (including all pages are verified) into the medical record.
• The PI audit is being completed by the DON or designee for any residents admitting to the facility for the previous day, daily for seven days, then three times per week for four weeks, then weekly for four weeks, and then monthly.
• The results of the PI worksheet will be reviewed by the QAPI team.
• Quality Assurance meetings were held with the Administrator, Medical Director, the DON, CNE #200, Regional Nurse #350, and Consultant Pharmacist #400.
• Five additional medical records were reviewed with no concerns for significant medication errors identified.

Penalty

Inspection fine: $22,925

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medication was dispensed and administered as ordered for one resident with a diagnosis of insomnia. Upon admission, the resident had a physician's order for zolpidem 10 mg at bedtime, but review of the medication administration records (MAR) showed that the medication was not administered on several occasions, with some doses marked as 'Medication Unavailable/Pharmacy Notified' and others left blank. The facility's records indicated that the medication was not available in the automated dispensing system (Pyxis), and pharmacy deliveries were delayed, with only a partial supply delivered several days after admission and the remainder not delivered until the day of discharge. Staff interviews revealed that when medications were unavailable, the protocol was to contact the pharmacy and document the communication, but there were lapses in follow-up to obtain a new prescription when needed. The pharmacy required a new prescription to dispense the medication, and although a three-day supply was eventually provided after pharmacy contact with the provider, there was no evidence of timely follow-up for additional prescriptions. The Director of Nursing was unaware that the medication had not been available and stated that the expectation was for staff to obtain necessary prescriptions or escalate the issue for assistance. Facility policy required prompt delivery of drugs and documentation of any shortages or irregularities, but in this case, the process failed to ensure the resident received the prescribed hypnotic medication as ordered. The deficiency was identified through record review, staff and pharmacy interviews, and policy review, confirming that the facility did not meet the requirement to provide pharmaceutical services to meet the needs of each resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an accurate reconciliation and accounting of all controlled substances for a resident who was admitted with multiple diagnoses, including chronic ulcers, diabetes with foot ulcer, rheumatoid arthritis, and spondylolisthesis. The resident had a physician's order for Oxycontin 10 mg, to be administered twice daily for chronic pain. On a specified date, the pharmacy delivered 30 tablets of Oxycontin for the resident, but these tablets could not be accounted for during a subsequent review. Medical record review showed that the resident was discharged home with his wife and was sent with medications for the rest of the weekend. However, the day after discharge, the facility discovered that the full supply of 30 Oxycontin tablets delivered earlier was missing. The facility was unable to determine the whereabouts of the medication, and the discrepancy was identified through inconsistencies between narcotic proof of use sheets and narcotic skids. Interviews with facility staff revealed that two nurses failed to follow protocol by transferring narcotic keys without conducting a required count of the controlled substances. This lapse in procedure contributed to the inability to reconcile the controlled drug records and maintain an accurate account of the medication, as required by facility policy and federal regulations.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and care for a resident, resulting in Immediate Jeopardy and serious life-threatening harm that ultimately led to the resident's death. The resident, who was dependent on staff for oral intake, began coughing and showing signs of respiratory distress while being fed breakfast by a CNA. Despite the resident's evident distress, the CNA left the room to inform an LPN, who later entered the room but failed to perform a thorough assessment of the resident's condition. Throughout the morning, multiple staff members, including CNAs and LPNs, entered the resident's room and observed white phlegm-like secretions and signs of respiratory distress. However, none of the staff conducted a comprehensive assessment or took appropriate action to address the resident's deteriorating condition. The resident continued to exhibit signs of respiratory distress, including coughing and increased secretions, until he stopped breathing and CPR was initiated. The resident was pronounced dead after failed resuscitation attempts by EMS. The facility's failure to assess and respond to the resident's change in condition, despite multiple opportunities to do so, directly contributed to the resident's death. The report highlights the lack of timely and adequate medical intervention by the facility's staff, which was a significant factor in the adverse outcome.

Removal Plan

• Resident #60's progress notes, orders, and care plans were reviewed by Corporate Registered Nurse/Nurse Educator #111. No concerns were noted.
• The DON and UM/LPN #21 interviewed LPN #22, CNAs #12, #11 and #13 in regard to Resident #60's condition prior to the resident coding. Interviews were completed.
• ADON #45 reviewed all current residents with any new progress notes during the past 24 hours to review for a possible change of condition. No concerns were identified.
• The DON reviewed all current residents with any new progress notes during the past 24 hours to review for a possible change of condition. No concerns were identified.
• The DON was provided in-service education by VPN #112 on the Change of Condition policy and conducting assessments including, but not limited to, vital signs and pulmonary assessment.
• A Quality Assurance (QA) meeting was held with the Administrator, Medical Director #90 (Via Phone), the DON, ADON #45, CRN/Nurse Educator #111, and VPN #112 to review findings. The QA committee developed, reviewed and approved the plan of action. This QA meeting included a review of the Change of Condition policy. No changes were made to the Change of Condition policy. A determination was made for a plan of action including, but not limited to, plan to assess all residents' vitals and lungs in house.
• All 107 current residents' vital signs were obtained by the DON, ADON #45, LPN #21, RNs #32, #30, #33, #28, Physical Therapist #110, Director of Therapy #100 and all vital signs were completed. Resident #05 refused vital signs.
• All 107 current residents' pulmonary status were assessed by the DON, ADON #45, UM/LPN #21, RNs #32, #30, #33 and #28. All assessments were completed. Resident #05 and Resident #42 refused assessments. Resident #32 was assessed with left lung rhonchi and right lung with diminished breath sounds. NP #80 was notified, and a new order for chest x-ray and albuterol was obtained. Resident #30 was assessed with coughing and diminished bilateral lung sounds. NP #80 was notified, and guaifenesin and a chest x-ray were ordered.
• The DON and CRN/Nurse Educator #111 started an additional in-service education to the current 37 licensed nurses. This education was sent electronically, verified it was delivered, then reached out to every nurse for verification. The education included, but was not limited to, ensuring a nurse assesses residents for potential change in condition. A resident assessment for a change in condition assessment includes, but not limited to, vital signs and cardiopulmonary assessment.
• The DON and CRN/Nurse Educator #111 provided the 37 licensed nursing staff with one-on-one additional in-service education. This additional in-service education included, but was not limited to, ensuring a nurse assesses residents for potential change in condition. A resident assessment for a change in condition assessment includes, but not limited to, vital signs and cardiopulmonary assessment. Any licensed nurse not on-site was provided education via telephone by the DON. The education onsite and via telephone were completed for all licensed nursing staff. All licensed nurses were able to verbalize understanding of the educational content.
• The DON reviewed all current residents with any new progress notes during the past 24 hours to review for a possible change of condition. No concerns were identified.
• To monitor ongoing compliance, the DON or designee will review current residents progress notes daily from the past 24 hours to review for a possible change of condition. This will be completed daily for 30 days.
• A Performance Improvement Audit Worksheet is being completed for 10 random residents to ensure the residents are assessed for potential changes in condition using a general physical assessment and obtaining vital signs. The Performance Improvement Audit Worksheet is being completed by the DON or designee daily for seven days, then three times per week for four weeks, then weekly for four weeks, then monthly. If any issues are noted, the DON will take appropriate action at the time the concern is noted. Results of the Performance Improvement Audit Worksheet will be reported to the QA committee for a determination of the need for further ongoing formal monitoring.
• A QA meeting was held with the Administrator, Medical Director #90 (Via Phone), DON, ADON #45, CRN/Nurse Educator #111, and VPN #112 to review education and the audit findings. The QA committee reviewed the plan and no concerns were identified. The QA committee will monitor weekly for four weeks.
• Medical Director #90 was notified of Immediate Jeopardy by the Administrator.
• Interviews with LPN #23, LPN #27, LPN #24, LPN #21, and ADON #45 revealed the staff had received education and in-service training on change in condition, physician notification, documentation and were knowledgeable about the facility's procedures and processes.
• Review of the medical records for five additional residents (#30, #32, #75, #112, and #113) related to a change in condition, revealed no concerns were noted.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were free from verbal abuse, specifically affecting one resident with severe cognitive impairment and multiple medical conditions, including major depressive disorder and hemiplegia. The resident was dependent on staff for all activities of daily living and had behavior problems such as being combative and using racial slurs. During an incident, a Certified Nursing Assistant (CNA) was observed on video being rough with the resident during care, which led to the resident becoming agitated and using profanity. The CNA responded with verbal abuse, including using profanity and making threatening gestures towards the resident. The incident escalated as the CNA continued to taunt the resident, who attempted to raise an arm in a possible attempt to hit the CNA. The CNA threatened to call the police on the resident if he hit her, further agitating the resident. Another CNA present during the incident did not intervene to stop the verbal abuse. The Director of Nursing (DON) arrived after the incident and separated the involved staff from the resident. The facility's policy on abuse and neglect was not followed, as the staff failed to protect the resident from verbal abuse. The policy requires immediate reporting of such incidents to the Administrator and the State Survey Agency. The incident was reported by the resident's sister, who observed the live feed of the electronic monitoring device in the resident's room. The facility's failure to prevent and address the verbal abuse led to the deficiency being cited.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement timely interventions to appropriately treat a urinary tract infection (UTI) for a resident with moderate cognitive impairment and multiple diagnoses, including osteomyelitis of the vertebra and atrial fibrillation. The resident, who was dependent on staff for all activities of daily living, was noted to have suprapubic tenderness and cloudy urine with sediment on examination. Despite a physician's order for a urinalysis with culture and sensitivity (UA C&S) due to urinary discomfort, there was a significant delay in collecting the urine sample. The initial order for the UA C&S was placed on 08/07/24, but the sample was not collected until 08/16/24, resulting in a delay in diagnosing the UTI and starting antibiotic treatment. Interviews with the Nurse Practitioner and Director of Nursing confirmed the delay in obtaining the urine sample, despite the resident having an indwelling catheter, which should have facilitated timely collection. The delay in collecting the UA C&S led to a delay in the administration of the prescribed antibiotic, Macrobid, which was not started until 08/19/24. This deficiency was identified during an investigation under Complaint Numbers OH00159762 and OH00159005, highlighting a lapse in the facility's adherence to timely intervention protocols for treating infections.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the physician and nurse practitioner's (NP) progress notes were timely written and signed at each visit, affecting three residents. Resident #30, who had moderate cognitive impairment and multiple diagnoses including malignant neoplasm and chronic kidney disease, had a progress note dated 11/12/24 that was not signed until 11/13/24. Resident #32, with severe cognitive impairment and conditions such as Parkinson's disease and diabetes mellitus, had multiple progress notes with delays in signing, ranging from one to three days after the date of service. Resident #75, who had a significant change in condition and was unable to complete a BIMS due to communication difficulties, also experienced delays in the signing of progress notes, with some notes signed two days after the date of service. The NP involved, identified as NP #80, admitted during an interview that she did not chart her visits while seeing the residents. She reported that upon being hired, she was instructed by her manager that she had up to 48 hours to complete and sign her progress notes after seeing the residents. This practice led to the deficiency, as the progress notes were not signed and completed at the time of the visit for the residents involved.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were seen by their physician at least every 60 days after the initial assessment, as required. This deficiency affected two residents, Resident #32 and Resident #75. Resident #32, who was admitted with diagnoses including Parkinson's disease, diabetes mellitus type II, convulsions, and atrial fibrillation, had not been seen by their physician, MD #90, since July 19, 2024, despite having severe cognitive impairment as indicated by a BIMS score of seven. Similarly, Resident #75, who was admitted with conditions such as a fracture of the right femur, type two diabetes mellitus, anxiety disorder, and Alzheimer's disease, had not been seen by MD #90 since February 27, 2024, even though the resident was unable to complete a BIMS due to being rarely or never understood. The deficiency was confirmed during an interview with the Administrator on November 14, 2024, who verified that both residents had not been evaluated by their physician every 60 days. The job description for the medical director indicated that the medical provider is responsible for coordinating and overseeing medical care and treatment, including ensuring that all necessary medical services provided to residents are adequate and appropriate. However, the facility did not adhere to these requirements, resulting in the failure to provide timely physician visits for the affected residents.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate documentation in a resident's medical record, specifically affecting one resident. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed through video footage on a specific date. During this observation, an LPN entered the resident's room, administered medication, and took the resident's blood pressure. However, the LPN did not complete an oxygen saturation level assessment, despite documenting a pulse oximetry of 94% in the resident's medical record. The LPN's actions were reviewed in an interview with the Director of Nursing, where it was confirmed that the oxygen saturation assessment was not performed, yet it was inaccurately documented. The LPN's job description includes maintaining appropriate documentation and evaluating resident care needs, which was not adhered to in this instance. This deficiency was identified through a combination of medical record review, video footage, and staff interviews.

Penalty

Inspection fine: $20,965

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate hand hygiene during resident care, affecting two residents. For Resident #60, a CNA was observed on video footage entering the resident's room with a breakfast tray, handling various items, and feeding the resident without performing any hand hygiene or wearing gloves. The CNA touched her face, personal phone, and pants during the process, further compromising infection control. The resident had severe cognitive impairment and was dependent on staff for all activities of daily living. For Resident #114, who had an indwelling Foley catheter and severe cognitive impairment, a CNA was observed performing catheter and peri-care without proper hand hygiene. The CNA was coached by a Unit Manager/LPN to change gloves and wash hands after moving from dirty to clean areas, but failed to do so, contaminating a washcloth used to rinse the catheter tubing. The facility's hand hygiene policy required staff to change gloves and wash hands when moving between contaminated and clean areas, which was not adhered to in these instances.