WEATHERLY, PA - Forest Hills Rehabilitation & Healthcare Center faced federal citations after inspectors discovered critical failures in psychiatric documentation, including omitting a resident's suicidal statements and falsely recording medication use during a July 2024 inspection.
Psychiatric Records Failed to Document Suicidal Statements
Federal inspectors found that psychiatric documentation for Resident 178 contained significant omissions and inaccuracies that compromised the facility's ability to provide appropriate mental health monitoring and care.
The resident, who had diagnoses including anoxic brain damage, hypertension, and disorientation, made statements to staff expressing suicidal thoughts. On June 6, 2024, at 1:34 AM, a nurse aide informed the nurse that Resident 178 stated she wanted to kill herself. The nurse documented speaking with the resident, who stated she did not have a plan but wished to die.
Later that day, a social worker conducted a support visit and documented that the resident confirmed not wishing to hurt herself and denied suicidal ideations at the time of that conversation. A psychiatric referral was made following the incident.
Psychiatrist's Note Contained False Information
Four days later, on June 10, 2024, a psychiatrist conducted an initial psychiatric evaluation. The psychiatric note documented that the resident admitted to anxiety, depression, and racing thoughts, and appeared tearful and anxious during the visit.
However, inspectors identified two critical problems with the psychiatric documentation. The psychiatrist's note made no reference to the resident's statements four days earlier about wanting to kill herself and wishing to die - information essential for proper psychiatric assessment and safety planning.
Additionally, the psychiatric note stated that "Resident has been compliant with psychotropic medications with no adverse effects noted" and concluded that "the continued use of psychotropics is in accordance with relevant current standards of practice."
This documentation was factually incorrect. A review of the resident's medication administration record for June 2024 revealed that the resident was not prescribed, nor receiving, any psychotropic medications at the time of the June 10 psychiatric note.
Accurate psychiatric records are fundamental to mental health care in nursing facilities. When residents express suicidal thoughts, this information must be clearly documented and communicated to all members of the care team, particularly psychiatric providers. Suicidal ideation requires careful assessment, monitoring, and treatment planning.
The presence or absence of psychiatric medications is a basic factual element that must be accurately recorded. Psychiatric treatment decisions depend on knowing what medications a patient is actually receiving. False documentation about medication use could lead to dangerous prescribing decisions or failure to initiate needed treatment.
The Director of Nursing confirmed during the inspection that there was no documented evidence in the psychiatric note of the resident's suicidal statements, and acknowledged that the note inaccurately stated the resident was receiving psychotropic medications.
Bed Bug Incident Lacked Required Documentation
Inspectors also found that the facility failed to maintain complete clinical records regarding a bed bug incident affecting two residents.
On April 16, 2024, bed bugs were discovered in a room shared by Residents 127 and 149. Both residents were relocated to separate rooms. Resident 127 had been admitted with cerebral infarction, muscle weakness, and lack of coordination. Resident 149 had chronic obstructive pulmonary disease and emphysema.
When inspectors reviewed the clinical records during the July 2024 survey, they found no documented evidence that either resident had been assessed for physical effects such as bites, rash, swelling, or skin irritation from the bed bugs.
The records also contained no documentation that the residents' representatives had been informed of the temporary room change and the reason for the relocation.
During an interview on July 11, 2024, the Director of Nursing acknowledged that while nursing staff performed skin assessments when the bed bugs were found, they did not document the assessments in the residents' clinical records.
Professional nursing standards require documentation of assessments and communications regarding patient status. When environmental issues like bed bugs occur, facilities must document the incident, any assessments performed, actions taken, and notifications made to families or representatives.
Bed bug exposure can cause skin reactions, allergic responses, and psychological distress. Proper assessment and documentation ensures that any health effects are identified and treated, and provides a record of the facility's response to the incident.
Hospice Communication Records Missing
The inspection revealed failures in coordinating and documenting hospice services for two residents receiving end-of-life care.
Resident 101 had dementia and atherosclerotic heart disease and was receiving hospice care. The resident's care plan indicated that hospice nurse aides would visit every Tuesday and Friday at noon, with a hospice registered nurse visiting every Tuesday at noon. The care plan specified that integrated care would be provided by facility nursing staff and hospice staff.
Resident 98 had Parkinson's disease and quadriplegia and was also under hospice care. This resident's care plan indicated hospice nurse aides would visit Monday through Friday at 10 AM, with hospice registered nurses visiting Tuesday, Thursday, and Friday at 11:30 AM.
Both care plans included interventions for nursing staff to collaborate with the hospice team to ensure residents' spiritual, emotional, intellectual, physical, and social needs were met.
However, when inspectors reviewed the hospice communication binders during the survey, there was no documented evidence of care provided by hospice registered nurses or hospice nurse aides. The clinical records contained no documentation of communication between hospice staff and facility nursing staff.
Effective hospice care requires close coordination between the hospice provider and the nursing facility. Documentation of hospice visits, care provided, and communication between teams ensures continuity of care and that all providers are aware of changes in the resident's condition or needs.
The Director of Nursing stated during the interview that communication information should be kept in each resident's hospice communication binder to coordinate care and ensure residents' physical and psychosocial needs are met, but was unable to provide such documentation for either resident.
Regulatory Violations
The facility was cited for violating federal regulation F842, which requires facilities to safeguard resident-identifiable information and maintain medical records according to accepted professional standards.
According to the American Nurses Association Principles for Nursing Documentation, nurses must document their work and outcomes in an integrated, real-time method to inform the healthcare team about patient status. Timely documentation should include assessments, clinical problems, and communications with other healthcare professionals regarding the patient.
Pennsylvania nursing regulations require registered nurses to assess human responses and plan, implement and evaluate nursing care. Nurses must carry out nursing care actions that promote, maintain, and restore well-being, and are fully responsible for their actions and accountable for the quality of care delivered. The regulations specifically require nurses to document and maintain accurate records.
The facility was also cited for violating regulation F849 regarding the provision of hospice services, due to the failure to coordinate and document hospice care for the two residents.
Facility Response Required
Forest Hills Rehabilitation & Healthcare Center submitted a plan of correction to address the identified deficiencies. Federal regulations require facilities to correct cited violations and implement systems to prevent recurrence.
The violations were classified as causing minimal harm or potential for actual harm. The deficiencies affected some residents at the facility.
Complete details of the inspection findings and the facility's plan of correction are available in the official inspection report from the Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Weatherwood Healthcare and Rehabilitation Center from 2024-07-12 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.