Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT SCRANTON, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT SCRANTON, THE
Inspection Results For:

There are  120 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT SCRANTON, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit and abbreviated complaint survey completed on March 15, 2019, it was determined that The Gardens at Scranton corrected the federal deficiencies cited during the survey of January 12, 2019, but failed to correct the deficiencies cited during the survey of February 6, 2019, and continued to be out of compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Requirements





 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on a review of the facility's abuse prohibition policy and clinical records and staff interview, it was determined that the facility failed to ensure that a resident was free from mental abuse, which compromised the physical condition and negatively affected the psychosocial well-being of one of 10 residents reviewed (Resident 55).

Findings include:

A review of a facility policy for "Abuse Protection" reviewed by the facility November 2018, revealed that residents have the right to be free from verbal, sexual, physical and mental abuse. The facility shall have processes in place include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals.

A review of the Resident 55's clinical record revealed that the resident was admitted to the facility on December 18, 2018, with diagnoses to include major depression (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and diabetes.

An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 25, 2018, indicated that the resident was cognitively intact, required extensive assistance of two people for activities of daily living and his mood was depressed, but the resident denied any thoughts of harming himself.

A review of the clinical record revealed that Resident 87 was admitted to the facility on June 17, 2016, with diagnoses to include depression.

A quarterly Minimum Data Set Assessment dated January 15, 2019, indicated that the resident was cognitively intact and his mood was depressed .

The resident's care plan initiated February 7, 2018, indicated that Resident 87 had the potential to exhibit distressed behavioral symptoms as evidenced by the problematic manner in which he acts, characterized by verbal abuse (yelling and cursing at others).

A review of nursing documentation, and information dated February 12, 2019, at 4:10 PM submitted by the facility revealed that Resident 55 attempted to harm himself by cutting his wrists with the tab of a soda can. Upon facility examination, Resident 55 had superficial scratches and a small amount of bleeding to the left wrist. The physician and ambulance were called and Resident 55 was sent to the hospital for mental health crisis intervention.

A review of an employee witness statement dated February 12, 2019, (no time), revealed that Employee 3, nurse aide, indicated that she had asked Resident 55 why he was cutting his wrist. Resident 55 replied that his roommate, Resident 87, told him to do it. Resident 55 further stated that "he was better off, as well as his family, with him gone."

A review of nursing documentation dated February 12, 2019, at 4:15 PM revealed that Employee 2 (Registered Nurse - RN) noted "called to room by charge nurse who reported that Resident 55 had cut his wrist. Upon examination noted superficial cuts to his inner left wrist with minimal blood loss." Employee 2 noted that during an interview with Resident 55, he stated that "the other guy in his room (Resident 87) keeps telling him that he is worthless and a burden on his family, that he can't walk and doesn't try and that we all would be better off without him here. He might as well off himself." Resident 55 said "it finally made sense" so he tried to (kill himself).

A review of hospital discharge records dated February 12, 2019, at 6:06 PM revealed that Resident 55 was seen in the hospital emergency department for self mutilating behavior. He was examined and given patient educational materials entitled "suicidal feelings: how to help yourself." He returned to the facility on a 1 to 1 safety watch, until mental health services could see him in the morning. Resident 55 returned to the same room he had previously resided, with Resident 87 as his roommate.

A review of mental health consultation dated February 13, 2019, at 11:00 AM revealed " met with Resident 1 in his room. He appeared in no apparent distress at the time of the interview. His affect was blunted. His thought process was circumstantial and he self reports depression and hopelessness. He openly discussed his suicidal attempt. He stated "I have him (his roommate) telling me that I'm worthless and that I shouldn't be around anymore." He denied suicidal ideation."

The mental health clinician recommended to discontinue the 1 to 1 safety watch, to adjust his antidepressant medication and agreed with a room change for him.

Resident 55's room was changed after the mental health consultation February 13, 2018, at 11:00 AM.

During an interview on March 14, 2019, at approximately 10:00 AM Resident 55 stated that prior to cutting his wrist with the soda can lid, his roommate (Resident 87) had told him multiple times that he is worthless and that he and his family would be better off if he harmed himself. Resident 55 stated that he feels a little better now that he has a different roommate.

During an interview March 14, 2019, at approximately 1:30 PM Employee 4 (Licensed Practical Nurse - LPN) stated that Resident 87 had been speaking inappropriately to Resident 55 since his admission to the facility. Employee 4 stated that nursing administration was aware of Resident 87's problematic behaviors, which were identified on the resident's plan of care.

There was no evidence at the time of the survey that the facility had protected Resident 55 from mental abuse perpetrated by Resident 87, which contributed to Resident 55's suicide attempt.


28 Pa. Code 201.18(e)(1) Management
Previously cited 2/6/19, 10/19/18, 7/24/18, 8/26/18, 6/14/18, 3/4/18, 11/2/17

28 Pa. Code 201.29(a)(d) Resident Rights
Previously cited 2/6/19, 11.2.17

28 Pa. Code 211.12(a)(c)(d)(3) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 6/14/18, 5/16/18, 3/4/18, 11/2/17

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 5/16/18, 3/4/18, 11/2/17

28 Pa. Code 211.16(a) Social Services
Previously cited 5/16/18, 11/2/17






















 Plan of Correction - To be completed: 04/09/2019

1. The resident's room was changed following facility being made aware of roommate complaint.
2. No other residents affected. Social Services to interview Resident 87's roommates now and going forward to ensure they insure they feel safe in room.
3. Facility will educate staff on policy and procedures for reporting abuse.
4. NHA/designee will do random staff interviews weekly for 4 weeks and monthly for 2 months to insure policy and procedure for abuse is followed accordingly.
5. Audits will be submitted to QAPI for review.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to consistently implement interventions designed to prevent pressure sore development, prevent worsening and promote optimal healing for one of 10 residents reviewed (Resident 55) with pressure sores.

Findings include:

A review of the Resident 55's clinical record revealed that the resident was admitted to the facility on December 18, 2018, with diagnoses to include major depression (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and diabetes.

An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 25, 2018, indicated that the resident was cognitively intact, required extensive assistance of two people for activities of daily living including bed mobility (moving to and from lying position, turning side to side and positioning body while in bed) and transfers and was incontinent of bladder and bowel.

A review of a "Braden Scale" (a tool used to determine/predict pressure sore development) dated January 21, 2019, revealed that the resident received a score of 16, indicating that the resident was at risk for pressure sore development.

A review of the resident's care plan initiated on December 31, 2018, and revised January 25 2019, revealed that the resident was at risk for pressure sore development due to requiring assistance with bed mobility. Planned interventions dated December 31, 2018, included to conduct weekly skin inspection, nutrition and hydration support as ordered, pressure reducing wheelchair cushion and pressure reduction/relieving mattress, provide thorough skin care after each incontinent episodes and apply barrier cream.

Review of the facility's "Skin and Wound management System" policy, dated as reviewed by the facility April 20, 2018, indicated the skin management system is designed to identify and assess residents with wounds and/or pressure ulcers, as well as those at risk for skin compromise. Such residents are then provided appropriate treatment to encourage healing and /or integrity. Ongoing monitoring and evaluation are then provided to ensure optimal resident outcomes. Practice guidelines directed that an assessment of skin integrity is to be preformed on each resident upon admission to the center by completing a head to toe physical evaluation of skin conditions and a risk evaluation for predicting pressure areas. Ongoing weekly evaluations of residents' skin will be completed and documented in the residents' electronic record and preventative interventions will be implemented for residents identified at risk, as appropriate.

A review of nursing documentation on January 25, 2019, at 4:30 PM "staff reported three new areas to the resident's butt and sacral area. Upon exam by me (registered nurse) that he had three areas of DTI (pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise. These lesions may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment) all deep purple and blanchable (lesion that loses all redness when pressed is termed). One area #1 right butt I found a dark spot measuring 1.5 cm x 1 cm x .01 cm. Left butt had spot 1.5 cm x 1 cm x .01 cm that included the DTI with an open are next to it. The sacrum had an area 2 cm x 4 cm .01 x cm with DTI at 12 o' clock (location based on the face of a clock) and open area attached below open area. Surrounding tissues red/pink with no MASD (moisture associated skin damage) injury noted but normal in appearance. MD made aware and NON (new order noted) for hydrogel (gel-based wound care dressing which protects and provides a moist wound-healing environment and helps remove dead tissue) wound care to sacrum and left butt, barrier cream to right butt and q (every) 2 repositioning side/side only."

Nursing documentation dated January 25, 2019, further noted that the resident would be seen by consultant the facility's wound care physician.

Further review of nursing documentation and a pressure ulcer investigation tool dated January 25, 2019, revealed that Resident 55 was at risk for pressure sore development and had impaired transfer and bed mobility. The documentation noted that this resident had refused repositioning during the past month. However, a review of nursing documentation for the month of January 2019 conducted at the time of the survey ending March 15, 2019, revealed no documented evidence that the resident had refused turning and repositioning prior to the January 25, 2019, discovery of the pressure sores.

A review of an initial wound consultant, evaluation and management summary dated January 29, 2019, identified an unstageable [full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough (dead skin) or eschar (thick black or brown scabbed dead skin)] measuring 7 cm x 6 cm x 0.2 cm, with light serous (watery, clear fluid) covered with thick, adherent black necrotic (dead) tissue in the resident's sacral area [sacral region (sacrum) is at the bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone)].

The area was surgical debrided (the removal of dead skin) and a treatment of Santyl (a topical debridement medication) apply daily to the area was prescribed by the physician.

The next wound care consultant visit was documented as completed on February 5, 2019. The sacral area was remained unstageable; measuring 13 cm x 7 cm x 0.2 cm with light serous drainage with 50% thick adherent necrotic tissue. The physician documented no change to the condition of this wound. The area was surgically debrided at the bedside.

Facility wound tracking dated February 12, 2019, indicated a Stage IV pressure area (Full thickness tissue loss with exposed skin, muscle, tendon, ligament or bone in the ulcer), measuring 12 cm x 9 cm x 1 cm, 75% necrotic tissue and 25 % skin. The area was again surgically debrided at the bedside by the wound care physician.

Nursing documentation dated February 18, 2019, at 11:26 AM revealed that Resident 55 was verbalizing that he wanted to kill himself. The physician was notified and the resident was sent to the hospital for evaluation.

Resident 55 was admitted to the hospital February 18, 2019. A review of emergency physician history and physical (H & P) dated February 19, 2019, at 4:20 PM indicated that while Resident 55 was in the emergency department the resident had been incontinent of bowel. The resident did not want to receive incontinence care until he was admitted to a room in the hospital. The H & P identified skin issues on both his wrists due to the suicide attempt, but no mention of the pressure sore on the resident's sacral area

A review of a hospital discharge summary dated March 1, 2019, indicated that Resident 55 was admitted to the hospital with suicidal ideations and attempt at the facility. While a patient at the hospital, Resident 55 had a surgical consult for a sacral wound. The hospital found that the resident had a gangrenous (localized death and decomposition of body tissue, resulting from either obstructed circulation or bacterial infection) decubitus ulcer (pressure sore), Stage IV. The surgical consult recommended surgical debridement of the area and a diverting colostomy (a surgical procedure to create a colostomy, for external bowel movements, in which a bag is placed on the outside of the abdomen to collect feces. This was done so this resident would have no fecal matter in his sacral wound to prevent further decline and infection). A wound vac (also referred to as a negative pressure wound therapy is a machine used to treat advanced bed sores. A wound vac uses a pump to suction fluids from bed sores or other wounds that are difficult to heal on their own) was placed on this resident to promote healing.

On March 1, 2019, Resident 55 was readmitted to the facility with colostomy and wound vac remaining in place.

There was no documented evidence at the time of the survey ending March 15, 2019, that the facility had consistently provided turning and repositioning of the resident, both in and out of bed, prior to the discovery of the sacral wound on January 25, 2019. Nursing noted on January 25, 2019, that the resident had refused repositioning during that past month. However, there was no documented evidence of staff's attempt to reposition the resident or the resident's refusals, prior to the identification of the pressure sore on January 25, 2019. Turning and repositioning was noted to be added to the resident's care plan January 25, 2019, the day of the pressure sore discovery, although the resident had been identified at risk for pressure sore development since initiation of the resident's care plan, December 31, 2018.

The resident's refusals to be repositioned were not addressed on the resident's care plan nor alternative interventions to promote the resident's compliance.

There was no documented evidence that the facility's nursing staff had consistently monitored and assessed the status of the resident's pressure sore between visits by the Wound Care physician to timely identify and address lack of healing or worsening.

Interview with the Director of Nursing (DON) on March 14, 2019, at approximately 2:00 PM revealed that the facility's contracted Wound Care physician conducts the wound assessments for the residents in the building with pressure areas. The DON stated that other types of resident wounds in the facility are monitored by nursing staff. The DON confirmed that when the Wound Care physician is unable to visit the facility, nursing staff assess and measure the pressure wounds and document the results. The DON confirmed that nursing was not consistently monitoring residents' pressure sores and documenting accurate description of the wounds based on a nursing assessment.

The DON also stated that Resident 55 had a standard pressure relieving cushion on his wheelchair and standard pressure relieving mattress on his bed. The DON also confirmed that the intervention of turning and repositioning was not implemented until after the discovery of the resident's wound on January 25, 2019. The facility was unable to demonstrate that the frequency of the resident's turning and repositioning had been evaluated for adequacy as the resident's wound worsened.

There was no evidence that the facility had consistently provided timely and adequate measures to prevent pressure sore development and prevent worsening of the pressure sore, which required surgical intervention and a colostomy.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 2/6/19, 10/19/18, 11/2/17

28 Pa. Code 211.5(g)(h) Clinical records.
Previously cited 11/2/17

28 Pa. Code 211.10(a) Resident care policies
Previously cited 2/6/19, 10/19/18, 5/16/18, 3/4/18

28 Pa. Code 211.10(d) Resident care policies
Previously cited 2/6/19, 5/16/18, 3/4/18

28 Pa. Code 211.12(a)(c)(d)(3) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 6/14/18, 5/16/18, 3/4/18, 11/2/17

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 5/16/18, 3/4/18, 11/2/17












 Plan of Correction - To be completed: 04/09/2019

1. Resident 55 has proper wound tracking in place and interventions in place to promote healing.
2. Facility will insure residents with current wounds have proper tracking and interventions in place.
3. DON/ADON will re-educate licensed staff on policy and procedure for skin and wound management. Facility will implement routine reviews of Braden Scores to identify changes as indicated and ensure proper interventions are in place for prevention/healing. NHA and DON will complete weekly review of skin tracking log to insure adequate monitoring.
4. NHA will audit skin tracking log weekly for 4 weeks and monthly for 3 months.
5. Audits will be submitted to QAPI for review.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on a review of clinical records and a facility investigative report and staff interviews it was determined that the facility failed to implement pharmacy procedures for the timely disposition of unused/outdated medications for one of 10 residents reviewed (Resident 69).


Findings include:

A review of the clinical record revealed that Resident 69 was admitted to the facility on January 22, 2016, with diagnoses to include anxiety, depression and pain.

The resident had a current physician order, initially dated December 9, 2016, for Norco tablet (a combination narcotic and non-narcotic pain medication) 5-325 mg, take 1 tablet every 4 hours as needed for pain.

A review of pharmacy documentation revealed that a medication card containing Norco 5-325 mg tablets was dispensed from the pharmacy on May 30, 2018, for Resident 69.

A review of the resident's monthly medication administration records dated June 2018 through December 2018, revealed that Resident 69 did not request or receive the Norco 5-325 mg, during that six month time period.

A review of the resident's monthly medication administration records dated January 2019 revealed that Resident 69 received Norco 5-325 mg on 10 occassions during January 2019. Employee 5 (Licensed Practical Nurse - LPN) had documented administration of the Norco 5-325 mg to the resident on five of those occasions. The resident's February 2019 MAR revealed that Resident 69 received 9 doses of the Norco medication of which Employee 5 administered 8 of the 9 doses.

A review of information dated February 24, 2019, submitted by the facility revealed that on February 24, 2019, at 2:30 PM the narcotic count (no resident unit or specific medication cart identified) was completed and correct. At 5:00 PM on February 24, 2019, the narcotic count was found to have a discrepancy. There was a discrepancy related to a medication card of Norco 5-325 mg (a combination narcotic and non-narcotic pain medication) for Resident 69. The card reportedly contained 40 pills and was identified as missing from the medication cart.

There was no evidence at the time of the survey ending March 15, 2019, that the facility had implemented procedures for identification and/or disposition of unused medications. Resident 69 had not used Norco 5-325 mg since it was dispensed in May 2018, until January 2019. Potential drug diversion of the narcotic drug occurred in February 2019.

During an interview March 14, 2019, at approximately 10:30 AM the Director of Nursing confirmed that there was no evidence that nursing or pharmacy personnel had checked dispensed medications for non-use and/or expiration dates during during the seven months of non-use of the narcotic drug by Resident 69.

28 Pa. Code 211.9(a)(1) Pharmacy services
Previously cited 11/2/17

28 Pa. Code 211.9(k) Pharmacy services
Previously cited 1/12/19, 11/2/17

28 Pa. Code 211.12(a)(c)(d)(1)(3) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 6/14/18, 5/16/18, 3/4/18, 11/2/17

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 5/16/18, 3/4/18, 11/2/17




 Plan of Correction - To be completed: 04/09/2019

1. Resident 69 med Narco was discontinued per MD order and disposed of accordingly.
2. Facility will do sweep of current narcotic orders and dispose of properly if not used within 60 days.
3. DON/ADON will educate Pharmacy Consultant on addressing non-use of PRN narcotic medication.
4. DON will audit pharmacy recs weekly to ensure that PRN narcotic non-usage is being monitored.
5. Audits will be submitted to QAPI for review.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Based on clinical record review and staff interview it was determined that the pharmacist failed to identify drug irregularities in the drug regimen of one of 10 residents reviewed (Resident 69).

Findings include:

A review of the clinical record revealed that Resident 69 was admitted to the facility on January 22, 2016, with diagnoses to include anxiety, depression and pain.

The resident had a current physician order, initially dated December 9, 2016, for Norco tablet (a combination narcotic and non-narcotic pain medication) 5-325 mg, take 1 tablet every 4 hours as needed for pain.

A review of the resident's monthly medication administration records dated June 2018 through December 2018, revealed that Resident 69 did not request or receive the Norco, during that six month time period.

A review of the drug regimen reviews conducted by the pharmacist from June 2018 through December 2018, revealed that the pharmacist failed to identify Resident 69's non-use of the pain medication during this time period and recommend that the physician evaluate Resident 69's continued need for the prescribed medication.

During an interview March 14, 2019, at approximately 1:00 PM the Director of Nursing confirmed confirmed that the pharmacist had not identified Resident 69's non-use of the pain medication, Norco.

28 Pa. Code 211.9(a)(1) Pharmacy services
Previously cited 11/2/17

28 Pa. Code 211.9(k) Pharmacy services
Previously cited 1/12/19, 11/2/17





 Plan of Correction - To be completed: 04/09/2019

1. Resident 69 med Narco was discontinued per MD order and disposed of accordingly.
2. Facility will do sweep of current narcotic orders and dispose of properly if not used within 60 days.
3. DON/ADON will educate Pharmacy Consultant on addressing non-use of PRN narcotic medication.
4. DON will audit pharmacy recs weekly to ensure that PRN narcotic non-usage is being monitored.
5. Audits will be submitted to QAPI for review.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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.
483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on a review of clinical records and facility investigative reports and staff interviews it was determined that the facility failed to accommodate a resident's individual preference while not endangering the health and safety of one of 10 residents reviewed (Resident 55).


Findings included:

A review of the Resident 55's clinical record revealed that the resident was admitted to the facility on December 18, 2018, with diagnoses to include major depression (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and diabetes.

An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 25, 2018, indicated that the resident was cognitively intact, required extensive assistance of two people for activities of daily living and his mood was depressed, but the resident denied any thoughts of harming himself.

A review of the clinical record revealed that Resident 87 was admitted to the facility on June 17, 2016, with diagnoses to include depression.

A quarterly Minimum Data Set Assessment dated January 15, 2019, indicated that the resident was cognitively intact and his mood was depressed .

The resident's care plan initiated February 7, 2018, indicated that Resident 87 had the potential to exhibit distressed behavioral symptoms as evidenced by the problematic manner in which he acts, characterized by verbal abuse (yelling and cursing at others).

A review of nursing documentation, and information dated February 12, 2019, at 4:10 PM submitted by the facility revealed that Resident 55 attempted to harm himself by cutting his wrists with the tab of a soda can. Upon facility examination, Resident 55 had superficial scratches and a small amount of bleeding to the left wrist. Blood was physician and ambulance were called and Resident 55 was sent to the hospital for mental health crisis intervention.

A review of nursing documentation dated February 12, 2019, at 4:15 PM revealed that Employee 2 (RN) noted "called to room by charge nurse who reported that Resident 55 had cut his wrist. Upon examination noted superficial cuts to his inner left wrist with minimal blood loss." Employee 2 noted that during an interview with Resident 55, he stated that "the other guy in his room (Resident 87) keeps telling him that he is worthless and a burden on his family, that he can't walk and doesn't try and that we all would be better off without him here. He might as well off himself." Resident 55 said "it finally made sense" so he tried to (kill himself).

A review of hospital discharge records dated February 12, 2019, at 6:06 PM revealed that Resident 55 was seen in the hospital emergency department for self mutilating behavior. He was examined and given patient educational materials entitled "suicidal feelings : how to help yourself." He returned to the facility on a 1 to 1 safety watch, until mental health services could see him in the morning. Resident 55 returned to the same room he had previously resided, with Resident 87 as his roommate.

A review of mental health consultation dated February 13, 2019, at 11 AM revealed " met with Resident 1 in his room. He appeared in no apparent distress at the time of the interview. His affect was blunted. His thought process was circumstantial and he self reports depression and hopelessness. He openly discussed his suicidal attempt. He stated "I have him (his roommate) telling me that I'm worthless and that I shouldn't be around anymore." He denied suicidal ideation."

The mental health clinician recommended to discontinue the 1 to 1 safety watch, to adjust his antidepressant medication and agreed with a room change for Resident 55. The mental health clinician noted that if the resident demonstrated an increased risk of harm to self or others, staff should follow the facility's protocol.

A review of a social services note dated February 13, 2019, indicated that the social service director made a supportive visit to Resident 55. After discussing the incident from the previous day (suicide attempt) and ensuring Resident 55's safety, the social service director asked the resident's permission to remove the remaining soda cans from his room. It was noted that Resident 55 became very upset at this request and demanded that the soda cans be left in his room; stating again that he had no intent to self harm. The social service director noted that no soda cans were within the resident's reach at that time.

A review of nursing documentation dated February 18, 2019, at 11:26 AM revealed that a nurse aide reported to Employee 4 (LPN) that Resident 55 verbalized wanting to kill himself. The resident stated that he wanted to die. He stated " I have a plan, but I will not tell you, you will stop me." The resident was sent to the hospital emergency department for evaluation at that time.

A review of a hospital history and physical report dated February 19, 2019, at 4:20 PM revealed that Resident 55 was brought to the hospital from the facility where he tried to kill himself by using a full can of soda and hitting his forehead with it. The report noted that the resident had a previous attempt of suicide, during that attempt, he tried using a soda can lid and slicing his left wrist.

There was no evidence at the time of the survey that prior to the resident's second suicide attempt on February 18, 2019, that the facility had promptly removed the soda cans, from the resident's room/environment, but honored the resident's request for soda by alternative and safe means.

There was no indication that the facility had accommodated the resident's access to soda, but assured the resident's safety by providing soda to the resident, in a safe manner, using an alternate and safe container (i.e. a disposable receptacle, such as a styrofoam cup/pitcher, etc).

28 Pa. Code 201.18(e)(1) Management
Previously cited 2/6/19, 10/19/18, 7/24/18, 8/26/18, 6/14/18, 3/4/18, 11/2/17

28 Pa. Code 201.29(j) Resident Rights
Previously cited 10/19/18, 5/16/18, 11/2/17

28 Pa. Code 211.12(a)(c)(d)(3) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 6/14/18, 5/16/18, 3/4/18, 11/2/17

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 5/16/18, 3/4/18, 11/2/17

28 Pa. Code 211.16(a) Social Services
Previously cited 5/16/18, 11/2/17






















 Plan of Correction - To be completed: 04/09/2019

1. Soda cans will be removed from Resident 55 room. Offered plastic bottles instead.
2. Facility going forward will address the resident's plan of care weighing their resident rights as it relates to their safety. No other residents identified.
3. Interdisciplinary team will be educated on accommodation of resident preference while not endangering the health and safety. Staff will be educated that any patient request will have to be reviewed by the IDT team.
4. Facility will monitor patient request and insure their preference does not impeded their health and safety.
5. Audits will be submitted to QAPI for review.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

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

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on a review of clinical records, select facility policy and facility documentation and resident and staff interviews it was determined that the facility failed to timely and thoroughly investigate potential misappropriation of property for one resident of ten residents reviewed (Resident 69).

Findings include:

A review of facility policy entitled Abuse protection revised November 2018, revealed that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. The facility will have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse and neglect.

The reporting and filing of accurate documents relative to incidents of abuse, reporting to State agencies as required. In addition to the Department of Health (State Survey Agency), other entities will be notified. The area Agency on Aging will be notified immediately by oral report with a written report sent within 48 hours. Written notification will be completed for the following reasons : misappropriation of property.

Local Law enforcement will be notified immediately but not later than 2 hours after the allegation is made, or not later than 24 hours if the event does not involve abuse or result in serous injury, by oral report for the following reasons: intitial or alleged intentional misappropriation of resident property. This includes resident mediication and /or narcotics.
Corrective action will be implemented depending on the results of the investigation.

A review of information dated February 24, 2019, submitted by the facility revealed that on February 24, 2019, at 2:30 PM the narcotic count (no resident unit or specific medication cart identified) was completed and correct. At 5:00 PM on February 24, 2019, the narcotic count was found to have a discrepancy. There was a discrepancy related to a medication card of Norco 5-325 mg (a combination narcotic and non-narcotic pain medication) for Resident 69. The card reportedly contained 40 pills and was identified as missing from the medication cart. The facility noted that an investigation was immediately initiated and was ongoing. Local police were notified. The facility indicated that a PB-22 investigation report (a Pennsylvania Department of Health investigation report for allegations of abuse, neglect and misappropriation of property) will be completed when a perpetrator is identified. The facility noted that one nurse (Employee 5) potentially in question, had not responded to the facility's request to be interviewed. The facility began their disciplinary process for Employee 5 failing to come to work without giving notice. The facility did not notify the Pennsylvania Office of Attorney General, Bureau of Narcotics Investigation of the potential drug diversion.

A Pennsylvania Department of Aging. Act 13-Mandatory Abuse Report dated February 26. 2019, at 12:30 PM revealed that on February 26, 2019, at 10:00 PM the Director of Nursing was made aware that approximately 40 Norco pills were missing from Resident 69's narcotic supply. An investigation was started. On February 25, 2019, (no time indicated) the facility's investigation found that three licensed nursing employees (Employees 5, 6, 7) had the potential to divert the medication. Employees 6 (LPN) and 7 (LPN) cooperated with the facility's investigation, participating in an interview and submitting to drug testing, which was negative. Employee 5 (LPN), however, would not cooperate with the facility investigation, including drug testing and had not responded to the facility's requests related to the investigation. Employee 5 did not report to work as scheduled and was terminated.

A review of the clinical record revealed that Resident 69 was admitted to the facility on January 22, 2016, with diagnoses to include anxiety, depression and pain. The resident had a current physician order, initially dated December 9, 2016, for Norco 5-325 mg, take 1 tablet every 4 hours as needed for pain.

A review of the resident's monthly medication administration records (MAR) dated June 2018 through December 2018 revealed that Resident 69 did not request or receive the Norco, during that six month time period.

A review of the resident's monthly medication administration records dated January 2019 revealed that Resident 69 received Norco 5-325 mg on 10 occassions. Employee 5 had documented administration of the Norco 5-325 mg to the resident on five of those occasions. The resident's February 2019 MAR revealed that Resident 69 received 9 doses of the Norco medication of which Employee 5 administered 8 of the 9 doses.

A review of an employee witness statement dated December 26, 2018, two months prior to the discovery of the missing Norco 5-325 mg, Employee 4 (LPN) stated that on December 24, 2018, she was relieved at 3 PM by Employee 5 for the second floor, long hall assignment. Employee 4 noted that when "I returned to work at 7 AM on December 25, 2018, and was signing out in the narcotic book, my administered narcotics, I noticed a few issues. Resident CR1's 9 PM dose of morphine (a narcotic pain medication) was signed out for 9 PM twice. The second dose signed out for stated as "dropped." She was working with another licensed nurse at the time and the authenticity of the second licensed signature was questioned Employee 4 stated that the two licensed signatures were identical, the administering nurse and the nurse witnessing.

The employee's statement further stated that on December 25, 2018, Resident CR1 told Employee 4 (LPN) "I really have to start watching my pills when given by anyone except you." The resident stated that twice he looked at his 9 PM dose of morphine (a white pill) and it looked different. The resident stated that Employee 5 (LPN) told Resident CR1 that she mistakenly gave him another resident's 9 PM dose of Ativan (a smaller white pill). The statement continued to state " This would explain the "dropped pill" not properly witnessed with another nurse."

Employee 4 further stated that Resident 55's morphine pill was signed out on December 24, 2018, with an illegible signature beginning with the letter "J." "There are only two nurses with signatures beginning with the letter J and neither of us signed the form as giving the medication."

A review of an employee witness statement dated January 2, 2019 revealed that the facility's Assistant Director of Nursing indicated that the above investigative information was reviewed. The ADON noted that the nurse's signature "was sloppy, but the MAR was signed by Employee 5 (LPN).

The facility's investigation yielded findings, which resulted in reasonable cause to suspect Employee 5 of misappropriation of resident property (drug diversion). However, the facility failed to complete and submit a PB-22 investigation report (a Pennsylvania Department of Health investigation report for allegations of abuse, neglect and misappropriation of property) to the State Survey Agency with Employee 5 as the potential perpetrator.

Interview with the Nursing Home Administrator on March 14, 2019, at approximately 2:00 PM confirmed that the facility had not conducted a thorough investigation of potential drug diversion by Employee 5 and submitted the completed investigation to the State Survey Agency. The Nursing Home Administrator stated that a PB22 was not required because the facility had not identified a perpetrator.

483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation
Previously cited 2/6/19, 11/2/17

28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 2/6/19, 11/2/17

28 Pa. Code 201.18(a) Management
Previously cited 2/6/19

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 2/6/19, 1/10/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 2/6/19, 10/19/18, 7/24/18, 8/26/18, 6/14/18, 3/4/18, 11/2/17

28 Pa. Code 201.29(a)(d) Resident Rights
Previously cited 2/6/19, 11/2/17

28 Pa. Code 211.5(f) Clinical Records
Previously cited 2/6/19, 10/19/18, 11/2/17

28 Pa. Code 211.12(a)(c)(d)(1) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 6/14/18, 5/16/18, 3/4/18, 11/2/17

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 5/16/18, 3/4/18, 11/2/17
















 Plan of Correction - To be completed: 04/09/2019

1. PB22 will completed on Employee 5. Facility will report Employee 5 to OAG Bureau of Narcotics.
2. Facility will review pharmacy narcotic manifests for the past 30 days to insure all narcotics are accounted for.
3. NHA/DON/ADON will review the policy and procedure for investigating and reporting narcotic diversions. Licensed staff will be re-education on the policy and procedure for controlled substances. Facility will maintain pharmacy manifests according to policy.
4. NHA/designee will randomly audit pharmacy manifests weekly for 4 weeks and monthly for 3 months to insure narcotics are accounted accordingly.
5. Audits will be submitted to QAPI for review.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on a review of clinical records, select investigative reports and facility policy and staff interview and observation, it was determined that the facility failed to demonstrate consistent monitoring and the provision of necessary treatment of a wound for one of 10 residents reviewed (Resident 55).

Findings include:

A review of the Resident 55's clinical record revealed that the resident was admitted to the facility on December 18, 2018, with diagnoses to include major depression (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts) and diabetes.

A review of a facility investigation report dated February 12, 2019, at 4:20 PM revealed that Resident 55 had cut his wrist with a metal soda can tab. Upon examination by the licensed nurse, superficial cuts to the resident's inner left wrist with minimal blood loss were noted. A clean, dry dressing was applied and secured with tape. The resident stated that he tried to kill himself. The physician was called and the resident was transferred to the emergency department for evaluation. He was readmitted to the facility on February 12, 2019, at 6:00 PM.

A review of the facility policy for skin and wound management reviewed by the facility April 2018 revealed an assessment of skin was to be preformed on each resident upon admission to the center by completing, a head to toe physical evaluation of skin. Ongoing weekly evaluations of resident's skin will be completed and documented in PCC (Point Click Care - electronic system for documenting resident care) on the "weekly Skin Evaluation" form.

A review of facility wound evaluation flow sheet dated March 7, 2019, revealed that Resident 55 had a scab on his left wrist measuring 5 cm x 3 cm. The additional description noted that there was a "scab on his inner left wrist, found on admission" with no treatment noted at this time.

An observation conducted on March 14, 2019, at 10:00 AM of Resident 55's left inner wrist revealed a round area measuring 5 cm x 4 cm. The entire area was covered with thick, brown eschar (dead skin). The area was open to air.

Following surveyor inquiry on March 14, 2109, regarding the facility's wound tracking and treatment for Resident 55's wound, a treatment, skin prep (a liquid form protective dressing) every shift was ordered March 14, 2019.

There was no documented evidence that the licensed nursing staff had consistently monitored the resident's left wrist wound and treated the area as necessary, based on the nursing's ongoing assessment of the injury.

483.25 Quality of Care
Previously cited 10/19/18, 11/2/17

28 Pa Code 211.10(a) Resident care policies
Previously cited 2/6/19, 10/19/18, 5/16/18, 3/4/18

28 Pa Code 211.10(d) Resident care policies
Previously cited 2/6/19, 5/16/18, 3/4/18

28 Pa. Code 211.12(a)(c)(d)(1)(3) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 6/14/18, 5/16/18, 3/4/18, 11/2/17

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 2/6/19, 1/12/19, 10/19/18, 7/24/18, 5/16/18, 3/4/18, 11/2/17






 Plan of Correction - To be completed: 04/09/2019

1. Resident 55's area is currently being monitored.
2. Facility will complete two week look back of nursing notes to insure all noted skin areas are tracked and monitored accordingly.
3. DON/ADON will re-educate license staff on the policy and procedure for skin and wound management. DON/ADON will review 24 hr report to insure noted skin areas are tracked and monitored accordingly.
4. DON/ADON will audit noted skin areas weekly for 4 weeks and then monthly for 3 months.
5. Audits will be submitted to QAPI for review.

211.5(i) LICENSURE Clinical records.:State only Deficiency.
(i) The facility shall assign overall supervisory responsibility for the clinical record service to a medical records practitioner. Consultative services may be utilized, however, the facility shall employ sufficient personnel competent to carry out the functions of the medical record service.
Observations:

Based on a review of employee personnel files and staff interviews it was determined that the facility failed to ensure that a qualified medical records practitioner was assigned primary supervision of the facility's clinical record service.

Findings include:

A review of an employee personnel files revealed that Employee 1 was employed as the medical records person until February 2, 2019.

From February 2, 2019 through March 11, 2019, the facility failed to employ a qualified medical records practitioner, who was assigned overall supervisory responsibility of the facility's medical records services.

During an interview March 14, 2019, at approximately 2:00 PM the Nursing Home Administrator confirmed that from February 2, 2019, through March 11, 2019, the facility did not have sufficient qualified personnel to carry out the medical records department functions.





 Plan of Correction - To be completed: 04/09/2019

1. Facility employs a certified medical records consultant.
2. Medical Records will ensure resident records are filed appropriately.
3. Medical Records employee will be educated on proper filing for the clinical chart.
4. NHA/designee will ensure the facility has personnel to carry out medical record functions.
5. Audits will be submitted to QAPI for review.


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