Nursing Investigation Results -

Pennsylvania Department of Health
LONGWOOD AT OAKMONT
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LONGWOOD AT OAKMONT
Inspection Results For:

There are  36 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.
LONGWOOD AT OAKMONT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on February 28, 2019, it was determined that Longwood at Oakmont was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations of the Health survey process.









































 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on review of facility policy and dietary job description, observations and staff interviews, it was determined that the facility failed to make certain that pots and large pans were thoroughly sanitized in the main kitchen of the facility (Brookwood kitchen).

Findings include:

The facility policy "Three Compartment Sink" dated 9/20/18, indicated that the correct sanitizer concentration level would be maintained by testing the water with test strips and recording the results on a log after each meal service and prior to washing the pots and pans.

The current job description for the "Dish Washer" included the responsibility of filling the pot sink (three compartment sink) and checking its sanitation level.

During an observation in the Brookwood kitchen on 2/25/19, at 7:10 a.m. each compartment of the three compartment sink was filled with water.
During an interview on 2/25/19, at 7:10 a.m. Cook Employee E4 confirmed that the three compartment sink was utilized to sanitize pots and other large containers used to prepare food.

During an interview on 2/27/19, at 9:45 a.m. a request was made for Cook Employee E4 to obtain the logs for the three compartment sink testing for August 2018 to the present.

A review of the "Three Compartment Sink" logs revealed the following:
-The facility was not able to provide logs for the Brookwood kitchen for the months of August 2018 to November 2018.
-The January 2019 log did not have documentation that the concentration of the sanitizer was checked on
15 of 31 opportunities after the breakfast meal; eight of 31 opportunities after the lunch meal and six of 31 opportunities after the supper meal.
-The February 2019 log did not have documentation that the concentration of the sanitizer was checked on seven of 27 opportunities after the breakfast meal; 17 of 26 opportunities after the lunch meal; and 26 of 26 opportunities after the supper meal.

During an interview on 2/27/19, at 9:50 a.m. Cook Employee E4 confirmed that the facility failed to consistently check the three compartment sink to make certain the concentration of the sanitizer was at the proper level.

During interviews on 2/27/19, at 2:00 p.m. and on 2/28/19, at 10:00 a.m. Director of Dining Services Employee E5 and Dietary Manager Employee E6 confirmed that the facility failed to make certain that pots and large pans were thoroughly sanitized in Brookwood kitchen.

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

28 Pa. Code: 211.6(c)(f) Dietary services.

28 Pa. Code: 201.14(a) Responsibility of licensee.




 Plan of Correction - To be completed: 04/16/2019

Dining Services Director or designee will reeducate dining service employees on the steps to ensure that the sanitizer concentration in the pot sink is effective by making sure the water is the correct temperature and that it has the proper amount of sanitizer. The dining services team member will check the solution into the pot sink will check the sanitizer solution utilizing the appropriate test kit to ensure the concentration is correct with every change of water and after every meal in the three compartment sink. Dining staff members will document the use of the three compartment sink in the sanitizer log after each measurement.
There is no indication that there were any negative outcomes from the alleged aberrant practice.
The Dining Service Closing Manager will ensure that the dining staff are consistently documenting the sanitizer concentration in the pot and pan sink. Dining Services Managers will then complete audits weekly for four weeks then monthly for two months.
Audit results will be reported to the Quality Assurance Performance Improvement Committee until substantial compliance is maintained.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on a review of the facility's infection control policies and procedures and staff interview, it was determined the facility failed to develop an antibiotic stewardship program for twelve of twelve months (February 2018 through February 2019).

Findings include:

Review of the facility policy entitled "Antibiotic Stewardship Program" dated 11/9/18, indicated that antibiotic stewardship is a coordinated program that promotes the appropriate use of antibiotics, thereby improving outcomes, limiting medication adverse effects, reducing microbial resistance, and decreasing the spread of infections caused by multi-drug resistant organisms.

The program did not include protocols to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections.

The program did not include a process for periodic review of antibiotic use by prescribing practitioner and did not include protocols to optimize the treatment of infections by ensuring residents receiving antibiotics are prescribed the appropriate antibiotic.

In an interview on 2/28/19, at 11:20 a.m., the Director of Nursing stated that the facility had not yet developed specific protocols relating to antibiotic use and was unable to provide evidence of a functioning antibiotic stewardship program in the facility at the time of the survey.


28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 1/9/18.

28 Pa. Code 201.18(b)(1) Management
Previously cited 1/9/18.

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12 (d)(1)(5) Nursing services
Previously cited 1/9/18.











 Plan of Correction - To be completed: 04/16/2019

The Director of Nursing (DON) was re-educated by the Senior Director of Clinical Services on the network's Antibiotic Stewardship Program. The DON will educate the licensed nursing staff on the Antibiotic Stewardship Program. Assessment tools for suspected infections, urinary antiobiogram, urinary tract infections and treatment recommendations.
Infection Control nurse (ICN)/designee will send weekly updates to Senior Clinical Director to audit for 6 weeks. ICN/designee will audit quarterly that prescribing practitioners receive documentation of antibiotic usage.
This plan of correction will be monitored by the QAPI committee until such time consistent substantial compliance has been met.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:
Based on review of resident council meeting minutes and resident and staff interviews, it was determined that the facility failed to demonstrate a response to grievances voiced at resident council 10 of 13 months (February, March, April, June, July, August, September, October, November and December 2018).

Findings include:

A review of the resident council monthly meeting minutes from February 2018, through February 2019, indicated that resident council voiced the following concerns:

2/19/18: food temperatures, menus, inconsistent staffing
3/19/18: food temperatures, seasonings and menus, call bell response time
4/16/18: food temperatures, menus, not enough staff
6/18/18: lack of menu variety, inconsistent staffing
7/16/18: food temperatures, call bell response times
8/27/18: texture of molded salads, call bell response times
9/17/18: texture of molded salads, poor dining service, call bell response times
10/22/18: food service, temperatures, salads
11/19/18: canned beans in soup, runny salads, long wait for staff assistance
12/17/18: food temperatures, menus and molded salads, call bell response times.

During a resident group interview on 2/26/19, at 11:00 a.m. nine of 10 residents (Resident R300, R301, R302, R303, R304, R305, R307, R308 and R309) indicated that resident council has voiced concerns related to facility meals and call bell response times without being notified of a response from the facility.

A review of the resident council meeting minutes and the facility grievance log from February 2018 through February 2019, did not include documentation that the facility had responded to grievances made by the resident council for 10 of 13 months (February, March, April, June, July, August, September, October, November and December 2018).

During an interview on 2/26/19, at 3:08 p.m the Nursing Home Administrator (NHA) confirmed that the facility failed to demonstrate a response to resident council grievances during the months listed above.

28 Pa Code: 201.18(e)(4) Management.








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

The dining services department and administrator reviewed the meeting minutes from the Longwood Hanna Healthcare Resident Council meeting for the last year. A written response to the concerns was will be presented at the March 2019 resident council meeting.
All residents could potentially be affected by the alleged aberrant practice.
A performance improvement project was initiated in January 2019 to develop a more formalized process to respond to concerns brought forth at the resident council. Department managers will be given access to a shared folder that will store the resident council meeting minutes. Department managers will be able to submit their written response to any concerns directly in the minutes prior to the next resident council meeting. The staff liaison to the resident council will read the responses of any concerns at the beginning of the following resident council meeting.
The administrator will educate team members on the new process to enter written responses to any concerns brought forth at the resident council. Responses will be tracked monthly by the grievance official to identify trends that require further action. All department managers will be educated on the new process on a share document and follow up will be in the meeting minutes for review at the following resident council meeting. Previous month's resident council meeting minutes will be reviewed with the resident council to acknowledge appropriate action has been taken on previous month's concerns. The grievance official or administrator will report any trends to the quarterly Quality Assurance Performance Improvement Committee for further recommendation and follow up.

483.90(g)(2) REQUIREMENT Resident Call System: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.
483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area.

483.90(g)(2) Toilet and bathing facilities.
Observations:
Based on observations and resident and staff interviews, it was determined that the facility failed to make certain that residents could call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for residents for nine of 10 residents (Resident Resident R300, R301, R302, R303, R304, R305, R307, R308 and R309) on one of four nursing units (Countryside nursing unit).

Findings include:

During a group interview on 2/26/19, at 11:00 a.m. nine of 10 residents (Resident R300, R301, R302, R303, R304, R305, R307, R308 and R309) voiced concern that the call bell system only alerts one caregiver of their need for assistance.

The facility was granted a permanent exception from the state survey agency on January 6, 2009, which allowed the facility to utilize a wireless telephone that would "eliminate the need for corridor dome and zone lights, as each nurse and nursing assistant would be provided a wireless telephone that would display that information." Monitoring would include "battery status checks of the devices as well as call response times."

During observations from 2/25/19, through 2/28/19, the resident call system on the Countryside, Woodside, Gardenside and Riverside nursing units was noted to work as follows: when a resident rings the call bell at their bedside or toilet area, the signal was not visible or audible on the nursing unit to all staff. The signal went directly to a wireless telephone carried by a nurse aide or nurse.

During an interview on 2/26/19, at 3:08 p.m. the Nursing Home Administrator (NHA) was asked for evidence that the facility had monitored the effectiveness of the call bell system, as specified in the exception. The NHA was unable to provide any evidence that the call bell system had been monitored.

During an observation on the countryside nursing station on 2/27/19, at 1:43 p.m. an unattended wireless telephone labeled for a nurse aide was heard announcing "you have a new alert", indicating that a resident had placed a call for assistance. The alert repeated at 1:44 p.m, however, the nurse aide who was assigned to the wireless telephone was not present.

During an interview on 2/27/19, at 1:45 p.m. Registered Nurse (RN) Employee E11 confirmed that the wireless telephone was not in the possession of the assigned nurse aide. Employee E11 also indicated that the system does not function consistently.

During an interview on 2/27/19, at 8:45 a.m. the NHA confirmed that the facility failed to make certain the call bell system was functioning correctly to meet the needs of residents.


28 Pa. Code: 205.67 (j) (k) Electric requirements for existing and new construction.



















 Plan of Correction - To be completed: 04/16/2019

The team members who currently carry a phone that receives calls for assistance will be re-educated by the administrator or Director of Nursing about the need to carry their phones with them at all times to be able to respond to call as quickly as possible. A complete call bell system audit will be completed. A plan is in place to replace the current call bell system to include dome lights outside of each room and a call light monitor at each nursing office as an indicator that a resident is calling for assistance. An initial audit will be conducted on the new system prior to switching to the new system to ensure it is functioning.
All residents had the potential to be affected by the call bell system effectiveness.
The maintenance team will conduct random system audits on each neighborhood twice weekly for one month weekly for one month and then randomly thereafter with appropriate maintenance action taken if there are any identified issues with the system. Team members will also report any issues concerning the current call system immediately upon discovery. The maintenance assistant will provide to the administrator and director of nursing reports weekly on call light response times from various shifts and different neighborhood units until the new system is in place. Any response times deemed excessive will be reviewed and addressed accordingly.
Longwood/Hanna Healthcare Center is in phase I of replacing the call light system to include a dome light indicator that will allow all team members to be made aware that a resident needs assistance. Additionally, the new system will include a monitoring panel in every neighborhood office for team members to see all activated call lights and how long they have been activated. The neighborhood nurse will also have a phone that indicates activated call lights to help direct staff.
Random audits and resident interviews will be conducted on each neighborhood five times weekly for one month and then one time weekly on each neighborhood to determine if residents feel like their call lights are being answered in a timely manner.

Call light effectiveness and response time audits will be reviewed by the Administrator, Director of Nursing and/or a representative from the maintenance team once per week until the new call system is in place to identify current trends and address any issues. Any negative trends identified with the current or the new system will be brought forth at the Quality Assurance Performance Improvement committee meeting each quarter to develop appropriate action and follow up.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:
Based on review of facility policy and infection control program records and staff interview, it was determined that the facility failed to maintain comprehensive infection control surveillance records for five of 10 months (July, September, October, November and December 2018).

Findings include:

The facility policy "Surveillance for Infections" dated 11/9/18, indicated that surveillance would be completed for healthcare associated infections and other epidemiological (disease associated) significant infections that have a substantial impact on potential resident outcome and that may have transmission based precautions and other preventative interventions. Surveillance should include any or all of the following information to help identify possible indicators of infection: laboratory records, infection documentation records and transfer summaries or logs.

Review of the Infection Control surveillance monthly logs did not include the pathogen/causative organism for residents admitted or readmitted from the hospital with an infection related diagnosis.

During an interview on 2/28/19, at 11:30 a.m. the Director of Nursing confirmed that the infection control surveillance line listing (comprehensive monthly log of all resident infections including onset, causative organism, treatment and precautions required) did not include the causative organism for residents who were admitted or re-admitted to the facility with an infection related diagnosis.

28 Pa. Code: 201.14(a) Responsibility of licensee
Previously cited 1/9/18.

28 Pa. Code: 211.10(d) Resident care policies
Previously cited 1/9/18.

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 1/9/18.







 Plan of Correction - To be completed: 04/16/2019

Cited resident that was admitted with UTI, organism was confirmed from hospital records.
Admitted residents within last 6 months with infections will be reviewed for proper organism and added to the listing, if applicable.
Regional Educator educated the IC nurse to ensure organisms for residents admitted to the facility are in the line listing for infection control data.
IC nurse /designee will audit newly admitted residents and any current residents with a new diagnosis requiring an order for an antibiotic to ensure they included in the line listing weekly for 6 weeks. Omissions in the line listing will be added at time of discovery.
This plan of correction will be monitored by the QAPI committee until such time consistent substantial compliance has been met.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:
Based on review of facility policy and admission packet, observations, and resident and staff interviews, it was determined that the facility failed to notify residents of the grievance process on three of four nursing units (Gardenside, Countryside and Woodside nursing units).

Findings include:

A review of the facility "Grievance Policy Form and Log" policy dated 11/9/18, indicated that the procedure to file a grievance would be prominently displayed at the facility, and that the facility would make an effort to promptly resolve resident grievances.

During a group interview on 2/26/19, at 11:00 a.m. 10 of 10 residents (Resident R300, R301, R302, R303, R304, R305, R306, R307, R308 and R309) indicated they did not know who the grievance official was, where to find a grievance form, or the specific process for filing a grievance.

A review of the admission packet, given to each resident upon admission, did not include the correct information on how to file a grievance, including the name and contact information for the Grievance Officer, information on providing a written response to residents and information on how to file an anonymous grievance.

During observations on 2/28/19, from 2:30 p.m until 2:45 p.m, the information board at the main entrance of the facility did not include the name or contact information for the grievance official, a time frame for grievance resolutions, information on providing a written response to residents and instructions for how to file an anonymous grievance. Information for residents and families on the Gardenside, Countryside and Woodside nursing units did not include instructions for the grievance procedure, accessible grievance forms, or instructions for how to file an anonymous grievance.

During an interview on 2/28/19, at 2:45 p.m. the facility Nursing Home Administrator (NHA) was informed that the facility had failed notify residents of the facility grievance process.

28 Pa. Code 201.29(i) Resident rights.






 Plan of Correction - To be completed: 04/16/2019

The administrator reviewed the facility grievance policy for accuracy and completion. The grievance policy addresses all components required by the federal regulation.
Since all residents and family members have the potential to be affected by the alleged aberrant practice of not effectively communicating the grievance policy. All signage was reviewed for consistency and updated more detailed instructions on how to file a grievance. Grievance forms will be updated to a bright color green for easy visibility. The admission agreement was updated to include the updated grievance information in relation to the most recent grievance policy.
All residents received an updated grievance procedure form for their room and residents will be re-educated about our grievance policy at the next resident council meeting. The updated grievance information will be sent to family members and staff via the facility newsletter.
The administrator / grievance official will audit the publicly displayed information daily 5 days each week for 4 weeks to ensure the information is appropriately displayed.


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:
Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to update care plans to include physician ordered use of a mechanical lift for transfer for three of 16 residents (Resident R11, R47 and R58).

Findings include:

The facility policy "Comprehensive Care Plans" dated 11/9/18, indicated that assessments of residents are ongoing and care plans are revised as information about resident and the resident's condition changes. The Care Planning Interdisciplinary Team is responsible for the review and updating of care plans: when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted from the hospital or quarterly.

Review of the Profile Face Sheet indicated that Resident R11 was readmitted to the facility on 1/23/19, with diagnoses that included altered mental status, diabetes, congestive heart failure and osteoarthritis.

Review of an Interdisciplinary Nursing Note dated 1/24/19, indicated that Resident R11 was very difficult to get out of bed this morning, requiring the Sara lift with assistance of three staff (mechanical lift to assist mobility patients when they are unable to transition from a sitting position to a standing on their own).

Review of a physician order dated 1/24/19, indicated that Resident R11 could be transferred using a Hoyer lift (mechanical lift to fully assist transfer mobility) with assist of two staff.

Review of the care plan for Resident R11 updated on 2/19/19, included identified problems with risk of increasing weakness and inability to ambulate and risk for falls but did not include the intervention to use the physician ordered Hoyer lift for transfer assistance as needed.

Review of the Profile face sheet indicated that Resident R47 was readmitted to the facility on 1/9/18, with diagnoses that included fracture of right hip with surgical repair, Parkinsons disease (debilitating progressive disease causing movement and neurological disability) and generalized osteoarthritis (bone inflammation causing pain and stiffness).

Review of a physician order dated 8/27/18, indicated that Resident R47 could be transferred using a Sara lift as needed.

Review of the care plan for Resident R47 updated on 2/1/19, include identified problems with impaired mobility due to the right hip fracture, Parkinsons disease and osteoarthritis but did not include the intervention to use the physician ordered lift for transfer assistance as needed.

Review of the Profile face sheet indicated that Resident R58 was readmitted to the facility on 2/23/19, with diagnoses that included retroperitoneal (area behind the kidneys) bleeding, diabetes, Parkinsons disease and atrial fibrillation (irregular heart beat).

Review of a physician order dated 2/23/19, indicated that Resident R58 could be transferred using a Sara lift for transfers.

Review of Interdisciplinary Nursing Note dated 2/22/19, indicated that Resident R58 was weak and "did not do well with Sara lift."

Review of a physician order dated 2/25/19, indicated that use of the Sara lift for transfers was discontinued and Resident R58 was to be transferred with the Hoyer lift and assist of two staff members.

Review of the care plan for Resident R58 updated on 2/23/19, included identified problems with impaired left lower leg strength and flexibility, and risk for falls but did not include the intervention of use of the Hoyer lift for transfer assistance.

During an interview on 2/28/19, at 10:45 a.m. Registered Nurse Assessment Coordinator Employee E9 confirmed that the care plans for Resident R11, R47 and R58 were not revised to include physician orders for transfer with use of a mechanical lift.


28 Pa. Code 211.11(d) Resident care plans
Previously cited 1/9/18.

28 Pa. Code 211.12(1)(5) Nursing services
Previously cited 1/9/18.










 Plan of Correction - To be completed: 04/16/2019

Cited resident's Care plans were corrected with the correct transfer status and transfer to equipment (mechanical lifts).
Physicians order report for all residents in -house will be reviewed for orders for mechanical lifts and compare to residents care plans. Care plans will be updated with correct transfer status per physician orders.
MDS RN will educate nursing staff on facility procedure of updating resident care plans to be accordance with physician orders.
New physician orders will be audited 5 days/week to compare with residents care plans by MDS/designee for accuracy. Audits will be completed for 6 weeks.
This plan of correction will be monitored by the QAPI committee until such time consistent substantial compliance has been met.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
483.25(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 documents and staff interview, it was determined that the facility failed to maintain a system to track and trend all incidents and accidents to minimize the potential for reoccurrence for 11 of 11 months (March, April, May, June, July, August, September, October, November, December 2018, and January 2019).

Findings include:

During an interview on 2/27/19, at 1:40 p.m. documentation that the facility, on a routine basis, monitors accidents and other incidents, records these in the clinical or other record; and has in place a system to prevent and/or minimize further accidents and incidents was requested from the Director of Nursing (DON) and Nursing Home Administrator (NHA).

Review of the incident documentation provided by the facility revealed incidents other than falls were not being tracked and trended to minimize the reoccurrence.

During an interview on 2/28/19, at 10:45 a.m. the Nursing Home Administrator (NHA) confirmed that there was no system in place to track and trend incidents such as bruises, skin tears or medication errors to minimize the reoccurrence including but not limited to identification of staff trends or environmental hazards.

28 Pa. Code: 201.14(a) Responsibility of licensee.

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




 Plan of Correction - To be completed: 04/16/2019

The Director of Nursing and Regional Educator reviewed trends of non-fall incidents for past 3 months (January, February, March 2019) to identify any trends for further follow -up.
Director of Nursing, Regional Educator and RN staff nurse will develop a visual tracking and trending system to analyze trends with non-fall incidents. Mapping will be shared with team members for quality.
The Regional Educator will provide education to the Director of Nursing on tracking and trending non-fall incidents for monthly analysis.
Tracking and trending will be reviewed quarterly at QAPI for continuing process.
This plan of correction will be monitored by the QAPI committee until such time consistent substantial compliance has been met.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
483.35 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 facility policy, the nursing agency agreements and personnel files, observations and interviews, it was determined that the facility failed to make certain that two of five agency nursing staff were properly oriented to the facility prior to taking care of residents (Licensed Practical Nurse Employees E2 and E8).

Findings include:

The facility policy "Orientation Period" dated 11/9/18, indicated that the purpose of the orientation period was to provide an ongoing, consistent process to help the new employee reach full competence.

The "Agency Orientation Brochure" and the "Confidential, Computer Usage and Accountability Agreement for Agency Nurse" included facility specific information about abuse, reporting resident incidents, infection control practices and electronic health record (EHR) information about the software program the facility utilized were to be reviewed with and signed by each agency nursing staff person prior to caring for the residents.

During an observation on the Countryside nursing unit on 2/26/19, at 8:55 a.m. Licensed Practical Nurse (LPN) Employee E2, was in the process of starting medication pass and appeared flustered.

During an interview on 2/26/19, at 8:55 a.m. LPN Employee E2 reported being from an agency and that "It's my first day here at the facility and I don't know their computer program."

During an observation on 2/26/19, at 8:58 a.m. LPN Employee E2 was joined at the medication cart by Registered Nurse (RN) Employee E1 and began to provide direction to the LPN.

During an interview on 2/26/19, at 9:00 a.m. LPN Employee E2's response when asked what orientation was provided about the facility was "None. No orientation just had nurses that gave me a password and now (RN) working with me."

During an interview on 2/26/19, at 9:40 a.m. the Director of Nursing (DON) reported that the facility usually has agency staff come in two hours prior to their shifts for orientation to the facility but this was not mandatory, confirmed that LPN Employee E2 only received a password to the EHR system utilized by the facility and that "I realize that (LPN Employee E2) needed more orientation."

A review of the employee file for LPN Employee E8 indicated the employee started working at the facility through an agency on 1/24/19. The employee file did not include documentation that LPN Employee E8 was oriented to the facility.

During an interview on 2/28/19, at 1:15 p.m. the Nursing Home Administrator confirmed that there was no evidence of orientation for LPN Employee E8.

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.18(e)(6) Management.

28 Pa. Code: 201.20(b) Staff development.

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








 Plan of Correction - To be completed: 04/16/2019

Agency LPN signed orientation packet per facility protocol.
Any new agency staff members will be given orientation packets prior to the start of their first shift. Agency staff will be provided with at least 30 minutes of orientation to include the review of the orientation packet at the start of their first shift.

Agencies that the facility is presently using will be educated on the new protocol for new agency staff.
DON/designee will audit completion of orientation packet 7 day/ week for 6 weeks.
This plan of correction will be monitored by the QAPI committee until such time consistent substantial compliance has been met.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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.
483.45(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on review of facility policies, manufacturer specifications and clinical records, observations and staff interviews, it was determined that the facility failed to administer medications with a medication error rate that was less than five percent for two of five residents (Resident R49 and R51).

Findings include:

Three medication errors occurred during 28 observed opportunities which resulted in a 10.7 percent medication error rate.

The facility policy "Administration Procedures for all Medications" dated 11/9/18, instructed the nurse to obtain and record any vital signs ordered or deemed necessary prior to medication administration.

The facility policy "Oral Inhalation Administration" dated 11/9/18, indicated that steroid inhalers required that the nurse provided the resident with a cup of water and instruct him/her to rinse mouth and spit water back into cup.

The manufacturer specifications for Flovent and Symbicort inhalers (both containing a steroid used to prevent asthma attacks) instructed to "Rinse you mouth with water without swallowing after each dose. This will help lessen the chance of getting a yeast infection (thrush-fungal infection resulting in white patches which can be painful) in your mouth and throat."

The Profile Face Sheet indicated that Resident R49 was admitted to the facility on 7/11/15, with diagnosis that included a repair of a fractured hip and heart disease.

The Minimum Data Set (MDS-periodic assessment of care needs) dated 7/10/18, included additional diagnoses of anemia and dementia.

An ongoing physician order originally dated 10/30/18, indicated that Resident R49 received "Flovent Inhaler two puffs, two times a day for wheeze."

An ongoing physician order originally dated 1/28/19, indicated that Resident R49 received "Amlodipine (used to treat high blood pressure) 2.5 milligrams by mouth every morning" and instructed the nurse to "Hold (do not administer) if SBP (systolic blood pressure-the top number in a blood pressure reading) was less than 100."

During an observation of a medication pass on 2/26/19, at 9:00 a.m. Licensed Practical Nurse (LPN) Employee E2 administered the Amlodipine and the Flovent to Resident R49 and did not take the resident's blood pressure and did not have the resident rinse out his/her mouth after the administration of the Flovent.

The Profile Face Sheet indicated that Resident R51 was admitted to the facility on 9/23/16, with diagnoses that included high blood pressure, dementia and hypoxemia (body with insufficient oxygen).

The MDS dated 7/24/18, included the same diagnoses for Resident R51.

An ongoing physician order originally dated 11/5/18, indicated that Resident R51 received "Symbicort inhaler two puffs twice daily for shortness of breath."

During an observation of a medication pass on 2/26/19, at 9:12 a.m. LPN Employee E2 administered Symbicort to Resident R51 and did not have the resident rinse out his/her mouth after the administration of the Symbicort.

During interviews on 2/26/19, at 9:30 a.m. LPN Employee E2 confirmed not taking Resident R49's blood pressure and not having Residents R49 and R51 rinse out their mouths after administering the inhalers to the resident.

During an interview on 2/26/19, at 9:40 a.m. the Director of Nursing confirmed the medication errors for Residents R49 and R51 and that the facility failed to administer medications with a medication error rate that was less than five percent for the residents.

28 Pa. Code: 211/12(d)(1)(2)(5) Nursing services.













 Plan of Correction - To be completed: 04/16/2019

The facility recognizes its responsibility to ensure it is free of medication error rates of five percent or greater.
The Contracted employee was educated by the Director of Nursing on proper medication administration.
The Director of Nursing will educate licensed nursing staff on medication administration to include administering inhalers and completing blood pressure monitoring per facility policy.
Nursing managers will conduct one medication observation pass daily five times weekly for six weeks. This plan of correction will be monitored by the QAPI committee until such time consistent substantial compliance has been met.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to secure medications properly on one of four nursing units (Countryside nursing unit).

Findings include:

The facility policy "Storage of Medications" dated 11/9/18, all medications were stored securely so they were not accessible to any unauthorized person(s).

During an observation of a medication pass on the Countryside nursing unit on 2/26/19, from 9:00 a.m. to 9:30 a.m. the following was observed:

There was a white plastic bin that contained three opened vials of insulin on the top of the medication cart.

During an observation of a medication pass on 2/26/19, at 9:00 a.m. Licensed Practical Nurse (LPN) Employee E2 prepared medications for Resident R49, left the medication cart in the hallway to enter the resident's room and the bin with the insulin vials was on the top of the medication cart. The medication cart was out of the view of the LPN and accessible to residents and/or visitors in the hallway.

During an observation of a medication pass on 2/26/19, at 9:12 a.m. LPN Employee E2 prepared medications for Resident R51, left the medication cart to enter the resident's room and the bin with the insulin vials was on top of the medication cart. The medication cart was out of the view of the LPN and accessible to residents and/or visitors in the hallway.

During interviews on 2/26/19, at 9:30 a.m. and at 9:35 a.m. LPN Employee E2 and Registered Nurse Supervisor Employee E10 confirmed that the bin containing three vials of insulin was left on top of the medication cart which was out of the view of the LPN and that the facility failed to secure medications properly on the Countryside nursing unit.

28 Pa. Code: 211.9(a) Pharmacy services.

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










 Plan of Correction - To be completed: 04/16/2019

Cited resident's vials of biological medications were checked for proper storage immediately and replaced if needed.
Residents that are ordered biological medications that require refrigeration will be reviewed for proper storage.
Contracted employee was re-educated by Director of Nursing on proper storage of medication. Director of Nursing will re-educate licensed nurses on proper storage of biological medications.
Audits will be completed with the medication pass two shifts per day five(5) days/ week for proper storage of biological medications for 6 weeks.
This plan of correction will be monitored by the QAPI committee until such time consistent substantial compliance has been met.

201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:
Based on review of facility infection control policies and procedures, quality assurance surveillance, and staff interview, it was determined that the facility failed to comply with the following requirement of MCARE Act 403(a)(1), for three of four Quality Assurance Committee quarterly meetings (April, July 2018 and January 2019).

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:
(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

A review of the facility infection control surveillance (tracking of all infections within the facility in an effort to identify trends or to prevent further infections from developing) and Quality Assurance Committee meeting minutes for calendar year 2018/2019, revealed no evidence that the facility had physical plant personnel as a part of the interdisciplinary Quality Control Committee for three of four meetings.

During an interview on 2/28/19, at 11:20 a.m. the Director of Nursing confirmed that the quarterly review of Infection Control data completed at the Quality Assurance Committee meetings did not include physical plant personnel as required for three of four meetings.



 Plan of Correction - To be completed: 04/16/2019

The Environmental service Director will be educated by the Director of Nursing that she or a representative from the department must attend quarterly infection control meetings.
Environmental service director/ representative will continue attend the meeting.
This plan of correction will be monitored by the QAPI committee until such time consistent substantial compliance has been met.


209.8(b) LICENSURE Fire Drills.:State only Deficiency.
(b) A written report shall be maintained of each fire drill which includes date, time required for evacuation or relocation, number of residents evacuated or moved to another location and number of personnel participating in a fire drill.
Observations:
Based on review of the facility fire drill logs and staff interview, it was determined that the facility failed to maintain written fire drill reports that recorded number of residents evacuated or moved to another location for 13 of 13 months (January 2018 through January 2019).

Findings include:

Review of the Fire Drill Reports did not include documentation to indicate the number of residents evacuated or moved to another location for the fire drills conducted on the following dates: 1/23/18, 2/15/18, 3/14/18, 4/25/18, 5/21/18, 6/26/18, 7/25/18, 8/20/18, 9/24/18, 10/31/18, 11/16/18, 12/27/18 and 1/22/19.

During an interview on 2/27/19, at 8:50 a.m. Maintenance Director Employee E7 confirmed that the number of residents evacuated or moved to another location were not recorded as required.


 Plan of Correction - To be completed: 04/16/2019

The fire drill log was reviewed by the maintenance director. It was determined that the maintenance director documented incorrectly on the form. The maintenance director was re-educated by the administrator about the appropriate way to document when residents are moved from one location to another during actual event or fire drill.
There are no indications of negative outcomes from the alleged aberrant practice.
The maintenance director/designee will review fire drill documentation with the administrator monthly for three months to ensure that drills accurately reflect the disposition of residents during the drill.
The results of the fire drill documentation will be reviewed at the quarterly Quality Assurance Committee meeting until substantial compliance is maintained.


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