Pennsylvania Department of Health
BARNES-KASSON COUNTY HOSPITAL SNF
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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BARNES-KASSON COUNTY HOSPITAL SNF - 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 March 7, 2024, it was determined Barnes Kasson County Hospital Skilled Nursing Facility was not in compliance with the following requirements of 42 CFR, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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 clinical records and select facility policy and staff interview it was determined that the facility failed to maintain an antibiotic stewardship program that includes a system to effectively monitor antibiotic usage as evidenced by five of 13 sampled residents (Resident CR1, 9, 3, 10 and 20).

Findings include:

A review of the facility policy for Antibiotic Stewardship, dated as reviewed February 2023, revealed that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the antibiotic steward ship program is to monitor the use of antibiotics in our residents. When a culture and sensitivity is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified or discontinued.

There was no evidence at the time of the survey ending March 7, 2024, of a functioning antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use to prevent unnecessary antibiotic use.

Clinical record review revealed that Resident CR1 was admitted to the facility on May 2, 2023 and discharged home on August 15, 2023. The resident's admission and renewed monthly physicians orders dated May 3, 2023, through the resident's discharge on August 15, 2023, included Macrobid (an antibiotic medication) 100 mgs by mouth at bed time for chronic urinary tract infections.

According to drugs.com Macrobid is usually given for 5 days in females and 7 days in males for uncomplicated UTI. If you use this medicine long-term, for prevention of UTI, you may need frequent medical tests.

There was no documented evidence in Resident CR1's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for chronic urinary tract infections.

Clinical record review of Resident 9, revealed a physician order, dated December 8, 2022, was noted for Macrobid 100 mg twice a day for chronic urinary tract infections, "lifelong."

A review of the resident's medication administration record for the months of December 2022 through the end of the current survey, March 7, 2024, revealed that the resident received twice daily doses of the Macrobid.

There was no documented evidence in Resident 9's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for lifelong chronic urinary tract infections.

Clinical record review revealed that Resident 20 was admitted to the facility on December 23, 2019 with diagnosis to include a history of urinary retention and a history of urinary retention.

A physician order was noted April 7, 2023, for a urinalysis and culture and sensitivity.
The culture report dated April 12, 2023, revealed growth greater than 100,000 col/ml that was susceptible to treatment with the antibiotic Macrobid. The physician was notified and an order dated April 12, 2023, for Macrobid 100 mg by mouth twice daily for urinary tract infection for 7 days and Macrobid 100 mg by mouth twice daily on April 19 2023, "prophylaxis" (to prevent UTIs) with no stop date.

Admission and monthly physicians orders dated April 19, 2023, and monthly renewed May 2023 through November 2023 included Macrobid 100 mgs by mouth two times a day for chronic urinary tract infections.

A review of a urinary consult dated May 22, 2023 revealed recommendations to start Macrobid 50 mg by mouth daily. The consultation report was signed as reviewed by the resident's attending physician, but no date or time indicated on the form. The Physician documented "ok" on the form. However, the nursing staff failed to transcribe the new physicians order for the decreased dose of the Macrobid medication as ordered and the resident continued to receive Macrobid 100 mg BID.

An order dated July 11, 2023, revealed a urinalysis and culture and sensitivity of Resident 20's urine was completed. The results of the urine culture and sensitivity (C&S) report dated July 14, 2023, revealed greater than 100,000 col/ml Proteus mirabilis (a fecal related bacteria).

Keflex (antibiotic medication) 500 mg by mouth 4 times a day for 7 days was ordered and the resident received all the doses as per the July 2023 MAR. The C & S report indicated that the bacteria was resistant to the daily Macrobid 100 mg twice daily antibiotic that the resident was receiving at the same time to prevent UTIs.

A review of a urinary consult report dated August 23, 2023, noted that Resident 20 was "currently taking" Macrobid 50 mg by mouth daily, although the resident was actually receiving Macrobid 100 mg by mouth twice daily. The recommendations included "continue with the Macrobid 50 mg by mouth daily and return to the clinic for a follow up in one year."

A physician order was noted September 25, 2023, for another urinalysis and culture and sensitivity for Resident 20. The culture report dated September 29, 2023, revealed Pseudomonas Aeruginosa (a fecal related bacteria), greater that 100,000 col/ml. A physician order was noted September 29, 2023, for Cipro 500 mg by mouth for 7 days. The C & S report did not include Macrobid as a possible antibiotic treatment for this bacteria. The resident received all Physician ordered doses of the medication Cipro 500 mg for treatment of the UTI, concurrently with the Macrobid 100 mg by mouth twice daily to prevent UTIs

A review of monthly medication administration records dated August 2023 through November 3, 2023, revealed that Resident 20 continued to receive Macrobid 100 mg by mouth twice daily.

A pharmacist's review, dated October 28, 2023, recommended that the physician consider a gradual dose reduction of the dose of Macrobid for prevention of urinary tract infection 100 mg BID and asked that the physician consider decreasing dosing frequency is once daily.

The GDR was addressed on November 3, 2023, on the dose was decreased to Macrobid to 100 mg by mouth daily.

During an interview March 7, 2024 at 10 AM the Director of Nursing (DON) stated that nursing staff failed to transcribe the physician order on May 22, 2023 to decrease the dose to Macrobid 50 mg by mouth daily and no dose reduction was completed until November 3, 2023.

Clinical record review revealed that Resident 10 was admitted to the facility on January 10, 2019, with a diagnosis of osteoarthritis.

A review of an orthopedic consult report dated March 3, 2020 revealed that Resident 10 had L2-3 (lumbar spine) osteodiscitis (Discitis is an infection of the intervertebral disc, a structure that separates the vertebrae in the spine). The consult noted that "Given the persistantly elevated inflammatory labs we think that it is reasonable to start lifelong chronic suppression of the infection (Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections.) We will begin Doxycycline 100 mg, given twice daily for an indefinite period. I (the infectious disease physician) will see her back in about 6 months. We will recheck her inflammatory labs at that time."

A physician order dated March 17, 2023, was noted for doxycycline Hyclate (an antibiotic medication) 100 mg, take one by mouth twice daily for prophylactic measures.

A review of monthly medication administration records dated March 2023 through the date of the survey ending March 7, 2024, revealed that Resident 10 received the twice daily doses of the antibiotic medication Doxycycline 100 mg.

A review an orthopedic clinic consult dated July 19, 2023 at 11:35 A.M. revealed, "the state is requiring followup for MRSA in the spine. \ was diagnosed in 2019 from infectious disease at the hospital. The resident with a history of L2-L3 spine discitis-MRSA status post (S/P) IV (intravenous) vancomycin ( an antibiotic medication) and oral Doxycycline in 2019. The oral antibiotic Doxycycline was stopped, however restarted by the facility in March 2023 for "??". ( no reason noted). Labs ordered, Infectious disease follow up not needed." There were no additional recommendations on the form.

There was no documented evidence at the time of the survey ending March 7, 2024, of the clinical necessity for the continued use and dose of Doxycycline.

A review of the clinical record revealed that Resident 3 was admitted into the facility on May 10, 2019, with diagnoses including methicillin resistant staphylococcus aureus ([MRSA] infection caused by bacteria that are resistant to commonly used antibiotics that can cause headache, pain, fever, shortness of breath and rashes), infection following a procedure to surgical site, and candidiasis (fungal infection caused by a yeast, some types of antibiotics can lead to this infection).

A review of record titled "Newly Diagnosed Infection Report" dated June 7, 2023, revealed that there were new orders for Doxycycline (antibiotic medication) 100 mg a day to treat an abdominal wound for lifelong suppressive therapy with the justification of purulent drainage (characterized by thick, yellowish, or greenish discharge that usually implies an infection in a wound).

A review of the undated "Revised McGeer Criteria for Infection Surveillance Checklist" revealed that the skin and subcutaneous infection (SSTI) met McGeer's criteria by having symptoms of pus at the wound, skin, or soft tissue site and with noted redness at the affected site.

A review of a record titled "Weekly Skin Documentation Flowsheet" from the months of June 2023 until February 2024 revealed that the resident's wound drainage was noted to have a small amount of serosanguineous or no drainage, failing to note the continued presence of purulent drainage and justify the need for lifelong suppressive antibiotic therapy.

A review of the resident's medication administration record (MAR) for the months of June 2023 until February 2024, revealed that the resident received one dose of Doxycycline 100 mg by mouth daily.

There was no corresponding physician documentation to indicate the clinical necessity of initiating lifelong antibiotic treatment to treat the resident's suspected SSTI or any follow up to assess the need for continuing antibiotic therapy at the time of the survey ending March 7, 2024.

During an interview March 7, 2024 at 1 P.M., the Director of Nursing confirmed that the facility did not implement protocols to monitor antibiotic use that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use and a facility-wide system to monitor the use of antibiotics.

Refer F757

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

28 Pa. Code 211.2 (d)(3)(5)(10) Medical director

28 Pa. Code 211.10 (a)(d) Resident Care Policies

Plan of Correction - To be completed: 04/25/2024

1. Resident 10, 9 and 20 are no longer on prophylactic antibiotic therapy.

2. Resident's on antibiotics for chronic infections reviewed by Infection Preventionist for appropriateness and necessity. Current policy revised to include guidelines preventing use of prophylactic antibiotic.

3. Infection Preventionist will review requirement for antibiotic use protocols via antibiotic stewardship toolkit and regulations.

4. Audit will be completed weekly by admin team to review monthly antibiotic usage x 12 weeks. Results will be reviewed at QAPI.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on review of clinical records, and staff interview, it was determined that the facility failed to timely consult with the resident's physician regarding the potential need to alter treatment due to repeated refusals of medication administration prescribed for one resident out of 12 sampled (Resident 8).

Findings include:

A review of the clinical record revealed that Resident 8 was admitted to the facility on February 24, 2023, with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain).

A review of Resident 8's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 11, 2023, revealed that the resident was moderately cognitively impaired.

Nursing notes dated between January 1, 2024, through the end of survey March 7, 2024, revealed Resident 8 was refusing at least one prescribed medication on a daily basis.

There was no documented evidence that the facility had consulted the resident's attending physician regarding the resident's repeated and ongoing refusal of prescribed medications, which was confirmed during interview with the Director of Nursing on March 7, 2024, at approximately 12:50 PM.

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

Plan of Correction - To be completed: 04/25/2024

1. MD was made aware of resident #8's refusal of medications.
2. Medication Administration Records in process of being reviewed for March and MD's notified of any refusals.
3. Policy reviewed with nursing staff regarding MD notification.
4. Audit will be completed by nursing regarding notification of MD of med refusals x 12 weeks. Results of audit will be reviewed by QAPI team.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§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 clinical records, the facility's infection control data, clinical records and the facility's infection control policy it was determined that the facility failed to develop and implement infection control procedures for tracking and managing chronic infections as evidenced by four of 13 residents sampled (Residents 10, 9, 20, CR1)

Findings include:

A review of the facility's current infection control policy dated as reviewed by the facility February 24, 2024, revealed that it is the policy of the facility will 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. The objectives to include, to maintain 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 agreement based upon the facility assessment conducted according to and following accepted national standards.

A review of facility infection control logs dated from July 2023 through February 2024 revealed that there were four chronic infections treated by ongoing antibiotics among residents of the facility. These logs did not include any attempt to monitor the need for the ongoing use of the antibiotic medications, including evidence that these specific lifelong or chronic infections were reassessed and tracked to determine the need for ongoing antibiotic usage.

A review of the facility's infection data dated July 2023 through September 2023, and September 2023 through February 2024 revealed that Residents 10, 9, 20 and CR1 had chronic infections which were identified in the facility's infection data each month. There was no evidence of re-evaluation or scheduled monitoring for these residents identified with chronic infections to evaluate the effectiveness and continued appropriateness of continued prophylactic antibiotic therapy. There was no descriptive information on the resident listings to include diagnostic criteria used.

There was no data indicated on the monthly infection control logs indicating periodic assessment or evaluation of any of the four residents on the logs with lifelong/chronic infections requiring daily administration of antibiotic therapy to prevent infections.

Interview on March 6, 2024, at 10 AM with the facility Infection Control Nurse confirmed that the facility's current infection control program did not include procedures to address those residents diagnosed with lifelong/chronic infections and clinical criteria to be used to determine best practices for treatment and any monitoring or surveillance related activities that may be required.

Refer F881

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

28 Pa Code 211.12 (c)(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/25/2024

1. Resident 10, 9 and 20 are no longer on prophylactic antibiotic therapy.
2. Resident's on antibiotics for chronic infections reviewed by Infection Preventionist for appropriateness and necessity.
3. Residents with lifelong/chronic infections will require outpatient follow up by appropriate specialist. Policy updated to reflect. Infection preventionist will create log specifically to track compliance with seeing specialist, follow appointments as necessary, periodic assessment/evaluation.
4. Audit will be completed by Admin team for accuracy/completion of log x 12 weeks. Results will be reviewed at QAPI.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:

§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

Observations:

Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotic drugs for six of 13 residents sampled (Resident CR1, 3, 9, 10, 20 and 30).

Findings included:

Clinical record review revealed that Resident CR1 was admitted to the facility on May 2, 2023 and discharged home on August 15, 2023. The resident's admission and renewed monthly physicians orders dated May 3, 2023, through the resident's discharge on August 15, 2023, included Macrobid (an antibiotic medication) 100 mgs by mouth at bed time for chronic urinary tract infections.

According to drugs.com Macrobid is usually given for 5 days in females and 7 days in males for uncomplicated UTI. If you use this medicine long-term, for prevention of UTI, you may need frequent medical tests.

There was no documented evidence in Resident CR1's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for chronic urinary tract infections.

Clinical record review of Resident 9, revealed a physician order, dated December 8, 2022, was noted for Macrobid 100 mg twice a day for chronic urinary tract infections, "lifelong."

A review of the resident's medication administration record for the months of December 2022 through the end of the current survey, March 7, 2024, revealed that the resident received twice daily doses of the Macrobid.

There was no documented evidence in Resident 9's clinical record of physician documentation to support the daily administration of the antibiotic medication or of the diagnostic criteria met to treat the resident for lifelong chronic urinary tract infections.

Clinical record review revealed that Resident 20 was admitted to the facility on December 23, 2019 with diagnosis to include a history of urinary retention and a history of urinary retention.

A physician order was noted April 7, 2023, for a urinalysis and culture and sensitivity.
The culture report dated April 12, 2023, revealed growth greater than 100,000 col/ml that was susceptible to treatment with the antibiotic Macrobid. The physician was notified and an order dated April 12, 2023, for Macrobid 100 mg by mouth twice daily for urinary tract infection for 7 days and Macrobid 100 mg by mouth twice daily on April 19 2023, "prophylaxis" (to prevent UTIs) with no stop date.

Admission and monthly physicians orders dated April 19, 2023, and monthly renewed May 2023 through November 2023 included Macrobid 100 mgs by mouth two times a day for chronic urinary tract infections.

A review of a urinary consult dated May 22, 2023 revealed recommendations to start Macrobid 50 mg by mouth daily. The consultation report was signed as reviewed by the resident's attending physician, but no date or time indicated on the form. The Physician documented "ok" on the form. However, the nursing staff failed to transcribe the new physicians order for the decreased dose of the Macrobid medication as ordered and the resident continued to receive Macrobid 100 mg BID.

An order dated July 11, 2023, revealed a urinalysis and culture and sensitivity of Resident 20's urine was completed. The results of the urine culture and sensitivity (C&S) report dated July 14, 2023, revealed greater than 100,000 col/ml Proteus mirabilis (a fecal related bacteria).

Keflex (antibiotic medication) 500 mg by mouth 4 times a day for 7 days was ordered and the resident received all the doses as per the July 2023 MAR. The C & S report indicated that the bacteria was resistant to the daily Macrobid 100 mg twice daily antibiotic that the resident was receiving at the same time to prevent UTIs.

A review of a urinary consult report dated August 23, 2023, noted that Resident 20 was "currently taking" Macrobid 50 mg by mouth daily, although the resident was actually receiving Macrobid 100 mg by mouth twice daily. The recommendations included "continue with the Macrobid 50 mg by mouth daily and return to the clinic for a follow up in one year."

A physician order was noted September 25, 2023, for another urinalysis and culture and sensitivity for Resident 20. The culture report dated September 29, 2023, revealed Pseudomonas Aeruginosa (a fecal related bacteria), greater that 100,000 col/ml. A physician order was noted September 29, 2023, for Cipro 500 mg by mouth for 7 days. The C & S report did not include Macrobid as a possible antibiotic treatment for this bacteria. The resident received all Physician ordered doses of the medication Cipro 500 mg for treatment of the UTI, concurrently with the Macrobid 100 mg by mouth twice daily to prevent UTIs

A review of monthly medication administration records dated August 2023 through November 3, 2023, revealed that Resident 20 continued to receive Macrobid 100 mg by mouth twice daily.

A pharmacist's review, dated October 28, 2023, recommended that the physician consider a gradual dose reduction of the dose of Macrobid for prevention of urinary tract infection 100 mg BID and asked that the physician consider decreasing dosing frequency is once daily.

The GDR was addressed on November 3, 2023, on the dose was decreased to Macrobid to 100 mg by mouth daily.

During an interview March 7, 2024 at 10 AM the Director of Nursing (DON) stated that nursing staff failed to transcribe the physician order on May 22, 2023 to decrease the dose to Macrobid 50 mg by mouth daily and no dose reduction was completed until November 3, 2023.

Clinical record review revealed that Resident 10 was admitted to the facility on January 10, 2019, with a diagnosis of osteoarthritis.

A review of an orthopedic consult report dated March 3, 2020 revealed that Resident 10 had L2-3 (lumbar spine) osteodiscitis (Discitis is an infection of the intervertebral disc, a structure that separates the vertebrae in the spine). The consult noted that "Given the persistantly elevated inflammatory labs we think that it is reasonable to start lifelong chronic suppression of the infection (Methicillin-resistant Staphylococcus aureus (MRSA) infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics used to treat ordinary staph infections.) We will begin Doxycycline 100 mg, given twice daily for an indefinite period. I (the infectious disease physician) will see her back in about 6 months. We will recheck her inflammatory labs at that time."

A physician order dated March 17, 2023, was noted for doxycycline Hyclate (an antibiotic medication) 100 mg, take one by mouth twice daily for prophylactic measures.

A review of monthly medication administration records dated March 2023 through the date of the survey ending March 7, 2024, revealed that Resident 10 received the twice daily doses of the antibiotic medication Doxycycline 100 mg.

A review an orthopedic clinic consult dated July 19, 2023 at 11:35 A.M. revealed, "the state is requiring followup for MRSA in the spine. \ was diagnosed in 2019 from infectious disease at the hospital. The resident with a history of L2-L3 spine discitis-MRSA status post (S/P) IV (intravenous) vancomycin ( an antibiotic medication) and oral Doxycycline in 2019. The oral antibiotic Doxycycline was stopped, however restarted by the facility in March 2023 for "??". ( no reason noted). Labs ordered, Infectious disease follow up not needed." There were no additional recommendations on the form.

There was no documented evidence at the time of the survey ending March 7, 2024, of the clinical necessity for the continued use and dose of Doxycycline.

A review of the clinical record revealed that Resident 3 was admitted into the facility on May 10, 2019, with diagnoses including methicillin resistant staphylococcus aureus ([MRSA] infection caused by bacteria that are resistant to commonly used antibiotics that can cause headache, pain, fever, shortness of breath and rashes), infection following a procedure to surgical site, and candidiasis (fungal infection caused by a yeast, some types of antibiotics can lead to this infection).

A review of record titled "Newly Diagnosed Infection Report" dated June 7, 2023, revealed that there were new orders for Doxycycline (antibiotic medication) 100 mg a day to treat an abdominal wound for lifelong suppressive therapy with the justification of purulent drainage (characterized by thick, yellowish, or greenish discharge that usually implies an infection in a wound).

A review of the undated "Revised McGeer Criteria for Infection Surveillance Checklist" revealed that the skin and subcutaneous infection (SSTI) met McGeer's criteria by having symptoms of pus at the wound, skin, or soft tissue site and with noted redness at the affected site.

A review of a record titled "Weekly Skin Documentation Flowsheet" from the months of June 2023 until February 2024 revealed that the resident's wound drainage was noted to have a small amount of serosanguineous or no drainage, failing to note the continued presence of purulent drainage and justify the need for lifelong suppressive antibiotic therapy.

A review of the resident's medication administration record (MAR) for the months of June 2023 until February 2024, revealed that the resident received one dose of Doxycycline 100 mg by mouth daily.

There was no corresponding physician documentation to indicate the clinical necessity of initiating lifelong antibiotic treatment to treat the resident's suspected SSTI or any follow up to assess the need for continuing antibiotic therapy at the time of the survey ending March 7, 2024.

A review of the clinical record revealed that Resident 30 was re-admitted into the facility on January 12, 2024, with diagnoses including MRSA infection, chronic venous hypertension with ulcers and local infection of skin and subcutaneous tissue.

A review of record titled "Newly Diagnosed Infection Report" dated October 13, 2023, revealed that there were new orders for Ceftin (antibiotic medication) 500 mg by mouth twice daily for 10 days and Rifampin (antibiotic medication) 300 mg by mouth twice a day for 10 days to treat MRSA in wounds.

A review of the undated "Revised McGeer Criteria for Infection Surveillance Checklist" revealed that the SSTI met McGeer's criteria by having symptoms of fever (oral temperature greater than or equal to 100.0 degrees Fahrenheit), heat, redness and serous (clear to yellow fluid that leaks out of wound) drainage at the infected site.

Further review of the clinical record revealed the resident's temperature was 97.0 degrees Fahrenheit on October 13, 2023, and there was no documentation of this resident having a fever, failing to meet the McGeer criteria for infection.

A review of laboratory test results for culture and sensitivity of left ankle wound dated October 13, 2023, at 7:54 AM revealed that the identified organism was resistant to the prescribed Cefuroxime Axetil (Ceftin).

A review of the resident's October 2023 MAR revealed that the resident received Ceftin 500 mg by mouth twice daily for 10 days receiving 20 unnecessary doses.

A review of record titled "Newly Diagnosed Infection Report" dated December 31, 2023, revealed that there were new orders for one dose of Vancomycin (antibiotic medication) 500 mg by mouth and one dose of Septra DS (antibiotic medication) for Escherichia coli ([E. Coli] bacteria that produces powerful toxins), extended-spectrum beta-lactamases ([EBSL] enzymes that confer resistance to most beta-lactam antibiotics) Enterobacter (a serious infection known to cause infections affecting parts of the body) and MRSA. Also, a new order to send the resident to the emergency department (ED).

A review of undated "Revised McGeer Criteria for Infection Surveillance Checklist" revealed that the resident had heat, redness, swelling and tenderness at the affected site. There was no documentation provided showing evidence that the SSTI criteria was met.

There was no corresponding physician documentation to indicate the clinical necessity of initiating antibiotic treatment to treat the resident's suspected SSTI.

A review of the resident's December 2023 MAR revealed that the resident received Vancomycin 500 mg by mouth one dose and Septra DS by mouth one dose receiving 2 unnecessary doses.

"Consultation Notes" from the hospital dated January 1, 2024, at 11:08 AM, revealed that the resident was admitted for an infectious disease consultation secondary to venous stasis ulcers. Wound cultures dated December 27, 2023, revealed MRSA plus EBSL E. coli. In summary, there is no cellulitis (bacterial infection of the skin), the wounds have colonized multidrug-resistant organisms ([MDRO] bacteria that resist treatment with more than one antibiotic) due to being in and out the hospital and long-term care facilities. At this point all antibiotic therapy should be discontinued. "

During an interview March 7, 2024 at 10 A.M, the Director of Nursing (DON) confirmed that the above noted residents were not free from unnecessary medications (antibiotics).

Refer F880, F881

28 Pa. Code 211.9 (k) Pharmacy services

28 Pa. Code 211.2 (d)(3)(5) Medical director

28 Pa. Code 211.5 (f) Medical records

Plan of Correction - To be completed: 04/25/2024

1. Resident's receiving prophylactic antibiotics were reviewed and antibiotics discontinued.
2. To protect residents in similar situations, any residents admitted who are on a daily dose of antibiotic prophylactically will be assessed for individual specific clinical rationale as to the benefits to the resident to support the continued use.
3. Licensed nurses and facility physicians will be educated on change to policy for ongoing daily use of antibiotic for prophylactic purposes by Infection Preventionist.
4. Nursing staff will audit and future residents on continued use of daily antibiotic therapy for specific clinical rationale x 12 weeks.
Results will be reviewed at monthly QAPI.

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

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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

Plan of Correction - To be completed: 04/25/2024

1. The physician reviewed #4's pharmacy recommendations, Tramadol was discontinued 1/24, Seroquel GDR initiated.
2. The most recent pharmacy recommendations for all current residents have been reviewed to ensure that the physician had acted upon the pharmacy recommendations or provided clinical justification
3. SNF Physicians will be in serviced on need to act on drug irregularities identified by pharmacist.
4. A monthly audit will be conducted by DON/designee to ensure that the attending physician is acting upon the recommendations of the pharmacist x 3 months. Audits will be presented at QAPI meetings for review and recommendations.

483.40 REQUIREMENT Behavioral Health Services:

§483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

Observations:

Based on observations, clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for two of 13 residents sampled (Residents 8 and 30).

Findings include:

A review of the clinical record revealed that Resident 8 was admitted to the facility on February 24, 2023, with diagnoses which included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain).

A review of Resident 8's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 11, 2023, revealed that the resident was moderately cognitively impaired.

Further review of Resident 8's clinical record revealed that the resident exhibited multiple behaviors, including physical aggression with staff and medication and treatment refusals. Resident 8 refused medications on an almost daily basis, throughout the months of January 2024, through end of the survey March 07, 2024, according to a review of nursing progress notes.

Review of Resident 8's care plan, initiated by the facility on February 24, 2023, indicated that the resident has behavioral problems. Review of care plan interventions revealed an intervention "seek MD/psych consult, as needed, for medication and behavioral management.

When reviewed during the survey ending March 7, 2024, the resident's clinical record revealed no documented visits from psychological services and no indication that the resident's physician had been notified of the resident's almost daily refusal of medications.

Review of the clinical record revealed that Resident 30 was admitted to the facility on January 5, 2024, and had diagnoses, which included bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania) or hypomania (lows) depression), anxiety and opioid dependence (dependence occurs when an opioid drug is used for more than six months to manage pain associated with a medical condition).

An admission MDS Assessment dated January 17, 2024, revealed that the resident was cognitively intact with a BIMS score of 14 (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact)

A review of the resident's current behavioral care plan dated January 6, 2024, revealed that the resident requires psychosocial interventions for bipolar disorder, opioid dependence, and pain. The planned interventions for the resident's behaviors included seeking physician/psychological consult, as needed, for medication and behavioral management.

An interview with Resident 30 on March 5, 2024, at 10:05 AM revealed that the resident has not received any psychological services since admission to the facility. The resident stated that her psychiatrist retired a few years ago and she has not been able to find another doctor. She stated that her previous psychiatrist prescribed her Neurontin and Ativan, medications, for her bipolar disorder and anxiety, which seemed to help her. She stated that she has been having increased anxiety especially prior to going to wound care to have debridement (a procedure to remove debris, infected/dead tissue from a wound) treatments during her stay at the facility. The resident stated that she has mentioned her concerns to several staff members without any resolution to date.

There was no documented evidence that the facility had developed and implemented individualized interventions related to the resident's diagnosed conditions, including psychological services and community substance use services, as noted in the resident's behavioral health care plans.

During an interview with the Director of Nursing (DON) on March 6, 2024, at approximately 12:00 PM confirmed that Resident 30 had not received any psychological services since admission to the facility.

During an interview with the Nursing Home Administrator (NHA), on March 7, 2024, at approximately 10:00 a.m., the NHA was unable to provide evidence that Residents 8 and 30 were being provided the necessary behavioral health services.

Refer F561

28 Pa. Code 211.10 (d) Resident care policies

Plan of Correction - To be completed: 04/25/2024

1. Social services met with resident #30 to discuss desire for behavioral health services and same scheduled. Social services discussed with family of resident #8 behavior/refusals and family agreeable to behavioral services and same scheduled. MD made aware of resident #8's refusals.
2. All resident's and/or their families with history of psychiatric diagnosis will be afforded opportunity to psychological services.
3. Policy will be updated to initiate behavioral health services upon admission, per resident request or identified symptom.
4. Audit will be completed by social services/designee regarding offering of behavioral health services upon admission or PRN to residents with psych diagnoses or indicators of same. Audit will be completed x 6 months in conjunction with care plan schedule. Audit will be completed regarding physician notification and refusals of medications.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§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 select facility policy and staff interview, it was determined that the facility failed to timely assess declines in skin integrity, consistent with professional standards of practice, for for two residents out of 13 sampled residents with pressure ulcers (Residents 15 and 27).

Findings include:

According to Title 49 Chapter 21 49 Pa. Code 21.145. Functions of the LPN
21.145. Functions of the LPN.

(a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place.

(1) An LPN shall communicate with a licensed professional nurse and the patient ' s health care team members to seek guidance when:

(i) The patient ' s care needs exceed the licensed practical nursing scope of practice.

(ii) The patient ' s care needs surpass the LPN ' s knowledge, skill or ability.

(iii) The patient ' s condition deteriorates or there is a significant change in condition, the patient is not responding to therapy, the patient becomes unstable or the patient needs immediate assistance.

(2) An LPN shall obtain instruction and supervision if implementing new or unfamiliar nursing practices or procedures.

(3) An LPN shall follow the written, established policies and procedures of the facility that are consistent with the act.

Resident assessment is outside the scope of an LPN. However, at the time of the survey ending March 7, 2024, the facility was utilizing an LPN to conduct resident pressure wound assessments.

A review of a facility policy entitled "Pressure Sore Strategies and Treatments" that was reviewed by the facility on January 24, 2024, indicated that documentation was to include weekly assessment and charting. The assessment is to include the specific skin problem, location, wound characteristics and drainage.

Review of Resident 15's clinical record revealed that the resident was admitted to the facility on October 18, 2021, with diagnoses to have included hypertension (high blood pressure), type II diabetes (is a condition results from insufficient production of insulin, causing high blood sugar), and shortness of breath.

Resident 15's plan of care initiated on October 19, 2021, at 7:58 a.m., identified that the resident was at risk for developing skin breakdown due to comorbidities (more than one illness at once) with planned interventions that included to document changes in skin condition and report to charge nurse, encourage turning and repositioning, and to apply treatments to areas as ordered.

A physician order dated August 16, 2023, was noted for Silver Sulfadiazine 1% Cream [(Silvadene) a medication used with other treatments to help prevent and treat wound infections in patients with serious burns], apply topically to the bilateral buttocks prophylactically.

A review of a "Wound Assessment Report" completed by Employee 1, a licensed practical nurse (LPN) and facility's wound care nurse, dated January 10, 2024, revealed that Resident 15 had a new wound, sheering (skin impairment caused by pulling that creates stress on the soft tissue layers (fat and muscle) and could lead to a tearing of the tissue depending on how high the shearing force becomes) to the sacrum that was originally identified on January 7, 2024. Employee 1 noted that the area was to the "whole sacral area with skin peeling off" and indicated that the resident wanted to be "pulled up in the bed causing friction." The area was cleansed, Silvadene (medication is used with other treatments to help prevent and treat wound infections in patients with serious burns) was applied as per TAR (treatment administration record), and no signs or symptoms of infection and that the area would be monitored weekly.

Resident 15's clinical record weekly "Wound Assessment Report" completed by Employee 1, dated January 31, 2024, revealed that the resident continued to have sheering to the coccyx area and no drainage and to continue with Silvadene and monitor weekly.

A review of a new wound assessment report completed by Employee 1, dated February 14, 2024, revealed that a new pressure ulcer was identified on February 12, 2024, to Resident 15's right great toe that was indicated to be an unstageable due to suspected deep tissue injury. Employee 1 noted that the resident continued with a "red area" to the right great toe that measured 0.6 cm in length by 1.0 in width and no signs or symptoms of infection. Bed cradle applied to bed and keep blankets and all pressure off toe and will monitor until healed.

Resident 15's clinical record failed to reveal that a registered nurse (RN) timely assessed the newly identified to the sacrum and right great toe and that the identified areas were assessed as per professional nursing standards that included measurements or description of the area, and that weekly wound monitoring was completed.

Additionally, the clinical record failed to reveal that the resident's attending physician was timely notified of the new areas and that the resident's care plan for skin breakdown was reviewed and revised for adequacy and continued appropriateness to promote healing and prevent further skin impairments.

A review of Resident 27's clinical record revealed that the resident was admitted to the facility on August 27, 2021, with diagnoses that included chronic pain.

A review of a nursing progress note completed by Employee 2, a LPN, dated February 15, 2024, at 9:37 a.m., revealed that Resident 15 had a new reddened area to his left second toe that measured 0.5 cm in length by 0.3 cm in width with and skin prep applied, family aware.

Further review of Resident 15's clinical record weekly wound assessment completed by Employee 1, LPN, dated February 28, 2024, at 10:27 a.m., revealing that the reddened area to his left second toe was now an unstageable area [underneath the discolored surface, this ulcer could be as deep as a stage 3 or stage 4 wound and may also form as a blood blister or be covered with eschar (a dry, dark scab or falling away of dead skin)] that measured 0.5 cm in length by 0.4 cm in width, non-blanchable, with a "white center" and tender to touch. No signs or symptoms of infection and to continue with skin prep and monitor weekly and as needed until heeled.

Resident 15's clinical record failed to reveal documented evidence that a RN assessed the resident's skin impairment to his left great toe and failed to reveal that the facility had promptly reviewed and revised the resident's care plan to assure effective interventions to maintain/improve skin integrity.

An interview with the facility's Director of Nursing (DON) on March 6, 2024, at 11:25 a.m., revealed that new pressure injuries and/or skin impairments should be immediately assessed and their origin investigated to plan care accordingly. The DON confirmed that the facility failed ensure timely assessment of newly identified skin impairments by a registered nurse and assessment of healing progress by a registered nurse.

28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services

Plan of Correction - To be completed: 04/25/2024

1. Resident 15 and resident 27's skin areas have resolved since survey.
2. A Registered Nurse has been appointed to wound care program and completing weekly skin rounds and reviewing plan of care for effective interventions. A registered nurse is assessing any declines in skin integrity within 24 hours of identification.
3. Timely assessment and revisions to plan of care will be completed on skin findings along with physician notification. Education will be provided to nursing staff regarding same.
4. An audit will be completed by nursing staff regarding RN assessment of wound timely, POC update and physician notification of same x 12 weeks. Results of audit will be completed QAPI team.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:

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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.

Observations:

Based on resident and staff interviews and review of clinical records, it was determined that the facility failed to ensure that residents are afforded the right to make choices about aspects of their lives that were significant to them, including medication treatment options, for one resident out of 13 sampled (Resident 30).

Findings include:

Review of the clinical record revealed that Resident 30 was admitted to the facility on January 5, 2024, and had diagnoses, which included bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania) or hypomania (lows) depression), anxiety and vitamin deficiency.

An admission MDS (minimum data set-federally mandated standardized assessment conducted at specific intervals to plan resident care) dated January 17, 2024, revealed that the resident was cognitively intact with a BIMS (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact) score of 14.

Interview with Resident 30 on March 5, 2024, at approximately 9:45 AM revealed that the resident stated that she has been requesting specific medications that she had received in the past. She stated that she was prescribed Neurontin for bipolar disorder by her psychiatrist in the community and that she felt as though she was doing much better when receiving that medication. The resident mentioned that she has been experiencing increased anxiety, especially prior to going for debridement treatment on her wounds, and in the past she would receive the antianxiety drug Ativan, as needed, which she no longer receives. The resident also expressed concerns that she was no longer taking vitamin D and a multivitamin (MVI) supplements. The resident stated that she has voiced these concerns to multiple facility staff members but her concerns have not been addressed.

A review of the resident's medication administration record (MAR) for the month of March 2024 revealed that the resident was not current prescribed any the above medications or vitamin supplements that she mentioned during the interview, Neurontin, Ativan, Vitamin D, or multivitamin.

An interview conducted on March 5, 2024, at approximately 10:30 AM with Employee 3, a nurse aide, confirmed that the resident has mentioned her medication concerns in the past. She stated that she was unaware of the resident's increased anxiety, but would convey the resident's complaints to the licensed nurse.

An interview with Director of Nursing (DON) on March 6, 2024, at approximately 12:00 PM revealed that Resident 30 was scheduled to see a behavioral health specialist in the community on April 18, 2024, at 1:00 PM to evaluate the resident's mental health and review the resident's medications.

Interview with the Nursing Home Administrator (NHA) and DON on March 7, 2024, at 1:45 PM, confirmed that the facility failed to demonstrate that the resident was timely afforded the right to participate in making choices about health care and treatment options.

28 Pa. Code 201.29 (a) Resident rights.

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

Plan of Correction - To be completed: 04/25/2024

1. Medication treatment options were discussed with resident 30 and behavioral health appointment completed and follow up appointment scheduled.
2. Residents/families will continue to be invited to their quarterly care plan meeting and encouraged to express any concerns about medication treatment options. Any medication/treatment changes are communicated to resident and/or family at time change occurs. Meds will be reviewed with resident and/or family upon admission for any discrepancies.
3. Social worker/designee will include in quarterly notes whether resident/family has any concerns with plan of care. Nursing will document notification of med/treatment changes and review of medications upon admission.
4. Audit will be completed by social worker/designee with residents at random to assure contentment with plan of care/medication regimen and follow up on any concerns identified x 8 weeks. Results will reviewed with QAPI team.

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

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

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

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

Observations:

Based on clinical record and select policy review and interview with facility staff, it was determined that the facility failed to evaluate the clinical necessity of an indwelling urinary catheter for of one resident out of 13 sampled (Resident 7).

Findings included:

Review of a facility policy entitled "Urinary Catheterization care and maintance" reviewed February 24, 2024 indicated that, the purpose of urinary catheterization is to facilitate urinary drainage when medically necessary. Urinary catheters should be evaluated every day for the need and removed promptly when no longer necessary.

a. On admission to the skilled nursing facility, a resident will be assessed for need for catheterization based on a list of acceptable clinical justification to include, urinary retention that cannot be otherwise teated; The resident is unable to pass urine due to an enlarged prostate; need for accurate output measurements for acutely ill persons being monitored for fluid balance where incontinence interferes with necessary monitoring; Assistance for the healing of coccyx and sacral wounds stage 3 or greater; comfort or palliative care, if requested by the resident.

b. If a resident is catheterized on admission to the facility and does not present with a clinically justifiable reason for catheterization, then the nursing staff will contact the attending Physician either to obtain written clinical justification for the catheter use or an order to remove the catheter.

Clinical record review revealed that Resident 7 was admitted to the facility on December 11, 2023, with diagnoses to include atrial fibrillation, heart failure and an indwelling foley catheter.

Admission physicians orders dated December 11, 2023, included an indwelling foley catheter, 16 fr, 10 cc balloon and 1800 cc fluid restriction.

A review of a facility form, entitled "clinical justification for foley catheter" dated December 11, 2023 revealed "Urinary catheters are deemed medically necessary for the following reason in the facility: Need for accurate hourly output measurements for acutely ill persons being monitored for fluid balance where incontinence interferes with necessary monitoring."

The form was signed by the resident's attending physician.

A review of the residents admission urinary continence evaluation dated December 21, 2023 revealed that the resident was continent of urine. The evaluation findings dated December 21, 2023 indicated that the resident remains continent and incontinent of bowels with a 16 fr/10 cc balloon foley catheter. Will start routine toileting (for bowels) at this time.

Monthly physician progress notes dated January 2024 and February 2024 failed to address the ongoing clinical necessity for continued use of the indwelling foley catheter.

A review of fluid intake documentation dated December 11, 2024, to the time of the survey ending March 7, 2024, revealed that the facility staff documented the resident's daily intake per shift. There was no indication that the resident's hourly urine output was being monitored and documented as noted on the clinical documentation for the foley catheter.

The DON confirmed during interview on March 7, 2024, that there was no physician documentation to clinically support the use of the indwelling Foley catheter for accurate hourly urine output measurement for acutely ill persons being monitored for fluid balance where incontinence interferes with necessary monitoring.

28 Pa. Code: 211.12 (d)(3)(5) Nursing Services

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

Plan of Correction - To be completed: 04/25/2024

1. Resident 7 has been scheduled a urology appointment to determine clinical necessity for foley catheter.
2. Policy updated to include monthly documentation by physicians to include ongoing clinical necessity for consinuted use of a foley catheter.
3. Physicians will receive education regarding requirement for documentation and education.
4. An audit will be completed to ensure monthly physician documentation on justification for foley catheters x 12 weeks.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued dose of an antipsychotic drug prescribed for one resident out of five sampled (Resident 4) and failed to attempt a gradual dose reduction of the antipsychotic drug.

Findings include:

A review of Resident 4's clinical record revealed that the resident was admitted to the facility on February 2, 2020, with diagnoses to have included anxiety disorder and delusional disorder.

The pharmacist conducted a medication review on July 23, 2023, that indicated that the resident had been receiving the antipsychotic drug Quetiapine (Seroquel - a psychotropic medication used to treat certain mental/mood disorders such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) 75 mg by mouth in the morning and 50 mg by mouth at bedtime for diagnosis of delusional disorder since July 2020. The pharmacist requested that the resident's attending physician consider a gradual dose reduction (GDR). If the attending physician disagreed with the GDR, requested that a clinical rationale be documented in the resident's clinical record.

At the time of the survey ending March 7, 2024, there was no documentation from the physician to support the lack of attempts at a gradual dose reduction of Resident 4' dose of the antipsychotic drug.

An interview with the Director of Nursing (DON) on March 7, 2024, at 9:30 a.m., confirmed that the facility could not provide documented evidence Resident 4's attending physician had documented individualized clinical rationale for Resident 4's ongoing need for the current dosage of Seroquel and the physician had not attempted a gradual dose reduction.

28 Pa. Code 211.2 (d)(3) Medical Director.

28 Pa. Code 211.5(f) Medical records.

28 Pa. Code 211.9 (k) Pharmacy services.

Plan of Correction - To be completed: 04/25/2024

1. Resident #4 order reviewed by physician. Seroquel GDR initiated.
2. Residents receiving antipsychotic medications were reviewed for clinical justification. Any discrepancies were corrected.
3. Nursing staff/physicians will be educated on the Unnecessary Drugs policy by NHA/DON and documentation for the justification of continued use of antipsychotic meds. MD's will document in medical record and contraindication.
4. Audit will be conducted by DON/designee monthly x 3 months to ensure that the attending physician is acting upon the recommendations of the pharmacist. Audits will be presented at QAPI meetings for review and recommendations.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 04/25/2024

1. The facility cannot retroactively correct cited issue.
2. Additional nursing staff have been scheduled to meet state nursing ratios.
3. Facility continues to advertise for additional nursing staff and higher-level staff scheduled as needed.
4. The DON/designee will audit the LPN ration to ensure that facility is meeting the regulatory requirement. Audits will be completed 5x per week x 4 weeks then monthly x 2 months with results reviewed at QAPI.

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