Nursing Investigation Results -

Pennsylvania Department of Health
MULBERRY HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MULBERRY HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  73 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.
MULBERRY HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and an incident survey completed on April 18, 2019, it was determined that Mulberry Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


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 manufacturer's directions and resident's clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that a safe environment was provided for one of 42 residents reviewed (Resident 21) who was transported in a shower chair, failed to ensure that air mattress safety assessments were completed prior to use of an air mattress for three of 42 residents reviewed (Residents 33, 36, 71), and failed to ensure fall prevention interventions were in place as care planned for one of 42 residents reviewed (Resident 10).

Findings include:

Manufacturer's directions for Innovative Products Unlimited (IPU) shower chair commode, dated March 14, 2005, revealed that for showering, the user was to be transferred into the chair in the shower room, and when the shower was finished, the chair was to be moved to a dry floor area and the user was to be transferred into a transport chair.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessments of a resident's abilities and care needs) for Resident 21, dated February 11, 2019, indicated that the resident was understood, could understand, required extensive assistance from staff with transfers, and was totally dependent on one staff for bathing.

Observations of Resident 21 on April 16, 2019, at 7:41 a.m. revealed that Nurse Aide 7 transported the resident from his room and down the hallway to the shower room while the resident was in an IPU shower chair. Interview with Nurse Aide 7 on April 16, 2019, at 11:30 a.m. confirmed that she transported Resident 21 in the IPU shower chair from the resident's room to the shower room.

Interview with the Nursing Home Administrator on April 18, 2019, at 7:00 p.m. revealed that she was unaware that the IPU shower chair was not to be used for transporting residents.


An annual comprehensive MDS assessment for Resident 33, dated February 20, 2019, indicated that the resident was understood, could usually understand, was dependent for transfers, required extensive assistance from staff with bed mobility, and had pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure).

Observations of Resident 33 on April 15, 2019, at 9:12 a.m. and April 17, 2019, at 10:03 a.m. revealed that the resident had an air mattress on her bed. However, there was no documented evidence that a safety assessment of the air mattress was completed to determine if its use created any potential safety hazards for the resident.


A quarterly MDS assessment for Resident 36, dated February 6, 2019, indicated that the resident was understood, could understand, was dependent for transfers, required extensive assistance from staff with bed mobility, and had pressure ulcers. Physician's orders, dated December 8, 2018, included an order for the resident to use a FlowT air mattress.

Observations of Resident 36 on April 17, 2019, at 6:23 p.m. revealed that the resident had an air mattress on his bed. However, there was no documented evidence that a safety assessment of the air mattress was completed to determine if its use created any potential safety hazards for the resident.


A quarterly MDS assessment for Resident 71, dated February 18, 2019, indicated that the resident was cognitively impaired, and dependent on extensive assistance with care, including bed mobility and transfers.

Observations of Resident 71 on April 15, 2019, at 12:11 p.m. revealed that the resident had an air mattress on her bed. However, there was no documented evidence that a safety assessment of the air mattress was completed to determine if its use created any potential safety hazards for the resident.

Interview with the Director of Nursing on April 17, 2019, at 3:17 p.m. confirmed that there were no safety assessments for air mattresses to determine if their use created any potential safety hazards for the residents prior to placing them on residents' beds, and the facility did not have a policy to address air mattress assessments.


The facility's policy regarding call lights, dated February 18, 2019, revealed that when a resident was in bed or confined to a chair, staff were to ensure that the call light was within easy reach of the resident.

A quarterly MDS assessment for Resident 10, dated February 6, 2019, revealed that the resident was understood and could usually understand, and required extensive assistance from staff for care, including toileting, transfers, and bed mobility. The resident's care plan, dated January 8, 2018, indicated that she was at risk for falls due to a history of falls, impaired balance/poor coordination, medication side effects, and an unsteady gait, and staff were to ensure that the call bell was within reach. A fall risk assessment for Resident 10, dated May 10, 2018, indicated that she resident was at high risk for falls.

Observations on April 15, 2019, at 9:37 a.m. revealed that Resident 10 was lying in bed and the call light was noted to be lying on the floor to her right side.

Interview with Nurse Aide 2 on April 15, 2019, at 9:42 a.m. confirmed that Resident 10 was capable of using the call light, which was lying on the floor out of the resident's reach.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 7/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/18, 7/20/18, 5/4/18.






 Plan of Correction - To be completed: 06/11/2019

1. Resident 21 was not found to have a negative outcome as a result of the observation. Resident 33, 71 and 36 air mattress safety assessment completed. Resident 10, call bell was placed within reach.
2. Shower Chairs labeled "not for transport", residents with air mattresses will have air mattress safety assessment completed. Monitor residents to ensure call bells are in place during clinical rounds.
3. Education will be provided to staff by Director of Nursing or designee on proper transporting devices. Education will be provided to registered nurses (RN) on completing safety assessments on air mattresses as well as ensuring call bells are within reach. Safety assessments/reassessments will be completed when initiated, quarterly and with significant changes in condition.
4. Audits of residents being transported in the building, as well as air mattress safety audits and call bells being within reach, will be conducted by Director of Nursing or designee randomly 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction for previous surveys by the state survey agency (Department of Health), as well as the results of the current survey, it was determined that the facility's Quality Assessment and Assurance (QA&A) program failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) surveys ending May 4 and July 20, 2018, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending April 18, 2019, identified repeated deficiencies related to accident hazards and prevention, labeling/storing drugs, food storage, and infection control.

The facility's plan of correction for a deficiency regarding a failure to ensure that each resident's environment was free from accident hazards, cited during the survey ending July 20, 2018, revealed that audits would be completed and the results of the audits would be presented to the QAA committee. The results of the current survey, cited under F689, revealed that the facility's QAA committee was ineffective in maintaining ongoing compliance with the regulation regarding accident hazards and accident prevention.

The facility's plan of correction for a deficiency regarding labeling and storing drugs, cited during the survey ending May 4, 2018, revealed that audits would be completed and the results of the audits would be presented to the QAA committee. The results of the current survey, cited under F761, revealed that the QAA committee was ineffective in maintaining ongoing compliance with the regulation regarding proper labeling and storage of drugs.

The facility's plan of correction for a deficiency regarding a failure to label and store food appropriately, cited during the survey ending May 4, 2018, revealed that audits would be completed and the results of the audits would be presented to the QAA committee. The results of the current survey, cited under F812, revealed that the QAA committee was ineffective in maintaining compliance with the regulation regarding proper labeling and storage of food.

The facility's plan of correction for a deficiency regarding infection control, cited during the survey ending May 4, 2018, revealed that audits would be completed and the results of the audits would be presented tot he QAA committee. The results of the current survey, cited under F880, revealed that the facility's QAA committee was ineffective in maintaining compliance with the regulations regarding using appropriate infection control practices.

Refer to F689, F761, F812, F880.

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



 Plan of Correction - To be completed: 06/11/2019

The facility administrator and the Director of Nursing, along with the interdisciplinary team will ensure that the results of annual survey within the facility Quality Assurance Performance Improvement Meeting including but not limited to completing audits and reporting the results of those audits to the Quality assurance committee for review to identify and correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively reoccurring deficiencies. The interdisciplinary team will be re-educated by the administrator regarding effective Quality Assurance meeting and information provided and discussed to identify and correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively address the reoccurring deficiencies by auditing and reporting.
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(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 policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food under sanitary conditions.

Findings include:

The facility's policy regarding food storage, dated February 18, 2019, indicated that the nutrition services manager was responsible for proper storage of nutritional services food and supplies, that all dry, refrigerated, and frozen items on shelves were to be used according to the "first-in, first-out" method, and all opened and partially used foods were to be dated, labeled, and sealed before being returned to the storage area.

The facility's policy regarding frozen food storage, dated February 18, 2019, indicated that prepared foods, such as cooked meats, casseroles and left over food items, were to be discarded after three months.

Observations in the walk-in freezer on April 15, 2019, at 9:00 a.m. revealed that there was a carton of whipped topping with a "best by" date of February 2017; a previously prepared container of chicken noodle soup that was dated October 9, 2018; a previously prepared container of salisbury steak dated August 5 (no year); and a half turkey that was wrapped in foil that had an illegible date as to when it was prepared and stored. Interview with the Dietary Manager at that time confirmed that the date on the turkey was not legible, and that she was not aware of the facility's policy regarding the storage of prepared foods that were frozen, but she does not like to keep them past one year. She indicated that the outdated whipped topping was used by the activities department.

Observations in the dry storage area on April 15, 2019, at 9:17 a.m. revealed that a Ziplock plastic bag that contained a brown powdered substance was not labeled with the product name and/or dated as to when it was opened. Interview with the Dietary Manager at that time revealed that the product was cocoa powder and she confirmed that the plastic bag should have been labeled and dated.

Interview with the Dietary Manager on April 17, 2019, at 9:55 a.m. confirmed that the facility's policy regarding the storage of prepared frozen foods was to discard them after three months.

Observations in the walk-in freezer on April 15, 2019, at 9:00 a.m. and April 17, 2019, at 10:00 a.m. revealed that there was an accumulation of ice on a pipe that exited the condenser, as well as an accumulation of ice on a box of pasta shells that was located below the condenser. Interviews with the Dietary Service Director at that time confirmed that there was an accumulation of ice in the walk-in freezer.

42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve - Sanitary.
Previously cited 5/4/18.

28 Pa. Code 211.6(f) Dietary services.
Previously cited 5/4/18.







 Plan of Correction - To be completed: 06/11/2019

1. The whipped topping, chicken noodle soup, turkey and Salisbury steaks were discarded. Repair company scheduled to repair freezer.
2. Monitoring of the kitchen will be completed by the Dietary Manager or designee to ensure no other boxes are opened without being labeled and dated. Moved items affected by dripping water in the freezer
3. Dietary staff will be educated by Dietary manager or designee, on the proper process for opening, labeling, storing, and dating foods
appropriately. Staff will be required to complete a daily kitchen survey checklist, they will also be required to mark on temperature log if there is any buildup and put in work order if ice is built up. Item that was affected by dripping water was a sealed box that was cleared of ice and moved to new location was inspected and was not damaged.
4. Audits will be conducted by Dietary Manager or designee, 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance improvement committee for further review and recommendations.

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

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

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

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

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

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 42 residents reviewed (Resident 29).

Findings include:

The facility's policy regarding medication administration, dated February 18, 2019, indicated that the individual administering the medication must initial on the appropriate line of the resident's Medication Administration Record (MAR) after giving each medication and before administering the next one.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 29, dated February 19, 2019, revealed that the resident was usually understood and could usually understand, required limited assistance from staff for care, frequently had pain, and had diagnoses that included arthritis and cancer. Physician's orders, dated October 9, 2018, included orders for the resident to receive 10 milligrams (mg) of Oxycodone (a narcotic pain medication) every six hours as needed for moderate to severe pain.

Resident 29's controlled substance records for January, February, March and April 2019 revealed that staff signed out doses of Oxycodone for administration to the resident on January 29 at 12:00 a.m. and 4:00 p.m., February 19 at 6:00 a.m., February 26 at 4:30 a.m., March 1 at 10:00 p.m., March 20 at 2:50 p.m., March 29 at 11:50 a.m., April 3 at 12:45 p.m., and April 6, 2019 at 4:00 p.m. However, there was no documented evidence in the resident's clinical record, including on the MAR and nursing notes, that the Oxycodone was actually administered to the resident at the above listed dates and times.

Interview with the Director of Nursing on April 18, 2019, at 11:24 a.m. revealed that she could not locate any documentation regarding why the Oxycodone was signed out on the above listed dates, or any documentation that the Oxycodone was administered after it was signed out on the above listed dates.

28 Pa. Code 211.9(h) Pharmacy services.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 5/4/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/18, 7/20/18, 5/4/18.




 Plan of Correction - To be completed: 06/11/2019

1. Resident 29 was not found to have negative outcome due to deficient documentation practices.
2. Any resident with controlled substance orders has the potential to be impacted by the findings, staff education was provided on documentation processes.
3. Educate licensed staff on proper documentation process for administration of controlled substances by DIrector of Nursing or designee. Medication Administration record and control drug sheet will be reviewed concurrently and education will be provided to licensed nursing staff on their responsibilities to ensure documentation on all records.Pharmacy does monitor control records during monthly reviews.
4. Audits of controlled substance documentation will be conducted by Director of Nursing or designee, 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

483.12 REQUIREMENT Free from Misappropriation/Exploitation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations:


Based on review of facility policies, residents' clinical records and facility investigative documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation of personal property for one of 42 residents reviewed (Resident 223).

Findings include:

The facility's abuse policy, dated February 18, 2019, revealed that the residents had the right to be free from abuse, neglect, misappropriation of resident property (theft), corporal punishment and involuntary seclusion.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 223, dated February 6, 2019, revealed that the resident was usually understood, could usually understood others, had cognitive impairment, and required assistance with decision making.

Facility investigation documents revealed that during an interview with Family Member 223A on December 14, 2018, she stated that she gave Resident 223 two $25.00 gift cards for a local store on December 3, 2018. The gift cards were placed in the resident's bedside drawer in a zipper pouch, and she told a staff member that the cards were there for Resident 223 to use on a shopping trip with the activities department. On December 11, 2018, Resident Family Member 223B looked for the gift cards and they were missing. The retail store was able to determine where the cards were and when the cards were used, and the local authorities were able to obtain the video from the local store and identify the individual that used the gift cards as Nurse Aide 4, who worked at the facility as a agency nurse aide.

Interview with the Director of Nursing on April 17, 2019, at 12:02 p.m. confirmed that Resident 223's gift cards were misappropriated (taken) by Nurse Aide 4, who was not permitted to return to the facility.

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








 Plan of Correction - To be completed: 06/11/2019

1. Resident 223 has since deceased. Nurse Aide 4 no longer works at facility.
2. On admission resident and family are offered a locked drawer to keep valuables.
3. Staff will be re-educated, by administrator or designee on facility Abuse Policy including resident right to be free from abuse, neglect, misappropriation of resident property (theft), corporal punishment and involuntary seclusion.
4. Education will be provided to staff by administrator or designee. Random staff interviews will be conducted post education. Interviews will be conducted 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of interviews will be discussed at Quality Assurance Performance Improvement meeting for review and recommendations.

483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for one of 42 residents reviewed (Resident 36).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, revealed that if the resident had an unhealed pressure ulcer (skin impairment caused by pressure), then Section M0210 was to be coded yes (1), and the number of pressure ulcers was to be coded in Section M0300A for Stage I pressure ulcers (reddened area that does not blanche), Section M0300B for Stage II pressure ulcers (superficial open area or blister), Section M0300C for Stage III pressure ulcers (full thickness skin loss), Section M0300D for Stage IV pressure ulcers (full thickness tissue loss exposing bone, tendons or muscle), Section M0300E for unstageable pressure ulcers related to a non-removable device, Section M0300F for unstageable pressure ulcers due to slough (yellow, tan, or green tissue, usually moist) or eschar (dead tissue this is black or brown in color and may appear scab like), and M0300G for unstageable pressure ulcers related to suspected deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue).

A wound evaluation note for Resident 36, dated January 26, 2019, revealed that the resident had a current non-pressure, chronic ulcer of the left ankle with necrosis (death) of the bone. Section M0210 of a quarterly MDS assessment, dated February 6, 2019, was coded yes (1), indicating that the resident had unhealed pressure ulcers and Section M0300C was coded one (1), indicating that the resident had a Stage III pressure ulcer. There was no documented evidence that the resident had skin impairment that was caused by pressure.

Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on April 18, 2019, at 2:30 p.m. confirmed that Sections M0210 and M0300C of Resident 36's MDS assessment of February 6, 2019, was not accurate and should have been coded zero (0) because the resident had a non-pressure chronic ulcer.

28 Pa. Code 211.5(f) Clinical records.








 Plan of Correction - To be completed: 06/11/2019

1. Resident 36, Minimum Data Set (MDS), was modified to reflect (0).
2. Registered Nurse Assessment Coordinator (RNAC) will review consults regarding wounds to ensure proper coding. Registered Nurse Assessment Coordinator overlooked documentation of wound identification in progress note during look back period.
3. Education will be provided by Regional Clinical Reimbursement Consultant on accuracy of coding Minimum Data Assessments.
4. Audits of Minimum Data Assessments, will be conducted by administrator or designee, randomly 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to develop individualized care plans that included resident-centered interventions for three of 42 residents reviewed (Residents 28, 33, 71).

Findings include:

A diagnosis record for Resident 28, dated April 8, 2019, revealed that the resident had diagnoses that included vancomycin resistant enterococcus (VRE - a bacteria that is resistant to the antibiotic vancomycin), and observations of Resident 28 on April 15, 2019, at 12:11 p.m.; April 17, 2019, at 12:04 p.m.; and April 18, 2019, at 11:00 a.m. revealed that the resident had isolation bins in his room and signage at the entrance of his room stopping visitors from entering his room.

Resident 28's care plan, dated October 19, 2018, revealed no documented evidence that a care plan addressing the resident's care needs related to isolation was developed.

Interview with Director of Nursing on April 18, 2019, at 11:31 a.m. confirmed that a care plan for Resident 28's infection and isolation was not developed.


An annual comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated February 20, 2019, indicated that the resident was understood, could usually understand, was dependent for transfers, required extensive assistance from staff with bed mobility, and had pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure).

Observations of Resident 33 on April 15, 2019, at 9:12 a.m. and April 17, 2019, at 10:03 a.m. revealed that the resident had an air mattress on his bed. However, the resident's care plan, dated May 17, 2018, revealed that the use of an air mattress was not included as an intervention on the plan.


A quarterly MDS assessment for Resident 71, dated February 18, 2019, indicated that the resident was cognitively impaired and was dependent on extensive assistance for care, including bed mobility and transfers.

Observations of Resident 71 on April 15, 2019, at 12:11 p.m. revealed that the resident had an air mattress on her bed. However, as of April 17, 2019, the resident's care plan revealed that the use of an air mattress was not included as an intervention on the plan.

Interview with the Director of Nursing on April 17, 2019, at 3:17 p.m. confirmed that there were no care plans related to the use of air mattresses for Residents 33, 36 and 71.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 7/20/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/18, 7/20/18, 5/4/18.



 Plan of Correction - To be completed: 06/11/2019

1. Resident 28 care plan updated to reflect care needs for isolation. Resident 33 care plan was updated to reflect air mattress as intervention. Resident 71 care plan was updated to reflect air mattress as intervention.
2. Check all care plans for residents that are on air mattresses for proper interventions. Check care plans for residents on isolation for identification of intervention.
3. Education will be provided to licensed nurses by Director of Nursing (DON) or designee on properly implementing and developing comprehensive care plans.Interdisciplinary team will monitor orders daily and apply changes to care plans as needed.
4. Audits of residents with isolation precautions as well as residents on air mattresses will be conducted by Director of Nursing (DON) or designee randomly 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

483.25(h) REQUIREMENT Parenteral/IV Fluids:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed as ordered by the physician for one of 42 residents reviewed (Resident 71).

Findings include:

The facility's policy regarding intravenous (IV) catheter care (a tube placed in a vein that can be used for an extended period of time to deliver fluids and/or medications), dated February 18, 2019, indicated that peripheral IV catheters were to be flushed prior to each infusion to assess catheter patency and function, and after each infusion to clear the catheter lumen of medication and to prevent contact between incompatible medications. The peripheral catheter was to be flushed with 10 milliliters (ml) of normal saline (sterile salt and water solution).

A nursing note for Resident 71, dated March 16, 2019, at 7:15 p.m. revealed that the resident was diagnosed with pneumonia, was getting IV antibiotics (at the hospital), and then would be returning to the facility. Physician's orders, dated March 17, 2019, included an order for the resident to receive 500 milligrams (mg)/milliliter (ml) of Levaquin (an antibiotic) intravenously (IV) in the evenings for aspiration pneumonia (type of lung infection that is due to material from the stomach or mouth entering the lungs); however, there was no specific order to flush the IV catheter. The resident's clinical record, including the Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for March 2019 revealed that there was no documented evidence that the IV catheter was flushed in accordance with the facility's policy.

Interview with the Director of Nursing on April 17, 2019, at 4:32 p.m. confirmed that there was no evidence that Resident 71's IV was flushed before and after each infusion in accordance with the facility's policy, and it should have been.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/18, 7/20/18, 5/4/18.




 Plan of Correction - To be completed: 06/11/2019

1. Resident 71 was not found to have a negative outcome as a result of the absence of
documentation.
2. Residents with intravenous catheters (IV) were observed to be receiving the IV flushes as per physicians orders and facility policy.
3. Education will be provided to licensed nurses on policy for IV catheter care by Director of Nursing or designee. Root cause undetermined , day to day system change is, daily review of orders by interdisciplinary team, flushes are recorded on medication administration record.
4. Audits of IV catheter flushes will be done by the Director of Nursing or designee randomly 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that oxygen was administered according to physician's orders for one of 42 residents reviewed (Resident 10).

Findings include:

Physician's orders for Resident 10, dated August 17, 2018, included an order for the resident to receive oxygen via nasal cannula (a plastic tubing with prongs inserted into the nostrils) at 3 liters per minute.

Observations on April 15, 2019, at 9:45 a.m. and 10:39 a.m. revealed that Resident 10 was in bed with oxygen being delivered via nasal cannula connected to a oxygen concentrator that was set at a flow rate of 2 liters per minute.

Interview with Licensed Practical Nurse 1 on April 15, 2019, at 10:41 a.m. confirmed that Resident 10's oxygen flow rate was set at 2 liters per minute, and it should have been set at 3 liters per minute.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/18, 7/20/18, 5/4/18.




 Plan of Correction - To be completed: 06/11/2019

1. Resident 10 was not found to have a negative outcome as a result of oxygen flow rate.
2. Flow rate of residents receiving oxygen was verified to be accurate with physicians order.
3. Educate staff, by Director of Nursing or designee,to follow physician's orders for oxygen flow rates. Root cause undetermined, isolated incident. System change is that on non-clinical rounds flow rate will be verified.
4. Audits of residents receiving oxygen therapy will be conducted by Director of Nursing or designee randomly 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(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 reviews and staff interviews, it was determined that the facility failed to ensure that residents did not receive unnecessary medications for one of 42 residents reviewed (Resident 20).

Findings include:

A diagnosis record for Resident 20, dated November 2, 2018, revealed that the resident had diagnoses that included depression, anxiety and dementia (a brain disease that alters memory and thought processes) with behaviors. Physician's orders, dated March 21, 2019, included an order for the resident to receive 0.25 milligrams (mg) of Ativan (an antianxiety medication) as needed every 2 hours, and if ineffective to give 0.5 mg, and if ineffective to give 1.0 mg every two hours as needed for anxiety.

Resident 20's Medication Administration Records (MAR's) for April 2019 revealed that staff administered 1.0 mg of Ativan on April 1 at 6:55 p.m., April 2 at 6:34 p.m., April 10 at 9:00 p.m., April 12 at 6:05 p.m. and April 15 at 3:18 a.m.; however, staff did not administer the 0.25 mg dose, or the 0.5 mg dose on those dates. The MAR's also revealed that staff administered the 0.5 mg dose on April 3, but did not administer the 0.25 mg dose first.

Interview with the Director of Nursing on April 18, 2019, at 9:03 a.m. confirmed that Resident 20's physician's orders for Ativan were not followed and that Resident 20 was overmedicated.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/18, 7/20/18, 5/4/18.


 Plan of Correction - To be completed: 06/11/2019

1. Resident 20 was not found to have negative outcome due to improper administration of anti anxiety medications.
2. Verification by Director of Nursing or designee that residents medications are being administered in accordance with physicians order.
3. Educate licensed nursing staff on administering medications per the physician's orders by Director of Nursing or designee.Root cause was misinterpretation of order by licensed nurse. Pharmacy is involved with review of orders for appropriate administration. 4. Audit 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

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 manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent.

Findings include:

Observations during medication administration on April 16, 2019, revealed that two medication administration errors were made during 30 opportunities for error, resulting in a medication administration error rate of 6.67 percent.

Manufacturer's instructions for Humalog insulin (a fast-acting insulin used to lower blood sugar levels), revised August 13, 2018, indicated that Humalog should be administered 15 minutes prior to a meal.

Physician's orders for Resident 69, dated January, 30 2018, included an order for the resident to receive Humalog insulin according to a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test) before meals and at bedtime. The order included that the resident was to receive 6 units of Humalog insulin for a blood sugar of 151 to 200 milligrams per deciliter (mg/dL).

Observations during medication administration on April 16, 2019, at 8:03 a.m. revealed that Licensed Practical Nurse 6 prepared and administered 6 units of Humalog insulin to the resident, whose blood sugar result obtained earlier was 173 mg/dL. The resident received her breakfast meal at 8:39 a.m. (36 minutes later).

Interview with the Director of Nursing on April 16, 2019, at 5:19 p.m. confirmed that fast-acting insulin was administered to Resident 69 too early.


Manufacturer's instructions for polyethylene glycol (a powdered laxative mixed with water), dated November 2008, indicated that the bottle was supplied with a dosing cup (the bottle top) that was marked to contain 17 grams of powder when filled to the indicated line.

Physician's orders for Resident 69, dated September 20, 2017, included orders for the resident to receive 17 grams of polyethylene glycol with 8 ounces of water daily for constipation. Observations during medication administration on April 16, 2019, at 8:03 a.m. revealed that Licensed Practical Nurse 6 filled a plastic cup with 30 cubic centimeters (cc's) of polyethylene glycol, instead of using a capful to measure 17 grams as indicated by the manufacturer's instructions and physician's order.

Interview with Licensed Practical Nurse 6 on April 16, 2019, at 8:15 a.m. revealed that she thought that the resident was to get 30 cc's of polyethylene glycol.

Interview with the Director of Nursing on April 16, 2019, at 5:19 p.m. confirmed that Licensed Practical Nurse 6 should have used the lid of the polyethylene glycol bottle to measure 17 grams.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/18, 7/20/18, 5/4/18.





 Plan of Correction - To be completed: 06/11/2019

1. Resident 69 was not found to have negative outcome due to improper administration of medications.
2. Monitor time of Humalog administration compared to tray delivery by Director of Nursing or designee. Monitor utilization of dosing cup provided with the polyethylene glycol by Director of Nursing or designee.
3. Educate staff on the manufacturer's instructions for administering Humalog prior to meals by Director of Nursing or designee. Educate licensed staff on the dosing cups provided with polyethylene glycol. Education provided by Director of Nursing or designee. Root cause was the licensed nurse was extremely nervous and knew immediately she made the error. Audits will include medication pass competencies.
4. Audits performed by Director of Nursing or designee, for medication administration will be done 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

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 policies, manufacturer's directions, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of insulin with the date they were opened in one of three medication carts reviewed (East Unit).

Findings include:

The facility's policy regarding medication administration, dated February 18, 2019, revealed that the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date it was opened was to be recorded on the container.

Manufacturer's directions for Humalog insulin (a fast-acting insulin used to lower blood sugar levels), dated August 13, 2018, included that opened vials were to be thrown away after 28 days of use, even if there was insulin left in the vial.

Physician's orders for Resident 51, dated January 16, 2018, included an order for the resident to receive Humalog insulin according to a sliding scale (the amount of insulin given is based on the results of a fingerstick blood sugar test) before each meal and at bedtime.

Observations of the East Unit medication cart on April 18, 2019, at 2:02 p.m. revealed that Resident 51's Humalog insulin vial was opened and was not labeled with the date it was opened. Interview with Licensed Practical Nurse 1 at that time confirmed that the resident's Humalog insulin vial was opened and should have been labeled with the date it was opened.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 5/4/18.

28 Pa. Code 211.9(a)(1) Pharmacy services.




 Plan of Correction - To be completed: 06/11/2019

1. Undated multi-dose humalog vial was disposed of.
2. All opened multi-dose insulin vials were checked to verify they were dated.
3. Education will be provided by Director of Nursing or designee on proper dating of opened medications. Root cause is undetermined. Consulting Pharmacist does review and monitor opened medications for proper dates with audits.
4. Audits on opened medications will be done by Director of Nursing or designee 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results: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.
483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain a physician's order for an invasive procedure to collect a urine specimen for a laboratory test for one of 42 residents reviewed (Resident 21).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated February 11, 2019, indicated that the resident was understood, could understand, was alert and oriented, required extensive assistance from staff for care, and was frequently incontinent (lack of voluntary control) of urine.

Physician's orders for Resident 21, dated December 4, 2018, included an order to obtain a urinalysis and culture & sensitivity (UA C&S - urine tests to check for the presence of bacteria and determine which antibiotics the bacteria is sensitive to). A nursing note, dated December 5, 2018, at 5:47 a.m. revealed that a straight catheterization procedure (temporary insertion of a plastic tube into the bladder to obtain urine) was performed and the urine specimen was obtained and sent for testing.

There was no documented evidence that staff obtained a physician's order for the straight catheterization procedure used to collect the urine specimen.

Interview with the Director of Nursing on April 18, 2019, at 6:28 p.m. confirmed that there was no documented evidence that a physician's order was obtained for Resident 21 to have straight catheterization procedures performed to obtain a urine specimen on December 5, 2018.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 5/4/18.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/18, 7/20/18, 5/4/18.




 Plan of Correction - To be completed: 06/11/2019

1. Resident 21 was not found to have a negative outcome due to order not being obtained.
2. Documentation will be monitored to ensure physician orders are being followed when obtaining a urine specimen.
3. Education will be provided by Director of Nursing or designee on obtaining physician orders for appropriate procedures.Audits of orders will include method of obtaining specimens. Interdisciplinary team will monitor orders daily. Staff education includes verification of orders to perform invasive procedures.
4. Audits will be conducted by DIrector of Nursing or designee on obtaining physician orders for straight catheterization when obtaining urine. Audits will be 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 42 residents reviewed (Resident 30).

Findings include:

A care plan for Resident 30, dated December 13, 2017, revealed that the resident had diagnoses that included diabetes (a disease that interferes with the body's ability to control blood sugar levels). A nursing note, dated April 11, 2019, revealed that Resident 30 stated he was not feeling well, wanted his sugar checked, and it was 41 milligrams per deciliter (mg/dL) (below normal). A nursing note, dated April 11, 2019, authored by Registered Nurse 5, revealed that she administered oral glucose into the resident's jejunostomy tube (a tube surgically inserted into the small intestine) and gave him juice to drink. There was no documented evidence of a physician's order for oral glucose to be administered via the jejunostomy tube.

Interview with the Nursing Home Administrator on April 18, 2019, at 2:42 p.m. revealed that the facility did not have a policy in place to address hypoglycemia (low blood sugar) and that the nurses would treat the resident according to the physician's orders.

An interview with Registered Nurse 5 on April 18, 2019, at 3:09 p.m. revealed that she called the doctor after she checked Resident 30's blood sugar and she forgot to write the physician's order for the oral glucose that she administered to Resident 30 via the jejunostomy tube.

An interview with Physician 6 on April 18, 2019, at 4:24 p.m. revealed that he did not recall if he gave the specific order to Registered Nurse 5 to administer oral glucose via the jejunostomy tube; however, he has ordered that oral glucose be administered into a feeding tube in the past.

28 Pa. Code 211.5(f) Clinical records.




 Plan of Correction - To be completed: 06/11/2019

1. Order documented for Resident 30 to receive instant glucose gel via jejunostomy tube.
2. Nurses obtaining verbal orders will be educated by Director of Nursing or designee, to complete documentation efficiently.
3. Education to licensed nurses by Director of nursing or designee, on procedures for documenting verbal orders completely and accurately in the clinical record.Education will be provided to licensed nurses to include proper route of administration. Interdisciplinary team reviews orders daily to ensure orders are complete.
4. Audits will be completed by Director of Nursing or designee on random nurse notes to verify that orders are in clinical record and documented accurately. 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while administering medications for one of 42 residents reviewed (Resident 69).

Findings include:

The facility's policy for administering oral medications, dated February 18, 2019, indicated that for unit dose tablets or capsules, staff were to place the packaged medications directly into the medication cup.

Observations during medication administration on April 16, 2019, at 8:10 a.m. revealed that while preparing medications for Resident 69, Licensed Practical Nurse 6 dropped a 30 milligram tablet of Imdur (medication used to treat high blood pressure) onto the top of the medication cart. The nurse touched the tablet of Imdur with her bare hands and placed the tablet into the medication cup. At 8:12 a.m. the resident took the medications.

Interview with Licensed Practical Nurse 6 on April 16, 2019, at 8:15 a.m. confirmed that she should not have touched Resident 69's medication with her bare hands.

42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Control, Prevent Spread, Linens.
Previously cited 5/4/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 5/4/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/30/18, 7/20/18, 5/4/18.





 Plan of Correction - To be completed: 06/11/2019

1. Resident 69 was not found to have a negative outcome due to the deficient practice.
2. Educate and monitor medication handling with licensed nursing staff. Education will be provided by Director of Nursing or designee.
3. Educate licensed nursing staff on proper infection control practices will be done by Director of Nursing or designee.
4. Medication pass audits to be complete by Director of Nursing or designee, 5 days a week for 1 week, weekly for 2 weeks and monthly for 2 months. Results of audits will be provided to the Quality Assurance Performance Improvement committee for further review and recommendations.

211.12(d)(2) LICENSURE Nursing services.:State only Deficiency.
(2) Nursing policy and procedure manuals.
Observations:


Based on review of the facility's policies and procedures, as well as staff interviews, it was determined that the facility failed to ensure that there were nursing policies and procedures for staff to follow regarding hypo/hyperglycemia (low and high blood sugar) and for assessing air mattresses for potential safety hazards prior to use.

Findings include:

A care plan for Resident 30, dated December 13, 2017, revealed that the resident had diagnoses that included diabetes (a disease that interferes with the body's ability to control blood sugar levels). A nursing note, dated April 11, 2019, revealed that Resident 30 stated he was not feeling well, wanted his sugar checked, and it was 41 milligrams per deciliter (mg/dL) (below normal). A nursing note, dated April 11, 2019, authored by Registered Nurse 5, revealed that she administered oral glucose into the resident's jejunostomy tube (a tube surgically inserted into the small intestine) and gave him juice to drink.

An interview with Registered Nurse 5 on April 18, 2019, at 3:09 p.m. revealed that she called the doctor after she checked Resident 30's blood sugar and she forgot to write the physician's order for the oral glucose that she administered to Resident 30 via the jejunostomy tube. An interview with Physician 6 on April 18, 2019, at 4:24 p.m. revealed that he did not recall if he gave the specific order to Registered Nurse 5 to administer oral glucose via the jejunostomy tube; however, he has ordered that oral glucose be administered into a feeding tube in the past.

Interview with the Nursing Home Administrator on April 18, 2019, at 2:42 p.m. revealed that the facility did not have a policy in place to address hypoglycemia (low blood sugar) and that the nurses would treat the resident according to the physician's orders.


An annual comprehensive MDS assessment for Resident 33, dated February 20, 2019, indicated that the resident was understood, could usually understand, was dependent for transfers, required extensive assistance from staff with bed mobility, and had pressure ulcers (skin breakdown caused by prolonged, unrelieved pressure). Observations of Resident 33 on April 15, 2019, at 9:12 a.m. and April 17, 2019, at 10:03 a.m. revealed that the resident had an air mattress on her bed. However, there was no documented evidence that a safety assessment of the air mattress was completed to determine if its use created any potential safety hazards for the resident.

A quarterly MDS assessment for Resident 36, dated February 6, 2019, indicated that the resident was understood, could understand, was dependent for transfers, required extensive assistance from staff with bed mobility, and had pressure ulcers. A care plan, dated December 8, 2018, included an order for the resident to use a FlowT air mattress. Observations of Resident 36 on April 17, 2019, at 6:23 p.m. revealed that the resident had an air mattress on his bed. However, there was no documented evidence that a safety assessment of the air mattress was completed to determine if its use created any potential safety hazards for the resident.

A quarterly MDS assessment for Resident 71, dated February 18, 2019, indicated that the resident was cognitively impaired and dependent on extensive assistance with care, including bed mobility and transfers. Observations of Resident 71 on April 15, 2019, at 12:11 p.m. revealed that the resident had an air mattress on her bed. However, there was no documented evidence that a safety assessment of the air mattress was completed to determine if its use created any potential safety hazards for the resident.

Interview with the Director of Nursing on April 17, 2019, at 3:17 p.m. confirmed that there were no safety assessments for air mattresses to determine if their use created any potential safety hazards for the residents prior to placing them on residents' beds, and the facility did not have a policy to address air mattress assessments.




 Plan of Correction - To be completed: 06/11/2019

Will develop policy and procedures for air mattress safety and hypoglycemia. Education will be provided by Administrator or designee to staff on policies and procedures.

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Health Promotion and Disease Prevention : Quality Assurance



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