Nursing Investigation Results -

Pennsylvania Department of Health
MONROEVILLE REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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MONROEVILLE REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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MONROEVILLE REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and Abbreviated Survey in response to two complaints, completed on May 3, 2019, it was determined that Monroeville Rehabilitation and Wellness Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,
Observations:

Based on policy review, and facility personnel file review, and staff interview, it was determined that the facility failed to complete thorough abuse screening on two of five employee records (Employees E7 and E10) and failed to complete abuse training for one of five employees (Employee E11).

Findings Include:

The facility "Screening employees for history of abuse, neglect, mistreatment of residents" last reviewed 2/12/19, states the facility will be thorough in their investigations of the past histories of individuals they are considering hiring. The facility should check information from previous or current employers and uncover information about past criminal prosecutions.

The facility "abuse protection" last reviewed 2/12/19, states each resident has the right to be free abuse. The abuse prevention program provides polices and procedures. Training is mandated for staff training/orientation that includes such topics as abuse prevention, identification, reporting of abuse, stress management, dealing with violent behavior.

Review of the Facility Driver Employee E7 personnel file indicates he was hired on 1/2/19. Facility Driver Employee E7 personnel file did not include documentation indicating the completion of a state criminal background check.

Review of Licensed Practical Nurse (LPN) employee E10 personnel file indicated he was hired on 1/16/19. LPN Employee E10's personnel file did not include documentation indicating the completion of a state criminal background check or Reference checks prior to his start date in the facility.

Review of Nurse Aide Employee E11 personnel file indicated she was hired on 2/2/19. Nurse aid Employee E11 personnel file did not include training for abuse.

During an interview on 5/2/19, at 10:12 a.m. Human Resources Supervisor Employee E5 confirmed that the facility failed to provide employee abuse training and screen employees history of abuse prior to hire.

28 PA Code: 201.14(c)(d)(e) Responsibility of licensee
28 PA Code: 201.19 Personal Policies and Procedures.
28 PA Code: 201.20 (a)(b)(c)(d) Staff Development.


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

1. The facility completed a state criminal background check on Employee E7 and Licensed Practical Nurse E10. The facility cannot correct that reference checks were not completed prior to start date for Employee E10. Abuse training was provided to Nurse Aide Employee E11 by the Director of Nursing/designee.
2. The facility will provide employee abuse training and screen employees history of abuse prior to hire.
3. The Director of Human Resources will be re-educated on the facility policy for abuse protection and screening of employees for history of abuse, neglect, mistreatment of residents by the Nursing Home Administrator/designee.
4. The Nursing Home Administrator/designee will audit new hire personal files weekly for four weeks and monthly for three months to ensure employees criminal background checks, reference checks and abuse training were completed prior to hire or start date. These audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
483.75(g)(1)(i)-(iii)(2)(i) REQUIREMENT QAA Committee: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)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role;

§483.75(g)(2) The quality assessment and assurance committee must:
(i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary.
Observations:
Based on review of facility policy and documents and staff interview, it was determined that the facility failed to make certain the quality assessment and assurance committee meets at least quarterly for two of four quarters for 2018 (Second and Third Quarters).

Findings include:

A review of the facility policy "Quality Assurance/Performance Improvement" (QAPI) dated 2/12/18, indicated the facility will conduct quality assurance/improvement and assessment meeting at least quarterly to identify areas of service that are non-complaint, or with potential for improvement.

A review of the QAPI sign in sheets from May 2018, through December 2018, did not include a meeting for the Second and Third quarters of 2018.

During an interview on 5/1/19, at 2:00 p.m. Regional Quality Assurance Employee E3 confirmed the above findings and that the facility failed to make certain the quality assessment and assurance committee meets at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary for two of four quarters for 2018.

28 Pa. Code Management.


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

1. The facility cannot correct that there was not a Quality Assurance Performance Improvement Meeting for the second and third quarters of 2018.
2. The facility will have Quality Assurance Performance Improvement Meetings at least quarterly.
3. The Nursing Home Administrator and Director of Nursing will be re-educated by the Regional Quality Assurance Nurse on the facility policy for Quality Assurance Performance Improvement with emphasis on meeting requirements.
4. The Nursing Home Administrator/designee will audit to ensure Quality Assurance Performance Improvement meetings are being held at least quarterly. These audits will be completed monthly for three months. The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a clean, comfortable and home-like environment for four of 25 resident rooms (Rooms 112, 128, 131, and Room 254).

Findings Include:

The "Resident Environment" policy, reviewed 2/12/19, indicated the facility will provide and environment that is safe, clean, comfortable and homelike.

During an observation on 4/29/19, at 12:17 p.m. a used incontinence brief was observed on the floor in Room 128. Resident R42 indicated that he was not able to change his own brief and that it was left there by a staff person.

During an interview on 4/29/19, at 12:35 p.m. Nurse Aide Employee E15 confirmed that she had left the brief on the floor instead of placing it in the garbage.

During observations on 5/2/19, the following was observed:

9:17 a.m. observation of Room 131 revealed chipped paint behind the bed.
9:24 a.m. observation of Room 254 revealed scuff marks on the wall below the window.
9:37 a.m. observation of Room 112 revealed chipped paint behind the bed.

During an interview on 5/02/19, at 10:57 a.m. the Maintenance Supervisor Employee E13 confirmed the above findings and that the facility failed to maintain a clean and home-like environment for rooms 131, 254, and 112.

28 PA Code: 207.2(a) Administrator's Responsibility.
28 PA Code: 201.29(k) Resident Rights.



 Plan of Correction - To be completed: 06/10/2019

1. The facility cannot retroactively correct the concern identified in room 128 with resident R42. Rooms 131 and 112 will have the chipped paint repaired, and the scuffmarks on the wall in 254 will be removed/cleaned.
2. The Director of Nursing or Designee will re-educate the nursing staff on the federal regulation F0584, to include placing briefs in the garbage and not leaving them on the floors in resident's room. The Nursing Home Administrator/designee will re-educate Maintenance and Housekeeping staff on maintaining a clean, home-like environment for the residents and reporting repairs that are needed. The guardian angel rounds will include monitoring rooms for chipped paint and scuffmarks.
3. The Nursing Home Administrator/ Designee will audit weekly times 4 weeks then monthly times 3 months to validate rooms are maintained in clean, homelike environment with rooms having no chipped paint or scuffmarks. These audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:
Based on review of facility policy and clinical records and interview with staff, it was determined that the facility failed to make certain the resident was free from neglect which resulted in a fall for one of three residents (Resident R75.)

Findings include:

A review of the facility policy "Abuse: Protection form Abuse" dated 2/12/19, indicated each resident has the right to be free from neglect.

A review of the clinical record reveled that Resident R75 was admitted to the facility on 3/27/19, with diagnoses that include respiratory failure, stroke, paraplegia, and anxiety disorder.

A review of a progress note dated 4/11/19, indicated that Resident R75 slipped out of the chair during a shower and the nursing assistant was educated on the use of a lift.

A review of Resident R75's physician orders dated 4/1/19, indicated transfer with maxi lift (mechanical lift that requires no resident participation) and assist of two people.

A review of Resident R75's Nurse Aide Tasks dated 3/27/19, indicated to transfer with a maxi lift and assist of two people.

A review of an incident report dated 4/18/19, indicated that nurse aide (NA) Employee E4 used a Sara lift (lift that requires resident strength participation) instead of a maxi lift and Resident R75 fell to the floor.

During an interview on 5/2/19, at 1:30 p.m., the Director of Nursing confirmed the above findings and that the facility failed to to make certain the resident was free from neglect which resulted in a fall for Resident R75.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.


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

1. The facility cannot correct the identified situation for resident R75. Resident R75 suffered no ill effects from identified situation.
2. Nurse Aide Employee E4 was re-educated by the Director of Nursing/designee on the proper use of facility mechanical lifts and facility abuse policy.
3. The Director of Nursing/designee will re-educate nursing staff on the facility abuse policy and mechanical lift policy.
4. The Director of Nursing/designee will audit five resident transfers weekly for four weeks and then monthly for three months to ensure appropriate mechanical lift is being used. These audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.

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 review of facility policy and clinical records and staff interviews, it was determined that the facility failed to make certain the facility developed and implemented a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs four of 16 residents (Resident R75, R66, R68 and R105.)

Findings include:

A review of the facility policy "MDS/RAI/Care Planning" dated 2/12/19, indicated that residents will have an individualized written plan of care that identifies the resident's problems and needs.

A review of the clinical record reveled that Resident R75 was admitted to the facility on 3/27/19, with diagnoses that include respiratory failure, stroke, paraplegia, and anxiety disorder.

A review of a physician order dated 4/1/19, indicated to transfer the resident with a maxi lift (mechanical lift) and assist of two people.

A review of the care plan initiated on 3/27/19, did not include the need for use of a maxi lift with assist of two people for transfers.

During an interview on 5/2/19 at 1:30 p.m., the Director of Nursing confirmed the above findings and that the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for the use of a maxi lift for transfers for Resident R75.

A review of Resident R66's quarterly MDS (Minimum Data Set assessment-assessment of resident care needs) dated 3/27/19, indicated Resident R66's active diagnoses included diabetes, major depressive disorder, and dementia.

A review of Resident R66's physician orders dated 4/1/19, stated to document anxiety behaviors. A review of April 2019, behavior symptoms documentation indicated Resident R66 had some documented behaviors.

A review of Resident R66's care plan did not include a care plan for behaviors.

During an interview on 5/3/19, at 1:18 p.m. the Director of Nursing confirmed the facility failed to develop a comprehensive care plan addressing Resident R66's behaviors.

A review of the quarterly MDS dated 4/16/19, indicated Resident R105 was admitted on 11/29/18, with current diagnoses that included uropathy, overactive bladder, and an unspecified wound.

A review of Resident R105's clinical record indicates he had an ostomy surgery (placement of an opening in the abdomen) in May 2018. A review of Resident R105's consultation report dated 1/17/19, indicated a foley catheter (tube to drain urine) in place.

During observation on 4/30/19, at 1:37 p.m. Resident R105 was observed with both an ostomy and a catheter.

A review of Resident R105's clincal record did not include a care plan related to the use of the ostomy or the foley catheter.

During an interview on 5/1/19, at 11:31 a.m. Regional Clinical Consultant Employee E3 confirmed the facility failed to develop a comprehensive care plan for the use of an ostomy and catheter for Resident R105.

A review of the clinical record for Resident R68 revealed a physician progress note dated 12/17/17, that included diagnoses of chronic kidney disease and dialysis (mechanical removal of impurities from the blood).

A review of Resident R68's care plan did not address the care and monitoring of Resident R68's dialysis port until 4/20/19.

During an interview on 5/02/19, at 1:20 p.m., Director of Nursing confirmed the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for residents R66, R68, R75, and R105.

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


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

1. Care Plan for Resident R75 has been updated to include use of a maxi lift with assist of two staff for transfers. Care Plan for Resident R66 has been updated to address resident's behaviors. Care Plan for Resident R105 has been updated to include use of the ostomy or the foley catheter. Care Plan for Resident R68 was updated to include care and monitoring of the dialysis port.
2. Minimum Data Set Assessment Coordinator reviewed resident care plans to assure residents have a comprehensive person-centered care plan.
3. Licensed nursing staff including the registered nurse assessment coordinator staff will be re-educated on developing a comprehensive person –centered care plan by the Regional Clinical Reimbursement Consultant/designee.
4. Minimum Data Set Assessment Coordinator team will conduct an audit of five residents weekly for four weeks, then monthly for 3 months to monitor compliance. Identified issues will be corrected by the Minimum Data Set Assessment Coordinator. The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
483.21(c)(1)(i)-(ix) REQUIREMENT Discharge Planning Process: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(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
Observations:
Based on review of clinical record and interviews, it was determined that the facility failed to develop a discharge plan for one of one resident (Resident R108).

Findings include:

Review of the Quarterly Minimum Data Set (MDS- a periodic review of care needs) dated 4/17/19, indicated that Resident R108 was admitted on 2/26/19, with diagnoses that included high blood pressure, diabetes mellitus (a disease characterized by high blood sugar over a prolonged period and cerebral infarction (stroke).

Section Q0400 Discharge Plan, indicated that active discharge planning was already occurring for the resident to return to the community, and that referrals had been made to the local contact agency.

During an interview on 04/30/19, at 10:12 a.m. Resident R108 indicated that she wanted to be discharged to the community and was concerned that this was not happening.

A review of the clinical record did not include documentation of a discharge plan for Resident R108.

Review of the care plan document last updated 4/24/19, did not include goals or interventions related to the resident's desire to return to the community.

During an interview on 5/1/19, at 11:00 a.m. Social Work Employee E6 confirmed that the facility failed to develop a discharge plan for Resident 108.

28 Pa Code: 201.25 Discharge Policy.


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

1. The facility will develop discharge plans for residents. A discharge plan will be developed for resident R108 to include goals and interventions related to the residents desire to return to the community.
2. The Social Services Director/designee will review residents admitted in the past 30 days to validate a discharge plan is in place.
3. The Regional Social Service Consultant/designee will re-educate the Social Service employees on the process of implementing discharge plans for residents.
4. The Director Social Services/designee will complete an audit weekly times four weeks then monthly times three months to validate a discharge plan is implemented for new residents. The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:
Based on review of facility policy, resident council group interview, observations and interviews, it was determined that the facility failed to provide assistance with activities of daily living for two of two residents (Resident R63 and R79).

Findings include:
Review of the facility "Flow of Care" policy, dated 2/12/19, indicated that care would be provided as needed 24 hours a day to attain and maintain the highest level of functioning and to promote quality of life with the resident.

Review of the facility "Call Light" policy, dated 2/12/19, indicated that staff should answer call lights as soon as possible and should respond to the needs of the resident.

Review of the Annual Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 3/22/19, indicated that Resident R63 was admitted to the facility on 7/15/16, with diagnoses that included stroke, muscle weakness and neurogenic bladder (loss of normal bladder function caused by damage to part of the nervous system). MDS Section G -Functional Status indicated that Resident R63 required extensive assistance by one staff person for toilet use, hygiene and dressing.

A review of the care plan for Resident R63 dated 2/26/19, indicated that Resident R63 had a problem with incontinence and was to be be encouraged to use the call bell to encourage continence and would be provided with assistance each shift and as needed for toileting and incontinence care.

During an interview on 4/29/19, at 10:55 a.m. Resident R63 indicated that she had put on her call light for assistance with the bathroom, but that Medical Records Employee E14 had turned it off around 10:30 a.m. She had experienced incontinence and was wet and uncomfortable. No one had returned to assist her with care. Resident R63 indicated that this was a common occurrence.

During an observation on 4/29/19, at 11:12 a.m. Resident R63 was still waiting for assistance. Resident R63 put the call light on again. Medical Records Employee E14 was observed going into the room and the call light was noted to go off.

During an observation on 4/29/19, at 11:25 a.m. Resident R63 was still waiting for assistance.

During an interview on 4/29/19, at 11:27 a.m. Medical Records Employee E14 confirmed that she had turned the call light off two times, and that Resident R63 had not been provided incontinence care after putting her call light on two times over a period of approximately 55 minutes.

Review of the Minimum Data Set (MDS- a periodic assessment of resident care needs) dated 3/15/19, indicated that Resident R79 was admitted to the facility on 3/8/19, with diagnoses that included stroke, high blood pressure and depression . MDS Section G "Functional Status" indicated that Resident R79 required extensive assistance from one staff person for dressing and personal hygiene and was totally dependent on staff for bathing.

During an observation on 4/29/19, at 9:07 a.m. Resident R79 was wearing a facility gown, had long dirty fingernails and stringy hair with white flakes.

During an observation on 5/1/2019, at 10:40 a.m. Resident R79 was wearing a facility gown, had long dirty fingernails and stringy hair with white flakes.

During an interview on 5/1/19, at 10:43 a.m. Resident R79 indicated that he hadn't had a shower in a long time, and that he did not like that his fingernails were long and dirty. He said he asked to have them trimmed, but it never happened.

Review of the resident care plan dated 4/2/19, indicated that the resident required assistance with nail care as needed.
Review of a facility shower schedule indicated that each resident had two scheduled "shower days" each week.

Review of the clinical record revealed that the resident had not received showers 53 of 54 days, with no refusals documented. Documentation did not include any nail care provided during the resident's stay.

During an interview on 5/1/19, at 11:30 a.m. the Director of Nursing confirmed that the facility failed to provide nail care and showers for Resident R79.

28 Pa Code: 201.14(a) Responsibility of Licensee.
28 Pa Code: 201.18 (b)(1)(e)(1) Management.
28 Pa Code: 201.29(j) Resident Rights.
28 Pa Code: 211.10(d) Resident Care Policies.
28 Pa Code: 211.12(d)(1)(2)(3)(5) Nursing services.


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

1. Resident R63 did not suffer any adverse effects from call bell not being answered timely. Resident R79's fingernails were trimmed and he was offered a shower.
2. Medical Records Employee E14 was re-educated on facility policy for call lights. The facility will provide assistance with activities of daily living for residents.
3. The nursing staff will be re-educated on the facility policy for call lights and flow of care by the Director of Nursing/designee. Ancillary staff will be re-educated on the facility policy for call lights by the Director of Nursing/designee.
4. The Director of Nursing/designee will audit five residents weekly for four weeks and monthly for three months to ensure showers are being completed and nail care is being provided. The Guardian Angels will complete call light audits on three times a week for two weeks, weekly for two weeks and monthly for three months to ensure call lights are answered timely and resident needs are being met. The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(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 facility policy and clinical records and staff interview, it was determined that the facility failed to make certain residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two of three residents (Resident R61 and R75.)

Findings include:

A review of the facility policy "Treatment Administration Technique and Documentation" dated 2/12/19, indicated all treatments will be properly administered and documented on appropriate records as ordered by the physician.

A review of the clinical record revealed that Resident R61 was admitted to the facility on 10/15/17, with diagnoses that included diabetes and obesity. A review of the face sheet dated 2/24/19, indicated diagnoses of pressure ulcer and diabetes.

A review of the wound evaluation flow sheets dated 4/3/19, indicated a Stage 4 pressure ulcer to the left buttock and sacrum.

A review of a physician order dated 4/3/19, indicated to cleanse R61's left buttock wound with saline and apply Drawtex (a water conductive dressing) and cover with foam dressing every day and as needed.

A review of the Treatment Administration Record (TAR) dated April 2019, indicated R61's left buttock dressing change was not completed on 4/16, 4/17, 4/20, and 4/23/19.

A review of a physician order dated 4/10/19, indicated to cleanse R61's sacral wound with saline and apply Xeroform (anti sticking) gauze to base of wound, apply santyl (a debriding agent), pack loosely with calcium alginate rope (helps to stabilize blood flow, absorbs wound fluid, and keeps wound moist), and cover with large foam dressing every day and as needed.

A review of the TAR dated April 2019, indicated that R61's sacral dressing was not completed on 4/17, 4/18, 4/20, and 4/23/19.

A review of the clinical record revealed that Resident R75 was admitted to the facility on 3/27/19, with diagnoses that included respiratory failure, stroke, and paralysis.

A review of Resident R75's wound evaluation flow sheets dated 3/27/19, indicated a Stage 4 pressure ulcer to the left buttock.

A review of Resident R75's physician order dated 3/29/19, indicated to cleanse the left ischium (upper buttock) wound with saline, pack with calcium alginate, and cover with a dry dressing every day.

A review of Resident R75's TAR dated April 2019, indicated that the left buttock dressing was not completed on 4/5, 4/6, 4/8, 4/10, 4/13, 4/14, 4/15, 4/16, and 4/17/19.

A review of Resident R75's physician order dated 3/27/19, indicated to turn and reposition every two hours and as needed every shift.

A review of Resident R75's TAR dated 2019, indicated turn and reposition every shift was not completed on 4/5, 4/6, 4/8, 4/10, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, and 4/25/19.

During an interview on 5/3/19, at 10:00 a.m., the Director of Nursing confirmed the above findings and that the facility failed to make certain Resident R61 and R75 received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing.

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


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

1. Resident R61 and R75 wounds were assessed by the CRNP and licensed nurse. No ill effects to Resident R61 and R75.
2. The Director of Nursing/designee will review current resident treatment administration record to ensure treatments are being administered and documented as ordered by the physician.
3. The Director of Nursing/designee will re-educate licensed nursing staff on facility policy for treatment administration technique and documentation.
4. The Director of Nursing/designee will audit five resident treatment administration records three times a week for two weeks, weekly for two weeks and monthly for three months to ensure treatments and being administered and documented as ordered by the physician. The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:

Based on staff interview, it was determined that the facility failed to provide evidence that nurse aides (NA) received at least 12 hours of annual in-service education for five of five employees (Employees E19, E20, E21, E22, and E23).

Findings include:

Review of the facilty policy "Staff Development" dated 2/12/19 , indicated that the facility will provide staff development and education to employees. Certified Nursing Assistants/Aides receive at least 12 hours of inservice per year.

During the entrance conference on 4/29/19 at 8:45 a.m., the Nursing Home Administrator and Regional Quality Assurance Registered Nurse Employee E3 were asked to provide a list of currently employed Nurse Aides (NA)who had been working at the facility for at least a year and evidence that the nurse aides had received 12 hours of annual in-service education.

A review of personnel files indicated the following:

NA Employee E19's date of hire was 2/11/14.
NA Employee E20's date of hire was 10/1/13.
NA Employee E21's date of hire was 12/2/14.
NA Employee E22's date of hire was 4/14/16.
NA Employee E23's date of hire was 6/12/17.

During an interview on 5/3/19 at 9:45 a.m., Director of Nursing confirmed that the facility could not provide documented evidence that nurse aides received at least 12 hours of annual in-service education for NA Employees E19, E20, E21, E22, and E23.

28 Pa.Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.20(a)(c) Staff development.


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

1. The facility correct the identified situation for Nurse Aide E19, 20, 21, 22 and 23 not having twelve hours of annual in-service education.
2. The Facility will provide twelve hours of annual in-service education to nurse aides.
3. The Director of Nursing will be re-educated by the Regional Quality Assurance Consultant on the facility policy staff development with emphasis on nurse aides having twelve hours of annual in-service education.
4. The Director of Nursing/designee will track nurse aide education to ensure twelve hours of annual in-service education is being completed. An audit of at least 5 Nurse Aide educations will be completed weekly until all Nurse Aides have been reviewed to validate compliance. The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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(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 review of facility policy and clinical records and interview with staff, it was determined that the facility failed to make certain each resident's drug regimen is free from unnecessary drugs when used without adequate indication for use for two of five residents (Resident R113 and R85.)

Findings include:

Based on review of the facility policy "Antipsychotic Drugs" dated 2/12/19, indicated that residents are not given psychoactive medications unless psychoactive drug therapy is necessary to treat a specific condition diagnosed and documented in the clinical record.

A review of the clinical record revealed that Resident R85 was admitted to the facility on 12/7/18, with diagnoses that included dementia, breast cancer, and seizures.

A review of a physician order dated 4/1/19, indicated to give olanzapine (antipsychotic) 0.5 mg (milligrams) every eight hours for "restlessness and agitation" which is not identified as a specific condition for the use of an antipsychotic.

A review of the Medication Administration Record (MAR) dated April 2019, indicated that Resident R85 received the olanzapine three times daily 4/1/19, through 4/30/19.

A review of the clinical record progress notes dated April 2019, did not include documentation that resident R85 had behaviors to support the use of olanzapine.

A review of the clinical record revealed that Resident R113 was admitted tot he facility on 4/29/15, with diagnoses that include dementia, psychosis, panic disorder, and major depression.

A review of a physician order dated 4/1/19, indicated to give clonazepam (anti-anxiety medication) 0.25 mg (milligrams) two times a day for "restlessness and agitation" which is not identified as a specific condition for the use of an antipsychotic.

A review of the Medication Administration Record (MAR) dated April 2019, indicated that Resident R113 received the clonazepam two times daily 4/1/19, through 4/30/19.

A review of the clinical record progress notes dated April 2019, did not include documentation that resident R113 had behaviors to support the use of clonazepam.

During an interview on 5/2/19, at 11:30 a.m., The Director of Nursing confirmed the above findings and that the facility failed to make certain each resident's drug regimen is free from unnecessary drugs when used without adequate indications for its use for Resident R113 and R85.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 211.2(a)(c)Physician services.
28 Pa. Code 211.9(a)(1)(d)(k) Pharmacy services.
28 Pa. Code 211.12(5)(c) Nursing services.


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

1. Resident R85 and R113 physicians were notified to clarify specific diagnoses for olanzapine and clonazepam.
2. The Director of Nursing/designee will review current residents on antipsychotic medications to ensure medications have specific diagnoses for use.
3. The licensed nursing staff will be re-educated by the Director of Nursing/designee on the facility policy for Antipsychotic Drugs.
4. The Director of Nursing/designee will audit five residents weekly for 4 weeks and then monthly for three months to ensure antipsychotic medications have specific diagnoses for use and behaviors are documented to the use of the antipsychotic medication. The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
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 facility policy review, observations and staff interviews, it was determined that the facility failed to properly store medications, label and date multi dose medication containers, dispose of medications for residents no longer residing in the facility and keep medications refrigerated as required in one of five medication carts (Medication cart #3 - 150 hall).

Finding include:

The facility policy "Labeling of Medications" dated 2/12/19, indicated that all medications maintained in the facility are properly labeled in accordance with current State and Federal regulations.

The facility policy "Storage of Medications" last dated 2/12/19, indicated that medications are stored in a safe, secure and orderly manner in accordance with State and Federal regulations and facility policies. Medications requiring a refrigerator must be stored in the refrigerator located in the drug room at the nurses' station.

During observations on 4/30/19, at 9:30 a.m. of the Medication cart #3 150 hall revealed:
A syringe of Enoxaparin NA (blood thinner used to prevent blood clots) in the back of the top drawer without packaging or a label.
A bottle of Lidocaine HCL (numbing agent used to block pain) 1% open- no date opened and no resident name.
2 vials of Retacrit inj (increases the number of red blood cells) 4000 Units in the drawer of the medication cart that required refrigeration.
3 Lantus Solostar (Insulin) Pens in the drawer of the medication cart that required refrigeration..
2 Humalog (Insulin) Kwikpens in the drawer of the medication cart that required refrigeration.
Allergy relief in cart open with no date opened, no name.
Bottle of Milk of Magnesia open with no date opened and no name.
Bottle of Advil Liquigels open with no date opened and no name.
Bottle of Liquid Pain Relief (Acetaminophen) open with no date opened and no name.
Benadryl 25 mg opened, no name.
Immodium HC opened, no name.
Melatonin 3 mg opened with no date opened and no name.
Senna 8.6 mg opened, no name.
Aspirin 325 mg opened, no name.
Tylenol PM 500/325 opened, no name.
Naproxen 220mg opened, no name.
Ibuprofen 200mg opened, no name.
Tylenol 325 mg opened, no name.
Acetaminophen Suppository 650 mg opened with no date opened and no name.
Gerimucil opened with no date opened and no name.
Haloperidol oral solution- 2mg/ml with no date opened and no name.
Haloperidol Concentrate 2mg/ml 15 ml with no date opened and no name.
Ondansetron Oral Solution 4mg/5 ml prescription label peeled off except for corner with no name legible but the bottle in the box was labeled with the name of a resident who was discharged from the facility.

During an interview on 4/30/19, at 10:15 am., Licensed Practical Nurse (LPN) Employee E18 confirmed the above findings and that the facility failed to properly store medications, label and date multi dose medication containers, dispose of medications for residents no longer residing in the facility and refrigerate medications as required.

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

28 Pa. Code: 211.9 (a)(1)(f)(2)(k) Pharmacy services.
Previously cited 4/24/18.

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


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

1. All identified medications from the medication cart #3 were removed and discarded.
2. The Director of Nursing/designee will complete an audit of medication carts to ensure medications are labeled with resident name, dated and labeled with medication name, refrigerated medications are not in the medication carts and there are not medications of residents who were discharged in the carts.
3. Licensed nursing staff will be re-educated on labeling and storage of medications by the Director of Nursing/designee.
4. The Director of Nursing/designee will audit medication carts weekly for four weeks and monthly for three months to ensure medications are dated, labeled, refrigerator medications are not in medication carts and there are not medications of residents who were discharged in the carts. The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
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 policy review, clinical record review, resident interview,and staff interview, it was determined that the facility failed to obtain an order for a resident's ostomy and urinary catheter for one of three residents (Resident R105).

Findings Include:

The facility "Flow of care" policy last reviewed on 2/12/19, states care will be provided to residents to attain and maintain the highest level of functioning. The flow of care is to be implemented on a continuous basis to promote quality of life. The provision of targeted are needs shall be documented.

Review of Resident R105 quarterly MDS assessment (Minimum Data Set Assessment-assessment of resident care needs) dated 4/16/19, indicated Resident R105 was admitted on 11/29/18, with current diagnoses that include uropathy, overactive bladder, and unspecified wound. The MDS assessment Section H-bladder and bowel indicated the use of indwelling catheter and ostomy.

Review of the clinical record indicated Resident R105 had ostomy surgery (artificial opening in the abdomen) in May 2018. Review of Resident R105 consultation report dated 1/17/19, indicates 14-French (size of tubing) foley catheter in place.

Review of recapitulations signed April 2019, did not include an order for the ostomy or care of the site or an order for the foley catheter or catheter care instructions.. Review of April 2019 Treatment Administration Record (TAR) and Medication Administration Record (MAR) did not indicate an order for the ostomy or foley catheter care needs.

During observation on 4/30/19, at 1:37 p.m. Resident R105 was observed with both an ostomy and a catheter.

During an interview on 05/01/19, at 10:36 a.m. Resident R105 stated he had a ostomy and a catheter. He stated he changed the ostomy himself with provided supplies.

During an interviw on 5/01/19, at 10:41 a.m. the Director of Nursing confirmed that the facility failed to acquire a physician's order for Resident R105 foley catheter.

During an interview on 5/01/19, at 12:01 PM the Director of nursing confirmed that the facility failed to acquire a physician's order for Resident R105 ostomy or assess Resident R105's ability to change it himself.

28 PA Code: 211.10(a)(c)(d) Resident Care Policies.
28 PA Code: 211.12(d)(1)(2)(3)(5) Nursing Services.


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

1. An order was obtained from Resident R105's physician for the foley catheter and the ostomy. Resident R105 was assessed by the Director of Nursing/designee to ensure he was able to change the ostomy his self.
2. The facility will ensure there are physician's orders for the direction of care with residents.
3. The licensed nursing staff will be re-educated by the Director of Nursing on the facility policy for flow of care.
4. The Director of Nursing/designee will audit five resident medical records weekly for four weeks and monthly for three months to ensure there are physician orders for the direction of care. The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
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 a review of facility policy, observation and staff interview, it was determined that the facility failed to prevent the potential for cross contamination during medication administration for one of four residents (Resident R90) and during a dressing change (Resident R22).

Findings include:

A review of the facility policy "Oral Medication Administration" dated 2/12/19, indicated to avoid touching tablets or capsules unless wearing gloves.

A review of the facility policy "Infection Control Plan, Program and Committee" dated 2/12/19, indicated that prevention of infection is a priority and is stressed through the promotion and compliance with Standard Precautions and hand hygiene.

During an observation of a medication administration pass on 4/30/19, at 9:00 a.m. Licensed Practical Nurse (LPN) Employee E1 touched Resident R90's Magnesium Oxide tablet and Tylenol tablets with ungloved hands and administered the medications to the resident.

During an interview on 4/30/19, at 10:00 a.m. Regional Clinical Consultant Employee E2 confirmed the above findings and the facility failed to prevent the potential for cross contamination during medication administration for Resident R90.

During an observation of a dressing change for Resident R22 on 5/1/19 at 10 a.m., the following was observed:

Registered Nurse Employee E17 washed hands and put on gloves. She pulled scissors out of her pocket and cut off the old dressing without cleaning the scissors. She soaked gauze pads with normal saline (NSS) and placed it on the old dressing, removed the old dressing and with the same gloves gathered 4x4 gauze pads and NSS and cleaned the wound on the right outer ankle. With the same gloves applied Santyl (debriding ointment) and anasept gel (topical antibiotic gel) with a tongue blade to the wound, covered with 4x4 gauze pads, and then wrapped it in a dry dressing. Employee E17 then removed the gloves and performed handwashing.

During an interview on 5/1/19 at 10:08 a.m., Employee E17 confirmed the above findings and the failure to change gloves and perform handwashing which created the potential for cross contamination during a dressing change for Resident R22.

28 PA Code: 201.14(a) Responsibility of Licensee.
28 PA Code: 211.10 (d) Resident Care Policies.
28 PA Code: 211.12(d)(1)(2)(3)(5) Nursing Services.


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

1. Resident R90 suffered no ill effects from medications being touched by Licensed Practical Nurse E1's ungloved hands. Resident R 22 suffered no ill effects from Registered Nurse E17 not changing gloves and performing hand washing.
2. Licensed Practical Nurse Employee E1 was re-educated on the facility policy for Oral Medication Administration by the Director of Nursing/designee. Registered Nurse Employee E17 was re-educated on infection control with dressing changes by the Director of Nursing/designee.
3. The licensed nursing staff will be re-educated on the facility policy for Oral Medication Administration and maintain infection control with dressing
4. The Director of Nursing/designee will complete five medication administration audits weekly for four weeks and monthly for three months to ensure infection control practices are being maintained. Director of Nursing/designee will complete five dressing change audits weekly for four weeks and monthly for three months to ensure infection control practices are being maintained.
The results of these audits will be reported to the monthly Quality Assurance and Process Improvement Committee for review and frequency of audits.
§ 201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:
Based on a review of facility policy and personnel files, and staff interview, it was determined that the facility failed to provide verification of employee health status for two of five employees. (Employee E8 and E10).

Findings Include:

The facility "Screening Employees for History of Abuse" policy last reviewed 2/12/19, states pre-employment screening will include a physical examination.

A review of Social Service Employee E8's personnel file indicated a hire date of 3/4/19. The personnel file did not include documentation indicating a verification of employee health status.

A review of Licensed Practical Nurse (LPN) Employee E10's personnel file indicated a hire date of 1/16/19. The personnel file did not include documentation indicating a verification of employee health status.

During an interview on 5/2/19, at 10:12 a.m. the Human Resource Supervisor Employee E5 confirmed that the facility failed to provide evidence of a verification of employee health status for Employee E8 and E10.



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

1. The facility will provide verification of health status for New Hires. A verification of health status will be completed for Employees E8 and E10.
2. A house audit of new hires in the past 30 days will be completed to validate a Verification of health status was completed by the Director of Human Resources/designee.
3. The Nursing Home Administrator/designee will re-educate the Human Resource Director on the requirements of completing a verification of health status for new hires.
4. The Nursing Home Administrator/designee will complete an audit weekly times 4 weeks to validate health status verifications are completed for new hires. These audits will be reported to the monthly Quality assurance and Performance Improvement Committee for review and frequency of Audits.
§ 201.22(j) LICENSURE Prevention, control and surveillance of TB.:State only Deficiency.
(j) New employes shall have the 2-step intradermal skin test before beginning employment unless there is documentation of a previous positive skin reaction. Test results shall be made available prior to assumption of job responsibilities. CDC guidelines shall be followed with regard to repeat periodic testing of all employes.
Observations:
Based on a review of facility policy and personnel files, and staff interviews, it was determined that the facility did not have two-step tuberculosis (TB) testing for three of five employees (Employee E7, E8, and E11).

Findings Include:

The facility "Screening Employees for History of Abuse" policy last reviewed 2/12/19, states pre-employment screening will include physical examination including 2-step TB testing or chest X-ray.

A review of the personnel file for facility driver Employee E7 indicated a hire date of 1/2/19. There was no documentation indicating the completion of a two-step TB test.

A review of the personnel file for social services Employee E8 indicated a hire date of 3/4/19. There was no documentation indicating the completion of a two-step TB test.

A review of the personnel file for nurse aid Employee E11 indicated a hire date of 2/2/19. There was no documentation indicating the completion of a two-step TB test.

During an interview on 5/2/19, at 10:42 a.m. the Director of Nursing (DON) confirmed that the facility does not have an exception (approval to utilize an alternate tuberculin test) for the completion of TB tests.

During an interview on 5/2/19, at 10:12 a.m. the Human Resources Supervisor Employee E5 confirmed that the facility failed to screen Employee E7, E8, and E11 with a two-step TB test prior to employment.


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

1. The facility will screen New Hires with a two step TB test prior to employment. The facility will complete a two step TB screening for Employees E7, E8 and E11.
2. A house audit will be completed of new hires in the past 30 days to validate a two step TB screen was completed prior to employment by the Director of Human Resources/designee.
3. The Nursing Home Administrator/designee will re-educate the Human Resource Director on the requirements of completing a two step TB screen prior to New Hires starting employment.
4. The Nursing Home Administrator/designee will complete an audit weekly times 4 weeks to validate new hires have a completed two step TB screen before beginning employment. The results of these audits will be reported to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
§ 211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:
Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide the minimum number of general nursing hours for each resident in a 24-hour period on two of 21 days (4/28/19, and 4/30/19).

Findings include:

Nursing time schedules for the weeks of 9/2/18, 1/6/19, and 4/28/19, indicated that the facility failed to maintain 2.7 hours of general nursing care per person per day (PPD) in a 24-hour period as required on the following dates:

4/28/19: 2.40 PPD
4/30/19: 2.54 PPD

During an interview on 5/3/19, at 8:50 a.m. the Director of Nursing confirmed that the facility failed to meet the nursing hour requirements for these days.


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

1. The facility will maintain the minimum 2.7 hours direct nursing care for each resident as required.
2. The facility will monitor nursing hours daily with staffing meeting and by RN Supervisor and Managers on duty on the weekends to validate maintaining at least the minimum required 2.7 hours for each resident.
3. Director of Nursing/designee will educate Department Managers and RN Supervisor on calculating and maintaining required 2.7 Nursing hours, and notifying Nursing Home Administrator and/or Director of Nursing if hours are not being maintained due to call offs or change in census.
4. Director of Nursing/designee will complete an audit three time a week for four weeks to validate facility is meeting required daily minimum hours of 2.7. The results of these audits will be reported to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.


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