Nursing Investigation Results -

Pennsylvania Department of Health
QUALITY LIFE SERVICES - CHICORA
Patient Care Inspection Results

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QUALITY LIFE SERVICES - CHICORA
Inspection Results For:

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QUALITY LIFE SERVICES - CHICORA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey, completed on January 8, 2019, it was determined that Quality Life Services - Chicora 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:


483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:
Based on a review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to follow a physician order and provide dental treatment in a timely manner for one of 32 residents (Resident R29).

Findings include:

The facility policy "Dental Services - NU 2.7" dated 11/6/18, indicated that the facility provides dental services to resident who request or need dental care.

The facility policy "Physician Orders - NU 2.18" dated 11/6/18, indicated that residents will receive treatment that is ordered by the physician in a timely manner.

A review of Resident R29's Admission Record indicated that the resident was admitted to the facility on 3/13/18 with the diagosis of dysphagia, oral phase (inability to swallow).

A review of Resident R29's physician order dated 11/29/18, revealed an order to schedule tooth extraction and upper/lower denture production.

A review of the dentist progress note dated 11/29/18, revealed Resident R29 was recommended to have teeth extracted due to pain and infection. Antibiotic therapy was prescribed due to the infection.

A review of Resident R29's progress notes dated 12/9/18, revealed that Resident R29 completed his last dose of antibiotic therapy for a tooth infection.

A review of a progress note dated 1/4/19, indicated that the facility had not yet scheduled Resident R29's oral surgery for the teeth extractions; 26 days after completion of antibiotic therapy.

During an interview on 1/8/19, at 9:30 a.m. Schedule Coordinator Employee E12 confirmed that the facility failed to follow a physician order and provide Resident R29 with dental treatment in a timely manner

28 Pa. Code: 211.10(c) Resident Care policies.

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









 Plan of Correction - To be completed: 02/22/2019


Intervention
- Resident R29 will be scheduled appointments for necessary extractions
- Facility will review all dental appointments and consults for the past 6 months to ensure that all follow up appointments and testing and ensure that these follow up appointments are testing have been setup or completed.
- Licensed nursing staff and the Schedule Coordinator will be educated regarding follow physician orders related to scheduling appointments in a timely manner
Responsible party: Director of Nursing or Designee
Evaluation
- Audits will be completed of physician ordered consult appointments for 3 months to ensure that all appointments are completed in a timely manner
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

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

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

Based on review of facility policies, observations, and staff interviews it was determined that the facility failed to properly restrain hair and sanitize equipment which created the potential for cross contamination in the Main Kitchen.

Findings include:

The facility policy "Employee Sanitary Practices - CU 4.3" dated 11/6/18, and 1/2/19, indicated that hair restraints such as hairnet, hats and beard restraint are worn to prevent hair from contacting exposed food.

The facility policy "Cleaning Dishes - Manual Dishwashing - CU 4.15" dated 11/6/18 and 1/2/19, indicated that the chemical used to sanitize equipment was to have a strength of 150 to 200 part per million (ppm).

During an observation of the lunch tray line on 1/3/19, at 11:52 a.m. Food Service Associate Employee E14 was observed completing various tasks in the Main Kitchen without his beard properly restrained.

During an interview on 1/3/19, at 12:18 p.m. Food Service Director Employee E13 confirmed that he failed failed to make certain that Dietary staff properly restrained their hair which created the potential for cross contamination.

During an observation of the testing of the chemical strength for the pot sink sanitizer on 1/4/19, at 9:38 a.m. the Food Service Director Employee E13 obtained a reading of 100 ppm.

During an interview on 1/4/19, at 9:56 a.m. the Food service Director Employee E13 confirmed that the chemical strength for the pot sink sanitizer was below the required strength which created the potential for cross contamination.

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










 Plan of Correction - To be completed: 02/22/2019

Intervention
- Dietary staff will be provided with proper hair restrains including coverage for facial hair.
- Dietary staff will be provided education regarding proper hair restraints including facial hair
- The chemical dispenser for the sanitation sink was serviced by a technician on 1/17/19 to ensure proper sanitation levels
- Dietary staff will be educated on proper cleaning and sanitization of equipment washed using a three compartment sink hand washing system, including the proper level of sanitizer and proper reporting if the concentration is not correct
Responsible Party: Dietary Manager
Evaluation
- Audits of the sanitization concentration will be completed randomly by Dietary Manager or Designee 3 x week for 3 months
- Audits of proper coverage of hair, including facial hair will be completed once daily for one week and then three times weekly for eight weeks
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings

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

483.45(h) Storage of Drugs and Biologicals

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

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on review of facility policies and manufacturer specifications, observations and staff interviews, it was determined that the facility failed to correctly label medications on one of four nursing units (Miller Crossing) and failed to store medications requiring refrigeration correctly in one of two medication refrigerators (Chicora Cove medication refrigerator).

Findings include:

The facility policy "Vials and Ampules of Injectable Medications"dated 11/6/18, and last reviewed by the facility on 1/2/19, indicated that the date a vial is opened and triggered expiration date were recorded on the vial/label.

The manufacturer specifications of Humalog and Levemir insulins indicated that multi-dose vials should be discarded 28 days after opening.

During an observation of the Miller Crossing medication cart on 1/3/19, at 9:55 a.m. the following opened, undated multi-dose vials of insulin were in the cart:
-One vial of Humalog insulin with the manufacturer expiration date of "5/2020" on the vial.
-One vial of Levemir insulin with the manufacturer expiration date of "9/2020" on the vial.

During an interview on 1/3/19, at 10:00 a.m. Licensed Practical Nurse Employee E2 confirmed the opened, undated vials of Humalog and Levemir insulin and that the manufacturer expiration dates were not accurate.

The facility policy "Storage of Medications" dated 11/6/18, and last reviewed by the facility on 1/2/19, indicated that medications requiring refrigeration were kept in a refrigerator and that the facility maintained a temperature log to record the temperatures in the refrigerator and freezer daily.

During an observation of the medication refrigerator in the Chicora Cove medication room on 1/3/19, at 12:37 p.m. revealed a five-inch build-up of ice in freezer section and no thermometer was visible. The temperature inside the refrigerator section was 43 degrees fahrenheit and there were unopened vials of insulin and suppositories in the refrigerator. A sign posted on the outside of the refrigerator read "Refrigerator temperature must be between 33 - 41 degrees at all times."

During an interview on 1/3/19, at 12:38 p.m. Registered Nurse Employee E4 confirmed the ice build-up in the freezer section of the Chicora Cove medication refrigerator and that the facility failed to store medications requiring refrigeration correctly.

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








 Plan of Correction - To be completed: 02/22/2019

Intervention
- The refrigerator in Chicora Cove was cleaned and defrosted on 1/4/19. Medication refrigerators will be cleaned weekly by nursing staff and the temperature on medication refrigerators will be completed daily by nursing staff
- Medication carts will be checked for open insulin vials to ensure that medications are properly dated with the date opened by Director of Nursing or Designee
- Licensed nursing staff will be educated regarding proper cleaning and monitoring of refrigerator temperatures and also regarding proper dating of medications when opening insulin vials
Responsible party: Director of Nursing or Designee
Evaluation
- Audits will be completed 3 x weekly for 3 months of all medication carts to ensure that insulin vials are properly dated when opened
- Audits will be completed 3 x weekly for 3 months of all medication refrigerators to ensure they are properly cleaned and temperatures are being properly obtained and recorded daily
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to exercise proper infection control technique during dressing changes for two of two residents (Resident R52 and R59).

Findings include:

The facility policy "Wound Dressing Change" dated 10/23/17, and last reviewed by the facility on 1/2/19, indicated that the nurse cleansed hands, opened all dressing supplies, removed soiled gloves, cleansed hands and applied clean gloves, cleansed the wound, removed soiled gloves, cleansed hands and applied clean gloves and applied the ordered treatment to the wound.

The Admission Record indicated that Resident R52 was admitted to the facility on 9/21/18, with diagnoses that included repair of a fractured left hip, diabetes and high blood pressure.

A review of the pressure wound tool indicated that Resident R52 developed a wound on the left heel on 11/6/18, treatment was initiated at that time and that the resident had various treatment changes as needed.

A physician order dated 12/27/18, instructed the nurse to cleanse the left heel wound with normal saline and apply Medihoney (advanced wound care product) to wound base then cover with clean, dry dressing daily and as needed.

During an observation of a dressing change on 1/4/19, at 10:30 a.m. Licensed Practical Nurse (LPN) Employee E6 gathered all packages of supplies needed for Resident R52's wound care, which included a small bottle of normal saline, 3 packages of 4x4 gauze, 1 package of border gauze, a box with a tube of Medihoney in it and several skin prep pads, and placed them on the overbed table. LPN Employee E6 did not sanitize or prepare a clean field on the overbed table. LPN Employee E6 washed hands but then donned a pair of gloves that she/he removed from uniform pocket, opened the bottle of normal saline, a package of gauze, removed the old dressing, dipped gauze in the bottle of normal saline and cleansed the left heel wound. LPN Employee E6 did this procedure several times removing exudate from the resident's wound. LPN Employee E6 then removed the soiled gloves, retrieved another pair of gloves from her/his uniform pocket, opened another package of gauze and removed the tube of Medihoney from the box. When the attempt to squirt Medihoney on the gauze pad was unsuccessful, he/she squirted it directly on the wound. LPN Employee E6 then opened a package of border gauze, retrieved a felt-tipped pen from her/his pocket, dated/initialed the border gauze and then applied the border gauze to the resident's left heel wound. LPN Employee E6 did not perform hand washing during the multiple steps of the dressing change procedure.

During an interview on 1/4/19, at 10:35 a.m. LPN Employee E6 confirmed not preparing a clean field, the multiple cross contamination issue and lack of handwashing during Resident R52's dressing change.

The Admission Record indicated that Resident R59 was admitted to the facility on 11/19/14, with diagnoses that included a stroke, depression, Parkinson's disease (a disease of the nervous system) and heart disease. The Minimum Data Set (MDS-periodic assessment of care needs) dated 11/30/18, included an additional diagnosis of anemia.

A physician order dated 12/21/18, instructed the nurse to apply Mupirocin ointment (antibiotic) to the left ear of Resident R59 two times a day and then cover with a gauze pad to protect from glasses.

During an observation of a dressing change on 1/7/19, at 9:35 a.m. LPN Employee E7 gathered all the supplies needed for Resident R59's dressing, which included two packages of 2x2 gauze, a tube of Mupirocin ointment which was in a plastic bag, a small bottle of normal saline, a roll of tape and two packages of cotton-tipped applicators, and placed them on the overbed table. LPN Employee E7 then donned gloves, opened two packages of the 2x2 gauze, and two packages of cotton-tipped applicators, removed the soiled dressing from Resident R59's left ear, dipped a 2x2 gauze in the normal saline, cleansed the wound on the left ear and then applied the new dressing. LPN Employee E7 did not change gloves or perform hand washing between the soiled and clean dressing procedure.

During an interview on 1/7/19, at 9:45 a.m. LPN Employee E7 confirmed the failure to exercise proper infection control technique during the dressing change for Resident R59's left ear.

During an interview on 1/7/19, at 1:00 p.m. the Director of Nursing confirmed that the facility failed to exercise proper infection control technique during dressing changes for Residents R52 and R59.

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

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









 Plan of Correction - To be completed: 02/22/2019

Intervention
- Licensed Nursing staff will be given educational training and visual instruction on proper dressing changes per facility policy and procedure and this will also include proper technique for taking treatment items to the rooms until 100% compliance is achieved
- Licensed staff involved with inappropriate dressing changes will be provided one on one training regarding proper policy and procedure dressing changes
- Residents 52 and 59 did not suffer adverse results from the improper dressing technique, no signs or symptoms of infection noted.
Responsible Party: Director of Nursing or Designee
Evaluation
- Audits and observations of actual dressing changes will be completed of the licensed nursing staff by the Director of Nursing or designee to include at least 4 dressing changes per week for 3 months. The audits will include proper technique for carrying supplies to the rooms.
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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(c) Menus and nutritional adequacy.
Menus must-

483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

483.60(c)(2) Be prepared in advance;

483.60(c)(3) Be followed;

483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

483.60(c)(5) Be updated periodically;

483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:
Based on a review of facility policy, diet spreadsheets, and staff interviews, it was determined that the facility failed to provide documentation that the Registered Dietitian (RD) approved the menus prior to implementation for five of five weeks of the cycle menus (Five week cycle menu).

Findings include:

The facility policy "Menu Planning-CU 1.1" dated 10/23/17 and 11/6/18, indicated that menus are approved by the
RD.

A review of the facility diet spreadsheets dated 10/14/18, did not include the signature of the RD to indicate approval of the five week cycle menu.

During an interview on 1/3/19, at 1:26 p.m. Food Service Director Employee E13 confirmed that the RD failed to sign (approve) the five week cycle diet spreadsheets as required.

28 Pa. Code: 211.6(a) Dietary services.





 Plan of Correction - To be completed: 02/22/2019

Intervention
- Menus and extensions were reviewed and signed by the Registered Dietitian on 1/4/19
- Education will be provided for the Registered Dietitian and Dietary Manager regarding regulations to review and sign of all menus
Responsible party: Director of Nursing or Designee
Evaluation
- Menus will be reviewed and then checked for proper signatures on the current menu cycle. Future menu cycles will be reviewed and audited for a signature by the Dietary Manager prior to implementation of menu cycles
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings

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 81F; and

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

Based on observations and resident and staff interviews, it was determined that the facility failed to maintain a homelike environment in one of 14 resident rooms on the Miller's Crossing nursing unit (Room 106).

Findings include:

During observations of the four paned window in resident room 106 on 1/2/19, at 9:45 a.m. the following was noted:
-The first glass window pane had foil-like tape around the glass frame and the window was opened a crack allowing the cold outside air to enter the room and was not able to be closed because the latch was broken.
-The second glass window pane was opened a crack allowing the cold outside air to enter the room and was not able to be closed because the latch was broken..
-The screen for the third glass window pane was out of the window, on the floor and propped against the window frame.
-The fourth glass window pane was cracked on the lower right side and taped with foil-like tape.
-The white paint of the entire frame of the window was chipped in numerous places.

During an interview on 1/2/19, at 9:48 a.m. Resident R85 reported that the screen was removed the other night and "I think they (staff) just forgot to put it back." The resident also reported that the glass in the fourth window pane was in that condition for a long time and that cold air and/or insects are able to come through the windows that were open.

During observations of the window in resident room 106 on 1/3/19, at 10:00 a.m. and on 1/7/19, at 9:55 a.m. the screen was no longer on the floor but the first and second window panes remained opened a crack and the fourth glass window pane was broken.

During interviews on 1/7/19, at 9:55 a.m., at 10:00 a.m. and at 10:05 a.m. Licensed Practical Nurse Employee E7, the Nursing Home Administrator and Maintenance Director Employee E8 respectively confirmed the poor condition of the window in resident room 106 and that the facility failed to maintain a homelike environment.

28 Pa. Code: 207.2 Administrator's responsibility.





 Plan of Correction - To be completed: 02/22/2019

Quality Life Services-Chicora has adopted internal processes as part of our on-going commitment to provide quality care to the residents we serve. The attached information contains Quality Life Services-Chicora's Plan of Correction which we are submitting in response to specific deficiencies identified by the Pennsylvania Department of Health and is required for purposes of our facility's licensure and certification. The information and responses contained in our Plan of Correction are consistent with our own quality improvement efforts and should not be construed as an admission of or agreement with the deficiencies cited in the Department's findings. This Plan of Correction is not an admission of wrongdoing on the part of Quality Life Services-Chicora.

Intervention
- The glass window pane which was taped is a storm window and this will be removed. Other storm windows in the facility will be checked for any type of glass breakage
- The window in room 106 that is opened slightly will have the latch repaired by maintenance and other windows will be inspected to ensure that there are no other broken latches
- The entire window frame in room 106 will be painted by maintenance and the other windows in the facility will also be inspected for paint chipping and painted as needed
- Education will be completed for nursing staff regarding proper reporting of repair issues within the facility
Responsible party: Facility Maintenance Director or Designee
Evaluation
- Confirmation of suitable repairs will be completed by NHA or Designee
- Random audits will be completed 3 x week for 1 month for broken window panes, malfunctioning latches, and peeling/chipping paint by Facility Maintenance Director or Designee
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings

483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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(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 a review of facility policy and personnel records and staff interviews, it was determined that the facility failed to properly screen and provide system orientation including abuse training for two of five employees (Employee E9 and E10).

Finding include:

The facility policy "Resident Protection from Abuse, Neglect or Exploitation" dated 10/23/17, 11/6/18, and 1/2/19, indicated that the facility would treat all residents in manner free from any form of abuse, neglect, misappropriation of property, exploitation or mistreatment. The facility will implement procedures in the areas of screening, training, prevention, identification, investigation, protection, reporting and corrective action.

A review of personnel files revealed Nurse Assistant (NA) Employee E9 was hired on 10/26/18. Documentation did not include that a criminal background check, verification of NA Registry or verification of past employment for NA Employee E9 were completed pre-employment.

A review of personnel files revealed NA Employee E10 was hired on 11/5/18. Documentation did not include orientation that included abuse training to NA Employee E10.

During an interview on 1/8/19, at 10:45 a.m. Human Resources Director Employee E11 confirmed that the facility failed to obtain a criminal background check and verify NA Registry and past employment for NA Employee E9 and provide orientation that included abuse training for NA Employee E10 pre-employment as required.

28 Pa. Code: 201.19 Personnel Policy and Procedures.

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









 Plan of Correction - To be completed: 02/22/2019


0607
Intervention
- Current employee files will be reviewed for current abuse training and any employees found to not be properly educated will be educated immediately or removed from the schedule until the education can be completed. Employee E9 and E10 no longer work at the facility.
- HR will be educated regarding proper abuse training for employees including contracted employees prior to any direct resident care by Director of Nursing
- Pre-hire check list will be developed and instituted by HR to ensure all pre-hire training and documentation is in place prior to any resident care. This check list will include criminal background, NA Registry, past employment, and abuse training.
Responsible party: Director of Nursing or Designee
Evaluation
- Audits of all new hire files will be completed for 3 months by DON or Designee to ensure proper abuse training and all other pre-hire documentation is being complete
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 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 facility policy and documents and staff interviews, it was determined that the facility failed to consistently reconcile controlled substance counts on two of four nursing units (Miller Crossing and Memory Lane nursing units).

Findings include:

The facility policy "Medication Storage in the Facility" dated 10/23/17, and last reviewed on 1/2/19, indicated that at each shift change a physical inventory of all controlled medications was conducted by two licensed nurses and was documented on the controlled substances accountability record.

During a review of the Miller Crossing "Shift Verification of Controlled Substances Count" on 1/3/19, at 10:00 a.m. the following was noted:
A shift-to-shift count was not conducted by two licensed nurses for six of 90 opportunities in November 2018, and for five of 93 opportunities in December 2018.

During an interview on 1/3/19, at 10:00 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the missed opportunities in November and December 2018, and that the facility failed to consistently perform shift-to-shift counts of controlled substances.

During a review of the Memory Lane "Shift Verification of Controlled Substances Count" on 1/3/19, at 10:50 a.m. the following was noted:
A shift-to-shift count was not conducted by two licensed nurses for six of 90 opportunities in September 2018, for six of 90 opportunities in November 2018, and for four of 93 opportunities in December 2018.

During an interview on 1/3/19, at 11:00 a.m. LPN Employee E3 confirmed the missed opportunities in September, November and December 2018, and that the facility failed to consistently perform shift-to-shift counts of controlled substances.

28 Pa. Code: 211.9(a)(1)(f)(2) Pharmacy services.

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
















 Plan of Correction - To be completed: 02/22/2019

Intervention
- Licensed nursing staff will be educated regarding proper policy and procedure for shift ot shift narcotic reconciliation and proper signing of documents when reconciliation is complete
Responsible party: Director of Nursing or Designee
Evaluation
- Audits will be completed 3 x weekly for 3 months to ensure that narcotic reconciliations are being complete correctly with the change of each licensed staff
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings


483.75(g)(1)(i)-(iii)(2)(i) REQUIREMENT QAA Committee: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.
483.75(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 a review of facility policies, documents and staff interviews it was determined that the Medical Director failed to attend the Quality Assurance (QA) Committee Meeting for one of four quarters (second quarter).

Finding include:

A review of the facility policy "Quality Assurance Performance Improvement Structure, Scope and Plan" dated 10/23/17, indicated that the Medical Director is a member of the QA Committee.

A review of the attendance records for the QA Committee revealed that during the second quarter (April, May, June) the Medical Director failed to attend a QA Committee Meeting.

During an interview on 1/8/19, at 11:54 a.m. the Director of Nursing confirmed that the facility failed to make certain that the Medial Director attended a QA committee Meeting during the second quarter as required.

28 Pa. Code: 201.18(e)(1)(2)(3)(4) Management.

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




 Plan of Correction - To be completed: 02/22/2019

Intervention
- Education will be provided for the Medical Director regarding need to attend quality assessment and assurance at least every quarter
Responsible party: Nursing Home Administrator
Evaluation
- Minutes for quality assessment and assurance will be monitored quarterly for Medical Director's attendance monthly by the Director of Nursing
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings

211.9(g) LICENSURE Pharmacy services.:State only Deficiency.
(g) If over-the-counter drugs are maintained in the facility, they shall bear the original label and shall have the name of the resident on the label of the container. The charge nurse may record a resident's name on the nonprescription label. The use of nonprescription drugs shall be limited by quantity and category according to the needs of the resident. Facility policies shall indicate the procedure for handling and billing of nonprescription drugs.
Observations:
Based on facility policy review, observation and staff interviews, it was determined that the facility failed to consistently label bottles of over-the-counter medications with the names of the residents for whom the medications were ordered on one of four medication carts (Fairgrounds Village medication cart).

Findings include:

The facility policy "Labeling of Over-the-Counter Medications" dated 1/2/19, indicated that bottles of over-the-counter medications had a blank label affixed to it and that the names of residents receiving medications from each bottle were placed on the blank label by the medication nurse.

During an observation of the Fairgrounds Village medication cart on 1/3/19, at 1:20 p.m. none of the opened bottles of over-the-counter medications had any resident names. The bottles included Vitamin D, Vitamin C, Vitamin E, Multiple vitamins, stool softeners, Acetaminophen, Aspirin, Calcium, Zinc Oxide, Iron tablets, Magnesium Oxide, Robitussin, Mucinex and Mylanta.

During interviews on 1/3/19, at 1:20 pm. and on 1/7/19, at 1:00 p.m. Licensed Practical Nurse Employee E6 and the Director of Nursing respectively confirmed that the facility failed to consistently label bottles of over-the-counter medications with the names of the residents for whom the medications were ordered.









 Plan of Correction - To be completed: 02/22/2019

Intervention
- Medication carts will be inspected for correct labelling of resident's names on all the Over-the Counter medications
- Licensed staff will be educated on putting appropriate names on all bottles of Over-the-Counter medications as the bottles are opened
Responsible Party: Director of Nursing or Designee
Evaluation
- Audits of medication carts will be completed 3 x weekly for 3 months to ensure proper labeling is being completed as bottles are opened
- Results of audits will be reviewed at the next scheduled quality assessment and assurance meetings




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