Nursing Investigation Results -

Pennsylvania Department of Health
GROVE AT LATROBE, THE
Patient Care Inspection Results

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GROVE AT LATROBE, THE
Inspection Results For:

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GROVE AT LATROBE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on complaint survey completed on April 25, 2019, it was determined that The Grove at Latrobe 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:


483.10(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 ensure that the resident's environment was maintained in a comfortable and homelike manner for one of 12 residents reviewed (Resident 2)

Findings include:

Observations of Resident 2's wheelchair on April 25, 2019, at 11:50 a.m. revealed that the vinyl covering on the right arm rest was split and torn in several places. Interview with Resident 2 at that time revealed that she was concerned that she may cut the skin on her arm due to the splits and tears in the arm rest, and that the arm rest was not comfortable.

Interview with the Director of Nursing on April 25, 2019, at 4:25 p.m. confirmed that the arm rest on Resident 2's wheelchair needed repaired.

42 CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment.
Previously cited 3/4/19, 9/6/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 10/17/18, 9/6/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 3/4/19, 9/6/18.

28 Pa. Code 207.2(a) Administrator's responsibility.
Previously cited 3/4/19, 9/6/18.





 Plan of Correction - To be completed: 05/15/2019

"The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."

F0584

Resident R2 wheel chair arm rests were immediately covered with "moleskin" a soft adhesive covering.
House surveillance was conducted by Director of Nursing and Director of Therapy to ensure that any wheel chair arm rests that were in disrepair were addressed.
Re-education provided by Director of Nursing/designee to staff on homelike environment, specific to arm rests on wheel chairs, education also includes the facility policy for the timely removal and repair of anything in disrepair or not safe in homelike environment. Nursing and Therapy staff routinely notify maintenance staff of equipment, including wheelchairs and arm rests.
Audits of wheel chair arm rests will be conducted twice weekly x3 weeks and then monthly x3. Additionally the Interdisciplinary Team will review Guardian Angel room rounds to ensure a safe and homelike environment is provided for the residents. The audits will be taken to the facility monthly Quality Assurance Performance Improvement meeting for further review and recommendations.
483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in responsibilities of the staff in the event the resident refused a treatment for one of 12 residents reviewed (Resident 2).

Findings include:

Physician's order for Resident 2, dated June 21, 2018, included an order for the resident have Ace wraps (elastic strips used as a wrapping) applied to both lower legs on Monday, Wednesday and Friday, with the bandages applied in the morning and removed at bedtime. The orders also included that in the event the resident refused the Ace wraps, the registered nurse was to be notified to confirm the refusal. A physician's order, dated February 7, 2019, discontinued the requirement that the registered nurse be notified to confirm refusals.

Following the physician's order of February 7, 2019, there was no documented evidence that Resident 2's care plan was updated. The resident's care plan, dated November 19, 2018, still included the requirement that the registered nurse be notified to confirm the refusal of Ace wraps.

Interview with the Director of Nursing on April 25, 2019, at 5:45 p.m. confirmed that Resident 2's care plan should have been updated to remove the requirement for the registered nurse to confirm the refusal of Ace wraps.

42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision.
Previously cited 9/6/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 10/17/18, 9/6/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/4/19, 10/17/18, 9/6/18.




 Plan of Correction - To be completed: 05/15/2019

F0657
Resident R2 careplan was updated to reflect current treatment order for her legs.
House surveillance of treatment orders by Director of Nursing/designee to ensure careplans were accurate.
Re-education to licensed staff by Director of Nursing on careplan updating prn, quarterly and annually.
Careplan audits of treatments will be conducted twice weekly x3 weeks to ensure accuracy with orders, and then monthly x3. Additionally, at daily clinical stand up meeting, new orders that are reviewed will be care planned accordingly.
The audits will be taken to the facility monthly Quality Assurance Performance Improvement meeting for further review and recommendations.
483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and 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 policies, clinical records, and an inventory record for the facility's emergency drug box, as well as staff interviews, it was determined that the facility failed to obtain needed medications from the pharmacy in a timely manner for one of 12 residents reviewed (Resident 6).

Findings include:

The facility's policy regarding obtaining of medications that were not available, dated February 26, 2019, indicated that if medications were not available on the medication cart, staff were to search the medication cart for the medications, and if unable to locate them, staff were to search the facility's emergency medication box and use the available medications. If the medications were not available in the emergency medication box, staff were to call the pharmacy to determine how soon the medication could be delivered. If the pharmacy was not available to deliver the medication in time for the ordered administration, and the medication was not available in the emergency medication box, then the registered nurse supervisor was to be notified. Follow-up action was to be taken to ensure the medication was delivered, administered as ordered, and stored in the medication storage drawer.

A nursing note for Resident 6, dated April 24, 2019, at 6:50 p.m. revealed that the resident was admitted to the facility with diagnoses that included infection following a procedure (knee replacement surgery), disruption of a wound (an infection in the wound), diabetes mellitus (disease that interferes with the body's ability to control blood sugar levels), hyperlipidemia (high levels of fat in the blood), post traumatic stress disorder (a mental health condition that may be triggered by a terrifying event), and bipolar disorder (mental health disorder that causes unusual shifts in mood, energy and activity levels).

Physician's admission orders dated April 24, 2019, at 6:54 p.m. included orders for the resident to receive 20 milligrams (mg) of atorvastatin (treats hyperlipidemia) at bedtime, 80 mg of Latuda (treats bipolar disorder) at bedtime, 100 mg of sitagliptin (controls blood sugar levels) daily, 4 mg of ropinirole (treats restless leg syndrome) at bedtime, 150 mg of Lyrica (treats nerve pain) every 8 hours, 4 mg of tizanidine every 8 hours for muscle spasms, and 240 mg of verapamil (treats high blood pressure) daily.

Resident 6's Medication Administration Record (MAR) for April 2019 revealed that the resident did not receive atorvastatin on April 24 at 8:00 p.m., Latuda on April 24 at 8:00 p.m. and April 25 at 8:00 a.m., sitagliptin on April 25 at 8:00 a.m., ropinirole on April 25 at 8:00 p.m., Lyrica on April 24 at 8:00 p.m. and April 25 at 6:00 a.m. and 2:00 p.m., tizanidine on April 24 at 8:00 p.m. and April 25 at 6:00 a.m. and 2:00 p.m., and verapamil on April 25 at 8:00 a.m.

A current undated inventory sheet for the facility's emergency medication kit, provided by the facility on April 25, 2019, revealed that atorvastatin was available in the dosage required by Resident 6.

There was no documented evidence of any attempts to obtain Resident 6's medications in a timely manner from the pharmacy, from a back-up pharmacy (local pharmacy to be contacted if medications are not delivered timely from the main pharmacy), or from the facility's emergency medication supply, and no documented evidence that the physician was notified that the medications were not administered as ordered.

Interviews with the Director of Nursing on April 25, 2019, at 5:25 p.m. and 5:45 p.m. confirmed that nursing staff should have obtained the medication that was available in the facility's emergency medication supply for Resident 6. She also confirmed that there was no documented evidence that the pharmacy was contacted to request an immediate delivery of the remaining medications or that the physician was notified about the missed doses.

42 CFR 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures/Pharmacist/Records.
Previously cited 10/17/18, 9/6/18.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 9/6/18.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 3/4/19, 10/17/18, 9/6/18.




 Plan of Correction - To be completed: 05/15/2019

F0755
Resident R6 physician was notified of missed doses of medications, and physician gave no new orders. Resident R6 was not affected by the missed medication. Root cause analysis identified the nurse did not check electronic medication list to see if meds available. Medication lists have since been placed at each nursing unit, instead of only in the central location electronic dispense room.
House surveillance of new medication orders to ensure medications were available and if not, then staff are to follow the facility policy on obtaining medications.
Re-education to licensed staff on facility policy for administering medications, specifically retrieving medications from the electronic dispense unit or making notification to the pharmacy to delivery the medication if it is not readily available in the facility.
Audits of new medication orders and administrations will be conducted twice weekly x2 weeks, and then monthly x3 to ensure medications are obtained and given as ordered.
The audits will be taken to the facility monthly Quality Assurance Performance Improvement meeting for further review and recommendations.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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


Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in the medication cart.

Findings include:

The facility's policies regarding medication storage, dated February 26, 2019, indicated that medication carts were to be kept locked and were not to be left unattended.

Observations of a medication cart on the West wing on April 25, 2019, at 6:50 a.m. revealed that the medication cart was unlocked and there were no staff members present in the vicinity of the cart.

Interviews with Licensed Practical Nurse 1 and the Director of Nursing on April 25, 2019, at 6:51 a.m. and 8:30 a.m., respectively, confirmed that the medication cart should not have been unlocked and unattended.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 9/6/18.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 9/6/18.

28 Pa. Code 211.12(d)(1)Nursing services.
Previously cited 3/4/19, 10/17/18, 9/6/18.



 Plan of Correction - To be completed: 05/15/2019

F0761
Licensed Practical Nurse 1 immediately locked her cart. Root cause analysis, Nurse 1 stated she left her cart to answer a bathroom light, she forgot to lock the cart.
Director of Nursing/designee conducted house surveillance of medication carts to ensure they were locked when not attended to.
Re-education with Licensed Practical Nurse 1 on locking medication carts when not in use, education extended to licensed staff by Director of Nursing/designee on keeping medication carts locked when not attended to.
Random audits daily of medication carts to ensure they are locked when not attended to. Audits will be done weekly x3 and then monthly x3.
The audits will be taken to the facility monthly Quality Assurance Performance Improvement meeting for further review and recommendation.

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