Nursing Investigation Results -

Pennsylvania Department of Health
FOXDALE VILLAGE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FOXDALE VILLAGE
Inspection Results For:

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FOXDALE VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on May 24, 2019, it was determined that Foxdale Village 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:


483.60(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 select facility policies, observation, and staff interview, it was determined that the facility failed to store and prepare food items in a safe and sanitary manner in the facility's main kitchen and on one of three nursing units (East).

Findings include:

Review of the facility policy entitled "Sanitation and Infection Control Cleaning Schedules," last reviewed on March 26, 2019, revealed cleaning schedules are used to maintain high levels of sanitation in the Food and Nutritional services department and cleaning tasks are assigned to various staff members. It also indicates heavy cleaning such as under equipment, walls, floors, and major equipment can be planned on a weekly basis.

Review of the facility policy entitled "Meal Service Remote Ware Washing," last reviewed on March 26, 2019, indicates the facility will follow established methods for the safe and effective use of the dish machine in the remote dining areas, and that a temperature log will be maintained for each machine for recording of wash and final rinse temperatures. The policy also revealed the dietary aide will record the temperature for breakfast, lunch, and dinner.

Initial tour of the facility's main kitchen on May 21, 2019, at 9:25 AM revealed the dry storage room was filled with open wire shelving units. Dry food products were stored on the bottom shelf of the units throughout. There was no barrier to protect the food products from being contaminated from splash from mop water or debris from sweeping. Several of the metal racks contained a buildup of dust and debris on the bases and shelf edges.

A dolly (a square solid base with wheels) containing a stack of boxes of chips and snacks contained dust and debris.

The large walk-in freezer floor contained frozen spills and dried food and debris throughout and a significant amount under the shelving. The freezer also contained open wire metal shelving units. Food products were stored on the bottom shelf with no protection from contamination of mop water splash or dirt and debris from sweeping. The ramp entering the freezer also had a significant amount of dirt/debris.

A speed rack (wheeled shelving unit that holds sheet tray pans) was in walk-in cooler number one. The rack was holding sheet trays that contained pans of stewed tomatoes and pastry dough. The trays holding the items had a significant amount of dried food debris on them.

Walk-in cooler number one also contained a clear plastic container labeled "tartar sauce," on a cooler shelf. The lid to the container was covered in a yellow powdery substance. A bulk container of thousand island dressing had "2/5" written on the lid. A bulk container of french dressing was also on the shelf with a date of "3/19" written on the lid. There was no indication as to whether the date on these products was the date opened, date received, or date expired. In a concurrent interview with Employee 1, director of dining services, he stated he believed the date was when the facility received the bulk dressing and was not able to identify when the product was opened, or when it expired. The floor in the walk-in cooler was also covered in dirt and debris.

The floor of walk-in cooler number three contained dirt/debris throughout the floor and under shelving.

The double stacked convection oven had drips of a dark brown sticky substance in multiple areas outside the oven doors. The interior of both ovens contained metal sheet tray pans on the bottom of both ovens with pieces of foil sticking up, the trays and foil were coated in dried brown debris. There were large pieces of dried brown debris piled in the corners of the ovens and at door edges. The interior of the oven doors was coated in a thick brown substance.

The shelf of the steam table contained dust and debris.

A garnish refrigerator beside the steam table held oranges, lemons, and other garnish items. The items did not have any date on them to indicate when they were put in use or when to use them by. The lower part of the refrigerator had a bag of bread with no label or expiration date, and a container of what Employee 1 identified as butter with no label or date.

Two dollies holding racks of glassware were dirty and dusty.

Two open wire shelving units were holding serving pans and dishes on the bottom shelf of the unit. The pans were filled with the serving side facing the floor. The bottom shelf did not contain and barrier to prevent the potential from contamination splash from mopping or sweeping the floor.

The above findings were concurrently reviewed with Employee 1.

A tour of the East kitchenette on May 21, 2019, at 10:11 AM revealed the unit contained a small household size dishwasher. In an interview with Employee 2, dietitian, she indicated that all the dishware from serving residents in that area gets washed in that dishwasher on the unit. A concurrent review of the temperature log for the dishwasher revealed temperatures were recorded for May 21, 2019, for breakfast with a wash temperature of 170 degrees Fahrenheit, and a final rinse temperature of 180 degrees Fahrenheit with the initials "LS," beside them. Further review of the temperature log also revealed temperatures were recorded for May 21, 2019, lunch meal, with a wash temperature of 171 degrees Fahrenheit and a final rinse temperature of 183 degrees with the initials "LS," beside them. The time of the observation was 10:11 AM, and Employee 2 confirmed lunch had not been served yet.

In an interview with Employee 3, dietary aide, she stated she did record the temperatures for May 21, 2019, and they were her initials on the temperature log. She stated she did not know why she recorded temperatures for lunch when the meal had not even been served.

The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 22, 2019, at 2:00 PM.

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


 Plan of Correction - To be completed: 07/12/2019

1) All identified dry storage room bottom wire shelving, walk-in-freezer, and two wire shelving units holding serving pans and dishes were lined with plastic liner. All identified areas with spills, dust, debris (3 dolly's, large walk-in freezer, ramp, speed rack, and walk in coolers) were cleaned and sanitized. All identified unlabeled food was removed and disposed of on May 21, 2019. Double Stacked oven was cleaned on May 21, 2019. Temperature log for dishwasher in East Kitchenette was immediately amended on May 21, 2019 and lunch temperature was taken. Employee one was immediately re-educated on facility policy for "Meal Service Remote Ware Washing."

2) All areas in the kitchen have been cleaned of spills, dust, and debris. All storage areas were reviewed for bottom wire shelving and plastic liner has been placed. All stoves have been cleaned and degreased. All dishwasher temperatures were reviewed. All items were reviewed for proper food storage labels in all storage areas.

3) All Dining staff re-educated on the following facility policies; "Sanitation and Infection Control Cleaning Schedules", "Meal Service Remote Ware Washing" and "label and dating."

4) The Director of Dining Services or designee will monitor all kitchen areas, kitchen equipment for sanitation requirements, food storage labels, and temperature logs daily for one week, weekly for three weeks, and monthly for two months to observe adhesion to facility policies on "Sanitation and Infection Control Cleaning Schedules," "label and dating," and "Meal Service Remote Ware Washing". All audits will be reviewed at the QAPI committee meeting.

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 select facility policies, observation, and staff interview, it was determined that the facility failed to provide an environment free from the potential spread of infection regarding bedpans for one of three nursing units (North Nursing Unit) and Oxygen equipment for two of two residents reviewed (Resident 1 and 10).

Findings include:

Review of the facility policy entitled "Cleaning and Disinfection of Resident-Care Items and Equipment," last reviewed without changes on March 26, 2019, revealed that resident care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current Centers for Disease Control and Prevention and the Occupational Safety and Health Administration Bloodborne Pathogens Standard.

Observation of the North Nursing Unit on May 21, 2019, at 9:48 AM revealed that staff had placed an uncovered urine hat (a container to measure urine) or an uncovered bedpan between the shower handrail and the shower tile on the wall in the following Resident Rooms:

Resident Room 331, urine hat
Resident Room 332, bedpan
Resident Room 335, bedpan
Resident Room 336, fracture bedpan
Resident Room 337, bedpan

Continued observation of the North Nursing Unit on May 22, 2019, at 9:25 AM and on May 23, 2019, at 9:38 AM revealed that the following Resident Rooms continued to have an uncovered urine hat or bedpan in between the shower handrail and shower wall tile as noted above:

Resident Room 331, urine hat
Resident Room 335, bedpan
Resident Room 336, fracture bedpan

Observation of Resident 1's room on May 21, 2019, at 9:55 AM revealed that her Oxygen concentrator was turned off beside her bed. The nasal cannula (a device used to deliver supplemental oxygen) was uncovered, not bagged and draped over the top of the concentrator.

Observation of Resident 10's room on May 21, 2019, at 11:33 AM revealed that his Oxygen concentrator was by his bed and turned on. Resident 10's nasal cannula was lying on the floor beside the concentrator, uncovered and not bagged. Immediately prior to this observation (11:30 AM), staff were observed leaving Resident 10's room.

Interview with the Nursing Home Administrator and the Director of Nursing on May 22, 2019, at 2:00 PM acknowledged the above findings.

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Previously cited 6/29/18


 Plan of Correction - To be completed: 07/12/2019

1) On May 22, 2019, the bed pans and urine hats for rooms 331, 335, and 336 were covered and stored in the residents' bathroom. On May 22, 2019, the nasal cannulas for Residents 1 and 10 were stored in a bag located on the oxygen concentrator.

2) All residents' rooms were reviewed on May 22, 2019 for proper storage and covering of bed pans and urine hats. All residents using oxygen were observed on May 22, 2019 for correct storage of the nasal cannula in respiratory bags on the resident's oxygen concentrator.

3) The Policy and Procedure for storage and use of bed pans and urine hats was revised and updated. The policy and procedure for storage of nasal cannulas when not in use was reviewed. Staff re-education will be provided to all nursing staff regarding storage of bed pans and urine hats and storage of oxygen nasal cannulas. When a resident uses a bed pan or urine hat, a task will be added to Certified Nursing Assistant documentation for correct storage. A documentation task will be added to the licensed nurse documentation for the correct storage of the nasal cannula of a resident using oxygen.

4) Audits of oxygen nasal cannulas, bed pan and urine hat coverage and storage will be conducted every shift by the Director of Nursing or designee of five resident rooms for one week. Audits will then be conducted weekly for four weeks and monthly for two months. All audits will be reviewed at the QAPI committee meeting.

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

Based on clinical record review and staff interview, it was determined that the facility failed to implement a comprehensive plan of care for one of 13 residents reviewed (Resident 1).

Findings include:

Clinical record review for Resident 1 revealed that on February 15, 2019, her physician ordered Oxygen 2 liters per minute (LPM) via nasal canula (NC, a device used to deliver supplemental oxygen) for SpO2 (pulse oxygenation, the amount of Oxygen in the bloodstream) less than or equal to 89 percent room air (RA) every shift for decreased SpO2. There was no documentation that the facility implemented an Oxygen care plan for Resident 1

Interview on May 23, 2019, at 2:00 PM with the Nursing Home Administrator and the Director of Nursing confirmed the above findings.

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

28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services
Previously cited 6/29/18


 Plan of Correction - To be completed: 07/12/2019

1) Oxygen care plan added regarding oxygen use based on oxygen saturation for Resident one on May 23, 2019.

2) Reviewed all residents with physician orders for oxygen saturation and updated all care plans needed regarding oxygen.

3) All licensed staff will be educated on updating residents care plans with physician orders for oxygen saturation.

4) Residents with physician orders for oxygen saturation will be audited weekly for one month and then monthly for two months. All audits will be reviewed at the QAPI committee meeting.

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 select facility policies, clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to review and revise the plans of care to meet the physical needs of the resident for one of 12 residents reviewed (Resident 20).

Findings include:

Review of the facility policy entitled "Falls Prevention," last reviewed on March 26, 2019, revealed the facility's goal was to maintain the resident's environment as free from fall hazards while providing adequate support for the resident. The licensed nurse is responsible to implement appropriate interventions immediately after the fall based on the identified cause and the resident's care plan will be updated at the time the intervention is placed.

Clinical record review for Resident 20 revealed the resident was admitted to the facility on June 26, 2018.

Review of Resident 20's plan of care revealed a falls care plan initiated on June 26, 2018, (admission), which indicated the resident had a history of falls and poor vision, and a care plan goal that the resident would be free from serious injury in the event of a fall.

Review of facility fall investigations revealed the following for Resident 20:

August 6, 2018, resident reported she fell in her room, with complaints of wrist pain
September 29, 2018, staff found the resident on the floor in her room and she sustained a hematoma to the right side of her head
November 15, 2018, staff found the resident on the floor in her room
November 21, 2018, the resident reported she fell in her room
December 27, 2018, staff found the resident on the floor in her room and she sustained a fracture of the upper right arm

Review of facility investigations revealed that Resident 20 continued to have falls on February 1, 3, 7 (2 incidents), and 13, 2019; March 4 and 12, 2019; April 8 and 24, 2019; and May 18, 2019.

The facility investigations dated November 15, 2018, and November 21, 2018, indicated Resident 20's care plan was reviewed and revised as an immediate action taken in response to the falls.

Further review of Resident 20's plan of care revealed the resident's falls care plan goal (to be free from serious injury) was not revised until January 15, 2019, after the resident had five falls with one resulting in a fracture to the upper right arm. There were no new or revised interventions on the resident's falls plan of care since July 4, 2018 until February 1, 2019 after the resident had five falls/incidents.

The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 24, 2019, at 11:52 AM.

483.21(b) Care Plan Timing and Revision
Previously cited 6/29/18

28 Pa. Code 211.11(d) Resident care plan
Previously cited 6/29/18


 Plan of Correction - To be completed: 07/12/2019

1) Resident twenty's care plan for falls was reviewed, revised, and updated on May 31, 2019.

2) Care plans for residents that are at risk of falls were reviewed, revised, and updated.

3) Director of Nursing or designee will review all falls reports within 72 hours of occurrence. The review will include appropriate intervention placement and care plan updates completed. The falls committee will review resident falls weekly to determine care plan updates. Staff re-education will be provided for care plan updates.

4) Director of Nursing or designee will review all falls daily for seven days, weekly for three weeks, and monthly for two months. Audits will include verification that care plans have been updated properly. All audits will be reviewed at the QAPI committee meeting.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on select facility polices, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure an environment free from potential accident hazards related to elopement for two of two residents reviewed and to prevent accidents related to falls for one of 5 residents reviewed. (Residents 6, 9, and 20)

Findings include:

The facility policy entitled, "Elopement Protocol for Skilled Nursing" last reviewed without changes on March 26, 2019, defined elopement as the resident exiting the facility without staff knowledge and potential elopement as when a resident leaves their area of the skilled nursing unit to another neighborhood of the Skilled nursing facility without staff knowledge. Residents on the East neighborhood (unit) who have attempted elopement or have other behaviors to suggest possible elopement, will wear a wander alert device until they can be moved to a secured neighborhood.

Review of the facility policy entitled "Falls Prevention," last reviewed on March 26, 2019, revealed the facility's goal was to maintain the resident's environment as free from fall hazards while providing adequate support for the resident. The licensed nurse is responsible to implement appropriate interventions immediately after the fall based on the identified cause and the resident's care plan will be updated at the time the intervention is placed.

Observation on May 21, 2019 at 10:14 AM revealed Resident 6 ambulating in the hallway with her walker. She stated to the surveyor that she wished there was a way for her to go outside. She went to the end of the hallway where the door opens to the outside and noted that the alarm would go off if she went out that door. Resident 6 then turned and started toward the end of the hallway that would lead to the main lobby of the facility and stated that she will have to "go out that way" pointing to a door that exits the unit to the facility lobby. Resident 6 has a BIMs (Brief Interview for Mental Status) of 7 on her most recent quarterly MDS (an assessment performed by the facility to determine the resident care needs) dated May 15, 2019, indicating that her cognition is severely impaired. Resident 6 started ambulating to the doorway and stated she better go to the bathroom first and went back towards her room.

The surveyor noted the lobby entrance doors were unattended at least 3 times when the receptionist was not at her desk on May 21, 2019, at 12:30 PM, May 21, 2019, at 2:50 PM, and May 22, 2019, at 2:55 PM.

Clinical record review for Resident 6 revealed that the facility completed a wandering risk assessment on her on February 4 and May 15, 2019, and determined she was at moderate risk for wandering.

Further clinical review revealed a health status noted dated February 19, 2019, at 5:57 PM that indicated Resident 6 continued to wander throughout the unit and was adamant about leaving. She was standing in the hallway outside the dining area. The facility initiated 15 minute checks on the resident.

A health status note dated March 1, 2019, at 8:13 PM revealed that at approximately 4:30 PM, Resident 6 was agitated. She ambulated out of her room and requested to go to the main dining room off the unit for dinner and wanted to go right away. Staff offered to assist Resident 6 at 5:30 PM. At 5:00 PM Resident 6 stated she refused to wait any longer and began to ambulate with her walker to the unit doors. The nurse aide notified the licensed nurse and then accompanied the resident to the dining room.

A health status note dated March 18, 2019, at 4:02 PM revealed that Resident 6 ambulated alone up to cafe prior to lunch to visit with the pastor and receive communion. Staff reinforced for her to wait for someone to accompany her. Resident 6's most recent BIMS score prior to this event was a 3 from her MDS dated February 13, 2019, indicating severe cognitive impairment.

Interview with the Nursing Home Administrator and Director of Nursing on May 23, 2019, at 9:45 AM revealed that Resident 6 does not have a wander alert device as per policy and is an elopement risk.

Clinical record review for Resident 9 revealed that on August 1, 2018, she was observed in the hallway near the medical home (not part of the skilled nursing unit) at 9:30 AM. Resident 9's BIMs score on the MDS prior to this event was not able to be completed by questioning the resident on May 21, 2018. The staff assessment on the MDS dated May 21, 2018, revealed Resident 9 had a memory problem.

Review of the facility investigation into this event revealed that Resident 9 was cognitively impaired. Resident 9 was sitting in the living room on East hall prior to leaving the unit. Resident 9 had no prior attempts at leaving the nursing unit. The facility noted the contributing factors to this event to be a change in mental status with confusion. Upon her return to the unit, Resident 9 was provided a wander bracelet.

Interview with the Nursing Home Administrator and Director of Nursing on May 23, 2019, at 9:45 AM confirmed the above noted findings related to Resident 6 and 9.

Clinical record review for Resident 20 revealed the resident was admitted to the facility on June 26, 2018.

Further clinical record review revealed a Morse Fall Scale (an assessment to determine fall risk) was completed on June 26, 2018, (admission), assessing the resident as a high risk for falling.

Review of Resident 20's plan of care revealed a falls care plan initiated on June 26, 2018, (admission), which indicated the resident had a history of falls and poor vision, and a care plan goal that the resident would be free from serious injury in the event of a fall.

Review of Resident 20's quarterly MDS (Minimum Data Set, an assessment completed at periodic intervals to assess resident care needs) completed on October 2, 2018, revealed the resident has a BIMS (Brief interview for Mental Status) score of four, which indicates severe impairment, and was independent with set up only for bed mobility, eating, and transfers. The resident was assessed as needing supervision of setup only for walking in her room and corridor, and supervision of one person physical assist dressing, toilet use, and personal hygiene.

Review of facility fall investigations revealed the following for Resident 20:

August 6, 2018, resident reported she fell in her room, with complaints of wrist pain
September 29, 2018, staff found the resident on the floor in her room and she sustained a hematoma to the right side of her head
November 15, 2018, staff found the resident on the floor in her room
November 21, 2018, the resident reported she fell in her room
December 27, 2018, staff found the resident on the floor in her room and she sustained a fracture of the upper right arm

A significant change MDS completed on January 2, 2019, revealed Resident 20 was assessed as needing extensive assistance of two plus persons for bed mobility, transfers, and toilet use, had only walked in her room or corridor once or twice in the assessment period, required extensive assist of one person for dressing and hygiene, and limited assistance of one person physical assist for eating.

In an interview with the Director of Nursing on May 24, 2019, at 11:52 AM she confirmed the decline in Resident 20's bed mobility, transfers, toilet use, walking, dressing, hygiene, and eating were a result of the fracture the resident sustained from the fall on December 27, 2018.

Review of Resident 20's plan of care revealed the resident's falls care plan goal (to be free from serious injury) was not revised until January 15, 2019, after the resident had five falls with one resulting in a fracture to the upper right arm. There were no new or revised interventions on the resident's falls plan of care since July 4, 2018 until February 1, 2019 after the resident had five falls/incidents.

Resident 20 continued to have 10 more falls on the following dates: February 1, 3, 7 (2 incidents), and 13, 2019; March 4 and 12, 2019; April 8 and 24, 2019; and May 18, 2019.

The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 24, 2019, at 11:52 AM.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 6/29/18

28 Pa. Code 201.18(b)(1) Management
Previously cited 6/23/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 6/29/18 and 6/23/17


 Plan of Correction - To be completed: 07/12/2019

1) Resident 6 was issued a wander device per facility policy, care plan updated, and family made aware on May 31, 2019. Resident 9's BIMS was completed on 5/28/19 and wander risk assessment completed 6/4/19, resident's BIMs score was 14 and wander risk was a low risk for wandering and no longer requires wander device or secured unit care plan updated accordingly. Resident twenty's care plan for falls was reviewed, revised, and updated on May 31, 2019.

2) Elopement policy updated to state that residents living on East Neighborhood with moderate to severe wander risk and BIMs of 7 or below, or BIMs of 8-12 with a severe wander risk will be issued a wander device. All residents on East Neighborhood wander risk assessments review and BIMS reviewed and any residents with a moderate to severe wander risk and BIMs of 7 or below, or BIMs of 8-12 with a severe wander risk will be issued a wander device. Care plans for residents that are at risk of falls were reviewed, revised, and updated.

3) All Health Services staff educated on updated Elopement policy. Director of Nursing or designee will review all falls reports within 72 hours of occurrence. The review will include appropriate intervention placement and care plan updates completed. The falls committee will review resident falls weekly to determine care plan updates. Staff re-education will be provided for care plan updates.

4) Director of Nursing or Designee will review all east residents BIM's and wander risk assessments monthly for four months to verify Elopement policy is being followed. Director of Nursing or designee will review all falls daily for seven days, weekly for three weeks, and monthly for two months. Audits will include verification that care plans have been updated properly. All audits will be reviewed at the QAPI committee meeting.

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

Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of two residents reviewed (Resident 1).

Findings include:

Review of the facility policy entitled "Oxygen: Administration and Equipment," last reviewed without changes on March 26, 2019, revealed that the facility will support residents in need of Oxygen therapy. Staff will verify that there is a physician's order and review the facility's protocol for Oxygen administration. After completing the Oxygen setup and/or adjustment, staff will document Oxygen administration in the resident's medical record.

Clinical record review for Resident 1 revealed on February 15, 2019, her physician ordered Oxygen 2 liters per minute (LPM) via nasal canula (NC, a device used to deliver supplemental oxygen) for SpO2 (pulse oxygenation, the amount of Oxygen in the bloodstream) less than or equal to 89 percent room air (RA) every shift for decreased SpO2.

Review of a facility form entitled, "Weights and Vitals Summary," a form used to document a resident's weight, blood pressure, pulse, respirations, temperature, and SpO2, revealed that staff failed to administer Oxygen to Resident 1 with an identified SpO2 less than or equal to 89 percent on room air on the following dates and times:

March 2, 2019, at 1:30 AM 85 percent RA
April 3, 2019, at 2:47 PM 88 percent RA
April 15, 2019, at 3:19 PM 89 percent RA
April 17, 2019, at 9:13 AM 89 percent RA
April 3, 2019, at 1:44 AM 86 percent RA
April 30, 2019, at 3:14 PM 88 percent RA

Interview with the Nursing Home Administrator and Director of Nursing on May 24, 2019, at 10:44 AM confirmed the above findings.

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

28 Pa. Code 211.12 (d)(1)(5) Nursing services
Previously cited 6/29/18


 Plan of Correction - To be completed: 07/12/2019

1) Resident one has had oxygen administered and documented appropriately per order as of May 24, 2019.

2) Any resident with oxygen ordered based on pulse oximetry will be reviewed for appropriate documentation and assessment of need. Documentation will be present in the resident's medical record.

3) Re-education will be provided to all licensed nurses regarding oxygen administration and documentation per physician's order.

4) The Director of Nursing or designee will monitor all residents with as needed oxygen orders daily for one week, weekly for three weeks, and monthly for two months to observe documentation of oxygen administration in the resident's medical record. All audits will be reviewed at the QAPI committee meeting.

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 employee personnel file review and staff interview, it was determined that the facility failed to ensure personnel records included verification of employees' health status for four of five employees reviewed (Employees 4, 5, 6, and 7).

Findings include:

Review of Employee 4's, nurse aide, personnel file revealed that the facility hired her on February 1, 2019. The facility never obtained verification of Employee 4's health status.

Review of Employee 5's, dietary aide, personnel file revealed that the facility hired her on March 1, 2019. The facility never obtained verification of Employee 5's health status.

Review of Employee 6's, housekeeping, personnel file revealed that the facility hired her on March 1, 2019. The facility never obtained verification of Employee 6's health status.

Review of Employee 7's, registered nurse, personnel file revealed that the facility hired her on May 20, 2019. The facility never obtained verification of Employee 7's health status.

Interview with Employee 8, human resource director, on May 24, 2019, at 9:40 AM and the Nursing Home Administrator and the Director of Nursing on May 24, 2019, at 10:20 AM, confirmed the above findings.



 Plan of Correction - To be completed: 07/12/2019

1. The verification of health status process will be completed, and documentation will be obtained for employee's four, five, six and seven and placed in the employee files within the next 30 days.

2. All employee files of staff hired from January 2019 to current will be reviewed. The verification of health status process will be completed, and documentation will be obtained and placed in the employee files within the next 30 days. The policy regarding collection of new hire forms has been revised to include a process for completing and documenting the verification of health status for each new hire.

3. All Human Resources staff have been educated on the new process for obtaining verification of health status on all new employees.

4. The Human Resources Director or designee will audit all new hire files prior to the start dates, for three months, to confirm verification of health status has been completed and documented. All audits will be reviewed at the QAPI committee meetings.


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