Nursing Investigation Results -

Pennsylvania Department of Health
ALTOONA CENTER FOR NURSING CARE
Patient Care Inspection Results

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ALTOONA CENTER FOR NURSING CARE
Inspection Results For:

There are  98 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
ALTOONA CENTER FOR NURSING CARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on February 7, 2019, it was determined that Altoona Center for Nursing Care 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:


483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to report an allegation of neglect to the State Survey Agency (Department of Health) for five of 42 residents reviewed (Residents 10, 12, 30, 54, 62).

Findings include:

The facility's policy regarding abuse, dated November 1, 2018, revealed that all allegations of abuse, neglect, exploitation or mistreatment of residents, including injuries of unknown origin, will be thoroughly investigated by the administrator and support staff.

An employee counseling form, dated January 4, 2019, revealed that on January 1, 2019, when the second shift staff arrived on the floor for work, they smelled a strong smell of urine and feces. According to Nurse Aide 5's statement, dated January 1, 2019, Nurse Aide 6 failed to provide incontinent care for several residents, and five residents were found at shift change to be sitting in urine and feces. Nurse Aide 5 revealed in her statement that Residents 10, 12, 30, 54, 62 were soaked with urine and Residents 30 and 54 were covered in feces as well. Licensed Practical Nurse 7's statement, dated January 1, 2019, revealed that Resident 12 had feces all over her bed and trash can and that Nurse Aide 6 refused to help clean it up stating it was not her job since it was second shift at that time. Licensed Practical Nurse 7 also stated that Nurse Aide 6 became angry and was throwing things and slamming drawers.

There was no documented evidence that the Department of Health was notified about the allegation of neglect of multiple residents made by Nurse Aide 5 and Licensed Practical Nurse 7.

Interview with the Director of Nursing on February 6, 2019, at 12:44 p.m. confirmed that the Department of Health was not notified about the allegation of neglect.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 8/13/18, 3/23/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.




 Plan of Correction - To be completed: 03/22/2019

DISCLAIMER: The following is submitted for plan of correction purposes only and should not be construed as an admission.
The event that occurred involving resident R10, R12, R20, R54 and R62 was has been reported and a PB22 was completed. The event number is 565798. The Director of Nursing verbalized that the reason it wasn't reported was because the documentation revealed that the care was given yet considered it poor job performance; therefore, disciplined staff and educated the staff member and recognizes now that any allegation has to be investigated and reported.

Grievances and concerns from the past thirty days will be reviewed to ensure that any allegations of abuse and neglect have been reported and investigated per policy.

All Grievances and disciplinary actions will be reviewed by the Administrator/designee to monitor for allegations of abuse/neglect.

The staff of the facility will also be educated on reporting regulations so they know the events that must be immediately reported to the Director of Nursing and/or Administrator.

All reported events will be reviewed at the quarterly Quality Assurance meeting on an ongoing basis to prove that the reportable events are reported per the regulation.

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were used during resident care for four of 42 residents reviewed (Residents 13, 16, 106, 212).

Findings include:

The facility's policy regarding incontinent care, dated November 1, 2018, indicated that staff were to always perform hand hygiene after gloves were removed and prior to providing additional care to residents.

The facility's hand hygiene policy, dated November 1, 2018, revealed that whether or not gloves were worn, hand hygiene was to be performed after contact with blood and body fluids, mucous membranes or secretions.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated November 2, 2018, revealed that the resident was cognitively intact, required extensive assistance for hygiene, was totally dependent on staff for bathing, and was always incontinent of bowel and bladder.

Observations of Resident 13 on February 4, 2019, at 11:40 a.m. revealed that the resident had been incontinent of urine and with gloves on, Licensed Practical Nurse 9 cleaned the resident's perineal area (in and around the genitals). After cleaning the resident, Licensed Practical Nurse 9 removed her gloves, and without washing her hands, she applied new gloves and continued care. Interview with Licensed Practical Nurse 9 at that time confirmed that she did not wash her hands before putting on new gloves and she should have.

Interview with the Director of Nursing on February 5, 2019, at 1:36 p.m. confirmed that staff are to wash their hands after taking their used gloves off and before putting on clean gloves.


An annual MDS assessment for Resident 16, dated November 6, 2018, indicated that the resident required the extensive assistance of two persons for daily care tasks, had diagnoses that included obstructive uropathy (when urine cannot drain through the urinary tract), and had an indwelling urinary catheter (tube inserted and held in the bladder to drain urine). Physician's orders dated May 23, 2018, indicated that the resident had a suprapubic catheter (tube surgically inserted into the bladder through an opening in the abdomen).

Observations on February 4, 2019, at 10:45 a.m. revealed that a closed urinary drainage bag, that was not connected to Resident 16's suprapubic urinary catheter, was hanging on the top bedrail of the resident's bed, and there was no protective cap on the tip (the part that gets connected to the resident's catheter).

Interview with Licensed Practical Nurse 3 on February 4, 2019, at 10:45 a.m. confirmed that Resident 16's urinary drainage bag was disconnected and hanging on the resident's bedrail without a protective cap on the tip.


A quarterly MDS assessment for Resident 106, dated January 4, 2019, indicated that the resident was alert and oriented, dependent on limited-to-extensive assistance of one to two persons for daily care, had diagnoses that included urinary retention (residual urine retained in the bladder), and had an indwelling urinary catheter.

Observations on February 4, 2019, at 9:40 a.m. revealed that the resident's closed drainage urinary catheter bag was on the floor with the port side (tube that is used to empty the urine from the bag) was in direct contact with a fall mat (device placed on the floor next to the bed to prevent injuries from falls).

Interview with Registered Nurse 1 on February 4, 2019, at 9:45 a.m. confirmed that Resident 106's catheter bag was on the floor, should not have been, and should have been covered with a dignity bag for privacy.


The facility's policy regarding aerosol nebulizer therapy (turns breathing medication into a mist that can be inhaled into the lunges), dated May 15, 2018, indicated that cleaning and maintenance of the nebulizer machine would be completed following the facility's infection control practices.

A diagnosis record for Resident 212, dated January 2, 2019, revealed that the resident had diagnoses that included chronic obstructive pulmonary disease (COPD - progressive lung disorder that makes it difficult to breathe). Physician's orders, dated January 31, 2019, included an order for the resident to receive one vial of Ipratropium-Albuterol Solution 0.5-2.5 (3) milligrams/3 milliliters (used to treat COPD) via nebulizer, inhale orally two times a day for shortness of breath/wheezing, and 1 vial inhale orally every six hours as needed for shortness of breath.

Observations of Resident 212's nebulizer equipment on February 4, 2019, at 11:48 a.m. and 4:08 p.m. revealed that the nebulizer mask was lying face down in direct contact with the bedside stand and there was a plastic bag bedside it labeled February 3, 2019.

Interview with Registered Nurse 13 (the facility's infection control nurse) on February 4, 2019, at 2:59 p.m. revealed that after a nebulizer treatment was provided, the mask was to be washed, dried with a paper towel, and then placed into the bag. She confirmed that Resident 212's mask should not have been lying on the bedside stand.

42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control.
Previously cited 3/23/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/6/18, 8/13/18, 3/23/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.




 Plan of Correction - To be completed: 03/22/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.
Resident 13 continues to reside at the facility. She receives extensive assistance for hygiene activities in a manner that promotes and maintains infection prevention and control practices.
Licensed Practical Nurse 9 has been re-educated on facility hand hygiene policy, policy regarding incontinence care, and has successfully completed hand hygiene competency.
The nursing staff will be educated on the facility hand hygiene policy, facility policy regarding incontinence care, and federal regulation 880. Nursing staff will complete hand hygiene competencies with the Infection Control Coordinator/designee.
The Infection Control Coordinator/designee will audit staff members providing assistance to residents requiring assistance with incontinence care to ensure infection prevention and hand hygiene practices are maintained throughout the incontinence care. These audits will be completed on 5 residents daily for one week, weekly for two weeks, monthly for two months, and randomly thereafter. Results of these audits will be reviewed in the facility Quality Assurance meeting for further recommendations for continued compliance.
Resident 16 and resident 106 continue to reside at the facility. The Resident's urinary catheters and their drainage system are maintained in a manner that promotes and maintains infection prevention and control practices.
The Infection Control Coordinator/Designee will audit all residents with urinary catheters to ensure indwelling catheter positioning and infection control and prevention practices are maintained. These audits will be completed daily for one week, weekly for two weeks, monthly for two months, and randomly thereafter. Results of these audits will be reviewed in the facility Quality Assurance meeting for further recommendations for continued compliance.
Checking indwelling urinary catheter systems for proper positioning and covering will become part of resident rounds and will be done by both licensed and non-licensed staff. Any needed corrections will be completed immediately.

Resident 212 continues to reside at the facility and her nebulizer equipment is maintained in a manner that promotes and maintains infection prevention and control practices.
Checking respiratory equipment for proper positioning and covering will become part of resident rounds and will be done by both licensed and non-licensed staff. Any needed corrections will be completed immediately.
The Infection Control Coordinator/designee will audit residents receiving nebulizer and or respiratory therapy to ensure proper placement/covering of equipment and infection control and prevention practices are maintained. These audits will be completed on 5 residents daily for one week, weekly for two weeks, monthly for two months, and randomly thereafter. Results of these audits will be reviewed in the facility Quality Assurance meeting for further recommendations for continued compliance.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.75(g) Quality assessment and assurance.

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


Based on review of the facility's plans of correction for previous Department of Health surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending March 23 and August 13, 2018, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 7, 2019, identified repeated deficiencies related to a failure to thoroughly investigate allegations to rule out neglect; failure to develop comprehensive care plans; failure to update care plans; failure to provide proper nail care; failure to ensure that residents received care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices; failure to ensure that physician's orders were followed; failure to ensure that clinical records were complete and accurate; and failure to use proper infection control practices during resident care.

The facility's plan of correction for a deficiency regarding a failure to investigate incidents to rule out abuse/neglect, cited during the survey ending August 13, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F610, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding thoroughly investigating allegations of potential neglect.

The facility's plan of correction for a deficiency regarding a failure to develop comprehensive care plans, cited during the survey ending March 23, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plans to ensure ongoing compliance with regulations regarding the development of comprehensive care plans.

The facility's plan of correction for a deficiency regarding a failure to update residents' care plans, cited during the survey ending March 23, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans.

The facility's plan of correction for a deficiency regarding a failure to provide nail care, cited during the survey ending March 23, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F677, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding nail care.

The facility's plan of correction for a deficiency regarding a failure to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, cited during the survey ending August 13, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding providing care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

The facility's plan of correction for a deficiency regarding a failure to maintain complete and accurate clinical records, cited during the survey ending August 13, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F842, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding maintaining complete and accurate clinical records.

The facility's plan of correction for a deficiency regarding a failure to maintain an effective infection control program, cited during the survey ending March 23, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plans to ensure ongoing compliance with regulations regarding infection control.

Refer to F610, F656, F657, F677, F684, F842, F880.

42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities.
Previously cited 3/23/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 3/23/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 3/23/18.













 Plan of Correction - To be completed: 03/22/2019

DISCLAIMER: The following is submitted for plan of correction purposes only and should not be construed as an admission.
The Quality Assurance Committee will meet to review the repeat deficiencies: F610, F656, F657, F677, F684, F842 and F880. A facility Quality Assurance Performance Improvement Plan will be developed for these repeat federal deficiencies. To ensure sustained compliance, these areas will continue to be audited, with outcomes presented at the quarterly Quality Assurance Committee meetings for review and recommendations.
The Quality Assurance Committee will be educated by the Nursing Home Administrator or Designee, on Federal Regulation 867. The Quality Assurance Committee will then review the facility's current Quality Assurance Performance Improvement Process to ensure that a systemic approach is being utilized to determine underlying causes of non-compliance in order to prevent repeat deficiencies and that corrective action plans address any changes at the systems level. The Committee will also reevaluate how the effectiveness of its performance improvement efforts is currently being monitored. After this review of the facility's Quality Assurance Improvement Process, the Committee will make any necessary revisions to the process that will better ensure improvements are sustained and repeat deficiencies are avoided.
An outside Consultant will attend the Quality Assurance Committee Meeting to monitor the effectiveness of the Quality Assurance Improvement Process, including if compliance with the federal regulations identified as being deficient are being sustained.
The interdisciplinary team and licensed nursing staff will be in-serviced by the Director of Nursing or Designee on the facility's Quality Assurance Improvement Process, including any revisions, as well as on Federal Regulations: F610, F656, F657, F677, F842 and F880.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for one of 42 residents reviewed (Resident 63).

Findings include:

The facility's policy regarding consultations, dated January 2019, indicated that all consultations would be documented and maintained on the resident's clinical record, and if recommendations were approved by the attending physician, an order to follow the recommendations would be written. If the consultant's recommendations were declined by the attending physician, a progress note would be completed in the record indicating the attending physician's response.

A diagnosis record for Resident 63, dated November 3, 2018, revealed that the resident had diagnoses that included malignant neoplasm (cancer) of the prostate and cirrhosis of the liver (chronic liver damage that leads to scarring and liver failure).

A hospital discharge summary and physician's orders for Resident 63, dated November 16, 2018, revealed that the resident was to receive two 500 milligram (mg) tablets of Zytiga (used to treat prostate cancer) at bedtime for 7 days, along with 5.0 mg of prednisone twice a day (given together with Zytiga for prostate cancer).

A consultation report from oncology (branch of medicine that deals with cancer), dated November 22, 2018, indicated that Resident 63 had metastatic cancer (cancer that has spread) to the bone and that he was on Zytiga (used to treat prostate cancer) and prednisone (given together with Zytiga for prostate cancer). The report indicated that the plan was to continue the resident on these medications.

Resident 63's Medication Administration Records (MAR's) for November and December 2018 revealed no documented evidence that staff administered Zytiga to the resident on November 16 and on November 23 through December 17, 2018.

There was no documented evidence that the consulting oncologist's recommendation to continue Zytiga was communicated to Resident 63's attending physician, or that the order for Zytiga to be for only seven days was clarified with the physician until December 18, 2018, at which time Zytiga was ordered to be provided daily.

Interview with Registered Nurse 14 on February 5, 2019, at 4:36 p.m. revealed that the nursing supervisor is to review the consultant's recommendations, and if no information comes back with the resident from the consulting physician's office, the nurse is to call for information and then notify the attending physician of the consultant's plan for the resident. She confirmed that Resident 63's documentation from the consulting oncologist was not on the resident's clinical record.

Interview with the Director of Nursing on February 7, 2019, at 11:33 a.m. confirmed that Zytiga was provided to Resident 63 for only six of the seven days originally ordered. She also confirmed that the nursing supervisor should have called the consulting physician's office to obtain the recommendations and then called the attending physician with the consultant's recommendations.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/13/18, 3/23/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.







 Plan of Correction - To be completed: 03/22/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.
Resident 63 was discharged from facility. Resident was previously restarted on medication Zyteiga prior to discharge.
Review of consults for past 30 days to ensure all consult sheets were returned with follow up on all recommendations.
A Binder will be designed and placed at nursing station with dividers for daily monitoring of consults. The Unit Secretary /Supervisor/designee will copy the transport list, followed by copies of all consults when resident returns. The original will go to supervisor to follow up with the primary care physician for confirmation of recommendations with orders and implementation of orders. The Binder will be checked daily for all consults being returned and orders clarified and initiated.
The Director of Nursing/ Designee will review the Consult binder daily for initiated follow ups for two weeks, weekly for two weeks then monthly for two months then randomly.
Results of these audits will be reviewed at the Quality Assurance meeting. Any negative findings will result in a formation of a Quality Assurance Performance Improvement meeting.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents' care plans were updated to reflect current care needs for five of 42 residents reviewed (Residents 13, 14, 20, 51, 58).

Findings include:

The facility's policy regarding resident care plans, dated November 1, 2018, indicated that care plans would be updated with a significant change in condition, and that it was the policy of the facility to develop and implement an individualized, comprehensive, person-centered care plan based on preferences, goals, needs, and strengths of the resident.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 13, dated November 2, 2018, revealed that the resident was cognitively intact, required extensive assistance for hygiene, was totally dependent on staff for bathing, and was always incontinent of bowel and bladder. Physician's orders, dated December 7, 2018, included an order for a wound on the left buttock to be treated/protected by applying skin prep (form a protective film) to the area around the wound and Optifoam (non-stick dressing) to the wound.

Observations of Resident 13 during incontinent care on February 4, 2019, at 11:40 a.m. revealed that the resident had a tan-colored dressing on the left inner buttock.

Resident 13's care plan, dated December 18, 2018, revealed no documented evidence the care plan was updated to reflect the physician's order to apply Optifoam to the left buttock.

Interviews with the Wound Nurse on February 6, 2019, at 10:26 a.m. and with the Director of Nursing on February 7, 2019, at 12:10 p.m. confirmed that Resident 13's care plan should have been updated to reflect the physician's order for Optifoam to the left buttock wound on December 7, 2018.


A quarterly MDS assessment for Resident 58, dated December 4, 2018, indicated that the resident was cognitively impaired, required the extensive assistance of one to two staff for daily care tasks, and had a Stage II pressure ulcer (superficial skin breakdown caused by unrelieved, prolonged pressure). The resident's care plan regarding a pressure ulcer on the mid-back, dated June 4, 2018, indicated that the treatment to the area included cleansing the mid-back with normal saline solution (balanced salt and water), drying the area, applying Santyl (product to clean and remove dead tissue from the wound), applying moist gauze, and then applying dry gauze over top. Physician's orders, dated January 10, 2019, included an order to cleanse the mid-back with normal saline solution, dry the area, apply Fibercol (a collagen dressing to promote new tissue growth), and Allevyn (a protective dressing).

As of February 6, 2019, there was no documented evidence that Resident 58's care plan was updated to reflect the current treatment orders for the wound on the mid-back.

Interview with the Wound Nurse on February 6, 2019, at 10:26 a.m. revealed that she was responsible for updating wound care plans and she confirmed that Resident 58's care plan was not updated with the current physician's orders for treatment.


A quarterly MDS assessment for Resident 14, dated November 2, 2018, indicated that the resident was not ambulatory (could not walk), required the extensive assistance of two staff for bed mobility and transfers, and that she was at risk for pressure ulcers. Current physician's orders, dated May 12, 2018, included that the resident's heels were to be elevated off the bed.

Observations on February 4, 2019, at 3:45 p.m. revealed that Resident 14 was in bed lying on her right side and that her right lateral leg, foot and heel were directly on the bed. There was a wedge-type device sitting on top of the blanket at the bottom of the bed that was not in use.

There was no documented evidence that Resident 14's care plan was updated to reflect the current physician's orders for the resident's heels to be elevated.

Interview with the Nursing Home Administrator on February 7, 2019, at 12:28 p.m. confirmed that Resident 14's care plan did not reflect that her heels were to be elevated and the care plan should have been updated.


A diagnosis record for Resident 20, dated October 1, 2018, revealed that she had diagnoses that included shortness of breath and chronic obstructive pulmonary disease (COPD - a lung disorder that makes it hard to breathe). Physician's orders, dated January 20, 2019, included an order for the resident to use continuous oxygen at a flow rate of 3 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils).

Observations of Resident 20 on February 4, 2019, at 3:35 p.m. revealed that she was using oxygen at 3 liters per minute via nasal cannula.

Resident 20's current care plan, dated December 6, 2018, indicated that the resident used continuous oxygen at 2 liters per minute via nasal cannula.

Interview with the Nursing Home Administrator on February 7, 2019, at 12:51 p.m. confirmed that Resident 20's care plan regarding oxygen did not reflect her current physician's order and should have been updated.


A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated December 6, 2018, indicated that the resident was confused, required the extensive assistance of two staff for bed mobility and transfers, was non-ambulatory (could not walk), had range of motion impairment to the upper and lower extremities on one side (impairment to the movement of the joints), had an unstageable (the wound cannot be staged because the wound bed cannot be visualized due to the presence of non-viable or dead tissue) pressure ulcer, and was at risk for further pressure ulcers.

Skin detail reports for Resident 51, dated January 29, 2019, indicated that the resident had an unstageable pressure ulcer of her right lateral (side of) heel. An occupational therapy note, dated December 3, 2018, indicated that the resident reported that she did not like the bilateral (both sides) heel boots and that she was a trialing a heel suspension device that the resident reported increased her comfort.

Physician's orders for Resident 51, dated January 14, 2019, and the resident's treatment records for February 2019, included that she was to have bilateral heel lift boots on while in bed, and her care plan, revised on January 25, 2019, indicated that she needed a heel suspension device to protect the skin while in bed.

Observations of Resident 51 on February 4, 2019, at 4:14 p.m. revealed that she was lying on her back in bed with her feet directly on the bed, and the heels suspension device was sitting against the wall. Observations on February 5, 2019, at 4:49 p.m. revealed that Resident 51 was in bed with her feet directly on the bed, and the heels suspension device was to right side of her bed on a chair.


Upon interview with Registered Nurse 1 on February 4, 2019, at 4:42 p.m. she indicated that Resident 51 does not like to use the heels suspension device at times. Interview with Licensed Practical Nurse 11 on February 4, 2019, at 4:44 p.m. revealed that she was not aware that the device was not in use at that time; however, at times, the resident does not want to use the device, at which times, pillows should be used. The nurse also indicated that the resident is more cooperative with using the device in the evenings.

There was no documented evidence on Resident 51's clinical record related to her intolerance with using the heel suspension device at times, as indicated during the interviews with Registered Nurse 1 and Licensed Practical Nurse 11.

Interview with Registered Nurse 10 (the facility's wound nurse) on February 6, 2019, at 10:38 a.m. revealed that she was not aware that Resident 51 would not use the heels suspension device at times, and that she should have been notified so she could monitor the resident to determine any trends/patterns of non-compliance, and to determine if changes were needed to the resident's care plan.

42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision.
Previously cited 3/23/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 3/23/18.





 Plan of Correction - To be completed: 03/22/2019

DISCLAIMER: The following is submitted for plan of correction purposes only and should not be construed as an admission.
Care plans for Resident R20,R13, R14, R51 and R58 have been reviewed and updated.
All residents currently receiving oxygen will have their care plans reviewed with the current orders and updated as appropriate.
All residents will have their wound care plans reviewed with current orders and updated to reflect specific treatments, orders and resident preferences as appropriate. The Wound Nurse has been educated by the Registered Nurse Assessment Coordinator on care plan requirements per the Resident Assessment Instrument Manual and the need to specify any treatments and resident preferences as she is now updating the wound care plans.
New employees to specific departments, who are responsible for care plans, will be educated by the Registered Nurse Assessment Coordinator, on care plan requirements per the Resident Assessment Instrument Manual. This will be an ongoing process.
The facility's Registered Nurse Assessment Coordinators and Interdisciplinary Team will be re-educated on updating and revising care plans, per the Resident Assessment Instrument (RAI) guidelines, by the Consultant.
Care plans will be reviewed ongoing daily, for those residents with new physician orders or instructions to ensure new interventions have been addressed.
The Director of Nursing Services or designee will review a random sample of care plans one (1) time per week for one (1) month, then monthly for 3 months assure the review and revision of care plans.
Results will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to ensure that a resident's dignity was maintained for one of 42 residents reviewed (Resident 106).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 106, dated January 4, 2019, indicated that the resident was alert and oriented, required limited to extensive assistance of one to two persons for daily care needs, had diagnoses that included urinary retention (residual urine retained in the bladder), and had an indwelling urinary catheter (tube inserted and held in the bladder to drain urine into a collection bag).

Observations on February 4, 2019, at 9:40 a.m. revealed that Resident 106's urinary catheter bag was on the floor in direct contact with a fall mat (device placed on the floor next to the bed to prevent injuries from falls) and was not covered or concealed in a privacy bag.

Interview with Registered Nurse 1 on February 4, 2019, at 9:45 a.m. confirmed that Resident 106's catheter bag was on the floor and not covered with a privacy bag and should have been covered to maintain the resident's privacy.

28 Pa. Code 201.29(j) Resident rights.






 Plan of Correction - To be completed: 03/22/2019

DISCLAIMER: The following is submitted for plan of correction purposes only and should not be construed as an admission.
Resident 106 continues to reside in this facility and his indwelling urinary catheter and drainage system are being maintained in a manner that promotes the resident's dignity. The investigation revealed that the reason a dignity bag was not utilized was a lack of education of the Nurse's Aide assigned to the resident.
Current residents with indwelling urinary catheters will be reviewed to ensure that they are being maintained in a manner that promotes and maintains dignity.
Checking indwelling urinary catheter systems for proper positioning and covering will become part of resident rounds and will be done by both licensed and non-licensed staff. Any needed corrections will be completed immediately.
The Director of Nursing/Designee will educate nursing staff on federal regulation 550 and the importance of maintaining indwelling urinary catheter systems in a manner that promotes and maintains resident dignity.
The Director of Nursing/Designee will audit residents with indwelling urinary catheters to ensure they are maintained appropriately. These audits will be completed daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter.
Results of these audits will be reviewed in the facility Quality Assurance Performance Improvement ( QAPI )meeting for further recommendations to maintain compliance.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of policies, clinical records and investigative reports, as well as staff interviews, it was determined that the facility failed to complete thorough investigations of incidents to rule out that neglect and/or abuse were involved for five of 42 residents reviewed (Residents 10, 12, 30, 54, 62).

Findings include:

The facility's policy regarding abuse, dated November 1, 2018, revealed that all allegations of abuse, neglect, exploitation or mistreatment of residents, including injuries of unknown origin, would be thoroughly investigated by the administrator and support staff.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated January 23, 2019, indicated that the resident was confused, required staff assistance for toileting, and was always incontinent of urine and bowel.

A quarterly MDS assessment for Resident 12, dated November 16, 2018, revealed that the resident was confused, required staff assistance with toileting, and was incontinent of urine and bowel.

A quarterly MDS assessment for Resident 30, dated February 1, 2019, revealed that the resident was confused, required staff assistance with toileting, was incontinent of bowel, and had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine).

A quarterly MDS assessment for Resident 54, dated December 7, 2018, revealed that the resident was confused, required staff assistance with toileting, and was incontinent of urine and bowel.

An annual MDS assessment for Resident 62, dated December 25, 2018, revealed that the resident was confused, required assistance with toileting, and was incontinent of urine and bowel.

An employee counseling form, dated January 4, 2019, revealed that on January 1, 2019, when the second shift staff arrived for work, they smelled strong odors of urine and feces. According to Nurse Aide 5's statement, dated January 1, 2019, Nurse Aide 6 (who worked the day shift) failed to provide incontinent care for several residents and five residents were found at shift change to be sitting in urine and feces. Nurse Aide 5 revealed in her statement that Residents 10, 12, 30, 54 and 62 were soaked with urine, and Residents 30 and 54 were covered in feces as well. Licensed Practical Nurse 7's statement, dated January 1, 2019, revealed that Resident 12 had feces all over her bed and trash can and that Nurse Aide 6 refused to help clean it up, stating that it was not her job because it was second shift at that time. Licensed Practical Nurse 7 also stated that Nurse Aide 6 became angry and was throwing things and slamming drawers.

There was no documented evidence that statements were obtained from staff who worked during the shift in question, and there was no documented evidence that a thorough investigation was completed to rule out neglect for Residents 10, 12, 30, 54 and 62, including interviews with all pertinent staff.

Interview with the Director of Nursing on February 6, 2019, at 12:44 p.m. confirmed that she did not do an investigation to rule out neglect for the situation that occurred on January 4, 2019.

42 CFR 483.12(c)(2)-(4) Investigate/Prevent/Correct Alleged Violation.
Previously cited 8/13/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 8/13/18, 3/23/18.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.


 Plan of Correction - To be completed: 03/22/2019

DISCLAIMER: The following is submitted for plan of correction purposes only and should not be construed as an admission.
The event that occurred involving resident R10, R12, R20, R54 and R62 was reported on February 11, 2019 and a abuse/neglect investigation was completed. The event number is 565798.


The Director of Nursing has been educated regarding what constitutes a complete and thorough investigation and was also educated on the policy on abuse.

The staff of the facility will be educated on reporting regulations so they know the events that must be immediately reported to the Director of Nursing and/or Administrator. They will also be educated on what constitutes a complete and thorough investigation.

All reported events will be reviewed at the quarterly Quality Assurance meeting on an ongoing basis to prove that the reportable events are reported per the regulation.

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a care plan was developed for pain management for one of 42 residents reviewed (Resident 14).

Findings include:

The facility's policy regarding care plans, dated April 12, 2018, indicated that a resident's care plan would include interventions based on the resident's needs.

A quarterly Minimum Data Set (MDS) assessment for Resident 14, dated November 2, 2018, revealed that the resident was cognitively impaired, required extensive assistance for most daily care tasks, and received routine and "as needed" pain medications. A diagnosis record, dated January 24, 2019, revealed that the resident had diagnoses that included muscle weakness, diabetes (a disease that interferes with blood sugar control), osteoarthritis (inflammation of the joints) of the right shoulder and difficulty walking. Physician's orders, dated August 28, 2018, included an order to the resident to receive one 650 milligram (mg) extended release tablet of Tylenol (an over-the-counter pain medication) every 8 hours for ankle/foot pain, and orders dated October 24, 2018, included an order for one 5 mg tablet of Oxycodone (a narcotic pain medication) two times a day for chronic osteoarthritis pain. Physician's orders, dated October 25, 2018, included an order for a kpad (heating pad) to be placed on the resident's shoulders and back for 30 minutes four times daily for three days, then as needed.

Current physician's orders, originally dated May 29, 2018, included an order for Resident 14's pain level to be evaluated every shift, and that care planned-interventions were to be followed as needed.

There was no documented evidence that a plan of care for pain management was developed for Resident 14.

Interview with the Director of Nursing on February 7, 2019, at 11:48 a.m. confirmed that Resident 14 should have had a care plan developed related to her pain.

42 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plan.
Previously cited 3/23/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 3/23/18.




 Plan of Correction - To be completed: 03/22/2019

DISCLAIMER: The following is submitted for plan of correction purposes only and should not be construed as an admission.

On February 7, 2109 the Registered Nurse Assessment Coordinator updated the care plan for Resident # R14
The facility will review all residents receiving routine or as needed pain medications to ensure care plans are current and reflective of the resident's current needs.

All current residents and new admissions will be reviewed for being at risk for pain and current care plan will be updated or new care plan will be initiated as appropriate.

All interdisciplinary care plan team members responsible for writing care plans will be re-educated on developing Comprehensive Care Plans, per the Resident Assessment Instrument (RAI) guidelines, by the Consultant.

Care plans will be reviewed weekly in accordance with the care plan review schedule by the Registered Nurse Coordinator(s) and the interdisciplinary team. The Registered Nurse Assessment Coordinator will be responsible for bringing the resident's chart to care conference along with the computer to review on line the user defined assessments, progress notes, and physician orders. The interdisciplinary team members will be responsible for bringing their information to care conference, including any progress notes, user defined assessments and resident preferences to care conference. All care plans will be updated accordingly.

The Director of Nursing Services, or designee, will complete weekly audits of care plan for six (6) consecutive weeks. Monthly audits will be completed to ensure that comprehensive care plans are developed for residents.
Audit records will be reviewed by the Quality Assurance Committee until such time consistent substantial compliance has been achieved as determined by the committee.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate services to maintain personal hygiene for one of 42 residents reviewed (Resident 70).

Findings include:

The facility's policy regarding nail care, dated November 1, 2018, indicated that nursing staff were to clean residents' hands and fingernails with a.m. and p.m. care and after every meal as needed.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 70, dated November 23, 2018, revealed that the resident was cognitively impaired, required extensive assistance with personal hygiene, and was totally dependent on staff for bathing. The resident's care plan, dated November 16, 2018, indicated that the resident had a self-care deficit due to confusion.

Observations of Resident 70 while in bed on February 4, 2019, at 11:45 p.m.; February 5, 2019, at 1:25 p.m.; and February 6, 2019, at 8:30 a.m. and 9:40 a.m. revealed that the resident's fingernails had a brown, removable substance under them.

Review of Resident 70's clinical record revealed that there was no documentated evidence that nail care was completed, or that it was refused, on February 4 and 5, 2019, and the morning of February 6, 2019.

Interview with Nurse Aide 8 on February 6, 2019, at 9:41 a.m. confirmed the Resident 70's nails needed cleaned and they were to be cleaned with a.m. care and when the staff notice they are dirty. Interview with Nurse Aide 6 on February 6, 109, at 9:45 a.m. confirmed that Resident 70's nails needed cleaned and they were usually cleaned with bed baths.

Interview with the Director of Nursing on February 6, 2019, at 10:00 a.m. confirmed that residents' nails are to be cleaned with a.m. and p.m. care and after every meal as needed.

42 CFR 483.24(a)(2) ADL Care Provided for Dependent Residents.
Previously cited 3/23/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.






 Plan of Correction - To be completed: 03/22/2019

Disclaimer: The following is submitted for plan of correction purposes only and should not be construed as an admission.

Resident 70 was provided with nail care, her fingernails were cleaned, and debris was removed from under nails.

A baseline audit will be conducted of all residents to ensure that their fingernails are clean. Any resident that is identified as not having clean nails, will have nail care provided. Any non-compliance with nail care will be care planned accordingly.

Nail care is part of morning and evening care and also after every meal as needed. Nail Care is part of resident R70's care plan and is to be documented in the activities of daily living section of the electronic medical record every shift. This indicates that multiple staff failed to provide appropriate nail care to resident 70. This will be addressed as part of the facility's plan of correction education.


The policy regarding Hand-Nail Care has been reviewed and will be revised as necessary. Education will be provided to nursing staff concerning hand and nail care. All resident's will have a physician's order that their fingernails are neat and trimmed and the Licensed staff will verify each shift that the resident's nails are neat and trimmed and sign accountability on the treatment sheet.


Audits will be completed for hand and nail care, by Director of Nursing/designee daily for one week weekly for two weeks and monthly for two months. Ongoing random audits will be completed to ensure continued compliance. Negative findings will result in a formation of a Quality Assurance Performance Improvement Committee meeting. Results of all audits will be discussed at the quarterly Quality Assurance Meeting.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that residents were properly positioned for two of 42 residents reviewed (Residents 38, 51), and failed to ensure that physician's orders for medications to prevent constipation were followed for one of 42 residents reviewed (Resident 20).

Findings include:

A diagnosis record for Resident 38, dated January 24, 2019, revealed that the resident had diagnoses that included muscle weakness, Parkinson's disease (disorder of the central nervous system that affects movement and causes tremors) and anxiety disorder. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated November 28, 2018, indicated that the resident was cognitively impaired, required the extensive assistance of two staff for bed mobility and transfers, and required the extensive assistance of one staff for dressing and hygiene.

An occupational therapy discharge summary for Resident 38, dated December 31, 2018, indicated that the resident exhibited good alignment in the chair when out of bed and was able to be safely adjusted by staff when needed. The resident's care plan, dated February 1, 2019, indicated that staff were to ensure proper positioning for the resident when in her wheelchair.

Observations of Resident 38 on February 4, 2019, at 12:06 p.m. revealed that she was sitting in her wheelchair by the nursing station and was leaning to her left side with her left arm resting on the wheel of the wheelcahir. Housekeeping Aide 15 pushed the resident into the elevator while she was still leaning over and with her arm in direct contact with the wheel of her wheelchair.

Observations of Resident 38 on February 4, 2019, at 1:34 p.m. revealed that she was sitting in her wheelcahir in her room and was leaning to the left with her left arm dangling over the wheelchair's arm rest. The resident's left elbow was in direct contact with a silver self-propel device, her left lower arm was in direct contact with the wheel, and her head was tilted to the left. At 1:42 p.m. Licensed Practical Nurse 16 entered the resident's room and administered her medications, and the nurse made no attempts to reposition the resident in her wheelchair.

Interview with Housekeeping Aide 15 on February 4, 2019, at 1:45 p.m. revealed that she did not notice that Resident 38 was leaning over in her wheelchair when she pushed the resident into the elevator.

Interview with Licensed Practical Nurse 16 on February 4, 2019, at 4:02 p.m. revealed that Resident 38 leans in her wheelchair at times, requires nursing assistance for repositioning, and she should have repositioned her when she administered her medications.


A diagnosis record for Resident 51, dated October 15, 2018, revealed that the resident had diagnoses that included a stroke and convulsions (seizures). A quarterly MDS assessment, dated December 6, 2018, indicated that the resident could understand and be understood, that she did not refuse care during the assessment period, that she required the extensive assistance of two for bed mobility and transfers, was non-ambulatory (could not walk), required the extensive assistance of one staff for dressing and hygiene, and had range of motion impairment (impaired movement of the joints) of the upper and lower extremities on one side.

An occupational therapy treatment record for Resident 51, dated December 24, 2018, indicated that a bolster pillow was used under the resident's right upper extremity to decrease swelling. The resident's care plan, dated December 14, 2018, included that the resident's right hand was to be elevated on a bolster pillow when in bed to decrease swelling, and physician's orders dated January 14, 2019, included an order for the resident to have her right lower arm and hand elevated.

Observations of Resident 51 on February 4, 2019, at 4:14 p.m. revealed that the resident was in bed and her right arm and hand were not elevated.

Upon interview with Nurse Aide 12 on February 4, 2019, at 4:35 p.m. she indicated that Resident 51's arm was to be elevated when it was swollen and that she did not need it elevated at this time.

Interview with Registered Nurse 14 on February 6, 2019, at 12:14 p.m. confirmed that Resident 51's right arm and hand were to be elevated at all times when she was in bed, which was ordered by the physician to prevent edema (swelling).


A significant change MDS assessment for Resident 20, dated November 8, 2018, indicated that the resident was alert and oriented, required the extensive assistance of one staff person for hygiene and dressing, required the extensive assistance of two staff for bed mobility, and she was frequently incontinent of bowel. Physician's orders, dated January 19, 2019, included an order for the resident to receive 30 milliliters of Milk of Magnesia (an oral laxative) as needed for constipation if the resident did not have a bowel movement in eight shifts, and if the Milk of Magnesia was ineffective then a 10 milligram (mg) Bisacodyl suppository (a laxative inserted rectally) was to be given.

Resident 20's bowel records for January 2019 revealed that the resident did not have a bowel movement from January 28-31 (4 days), and there was no documented evidence that staff administered Milk of Magnesia or a Bisacodyl suppository as ordered by the physician.

Interview with the Director of Nursing on February 7, 2019, at 1:08 p.m. confirmed that staff should have administered Milk of Magnesia to Resident 20 on the third day without a bowel movement, and the a Bisacodyl suppository as needed if the Milk of Magnesia was ineffective, and there was no documented evidence that the medications were administered as ordered by the physician.

42 CFR 483.25 Quality of Care
Previously cited 8/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.



 Plan of Correction - To be completed: 03/22/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.
Resident 38 continues to reside in this facility and proper wheelchair positioning is being maintained.
Housekeeping Aide 15 has been re-educated on proper positioning of residents prior to transport.
Licensed Practical Nurse 16 has been re-educated on proper positioning of residents prior to administration of medications.
The milk of magnesia was to be given at bedtime on the third day if the resident did not have a bowel movement. The evening nurses are to obtain an electronic report of residents that did not have a bowel movement by the third day so the milk of magnesia could be given. Since other residents did receive the medication, it is apparent that the nurse failed to not that resident 20 also should have received the medication. It was also identified that the electronic medical record, Point Click Care, does not acknowledge small bowel movements as a bowel movement and this will be included in the nursing education.
Current residents will be reviewed to ensure they are properly positioned in their wheelchairs. Identified positioning needs will be referred to therapy for recommendations.
Appropriate facility staff will be educated on federal regulation 684 and the importance of maintaining proper resident positioning. Non-nursing staff will be educated to report identified positioning needs to nursing for intervention.
The Restorative Nurse/ Designee will conduct audits to ensure proper resident positioning in wheelchairs is maintained. These audits will be on 5 residents per unit daily for one week, weekly for two weeks, monthly for two months, and randomly thereafter.
Results of these audits will be reviewed in the facility Quality Assurance Performance Improvement meeting for further recommendations for continued compliance.

Resident 51 returned from the hospital on February 19, 2019 and is being evaluated by therapy for the need for elevation of the right arm and hand.
Current residents with Physician orders for positioning devices will be reviewed by the Restorative Nurse/designee to ensure the orders are being followed.
The Activities of Daily Living sheets that the Nurse Aides utilize will be updated with Physician's orders for positioning and other devices.
Nursing staff will be educated on federal regulation 684 and the importance of positioning residents per physician orders.
The Restorative Nurse/Designee will audit that residents are being positioned per physician's orders. These audits will be completed on 5 residents per unit daily for one week, weekly for two weeks, monthly for two months then randomly thereafter.
Results of these audits will be reviewed in the facility Quality Assurance Performance Improvement meeting for further recommendations for maintain compliance.

Resident 20 continues to reside in this facility and physician orders for constipation are being followed.
Current residents will be reviewed to ensure that those who have not had a timely bowel movement per protocol in the past two weeks had medications for constipation administered per physician orders.
Licensed Nurses will generate an electronic report at the end of the shift to identify residents who have not had a bowel movement and require physician ordered medications. Interventions for constipation for each identified resident will be communicated during change of shift report for appropriate follow up.
The licensed nurses will be educated on federal regulation 684 and the importance of following physician orders for constipation.
The Director of Nursing/Designee will audit that current residents are receiving physician ordered medications. These audits will be completed on five residents per unit daily for one week, weekly for two weeks, monthly for two months, then randomly.
Results of these audits will be reviewed in the facility Quality Assurance Performance Improvement meeting for further recommendations to maintain compliance.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that preventive pressure ulcer interventions were provided for one of 42 residents reviewed (Resident 51).

Findings include:

The facility's policy regarding pressure ulcers (skin impairment caused by unrelieved, prolonged pressure), dated November 1, 2018, indicated that the intervention to elevate (free float, suspend) the heels as tolerated would be initiated for residents with a moderate risk for pressure ulcers on a standardized pressure ulcer risk assessment tool.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated December 6, 2018, indicated that the resident was confused, required the extensive assistance of two staff for bed mobility and transfers, was non-ambulatory (could not walk), had range of motion impairment the upper and lower extremities on one side (impairment to the movement of the joints), had an unstageable (the wound cannot be staged because the wound bed cannot be visualized due to the presence of non-viable or dead tissue) pressure ulcer, and was at risk for further pressure ulcers.

Skin detail reports for Resident 51, dated January 29, 2019, indicated that the resident had an unstageable pressure ulcer of her right lateral (side of) heel. An occupational therapy note, dated December 3, 2018, indicated that the resident reported that she did not like the bilateral (both sides) heel boots and that she was a trialing a heel suspension device that the resident reported increased her comfort.

Physician's orders for Resident 51, dated January 14, 2019, and the resident's treatment records for February 2019, included that she was to have bilateral heel lift boots on while in bed, and her care plan, revised on January 25, 2019, indicated that that she needed a heel suspension device to protect the skin while in bed.

Observations of Resident 51 on February 4, 2019, at 4:14 p.m. revealed that she was lying on her back in bed with her feet directly on the bed, and the heels suspension device was sitting against the wall.

Observations on February 5, 2019, at 4:49 p.m. revealed that Resident 51 was in bed with her feet directly on the bed, and the heels suspension device was to right side of her bed on a chair.


Upon interview with Registered Nurse 1 on February 4, 2019, at 4:42 p.m. she indicated that Resident 51 does not like to use the heels suspension device at times. Interview with Licensed Practical Nurse 11 on February 4, 2019, at 4:44 p.m. revealed that she was not aware that the device was not in use at that time; however, at times, the resident does not want to use the device, at which times, pillows should be used. The nurse also indicated that the resident is more cooperative with using the device in the evenings.

There was no documented evidence on Resident 51's clinical record related to her intolerance with using the heel suspension device at times, as indicated during the interviews with Registered Nurse 1 and Licensed Practical Nurse 11.

Interview with Registered Nurse 10 (the facility's wound nurse) on February 6, 2019, at 10:38 a.m. revealed that she was not aware that Resident 51 would not use the heels suspension device at times, and that she should have been notified so she could monitor the resident to determine any trends/patterns of non-compliance, and to determine if changes were needed to the resident's care plan.

Interview with the Nursing Home Administrator on February 6, 2019, at 11:30 a.m. confirmed that there was no documented evidence regarding Resident 51's intolerance of the heel suspension device, and the resident's care plan should have reflected her needs related to her intolerance.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/6/18, 8/13/18, 3/23/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/13/18, 3/23/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.





 Plan of Correction - To be completed: 03/22/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.
Resident 51 was readmitted to the facility on February 19, 2019 and is being evaluated for her need to have her heels elevated. Resident intolerance to physician ordered elevation will be documented to ensure alternative interventions are initiated and will be care planned accordingly.
Current residents with physician ordered/care planned heel elevation interventions will be reviewed by the Wound Nurse/designee to ensure that these interventions are in place.
Physician ordered/care planned interventions for elevation of heels will be documented on the Nurse Aide Activities of Daily Living sheets and will be verified by the Licensed Nursing Staff on the Electronic Treatment record.
The Nursing staff will be educated on federal regulation 686 and the importance of elevating heels per physician orders and to document any resident intolerance or non-compliance so that alternative interventions can be offered.
The Wound Nurse/designee will audit residents to ensure interventions for elevation of heels are in place per order. These audits will be completed on five residents per unit daily for one week, weekly for two weeks, monthly for two months, then randomly.
Results of these audits will be reviewed in the facility Quality Assurance Performance Improvement meeting for further recommendations to maintain compliance.

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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions for fall prevention were in place to prevent injuries from falls for two of 42 residents reviewed (Resident 24, 51), and failed to complete investigations into incidents to ensure resident safety for one of 42 residents reviewed (Resident 43).

Findings include:

The facility's policy regarding fall management, dated November 1, 2018, indicated that the facility would implement measures for residents at risk, in an effort to manage falls and prevent serious injury.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated November 13, 2018, indicated that the resident was cognitively impaired and required extensive to total assistance of one to two persons for daily care tasks. Physician's orders, dated May 22, 2018, and a care plan regarding the resident's fall risk, dated August 10, 2018, included that the resident was to use a low bed with bilateral (on both sides) fall mats (placed on the floor beside the bed to prevent injury should the resident fall out of bed).

Observations on February 4, 2019, at 9:45 a.m. and 12:30 p.m. revealed that Resident 24 was in bed on her left side, and there was a fall mat on the floor on the left side of the bed. Another fall mat was leaning against a wheelchair in the room, and there was no fall mat on the floor on the right side of the bed.

Interview with Nurse Aide 2 on February 3, 2019, at 12:58 p.m. revealed that Resident 24's fall mat should have been down on the floor on the right side of the resident's bed. She indicated that housekeeping staff probably removed the mat when they mopped the floor in the resident's room and it was not replaced.


A diagnosis record for Resident 51, dated October 5, 2018, revealed that the resident had diagnoses that included stroke, anxiety, and convulsions (seizures). A quarterly MDS assessment, dated December 6, 2018, indicated that the resident was confused, required extensive assistance from two staff for bed mobility and transfers, was nonambulatory (could not walk), had a range of motion impairment (impaired movement of the joints) of the upper and lower extremities on one side, and had a history of falls. Physician's orders, dated November 27, 2018, included an order for her mattress to have a bolstered overlay in use (an overlay with built-up sides). Physician's orders dated January 14, 2019, and the resident's care plan dated November 28, 2018, included that bilateral assist handrails were to be in use to aid in positioning and that they were to be padded.

Nursing note for Resident 51, dated November 14, 2018, at 8:14 p.m. and November 28, 2018, at 12:20 p.m. revealed that the resident was found on the floor by her bed.

Observations of Resident 51 on February 4, 2019, at 4:14 p.m. , 4:23 p.m., and 4:35 p.m. revealed that the resident was in bed and there was no bolster on the right lower area of her bed, the right assist rail was not padded, and the left assist rail had padding on only the top four inches of the rail and the rest of the padding was hanging down and not covering the rail.

Interview with Nurse Aide 12 on February 4, 2019, at 4:35 p.m. revealed that therapy staff put Resident 51 into bed around 2:30 p.m. She confirmed that the bolster on bottom right of the resident's bed was not in place and that the assist rails were not padded properly. At 4:54 p.m. Nurse Aide 12 found the bolster foam behind the headboard of the resident's bed.

Interview with Registered Nurse 1 on February 4, 2019, at 4:42 p.m. revealed that both of Resident 51's assist rails were to be padded and that four bolsters should be in place on the upper and lower halves, and the right and left sides of the resident's bed. Registered Nurse 1 indicated that the bottom right bolster would have been removed when the resident was transferred out of bed and should have been replaced when she was put back into bed.


Admission diagnoses for Resident 43, dated May 2, 2017, revealed that the resident had diagnoses that included a fractured femur (long bone in the upper leg) and dementia (brain disorder that causes declines in memory and other thinking skills). A quarterly MDS assessment, dated November 30, 2018, revealed that the resident was cognitively impaired, required supervision with eating, required extensive assistance with hygiene, and was totally dependent on staff for bathing. The resident's care plan, dated November 16, 2018, revealed that the resident was known to cut off his Wanderguard (a bracelet that causes an alarm to sound when it is in the vicinity of an alarmed door), that he was to have no knives on his meal trays, and that the Wanderguard bracelet was to be checked for placement and function every shift.

A nursing note for Resident 43, dated December 21, 2018, at 5:09 p.m. revealed that a nurse aide notified the licensed practical nurse that the resident cut off his Wanderguard bracelet with a butter knife, and the roommate's family stated that they witnessed him cut off his bracelet and throw it in the trash can. The resident's Wanderguard was found and new bracelet was placed on the resident's left ankle.

There was no documented evidence that statements were obtained from staff who worked during the shift in question on December 21, 2018. There was no documented evidence that a thorough investigation was completed to determine how Resident 43 obtained the butter knife.

Interview with the Director of Nursing on February 7, 2019, at 2:45 p.m. confirmed there was no documented evidence that an investigation was completed for Resident 43's incident on December 21, 2018.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 8/13/18, 3/23/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/6/18, 8/13/18, 3/23/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.





 Plan of Correction - To be completed: 03/22/2019

DISCLAIMER: The following is submitted for plan of correction purposes only and should not be construed as an admission.

Resident R24 continues to reside in this facility and has a physician's order and is care planned for fall mats and they are in place.

Current residents with physician orders for fall mats will be reviewed to ensure that they are in place as ordered.
Housekeeping staff will be educated not to remove or relocate fall mats without nursing's knowledge in order to ensure fall mats are in place for resident's safety.
The nursing staff will be educated on federal regulation 689 and the importance of providing physician ordered/care planned interventions to prevent falls and injury.
The Restorative Nurse/ Designee will audit that physician ordered/care planned fall mats are in place. These audits will be completed on five residents per unit daily for one week, weekly for two weeks, monthly for two months, and then randomly.
Results of these audits will be reviewed in the facility Quality Assurance meeting for further recommendations for maintaining compliance.

Resident 51 was readmitted to the facility on February 19, 2019 is currently being evaluated for safety interventions and will be care planned accordingly. The bolsters and padding to the assistive side rails are in place.
Current residents with physician ordered fall safety interventions will be reviewed to ensure they are in place as ordered.
Therapy staff will be educated to inform nursing when they return a resident to bed to ensure all interventions are in place.
The Restorative Nurse/Designee will educate nursing staff on federal regulation 689 and the importance of ensuring physician ordered/care planned fall interventions for bed safety are in place.
The Director of Nursing/ Designee will audit that interventions for fall/bed safety are in place as ordered/ care planned. These audits will be completed on five residents per unit daily for one week, weekly for two weeks, monthly for two months, then randomly.
Results of these audits will be reviewed in the facility Quality Assurance meeting for further recommendations for maintaining compliance.

Resident 43 continues to reside in this facility and has a wanderguard in place. The investigation revealed that the resident ate his meal in the main dining room; therefore, would have had access to a butter knife that was used to cut the wanderguard bracelet. A second wanderguard bracelet was placed on the resident's means of mobility as an extra precaution. The resident is care planned not to have butter knifes on his tray to prevent the resident from removing the wanderguard bracelet. The resident currently eats his meals in the alcove under supervision.
Current residents with physician orders for Wanderguards will be reviewed to ensure that they are in place and care panned interventions for their safe use.
The nursing staff will be educated on federal regulation 689 and the importance of making sure that all care planned interventions for the safe use of the Wanderguards are in place.
The Director of Nursing/ Designee will audit that Wanderguards and related interventions for their safe use are in place. These audits will be completed on five residents per unit daily for one week, weekly for two weeks, monthly for two months, then randomly.
Results of these audits will be reviewed in the facility Quality Assurance meeting for further recommendations for maintaining compliance.

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 a review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen was administered according to physician's orders for two of 42 residents reviewed (Residents 16, 48), and failed to ensure that the air filters on oxygen concentrator units were cleaned in accordance with manufacturer's instructions for one of 42 residents reviewed (Resident 16).

Findings include:

The manufacturer's instructions for the DeVilbiss Oxygen Concentrator (device that concentrates oxygen in room air) indicated that the air filter should be cleaned at least once a week by removing it, washing it in warm water and dishwashing detergent, rinsing it thoroughly with warm tap water, towel drying it, and allowing the filter to completely dry before re-installing it into the oxygen concentrator unit.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated November 6, 2018, indicated that the resident used oxygen. Physician's orders, dated June 13, 2018, included an order for the resident to use continuous oxygen at 4 liters per minute via nasal cannula (tubing that delivers oxygen into the nostrils) for hypoxia (low oxygen level).

Observations on February 4, 2019, at 10:45 a.m. revealed that the resident was lying in bed without his oxygen in place as ordered by the physician, and there was an accumulation of dust on the outside of the vent that housed the air filter.

Interview with Licensed Practical Nurse 3 on February 4, 2019, at 10:45 a.m. revealed that the resident was usually compliant with wearing oxygen and he confirmed that the oxygen tubing and nasal cannula were on the floor and not in use as ordered. He also confirmed that there was an accumulation of dust on the oxygen concentrator vent, and he did not know who was responsible for cleaning the vents on the oxygen concentrator units.

Interview with the Nursing Home Administrator on February 6, 2019, at 11:00 a.m. revealed that the night shift staff (11:00 p.m. to 7:00 a.m.) were responsible for cleaning the air filters on the oxygen concentrator units, but she could provide no documented evidence that the air filters were cleaned.


An annual MDS assessment for Resident 48, dated December 5, 2018, indicated that the resident was cognitively impaired, dependent on the extensive assistance of one to two staff for daily care tasks, had diagnoses that included non-Alzheimer's dementia and congestive obstructive pulmonary disease (COPD - a lung disease that makes it difficult to breathe), and used oxygen. Physician's orders, dated January 19, 2019, and the resident's care plan for oxygen, dated August 28, 2018, revealed that the resident was ordered continuous oxygen at 3 liters per minute via nasal cannula for a diagnosis of COPD.

Observations on February 4, 2019, at 11:00 a.m. revealed that Resident 48 was in bed with oxygen in use and the oxygen concentrator unit was set at 5 liters per minute instead of 3 liters per minute as ordered by the physician.

Interview with Licensed Practical Nurse 4 on February 4, 2019, at 11:06 a.m. confirmed that Resident 48's oxygen concentrator unit was set at 5 liters per minute instead of 3 liters per minute as ordered by the physician, and she confirmed that there were no recent issues documented to indicate that the resident's oxygen flow rate was increased.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/6/18, 8/13/18, 3/23/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/6/18, 8/13/18, 7/10/18, 3/23/18.



 Plan of Correction - To be completed: 03/22/2019

DISCLAIMER: The following is submitted for plan of correction purposes only and should not be construed as an admission.
Resident R16 and R48's oxygen liter flow was immediately adjusted to the amount prescribed by the physician. Resident R16's oxygen filter was cleaned per the manufacturer's instructions.
Current residents receiving continuous oxygen will be reviewed to ensure that the resident is receiving the correct liter flow per physician's order. Residents receiving oxygen via a concentrator will have the filter on the concentrators checked by Central Supply to ensure that they are clean and free of dust.
Residents receiving oxygen will be monitored every shift by the licensed nurse and it will be documented on the medication administration record. Nursing Assistants do not administer oxygen.
Central Supply will order a duplicate set of concentrator filters and Central Supply will remove the filters every week on a specified day, will clean and dry the filters per manufacturer's instructions and place the duplicate filter on the concentrator.
Licensed nursing staff will be educated on federal regulation 695 and the need to provide respiratory care per physician's order.
Random audits will be completed by the Director of Nursing/designee to ensure that the residents are receiving the correct liter flow as ordered by the physician and that the resident's receiving oxygen via a concentrator have a clean filter.
These audits will be completed daily for one week, weekly for two weeks, monthly for two months and then randomly.
Negative findings will result in a Quality Assurance and Performance Improvement meeting.

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 manufacturer's instructions, observations and staff interviews, it was determined that the facility failed to label a multi-dose container of tuberculin serum with the date it was opened in one of one medication rooms reviewed (second floor).

Findings include:

The manufacturer's instructions for Tubersol (a serum used to test for tuberculosis - a bacterial infection of the lungs), dated March 2016, revealed that a vial of Tubersol that has been in use for 30 days should be discarded.

Observations in the second floor medication storage room on February 6, 2019, at 1:38 p.m. revealed that one previously opened vial of Tubersol serum was not labeled with the date it was opened. Interview with Registered Nurse 4 at that time confirmed that the vial of Tubersol should have been dated when it was opened.

28 Pa. Code 211.9(h) Pharmacy services.

28 Pa. Code 211.12(d)(1)Nursing services.
Previously cited 12/6/18, 8/13/18, 3/23/18.








 Plan of Correction - To be completed: 03/22/2019

The following is submitted for plan of correction purposes only and should not be construed as an admission.
The unlabeled/undated multi-dose container of tuberculin serum has been discarded.
An audit of all open containers will be conducted by the Director of Nursing/designee to ensure that the container is dated with the date that it was opened. Any container that is undated will be discarded. The pharmacy consultant will also check these areas during their routine visits.
The policy for dating and initialing medication vials after opening will be reviewed and revised. Licensed staff will be educated on regarding labeling and storing of drugs and biologicals and the facility policy.
A random ongoing audit of medication carts, rooms and refrigerators will be completed by the Director of Nursing/designee, as well as the pharmacy consultant, to ensure that policy is followed.
Findings of these audits will be reviewed at the Quality Assurance meeting on an ongoing basis to ensure compliance.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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

Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for two of 42 residents reviewed (Residents 91, 102).

Findings include:

A diagnosis record for Resident 102, dated May 11, 2018, revealed that the resident had diagnoses that included intestinal obstruction (blockage in the intestines) and post surgical malabsorbtion (defects occurring during the digestion and absorption of food nutrients following gastrointestinal surgery). Physician's orders, dated February 4, 2019, included an order for the resident to receive total parenteral nutrition (TPN - nutrition provided intravenously - directly into a vein) Monday, Wednesday and Friday at a rate of 152 cubic centimeters (cc's) per hour (cc/hr) from 12:00 p.m. to 1:00 p.m., then at 227 cc/hr from 1:00 a.m. to 10:00 a.m., then decreased back to 152 cc/hr from 10:00 p.m. to 12:00 a.m. for dumping syndrome (food moves too quickly from the stomach to the first part of the intestine).

Observations of Resident 102 on February 4, 2019, at 3:47 p.m. revealed that the TPN was infusing at the rate of 227 cc/hr and it was labeled to run over 12 hours.

Interview with Registered Nurse 4 on February 7, 2019, at 9:51 p.m. revealed that Resident 102's TPN was to run from 12:00 p.m. to 12:00 a.m. (12 hours), that the current physician's order was not correct, and that the Medication Administration Record (MAR) indicated that the TPN was to start at 12:00 p.m. and the rate increase to 227 cc/hr was at 1:00 p.m.

Interview with Registered Nurse 1 on February 7, 2019, at 3:03 p.m. revealed that Resident 102's TPN was changed to start at noon on January 21, 2019, that the rate increase was to be from 1:00 p.m to 10:00 p.m. and that the physician's order was entered incorrectly.

A diagnosis record for Resident 91, dated October 28, 2018, revealed that the resident had diagnoses that included bacteremia (bacteria in the blood) and left lower leg cellulitis (bacterial infection of the inner layers of the skin). Physician's orders dated January 9, 2019, included and order for the resident to receive intravenous (IV - directly into a vein) Rocephin (an antibiotic) via a hep lock (peripheral IV access) every 24 hours for 7 days.

A nursing note for Resident 91, dated January 9, 2019, indicated that Registered Nurse 10 inserted a 24 gauge intravenous catheter (IV) into the right wrist. A nursing note, dated January 12, 2019, indicated that the IV antibiotic was infusing through a peripherally inserted central catheter (PICC line - a long catheter inserted in the upper arm and that ends near the heart) in the left arm. Documentation from a vascular access specialist for Resident 91, dated January 12, 2019, indicated that the resident had a peripheral 20 gauge angio catheter (catheter placed in the vein) inserted. A nursing note, dated January 21, 2019, indicated that the nurse entered the resident's room and noted a mid-line catheter (a type of peripherally inserted catheter that is shorter than a PICC line and does not go near the heart) lying on the resident's night stand, that the registered nurse assessed the mid-line site for bleeding, and that she notified the physician that the midline catheter was dislodged.

There was no documented evidence that Resident 91 had a min-line catheter and no documented evidence regarding the removal of the 24 gauge catheter in the right wrist.

Interview with the Director of Nursing on February 7, 2019, at 12:10 p.m. confirmed that Resident 91 never had a midline catheter as indicated in nursing note dated January 21, 2019, and there was no documentation regarding the removal of the 24 gauge catheter, which should have been documented.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 8/13/18.


 Plan of Correction - To be completed: 03/22/2019

DISCLAIMER: The following is submitted for plan of correction purposes only and should not be construed as an admission.
Resident 102 physician orders regarding the total parenteral nutrition has been clarified.
Resident 91 continues to reside at the facility and no longer received intravenous antibiotic therapy.
Current residents receiving intravenous medication and/or total parenteral nutrition will be reviewed to ensure that the documentation regarding the order and the intravenous therapy are accurate.
The policy on nursing documentation-general guidelines will be reviewed an revised as necessary.
The licensed nursing staff will be educated regarding 0842 and the importance of accurate documentation. The licensed nurse's will verify and document the specific intravenous type on the medication administrator record every shift.
An audit of the medication administration record and nursing documentation will be completed by the Director of Nursing/designee to ensure accurate documentation. The audit will be completed daily for one week, weekly for two weeks and then randomly.
The results of the audit will be reviewed at the Quality Assurance meeting.
483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
483.95(g) Required in-service training for nurse aides.
In-service training must-

483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

483.95(g)(2) Include dementia management training and resident abuse prevention training.

483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at 483.70(e) and may address the special needs of residents as determined by the facility staff.

483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:


Based on review of a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides received at least 12 hours of in-service training for two of 26 nurse aides reviewed (Nurse Aides 12, 17).

Findings include:

A list of nurse aides provided by the facility revealed that based on their months and days of hire, Nurse Aides 12 and 17 should have received at least 12 hours of in-service training between October 2017 and October 2018. However, there was no documented evidence that Nurse Aides 12 and 17 received at least 12 hours of in-service training as required.

Interview with Registered Nurse 18 (the facility's staff education nurse) on February 7, 2019, at 3:13 p.m. confirmed that Nurse Aides 12 and 17 did not receive the required 12 hours of education between October 2017 and October 2018.









 Plan of Correction - To be completed: 03/22/2019

Nurse Aides 12 and 17 have now received their twelve hours of in-service training.
All Nurse Aide in-service training will be reviewed to ensure that the Nurse Aides have received at least twelve hours of in-service training.
The tracking mechanism for the in-service hours has been revised and the Staff Development Nurse has been educated regarding the importance of 0947.
The Staff Development Nurse/designee will audit the Nurse Aides in-service training hours on an ongoing monthly basis to ensure that the Nurse Aides are receiving/attending their required hours of education.
The findings of the audits will be reviewed at the quarterly Quality Assurance meetings.

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