Nursing Investigation Results -

Pennsylvania Department of Health
HARLEE MANOR NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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HARLEE MANOR NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  58 surveys for this facility. Please select a date to view the survey results.

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HARLEE MANOR NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to two complaints completed on June 4, 2019, it was determined that Harlee Manor 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 related to the health portion of the survey process.










































 Plan of Correction:


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 a review of clinical records, facility documentation, and interviews with facility staff, it was determined that the facility failed to provide medications as ordered by the physician for one of three resident records reviewed. (Resident R1)

Findings include;

Resident R1 was admitted to the facility at approximately 4:00 p.m. on May 17, 2019, from a hospital to continue treatment of the left foot with a wound vacuum (vacuum to assist closure of a wound and to promote healing), and intravenous antibiotics. The resident diagnoses included Diabetes (the body's inability to produce insulin which enables sugar to pass from the blood stream to the cells for nourishment), Abscess (swollen area within body tissue containing an accumulation of pus) with MRSA (Methicillin- Resistant Staphylococcus Aureus, more complicated infection due to the resistance of common antibiotics) infection of the left great toe, Depression (loss of interest in pleasurable activities, change in sleep patterns, appitite and routine), Obesity (excessive amount of body fat), and had a PICC line (catheter placed in a large vein that carries blood to the heart), and had an order to be non weight bearing on the left foot.

The resident admission assessment indicated that the resident had a BIMS (brief interview for mental status) of 15, which indicated the resident was cognitively intact. The Director of Nursing stayed beyond her shift to complete admission documentation for the new later admission, she forwarded the orders to the physician who responded and confirmed the orders by 7:43 p.m. The resident was due to receive 9:00 p.m. medications as follows; Buspirone 10 milligrams, for anxiety, Sertraline 100 milligrams, an anti depressant, Lipitor 40 milligrams, a cholesterol lowering medication, Accucheck (fingerstick to determine a persons blood glucose level) and an intravenous antibiotic Vancomycin 500 milligrams every twelve hours due at 9:00 p.m. to be administered through the PICC line. Review of documentation on June 4, 2019, revealed that the MAR ( medication Administration Record) was not signed by the nurse. There were no initials documented on the MAR indicating that the medications were given, and Nursing progress notes did not include any reference that these medications were provided to the resident. The facility has a Omnicell cabinet ( automated medication dispensing cabinet) which makes medications readily available for residents who are new admissions after verification is received by the physician, or a needed medication for a new order. Review of medications included in the Omnicell cabinet revealed that all of the medications ordered for the resident at 9:00 p.m. were available, but were not dispensed and provided to the resident as indicated in the physician's admission orders.

Interview with the Director of Nursing on June 4, 2019, at 2:45 p.m. confirmed that the resident had not received the 9:00 p.m. medications, which were available in the Omnicell. The facility policy "Admissions- Rules and Regulations" noted as new and reviewed on 11/ 2017, indicated that "Any medications needing to be administered after admission orders are verified with the attending physician should be obtained from the Omnicell".

The facility failed to obtain and administer medications as ordered by the physician to Resident R1.

28 Pa. Code 211.12 (d)(1)(5) Nursing services.
Previously cited 8/16/18 and 9/14/17.












 Plan of Correction - To be completed: 07/30/2019

F0684

As related to R1, the facility is unable to correct the deficiency as the resident is no longer a resident of our facility. To prevent reoccurrence of this violation and protect all residents from similar situations (including new admissions) in regard to receiving medications and appropriate treatments, the following plan of correction will be implemented.

Policies and procedures for providing Pharmaceutical services is being reviewed and will be updated if needed to include procedures that assure accurate acquiring, receiving, dispensing and administration of all medications to meet the needs of residents. The following will be implemented to insure reoccurrence of this practice does not occur.

1.Professional nurses (RN and LPN) will be reeducated on the use of the Omnicell (automated dispensing system).
2.Professional nurses (RN and LPN) will be reeducated on the Admission process.
3.In the event that any medication or treatment is not available in a timely manner, the attending physician and/or medical director will be notified for an appropriate alternative.
4.The Supervisors will be responsible for ensuring that all medications and treatments are completed in a timely manner.
5.IV Medications in Omnicell will be reviewed and updated if needed to insure availability. All IV medications will be called to the Pharmacy as soon as orders confirmed by attending physician.
6.DON/ADON and/or designee will review new admissions to ensure medications and treatments were received and implemented in a timely manner. This will be monitored and reported to the quarterly Quality Assurance Program Improvement meeting.

The Director of Nursing and/or designee is responsible for the implementation and compliance with this plan of correction.

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 a review of clinical records, facility documentation and interview with facility staff, it was determined that a resident was not adequately supervised and monitored allowing the resident to exit the facility without staff intervention for one of three resident records reviewed. (Resident R1)

Findings Include;

Resident R1 was admitted to the facility at approximately 4:00 p.m. on May 17, 2019, from a hospital to continue treatment of the left foot with a wound vacuum (vacuum assisted closure of a wound to promote healing), and intravenous antibiotics. The resident's diagnoses included Diabetes (the body's inability to produce insulin which enables sugar to pass from the blood stream to cells for nourishment), Abscess (swollen area within body tissue containing an accumulation of pus) with MRSA (Methicillin- Resistant Staphylococcus Aureus, more complicated infection due to the resistance of common antibiotics) infection of the left great toe, Depression (loss of interest in pleasurable activities, change in sleep patterns, appitite and routine), Obesity (excessive amount of body fat), and had a PICC (catheter placed in a large vein that carries blood to the heart) line in his upper right arm, to administer the intravenous antibiotic therapy, and had an order to be non weight bearing for the left foot.

The resident assessment on admission indicated that the resident had a BIMS (brief interview for mental status) of 15, which indicated the resident was cognitively intact. The resident was reported as being pleasant and friendly on admission. Nursing documentation indicated that the resident was approached at 1:15 a.m. to administer a PPD (Mantoux test to screen for tuberculosis- serious infectious disease that affects your lungs), which the resident refused stating that he had one at the doctors office. The nurse returned with the nursing supervisor at 1:30 a.m. to again ask to administer the PPD, and the resident again refused and complained that he would only speak to one person at a time. The resident indicated he wanted his door closed. At 3:25 a.m. the facility received a call from a local hospital to report that this resident had come to the emergency room on foot. Facility staff went to the hospital to retrieve the resident who was standing in the front of the hospital near the curb. Resident R1 refused to return to the facility. Staff called 911 but the resident continued to refuse stating he would only go to the hospital he was at before being transferred to the nursing home. The resident was transported by the police to the hospital he requested.

The facility has front doors which are locked from entering and exiting the building, however the North wing, where the resident resided, is locked only from entering, but not exiting the building. The resident left the building undetected and unnoticed until a call was received from the hospital at 3:25 a.m. The nurse at that time checked the resident's room, and his door was closed and he was not there. The resident, who had an order to be non weight bearing on his affected left foot, ambulated to the hospital which is approximately one half mile away.

The facility failed to provide adequate supervision for Resident R1.

28 Pa. Code: 211.12 (c)(d)(5) Nursing Services
Previously cited 9/14/17.

























 Plan of Correction - To be completed: 07/30/2019

F0689

As related to R1, the facility is unable to correct the deficiency as the resident is no longer in the facility. It was determined that R1 was able to exit the facility without staff intervention. The facility's front doors are locked from entering, however, not from exiting. In order to ensure that this violation does not reoccur and to protect all residents, the following plan of correction will be implemented. R1 was alert and oriented and non-weight bearing however, chose to leave on his own accord without informing the staff.

The facility has contacted a Lock & Alarm Company and received a proposal for installation of a "Door Management Alarm." This alarm will be programmed to ring between 10:00 PM and 8:00AM whenever the North Wing doors are opened from the inside. This is "Not" a locking arrangement. The alarm will alert the staff of anyone exiting the building during this specific time frame. Once this alarm system is approved and installed, the Maintenance staff will monitor function on a monthly basis.

Nursing staff on 3-11 and 11-7 shifts will be in-serviced on the importance of accounting for residents throughout the shift while maintaining resident dignity and privacy. A staff member will be at the Nursing Station at all times to monitor the doors beginning immediately.

The facility Administrator and the Director of Nursing/designees will be responsible for implementation and compliance with this plan of correction.


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