Nursing Investigation Results -

Pennsylvania Department of Health
HOLY FAMILY MANOR
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HOLY FAMILY MANOR
Inspection Results For:

There are  68 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.
HOLY FAMILY MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey and Civil Rights Compliance survey and an Abbreviated survey in response to three complaints and an abbreviated survey in response to an allegation of abuse completed on March 15, 2019, it was determined that Holy Family Manor, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure regulations as they relate to the Health portion of the survey.



 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 clinical record review, interview, and review of facility documentation submitted to the Department, it was determined that the facility failed to ensure that staff provided sufficient safety and supervision to prevent a fall that resulted in serious injuries (fracture) for one of three residents reviewed (Resident 184).

Findings include:

Clinical record review revealed that Resident 184 had diagnoses that included a history of falling, generalized muscle weakness, abnormal gait and mobility, stroke, and left-sided hemiparesis and hemiplegia (paralysis and weakness) related to the stroke. Review of documentation initially submitted by the facility to the Department on March 5, 2019, revealed that on March 3, 2019, at 1:30 p.m. Employee 6, a nurse aide, attempted to transfer the resident off the toilet alone. Documentation reflected that during the transfer the resident began to fall and Employee 6 lowered the resident to the floor. In a written statement dated March 5, 2019, Employee 6 noted that duing the transfer the resident's "right leg gave out and the left leg was a little to the side so I straighten [sic] it out and put her on the floor." Nurses' notes reflected that about 15 hours later on March 4, 2019, at 4:47 a.m. the resident began to complain of leg pain. Nurses' notes indicated that at 11:00 a.m. that day, the resident's left leg was "sore and swollen with bruising." Staff notified the physician who ordered X-rays which revealed fractures of the left tibia and fibula (two bones in the lower leg). On March 5, 2019, the resident was admitted to the hospital for evaluation and treatment of the fractures.

Review of the Minimum Data Set (MDS - a mandated assessment of resident care needs) annual assessment dated February 21, 2019, revealed that the resident had an ability to express ideas and wants if prompted and comprehends most conversation. The assessment also noted that the resident could not walk and was totally dependent on the assistance of two staff for toileting and transfers. Both the resident Care Area Assessment (CAA) and the revised care plan dated February 26, 2019, revealed that the resident had balance problems, was at risk for falls and was to be free from injuries.

Clinical record documentation revealed that since March 8, 2018, the resident had a physician's order directing that the resident was to be transferred with the assistance of two staff. In addition, physical therapy documentation dated March 1, 2019, reflected that the resident continued to require two staff for all transfers.

In an interview conducted on March 14, 2019, at 1:35 p.m. the resident confirmed that she "broke her left leg" because one nurse aide transferred her from the toilet to the wheelchair. The resident further stated that she has "pain and my body will never be the same."

483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices
Previously cited 3/23/18

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 3/23/18, 6/24/17, 4/6/17










 Plan of Correction - To be completed: 04/24/2019

0689
SS = G Free of Accident Hazards/Supervision/Devices: (failed to ensure that staff provided sufficient safety and supervision to prevent a fall that resulted in serious injury).
1. Employee who failed to follow resident plan of care and failed to follow facility policy no longer employed by facility.
2. In-service to nursing staff on importance of following each resident's Plan of Care to ensure safety of resident and employee.
3. Nursing Administration to monitor compliance and report to QAPI Committee monthly until resolved.
4. Completion by April 24, 2019.

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

Based on clinical record review, observation, and interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for one of 27 sampled residents (Resident 65) and the facility failed to implement comprehensive care plan interventions for three of 27 residents reviewed (Residents 16, 35, 77).

Findings include:

Clinical record review revealed that Resident 16 had a diagnosis that included dysphagia (difficulty swallowing). A Minimum Data Set (MDS - a mandated assessment of resident care needs) assessment completed February 25, 2019, revealed that the resident was alert and oriented and required extensive assistance of one staff member for personal hygiene. The Care Area Assessment (CAA) dated September 15, 2017, indicated Resident 16 wore a full upper denture. On March 12, 2019, at 8:30 a.m., and 12:15 p.m., and March 13, 2019, at 9:30 a.m., and 12:10 p.m., the resident was observed without her upper dentures in place. In an interview on March 12, 2019, at 8:30 a.m., and March 13, 2019, at 9:30 a.m., Resident 16 stated, "my dentures are in the cabinet and the aides forgot to give it to me." The care plan was not implemented as the resident stated she was not offered her dentures.

Clinical record review revealed that Resident 35 had diagnoses that included Alzheimer's disease and dementia (memory and thought process decline). An MDS assessment completed January 9, 2019, revealed that the resident had memory impairment and required extensive assistance of two staff member for activities of daily living. The current care plan identified that the resident often picks at her skin and the scabs despite verbal reminders and interventions included for staff to document the resident's moods and behaviors, as well as interventions implemented to manage those behaviors. Observation on March 12, 2019, at 8:30 a.m., revealed blood smears on the resident's pillowcase and top sheet. The resident had dried blood on her nose and face. In an interview on March 12, 2019, at 11:24 a.m. CNA 4 stated that the resident picks at the skin on her nose and face. On March 13, 2019, at 10:00 a.m. the resident's top sheet was, again, observed with dried blood smears and dried blood on her nose and face. There was no documentation of the behaviors as indicated in the care plan.

Clinical record review revealed that Resident 65 had diagnoses that included included repeated falls, muscle weakness, and abnormalities of gait and mobility. An MDS assessment was completed on February 11, 2019 and the corresponding CAA summary noted that the resident required assistance of two staff for transfers and that this was to be addressed in the care plan. There was a lack of evidence to support that the facility developed a comprehensive care plan based on the assessment that addressed this area.

Clinical record review revealed that Resident 77 had diagnoses that included Alzheimer's disease, dementia, and long term use of anticoagulants (medication that impairs blood clotting). An MDS assessment completed February 4, 2019, revealed that the resident had memory impairment and required extensive assistance of one staff member for activities of daily living. The most recent care plan identified that the resident was to have derma-savers to her left arm and both lower extremities for added protection against bruising. On March 14, 2019, at 8:58 a.m., 9:41 a.m., 10:12 a.m., 10:47 a.m., and 11:05 a.m., the resident was observed in bed with the derma-saver for her left arm laying next to her in bed.

28 Pa. Code 211.11(d) Resident care plan.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 3/23/18, 6/24/17

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/23/18, 6/24/17, 4/6/17












 Plan of Correction - To be completed: 04/24/2019

0656
SS=E Develop/Implement Comprehensive Care Plan
1. Resident 16 was under care of a dentist at time of survey. Resident 16 chooses when she wants to wear her dentures throughout the day. Kardex and Care plan were updated to reflect resident preference.
2. For Resident 35, CNA 4 did not witness the behavior. CNA 4 was educated to notify the licensed nurse of any blood smears for further assessment, root cause investigation and treatment.
3. Resident 35 Plan of Care was updated to reflect 2 staff for transfers.
4. Resident 77 prefers not to wear arm derma saver despite encouragement. Arm derma saver was discontinued 3/14/2019. Family and physician in agreement as resident is less at risk for bruising since her Coumadin was discontinued.
5. In- Service for all clinical staff on development, implementation, and timely revisions to resident care plans and related tasks.
6. Nursing Administration to monitor and report to QAPI Committee monthly until resolved.
7. Completion by April 24, 2019.

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 clinical record review and observation, it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity of three of 27 sampled residents (Residents 11, 62, 99).

Findings include:

Clinical record review revealed that Resident 11 had diagnoses that included dysphagia (difficulty swallowing). Resident 11 routinely requires extensive assistance of one staff for eating.

Clinical record review further revealed that Resident 62 routinely requires total assist of one staff for eating.

Clinical record review revealed that Resident 99 had a diagnosis of dysphagia (difficulty swallowing). Resident 99 routinely requires extensive assist of one staff for eating.

On March 12, 2019, between 12:15 p.m. and 12:30 p.m. LPN1 was observed feeding all three residents while standing.

28 Pa. Code 201.29(j) Resident rights.
Previously cited 4/6/17













 Plan of Correction - To be completed: 04/24/2019

Department of Health Plan of Correction for March 12, 2019
Preparation and/or execution of this Provider's Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies as perceived by representatives of the Department of Health relative to the on-site survey concluded on March 15, 2019.

The provider's Plan of Correction is prepared solely because it conveys this sincere message of the governing body, as follows:

All representative entities of Holy Family Manor ("HFM") have been, are, and will be committed to providing the highest quality of care and services to the elderly, in accordance with, or exceeding all applicable local, state and/or federal laws/mandates regarding the operation of a Long Term Care Facility in Pennsylvania.

Representative entities of Holy Family Manor will evidentially substantiate compliance with all applicable local, state, and/or federal laws/mandates regarding operation of a Long Term Care Facility in the Commonwealth of Pennsylvania during the survey conducted subsequent to that concluded on March 15, 2019.

Ftag
0550
SS=D Resident Rights (Dignity with Dining)
1. Re-education provided to LPN 1 involved with these residents.
2. In-service to all staff who assist in dining rooms and/or with feeding in resident rooms on Dinning with Dignity.
3. Nursing Administration to monitor and report to QAPI Committee monthly until resolved.
4. Completion by April 24, 2019.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on observation, clinical record review and interview, it was determined that the facility failed to ensure that a resident had a call bell accessible to request assistance from staff for one of 27 residents reviewed (Residents 65).

Findings include:

Clinical record review revealed that Resident 65 was admitted to the facility on January 29, 2019, with diagnoses that included repeated falls, muscle weakness, and abnormalities of gait and mobility. Review of the Minimum Data Set assessment (MDS - a mandated assessment of resident care needs) dated February 5, 2019, revealed that Resident 65 was alert and oriented, required extensive assistance with activities of daily living and was at risk for falls. Resident 65's most recent care plan dated February 12, 2019, revealed the resident had a potential for falls and directed staff to reinforce the need to use the call bell for assistance. Observation on March 13, 2019, at 9:40 a.m., revealed that Resident 65 was out of bed in his wheelchair next to the bed, his call bell was behind him in the bedside cabinet drawer.

In an interview on March 13, 2019, at 11:05 a.m. Resident 65 stated that the call bell was not accessible to request assistance from staff.

483.10(e)(3) Reasonable Accommodations Needs/Preferences
Previously cited 3/23/18

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 3/23/18, 6/24/17

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/23/18, 6/24/17, 4/6/17









 Plan of Correction - To be completed: 04/24/2019

0558
SS=D Reasonable Accommodations Needs/Preferences: (Call Bells in Reach)
1. Re-education provided to staff member assigned to this resident.
2. In-service for all staff to ensure all call bells are accessible to residents.
3. Nursing Administration to monitor and report to QAPI Committee monthly until resolved.
4. Completion by April 24, 2019.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice to the resident or the resident's representative following the end of their Medicare coverage for two of three residents reviewed who were discontinued from Medicare Part A with benefit days remaining and remained in the facility (Residents 58, 134).

Findings include:

Clinical record review revealed that Resident 58 received Medicare Part A services from November 9, 2018, through November 26, 2018. According to the SNF Beneficiary Protection Notification Review form completed by the facility, Resident 58 was discontinued from Medicare Part A with benefit days remaining and that the termination of skilled services was initiated by the facility. There was no documented evidence that the resident or representative was provided the required SNF Advanced Beneficiary Notice (SNF-ABN) form (a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage in a specific case).

Clinical record review revealed that Resident 134 received Medicare Part A serviced from November 19, 2018, through November 26, 2018. According to the SNF Beneficiary Protection Notification Review form completed by the facility, Resident 134 was discontinued from Medicare Part A with benefit days remaining and that the termination of skilled services was initiated by the facility. There was no documented evidence that the resident or representative was provided the required SNF-ABN form.

In an interview conducted on March 14, 2019, at 2:40 p.m. the Nursing Home Administrator stated that the SNF-ABN form was not issued to the residents or their representatives.

28 Pa. Code 201.18(e)(1) Management.









 Plan of Correction - To be completed: 04/24/2019

0582
SS=D Medicaid/Medicare Coverage/Liability Notice (Failed to issue ABN Notice)
1. Policy on Termination of Skilled Services revised March 13, 2019.
2. Education provided to staff members involved in issuing Advance Beneficiary Notices.
3. Director of Social Services to audit for compliance and report to QAPI Committee monthly until resolved.
4. Completion by March 14, 2019.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record review, observation and interview, it was determined that the facility failed to provide treatment and services to prevent further limitations in range of motion for two of 27 residents reviewed (Residents 11 and 51).

Findings include:

Clinical record review revealed that Resident 11 had diagnoses that included a contracture of the right hand and dementia (memory impairment and thought process decline). The Minimum Data Set (MDS - a mandated assessment of resident care needs) assessment, dated December 10, 2018, indicated that the resident had severe memory impairment, required extensive assistance for most activities of daily living and had limited range of motion in her right hand. The most recent Care Area Assessment (CAA) indicated that the resident was at risk for skin breakdown due to decreased mobility. The care plan reflected that staff were to apply a palm protector to the resident's right hand to prevent further complications. An Occupational Therapy discharge summary dated December 11, 2018, instructed staff to apply a palm protector in the morning. An observation made on March 13, 2019, at 10:38 a.m. revealed that the resident did not have the palm protector applied to her right hand.

Clinical record review revealed that Resident 51 had diagnoses that included dementia, recent fractured ankle and muscle weakness. The MDS assessment dated October 24, 2018, indicated that the resident required extensive assistance from staff for most activities of daily living and had limited range of motion of her lower extremities. The CAA indicated that the resident was at risk for skin breakdown due to decreased mobility. The resident had an ongoing physician order dated January 27, 2019, that required staff to apply Prevalon boots (pressure relieving devices) to both legs while in bed. Observations made on March 12, 2019, at 9:20 a.m., and 11:15 a.m., revealed that the resident was in bed and was not wearing the Prevalon boots.

In an interview on March 14, 2019, at 2:40 p.m. the Nursing Home Administrator confirmed that staff had not applied the Prevalon boots.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 3/23/18, 6/24/17

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/23/18, 6/24/17, 4/6/17








 Plan of Correction - To be completed: 04/24/2019

0688
SS = D Increase/Prevent Decrease in ROM/Mobility (failure to apply palm protector/ prevalon boots)
1. Resident 11 has history of removing Palm Protector due to diagnosis of dementia. Staff continue to re-apply throughout the day as resident will tolerate. Consulting therapy for consideration of alternative measures.
2. Resident 51 has history of refusing and/or removing Prevlon Boots. Prevlon Boots discontinued per resident preference. Resident consulting therapy for range of motion to both ankles.
3. In- Service for all clinical staff on proactive treatments and services available to reduce risk of decline in range of motion.
4. Nursing Administration to monitor and report to QAPI Committee monthly until resolved.
5. Completion by April 24, 2019.

483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to attempt to use alternatives prior to the use of an enabler bar or bed rail and failed to obtain informed consent for the use of bed rails prior to their use for three of 27 residents reviewed (Residents 16, 58, 77).

Findings include:

Review of the facility policy entitled, "Safety Management Policy", dated February 2019, revealed that when considering transfer assist bars/enablers, staff were to ensure that alternatives would be considered prior to the use of the bed rails.

Clinical record review revealed that Resident 16 was admitted to the facility on September 2, 2017, with diagnoses that included muscle weakness. A Minimum Data Set (MDS - a mandated assessment of resident care needs) assessment completed February 25, 2019, revealed that the resident was alert and oriented and required extensive assistance of two staff members for bed mobility. On March 12, 2019, at 8:30 a.m., and March 13, 2019 at 9:30 a.m., the resident was observed in bed with two enabler rails in the up position at the top of the bed. There was no documented evidence that alternatives to the enabler rails were attempted or that informed consent was obtained.

Clinical record review revealed that Resident 58 was admitted to the facility on November 9, 2018, with diagnoses that included muscle weakness and abnormalities with mobility. A MDS assessment completed March 4, 2019, revealed that the resident was memory impaired and required extensive assistance of two staff members for bed mobility. On March 12, 2019, and March 13, 2019, between 9:00 a.m., and 1:30 p.m., the resident was observed in bed with two enabler rails in the up position at the top of the bed. There was no documented evidence that alternatives to the enabler rails were attempted or that informed consent was obtained.

Clinical record review revealed that Resident 77 was admitted to the facility on March 1, 2015, with diagnoses that included muscle weakness. A MDS assessment completed February 4, 2019, revealed that the resident had some memory impairment and required extensive assistance of two staff members for bed mobility. On March 14, 2019, at 8:58 a.m., 9:41 a.m., 10:12 a.m., 10:47 a.m., and 11:25 a.m., the resident was observed in bed with two enabler rails in the up position at the top of the bed. There was no documented evidence that alternatives to the enabler rails were attempted or that informed consent was obtained.

In an interview on March 15, 2019, at 10:45 a.m. the Nursing Home Administrator confirmed that the facility had not attempted alternatives or obtained informed consent from any of the residents or their representatives prior to the bed rail usage.

483.25(n)(1)-(4) Bedrails
Previously cited 3/23/18

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 3/23/18, 6/24/17

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/23/18, 6/24/17, 4/6/17





 Plan of Correction - To be completed: 04/24/2019

0700
SS = D Bedrails
1. Resident 58 has since expired.
2. Resident 16 screened by therapy for appropriateness of alternate measures for transfer assist bars. Obtained informed consent for continued use of transfer assist bars.
3. Resident 77 was re-evaluated by therapy and determined that transfer assist bars were no longer needed and were discontinued on 3/19/2019.
4. Revise Policy on use of Transfer Assist Bars.
5. In-service for all nursing and therapy staff on revised policy.
6. Nursing Administration to monitor and report to QAPI Committee monthly until resolved.
7. Completion by April 24, 2019.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 observation and facility policy review, it was determined that the facility failed to ensure that staff handled resident equipment in a safe and sanitary manner to prevent the spread of infection for one of 27 residents reviewed (Resident 77).

Findings include:

Review of the facility policy entitled "Equipment and Disinfection Procedure," dated January 2019, revealed that all oxygen therapy supplies were to be bagged and dated when not in use.

Observations on March 14, 2019, at 8:58 a.m., 9:41 a.m., 10:12 a.m., 10:47 a.m., 11:25 a.m., and again March 15, 2019, at 8:45 a.m., revealed that Resident 77's nasal cannula and oxygen tubing was draped over the resident's wheelchair. The cannula and tubing were undated and unbagged.

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5)Nursing services.
Previously cited 3/23/18, 6/24/17, 4/6/17






 Plan of Correction - To be completed: 04/24/2019

0880
SS = D Infection Prevention & Control (failed to bag and date Oxygen tubing)
1. Re-education provided to staff members involved who failed to follow policy.
2. In-service for all staff on handling of resident equipment in a safe and sanitary manner to prevent the spread of infection.
3. Nursing Administration will audit for compliance and report to QAPI Committee monthly until resolved.
4. Completion by April 24, 2019.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:

Based on observations, it was determined that the facility failed to provide a clean and sanitary environment on one of four sampled nursing units (Second floor nursing unit).

Findings include:

Observation of the alcove area in the hallway on the second floor nursing unit on March 12, 2019, from 8:23 a.m. through 1:10 p.m., and on March 13, 2019, at 9:10 a.m., revealed that the floor was black, dusty, and soiled.

On March 12, 2019, from 8:23 a.m., through 1:15 p.m., and on March 13, 2019 at 9:12 a.m., in Room 208, there was dried tube feeding formula on the base of the tube feeding pole.

28 Pa. Code 207.2(a) Administrator's responsibility



















 Plan of Correction - To be completed: 04/24/2019

0921
SS = B Safe/Functional/Sanitary/Comfortable Environment: (dirty floor and tube feed pole)
1. The floor in alcove area and tube feed formula drippings on tube feeding pole in room 208 were cleaned 3/14/2019.
2. In-service for all staff on providing a safe, sanitary, and comfortable environment for residents.
3. Environmental Services to monitor and report to QAPI Committee monthly until resolved.
4. Completion by April 24, 2019.


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