Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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

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ABRAMSON RESIDENCE - 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, completed on March 28, 2019, it was determined that Abramson Residence 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 as they relate to the health portion of the survey process.

 Plan of Correction:

483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Based on observations, reviews of clinical records, hospital documentation and policies and procedures, it was determined that the facility failed to provide adequate assessment and monitoring for the care and maintenance of an intravenous catheter for one of fifty-seven residents reviewed. (Resident R298)

Findings include:

The facility policy for the care of a peripherally inserted central catheter (PICC) line was to have the PICC dressing changed twenty-four hours after insertion, then have the PICC dressing changed every seven days or sooner if the dressing becomes loose, soiled or wet. The policy also indicated that the PICC site was to be assessed for redness, swelling, drainage or tenderness at the site or along the vein, the external length of the catheter was to be measured and the arm circumference was to be recorded.

According to the standards of nursing practice guidelines in the Journal of the American Nurse's Association, dated November 2013, complications of a PICC line includes, but is not limited to catheter-tip migration(assessed by external length of the catheter-amount of catheter tubing that is visible outside of the vein moves from oriinal insertion and may cause medical complications).

Clinical record review and hospital record documentation review, indicated that Resident R289 was admitted to the facility on March 8, 2019. Resident R289 had a diagnosis of bacteremia complicated with lumbar epidural abscess. Resident R289 was admitted for continued antibiotic therapy for a spinal abscess. Observations of Resident R289 at 10:00 a.m., on March 28, 2019 revealed that this resident had a right upper extremity PICC line insertion.

The physician teflaro (antibiotic) to be administered intravenously starting March 8, 2019 and to continue the antibiotis therapy until April 24, 2019. The physician also ordered PICC dressing changes to be completed one time weekly.

There was no documentation to indicate that upon admission to the facility on March 8, 2019 that the nursing care facility staff determined the status of the PICC line dressing, which was reviewing the hospital transfer record documentation to determine if the PICC line was changed twenty-four hours after insertion.

There was no documentation to indicate that the nursing staff assessd the PICC line, while preforming a dressing change and measuring the external length of the catheter and the resident's arm circumference every seven days as care planned. The lack of documentation, monitoring and assessment for Resident R289 related to the resident's PICC (peripherally inserted central catheter) for March 8, 2019 through March 28, 2019 was confirmed at 1:00 p.m., by the Director of Nursing Services.

The facility failed to provide adequate assessment and monitoring for the care and maintenance of itravenous(IV-tube inserted through the skin into a vein to administer fluids and medications).

28 PA. Code: 211.10 (a)(b)(c)(d) Resident care policies

28 PA. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services

 Plan of Correction - To be completed: 05/01/2019

Physician orders for Resident R289 were revised to include assessment of PICC line while performing dressing change and measuring the external length of the catheter and the resident's arm circumference every seven days. Documentation of completion of these orders is completed on the Treatment Administration Record.

Physicians' orders and Treatment Administration Records for all residents with PICC lines will be reviewed to determine compliance with facility policy, and corrected or amended as necessary.

The order template for PICC lines has been revised to include the necessary requirements. Licensed Nurses have been educated regarding facility policy and professional standards for care of a PICC line and the Treatment Administration Record documentation requirements.

A Quality Assurance audit will be implemented to monitor compliance with the policy and professional standards. The audit will be completed for all residents in the facility with PICC lines weekly, and will be reported to the Quality Assessment and Assurance Committee monthly for three months.

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