Nursing Investigation Results -

Pennsylvania Department of Health
REHABILITATION & NURSING CENTER AT GREATER PITTSBURGH, THE
Patient Care Inspection Results

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REHABILITATION & NURSING CENTER AT GREATER PITTSBURGH, THE
Inspection Results For:

There are  91 surveys for this facility. Please select a date to view the survey results.

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REHABILITATION & NURSING CENTER AT GREATER PITTSBURGH, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on April 19, 2019, it was determined that The Rehabilitation and Nursing Center at Greater Pittsburgh 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:


483.25(h) REQUIREMENT Parenteral/IV Fluids: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.
483.25(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.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an intravenous line was flushed for one of 8 residents reviewed (Resident 6).

Findings include:

The facility's policy regarding flushing of midline catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated February 20, 2019, indicated that midline catheters were to be flushed to maintain patency and were to be flushed before and after the administration of medications. Staff were to use 10 milliliters (ml) of 0.9 percent sodium chloride (sterile salt water solution) for flushes, and 5 ml of 10 units/ml of heparin (an anti-clotting medication) instilled into the midline catheter after the post infusion flush of 0.9 percent sodium chloride. The policy indicated that the physician's orders were to be verified.

Physician's orders for Resident 6, dated March 5, 2019, included an order for the resident to receive one gram of Maxipine (an antibiotic) intravenously (IV - directly in a vein) every 24 hours for pneumonia; however, there was no physician's order to flush the midline catheter.

Resident 47's Medication Administration Record (MAR) for March 2019 revealed that Maxipine was administered on March 6 through 11, 2019, and there was no documented evidence that the resident's midline catheter was flushed from March 6 through 11, 2019.

Interview with the Director of Nursing on April 10, 2019, at 12:03 p.m. confirmed that there was no physician's order to flush Resident 6's midline catheter, and no documented evidence on the MAR that the midline was flushed in accordance with the facility's policy.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 11/7/18.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 2/28/19, 11/27/18, 11/7/18.




 Plan of Correction - To be completed: 05/15/2019

1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Residents #6 has since been discharged from the facility.

2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Residents admitted into the facility that have IV access have the potential to be affected. Audit completed on current residents with IV access to ensure that flushes are being administered as ordered and addressed as applicable in the electronic medical record.

3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Education to licensed nurses on ensuring that IV access devices are flushed as ordered to ensure patency and toe ensure IV flushes are ordered on the electronic medical record system to be signed off as ordered.

4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Director of nursing will audit IV access devices for proper flushing weekly x 4 weeks and monthly x 2 months.

Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.

Date of compliance-5/15/19

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 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.
483.20(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 review of policies, census information and resident's clinical records, as well as observations and staff interviews, it was determined that the facilty failed to ensure that clinical records were complete and accurately documented for four of eight residents reviewed (Residents 1, 5, 6, 8).

Findings include:

The facility's policy regarding room to room transfers, dated February 20, 2019, indicated that documentation of the room transfer would be recorded in the resident's medical record.

A facility census report revealed that Resident 1 was moved into a room with Resident 8 on February 22, 2019. There was no documented evidence in Resident 1's clinical record regarding when he was moved into the room with Resident 8. There was also no documented evidence in Resident 8's clinical record that he received written notice that he was getting a new roommate.

Interview with the Social Worker on April 10 2019, at 5:00 p.m. confirmed that there was no documentation in Residents 1 and 8's clincal records regarding the room change.


An admission assessment for Resident 5, dated March 29, 2019, revealed that the resident had an open ulcer to the left lower leg, and physician's orders dated March 29, 2019, revealed that staff were to wash the ulcer on the resident's left lower leg with normal saline solution and then apply Santyl ointment (removes dead tissue) daily. However, a wound note written by Licensed Practical Nurse 2, dated April 1, 2019, indicated that Resident 5 had an open area on the right lower leg versus the left lower leg.

An interview with the Director of Nursing on April 10, 2019, at 12:01 p.m. confirmed that Resident 5 had an open area on the left lower leg, not the right lower leg.


Physician's orders for Resident 6, dated March 7, 2019, included an order for the resident to have an indwelling urinary catheter (a tube placed and held in the bladder to drain urine) and to monitor the resident's urinary output every shift. The resident's Treatment Administration Record (TAR) for March 2019 revealed that the resident's urinary output was not documented during the day shift on March 13, 14, 15, 19, 20; during the evening shift on March 19, 20 and 21; and during the night shift on March 13, 14, 15, 17, 18, 19, 20 and 21, 2019.

An interview with the Director of Nursing on April 10, 2019, at 12:03 p.m. confirmed that Resident 6's urinary output was not charted on the above shifts.

42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable Information.
Previously cited 11/7/18.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 11/7/18.







 Plan of Correction - To be completed: 05/15/2019

1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Residents #1, #5, #6, and #8 have since been discharged from the facility.

2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Residents admitted into the facility have the potential to be affected. Audit completed on recent resident room changes to ensure proper notifications for resident(s) that are moving or the resident that is getting the new roommate and documented as appropriate. Audit completed on residents with pressure ulcers to ensure the skin progress notes match with the physician orders on the treatment sheets and addressed as appropriate. Audit completed on residents with foley catheters to ensure urinary output is placed in the electronic treatment record each shift to be recorded. Clear delineation of who is responsible for room change notifications were discussed with the team by the administrator. The treatment nurse is responsible ensuring accurate documentation exist between the physician and the nurse documentation on a daily basis. There was no dedicated space for foley catheter output on the paper medication administration record with the electronic medication record the output will be apart of the batch order set.

3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Education to social services departments on ensuring residents and resident's new roommates receive proper documented notification of changes. Education to licensed nurses on the ensuring that the electronic treatment record accurately reflects the correct skin site on physician orders. Education to licensed nurses on ensuring the urinary output is inputted and documented on each shift in the electronic treatment administration record.

4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Director of Social Services will audit documentation of room changes to all necessary parties weekly x 4 weeks and monthly x 2 months. Director of nurses will audit wound notes for accuracy of skin treatment sites and urinary output weekly x 4 weeks and then monthly x2.

Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.

Date of compliance-5/15/19

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 clinical record reviews and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician resulting in a significant medication error for two of eight residents reviewed (Residents 2, 7).

Findings include:

The manufacturer's instructions for ceftriaxone (an antibiotic used to treat bacterial infections), dated May 2010, indicated that the medication was to be given intramuscularly (IM - injected into a muscle) or intravenously (IV - administered directly into a vein). When given by intramuscular administration, ceftriaxone was to be injected well within the body of a relatively large muscle.

Physician's order for Resident 2, dated March 7, 2019, included orders for the resident to receive 20 units of Lantus insulin subcutaneously (SQ - injected into the fatty tissue below the skin) at bedtime and 1 gram of ceftriaxone SQ daily for infection. The resident's Medication Administration Record (MAR) for March 2019 revealed that staff did not administer Lantus insulin from March 8 to 17, 2019 (10 days), and ceftriaxone was administered SQ instead of IM from March 8 to 11, 2019.

Interview with the Director of Nursing on April 9, 2019, at 1:15 p.m. confirmed that there was no documented evidence that Resident 2 received Lantus insulin from March 8 to 17, 2019, and ceftriaxone should have been given by intramuscular injection from March 8 to 11, 2019.


Physician's orders for Resident 7, dated March 21, 2019, included orders for the resident to receive 300 mg of Cefdinir every 12 hours for seven days for a urinary tract infection. The resident's Medication Administration Records (MAR's) for March 2019 revealed that staff administered Cefdinir every 12 hours for six days versus seven days as ordered.

Interview with the Director of Nursing on April 10, 2019, at 3:38 p.m. confirmed that Cefidinir was not administered to Resident 7 for seven days as ordered by the physician.

42 CFR 483.45(f)(2) Residents are Free of Significant Medication Errors.
Previously cited 2/28/19, 11/7/18.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 2/28/19, 11/27/18, 11/7/18.



 Plan of Correction - To be completed: 05/15/2019

1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Residents #2 and #7 have since been discharged from the facility.

2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Residents admitted into the facility have the potential to be affected. Audit completed on current antibiotic orders to ensure proper route of administration is on the medication administration record and the physician order. Audit completed on residents with antibiotic orders to ensure medications are ordered in the electronic medical record per physician order timeframe. Licensed nurses are responsible for administering medications in the right recommended route of administration. The electronic medical record will send alerts to the pharmacy directly on ordered medications and licensed nurses will be responsible for approving the orders from the pharmacy for the medications with the suggested routes of administration.

3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Education to licensed nurses on transcription of proper routes of medication and to utilize drug reference materials. Education to nursing on ensuring medications are administered for the specified timeframe in the electronic medical record and documented on each day for effectiveness.

4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Director of nursing will audit antibiotics and antibiotic injections weekly x 4 weeks and monthly x 2 months for proper route of administration and for transcription of correct timeframe of medication administration.

Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.

Date of compliance-5/15/19

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 and observations, it was determined that the facility failed to develop care plans for individualized resident care needs for one of eight residents reviewed (Resident 6).

Findings include:

The facility's policy regarding comprehensive care plans, dated February 20, 2019, indicated that the interdisciplinary team was responsible for the development of an individualized, comprehensive care plan for each resident.

Physician's orders for Resident 6, dated March 5, 2019, included an order for the resident to receive one gram of Maxipine (an antibiotic) intravenously (IV - directly into a vein) every 24 hours for pneumonia. A nursing note, dated March 5, 2019, at 10:31 p.m. revealed that the resident had an IV access device.

Resident 6's Medication Administration Record (MAR) for March 2019 revealed that the resident was administered Maxipine from March 6 through 11, 2019; however, the resident's care plan revealed that the plan did not include the care and services to be provided related to the resident's IV access device.

Physician's orders for Resident 6, dated March 7, 2019, revealed that the resident had an indwelling urinary catheter (a tube inserted and held in the bladder to drain urine). Review of Resident 6's current care plan revealed that the plan did not include the care and services to be provided related to the resident's indwelling urinary catheter.

An interview with the Acting Director of Nursing on April 10, 2019, at 12:40 p.m. confirmed that care plans were not developed to address Resident 6's IV access device and indwelling urinary catheter.

42 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plans.
Previously cited 11/7/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 1/15/19, 11/7/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 2/28/19, 11/27/18, 11/7/18.




 Plan of Correction - To be completed: 05/15/2019

The filing of this plan of correction does not constitute an admission that the alleged deficiencies did, in fact, exist. This plan of corrections is filed as evidence to comply with requirements of participation and continue to provide high quality resident centered care.

1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Resident #6 has since been discharged from the facility.

2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Residents admitted into the facility have the potential to be affected. Audit completed on residents with IV access devices and foley catheters to ensure that these devices are on the careplan and corrections completed as necessary. Licensed nurses and nursing administration are responsible for initiating the careplan to include patient specific care and services.

3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Careplan meetings are weekly with the interdisciplinary team to address the individualized careplans for each resident. The Director of Nursing will complete education with licensed nurses on point of care/change of condition careplanning.

4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Director of nursing will audit the resident careplans 3x week x 4 weeks and monthly x 2 months to ensure that the care and services are present on the individualized careplans.

Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.

Date of compliance-5/15/19

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act, manufacturer's instructions and clinical records, as well as staff interviews, it was determined that the facility failed to clarify questionable physician's orders for three of eight residents reviewed (Residents 2, 3, 5).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

The manufacturer's instructions for ceftriaxone (an antibiotic used to treat bacterial infections), dated May 2010, indicated that the medication was to be given intramuscularly (IM - injected into a muscle) or intravenously (IV - administered directly into a vein). When given by intramuscular administration, ceftriaxone was to be injected well within the body of a relatively large muscle.

Physician's orders for Resident 2, dated March 7, 2019, included an order for the resident to receive 1 gram (gm) of ceftriaxone subcutaneously (injected just beneath the skin) daily for infection. The resident's Medication Administration Record (MAR) for March 2019 revealed that ceftriaxone was administered subcutaneously instead of intramuscularly from March 8 to 11, 2019.

Interview with the Director of Nursing on April 9, 2019, at 4:40 p.m. confirmed that Resident 2's physician's orders for ceftriaxone to be administered subcutaneously should have been clarified with the physician.


An admission comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated April 2, 2019, revealed that the resident was admitted on March 26, 2019, was alert and oriented, required limited to extensive assistance with daily care, and had a pressure ulcer (skin impairment caused by prolonged, unrelieved pressure). An admission nursing assessment, dated March 26, 2019, revealed that the resident had a Stage III pressure ulcer (a deep wound caused by pressure) on the sacrum (lower part of spine). Physician's orders, dated March 27 and April 1, 2019, included an order to wash the coccyx (tail bone) pressure ulcer with mild normal saline solution (sterile salt water), pack with calcium alginate (absorbent dressing), and cover with foam gauze daily.

A wound consultation for Resident 3, dated April 2, 2019, indicated that the coccyx wound was to be packed with 1/4 strength Dakin's (prevents germ growth in wounds) moistened gauze and covered with a dry dressing daily.

Resident 3's Treatment Administration Records (TAR's) for March and April 2019 revealed that the wound was cleansed with normal saline solution and packed with calcium alginate on April 2, and 4 to 8, 2019. There was no documented evidence that the coccyx wound was packed with 1/4 strength Dakin's moistened gauze daily as recommended by the wound consultation.

An interview with the Director of Nursing on April 10, 2019, at 10:54 a.m. confirmed that the treatment to Resident 3's coccyx wound should have been clarified with the physician following the wound consultation.


An admission assessment for Resident 5, dated March 29, 2019, revealed that the resident had an open ulcer to the left lower leg. Physician's orders, dated March 29, 2019, included an order for the left lower leg ulcer to be washed with normal saline solution and for Santyl ointment (removes dead tissue) to be applied daily.

A wound consultation for Resident 5, dated April 2, 2019, indicated that staff were to continue to cleanse the ulcer on the left lower leg with normal saline solution and apply calcium alginate AG (absorbent dressing) daily.

Resident 5's Treatment Administration Record (TAR) for April 2019 revealed that the left lower leg wound was cleansed with normal saline solution and Santyl ointment was applied daily from April 1 to 9, 2019. There was no documented evidence that calcium alginate AG was applied to the wound as recommended by the wound consultation.

An interview with the Director of Nursing on April 10, 2019, at 12:01 p.m. confirmed that the treatment to Resident 3's left lower leg ulcer should have been clarified with the physician following the wound consultation.

42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 11/7/18.

28 Pa. Code 211.12(d)(1)Nursing services.
Previously cited 11/7/18.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 2/28/19, 11/27/18, 11/7/18.



 Plan of Correction - To be completed: 05/15/2019

1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Residents #2, #3, and #5 have since been discharged from the facility.

2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Residents admitted into the facility have the potential to be affected. Audit completed on current antibiotic orders to ensure proper route of administration is on the medication administration record and the physician order. Audit completed on residents with pressure ulcers to ensure the wound consultation notes match with the treatment orders on the treatment sheets and on the physician orders. Treatment care nurse is responsible for ensuring proper treatments are transcribed and applied as ordered and has been trained on the skin care protocol.

3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Education to licensed nurses on transcription of proper routes of medication and to utilize drug reference materials. Education to nursing leadership on the proper process for weekly wound rounds that include the wound nurse and the wound physician. These wound rounds include assessing the wound, changing the orders if applicable, updating the treatment sheets, and documentation during the wound round on the specified facility wound day.

4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Director of nursing will audit antibiotic injections and pressure ulcer treatment orders weekly x 4 weeks and monthly x 2 months.

Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.

Date of compliance-5/15/19

F686-D

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 staff interviews, it was determined that the facility failed to ensure that pressure ulcers were monitored and physician-ordered treatments were completed as ordered for two of eight residents reviewed (Residents 1, 3).

Findings include:

The facility's policy regarding wound care, dated February 20, 2019, revealed that weekly wound evaluations were to be conducted to track the progress (or lack of progress) with a comprehensive evaluation. Weekly documentation was to include the date observed, the location with staging (determining the severity), measurements, type, color, odor, appearance, the approximate amount of drainage, wound bed characteristics, a description of wound edges and the surrounding skin, and evidence of progress or lack of progress toward healing.

An admission comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 24, 2019, revealed that the resident was alert and oriented, required extensive assistance with transfers and bed mobility, and had no pressure ulcers (skin impairment caused by pressure). An admission nursing assessment for Resident 1, dated February 17, 2019, revealed that the resident's left and right heels were pink. A note by a certified registered nurse practitioner (CRNP - a registered nurse with advanced training and the authority to diagnose and prescribe treatment), dated February 19, 2019, at 3:08 p.m. revealed that the resident complained of left heel pain, both heels were red but blanchable (with the left greater than the right), and there were no open wounds on the heels. The plan was to have staff apply skin prep (a liquid that forms a protective barrier) to both heels every shift. A CRNP note, dated February 22, 2019, at 9:13 a.m. revealed that the resident still complained of pain to both heels, but they were less reddened and were improving since skin prep was started.

A CRNP order, dated February 25, 2019, included an order for Duoderm (absorbent gel dressing) to be applied to the resident's left heel and changed every 72 hours. However, there was no documented evidence that the resident's wound was assessed at this time. The resident's Treatment Administration Record (TAR) for February 2019 revealed that there was no documented evidence that Duoderm was applied to the resident's left heel on February 25 and 28, 2019.

A CRNP note, dated March 4, 2019, at 8:19 a.m. and March 6, at 2019, revealed Duoderm was intact to the resident's left heel.

There was no documented evidence that Resident 1's left heel wound was monitored after February 22, 2019, until a CRNP note dated March 15, 2019, at 12:49 p.m. revealed that the resident had an area on the left heel that was erythmatous (redness of the skin) and had old, dried blood drainage.

Interview with Certified Registered Nurse Practitioner 1 on April 12, 2019, at 1:00 p.m. revealed that she heard that the physician was upset that the Duoderm was not initiated timely, and she confirmed that Resident 1's left heel got worse. She indicated that the resident's left heel was purplish, was starting to ooze, and on the day of the resident's discharge (March 15, 2019) was noted to be open.

Interview with the Director of Nursing on April 10, 2019, at 1:16 p.m. confirmed that there was no documented evidence that Resident 1's left heel wound was monitored from February 22 to March 15, 2019, and the wound should have been assessed at least weekly.


A comprehensive admission MDS assessment for Resident 3, dated April 2, 2019, revealed that the resident admitted on March 26, 2019, was alert and oriented, required limited to extensive assistance with daily care, and had a pressure ulcer. An admission nursing assessment for Resident 3, dated March 26, 2019, revealed that the resident had a Stage III pressure ulcer (a deep wound caused by pressure) on the sacrum (lower part of spine). Physician's orders, dated March 27 and April 1, 2019, included an order for the coccyx (tail bone) pressure ulcer to be washed with normal saline solution (sterile salt water), packed with calcium alginate (absorbent dressing), and covered with foam gauze daily.

Resident 3's Treatment Administration Records (TAR's) for March and April 2019 revealed that the wound was not cleansed with normal saline solution or packed with calcium alginate from March 27 to March 30, and April 1 and 3, 2019.

An interview with the Director of Nursing on April 10, 2019, at 10:54 a.m. confirmed that there was no documented evidence that Resident 3's wound treatment was completed on March 27 to 30, and April 1 and 3, 2019.

42 CFR 483.25(b)(1)(i)(ii) Treatment/Services to Prevent/Heal Pressure Ulcer.
Previously cited 11/7/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 2/28/19, 11/27/18, 11/7/18.




 Plan of Correction - To be completed: 05/15/2019

1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Residents #1, and #3 have since been discharged from the facility.

2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Residents admitted into the facility who have skin alterations have the potential to be affected. Audit completed on current residents with pressure ulcers to ensure proper treatment(s) are transcribed and applied as ordered, to ensure treatments are being documented after treatment order has been administered, and on weekly skin observation sheets for accuracy and consistency according to policy and addressed as applicable. Licensed nurses are responsible for ensuring the IV flow sheet has all the necessary components and filled out accordingly. The IV flush protocol was on the back of the IV flow sheet since implementing EMAR the flushes will be added into the EMAR batch system for administration.

3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Education to licensed nurses on proper documentation of administered treatments, on the electronic medical record dashboard to ensure that all treatments have been administered at the end of each shift, to apply skin prevention measures as ordered by the physician, and to ensure weekly skin assessment sheets are completed per policy.

4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Director of nursing will audit skin preventative measures as ordered and skin assessment sheets weekly x 4 weeks and monthly x 2 months and Director of nursing will audit electronic medical/treatment record dashboard for completion 3x week x 4 weeks and monthly x 2.

Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.

Date of compliance-5/15/19

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide pain management as ordered by the physician for one of 8 residents reviewed (Resident 5).

Findings include:

The facility's policy regarding pain management, dated February 20, 2019, indicated that staff were to implement the pain medication regimen as ordered by the physician.

Physician's orders for Resident 5, dated March 29, 2019, included orders for the resident to receive one 50 milligram (mg) tablet of Tramadol (narcotic-like pain medication) every six hours as needed for a pain rating of 4 to 6 (on a scale of 1-10, with 10 being the worst pain).

Resident 5's Medication Administration Records (MAR's) for March 2019 revealed that staff administered Tramadol for a pain rating that was less than four on April 2 at 8:00 p.m. and April 3 at 3:35 p.m., and administered Tramadol for a pain rating greater than six on April 6 at 11:37 p.m., April 8 at 11:41 a.m., and April 9 at 1:05 p.m.

An interview with the Director of Nursing on April 10, 2019, at 12:01 p.m. confirmed that Resident 5's Tramadol was not administered as ordered by the physician.

42 CFR 483.25(k) Pain Management.
Previously cited 11/7/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 2/28/19, 11/27/18, 11/7/18.




 Plan of Correction - To be completed: 05/15/2019

1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Resident #5 has since been discharged from the facility.

2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Residents admitted into the facility on pain management medications have the potential to be affected. Audit completed on pain medication orders with administration according to the pain rating scale and addressed as applicable. licensed nurses are responsible for the administration of pain management medications according to the pain scale. The paper MAR did not have a dedicated place for pain rating scale next to the administration of the pain medication. The pharmacy consultant does assess resident medications which includes pain medications and makes recommendations as necessary.

3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Education to licensed nurses on proper pain medication administration according physician orders. Electronic medical record has been implemented in the facility to address pain medication(s) with appropriate pain rating scales as ordered.

4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Director of nursing will audit pain medications with specified pain ratings weekly x4 weeks and monthly x 2 months to ensure proper administration according to the physician order.

Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.

Date of compliance-5/15/19

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on clinical records reviews and staff interviews, it was determined that the facility failed to obtain needed medications for one of eight residents reviewed (Resident 6).

Findings include:

Physician's orders for Resident 6, dated February 11, 2019, included an order for the resident to receive one 4 gram packet of Questran (lowers cholesterol) with 8 ounces of fluid three times a day.

Resident 6's Medication Administration Records (MAR's) for March 2019 revealed that the resident did not receive Questran as ordered on March 6 at 4:30 p.m.; March 7 at 7:30 a.m., 11:30 a.m., and 4:30 p.m.; and March 8 at 7:30 a.m., 11:30 a.m. and 4:30 p.m. The MAR and nursing notes indicated that the Questran was not available and not delivered from the pharmacy, and there was no documented evidence that any attempts were made to obtain the medication until March 8, 2019, at 12:50 p.m. when the pharmacy was called.

Interview with the Director of Nursing on April 10, 2019, at 12:03 p.m. confirmed that Resident 6's Questran was not received from the pharmacy, which resulted in the resident not receiving Questran as ordered by the physician.

42 CFR 483.45(a)(b)(1)-(3) Pharmacy Services/Procedures/Pharmacist/Records.
Previously cited 11/7/18.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 2/28/19, 11/27/18, 11/7/18.



 Plan of Correction - To be completed: 05/15/2019

1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Resident #6 has since been discharged from the facility.

2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Residents admitted into the facility have the potential to be affected. Review completed by the Director of nursing on resident medications to ensure availability on the medication carts as ordered and addressed as necessary with medication error reports and/or alternate ordered medications. Medication was on national back order from the pharmacy. Pharmacy will call RN supervisor directly to communicate any delays in medication availability to initiate a recommended change. Backup pharmacy is in place.

3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Education to licensed nurses on contacting the pharmacy for medication availability and/or contacting the physician to see if the ordered medication can be substituted for another medication.

4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Director of nursing will audit progress notes and electronic medical record dashboard for medication availability weekly x 4 weeks and monthly x 2 months.

Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.

Date of compliance-5/15/19

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:


Based on review of nursing staffing schedules and payroll records, as well as staff interviews, it was determined that the facility failed to provide the required minimum number of nursing care hours of 2.7 hours of direct resident care for each resident for one of 21 days reviewed.

Findings include:

The facility's nursing schedules and payroll records for the weeks of March 3, March 24, and March 31, 2019, revealed that the facility provided only 2.50 hours of direct nursing care per resident on March 3, 2019.

Interview with the Director of Nursing on April 10, 2019, at 4:10 p.m. confirmed that nursing staffing was below the required minimum number of nursing care hours on March 3, 2019.



 Plan of Correction - To be completed: 05/15/2019

1) Corrective Action for those residents found to be affected by the alleged deficient practice.
Facility has been properly staffed according to the allotted 2.7 hours of direct care.

2) Corrective Actions taken for residents with potential to be affected by alleged deficient practice.
Audit completed on current schedule to ensure facility is at or above the 2.7 hours of direct resident care and schedule changed as appropriate.

3) Systemic Changes put into place to ensure the alleged deficient practice does not recur.
Education to facility scheduler to ensure that the staffing ratios are consistently at or above the 2.7 hours of direct patient care. Administrator will meet with the scheduler daily to ensure that staffing ratios are appropriate and any scheduling issues addressed as appropriate.

4) Monitoring of corrective action to ensure the alleged deficient practice does not recur.
Administrator will audit staffing ratios daily x 2 weeks and weekly x 2 months.

Plan of correction information and audits will be reviewed in the quality assurance and performance improvement process for tracking/trending and any necessary additional interventions.

Date of compliance-5/15/19


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