Nursing Investigation Results -

Pennsylvania Department of Health
ANGELA JANE PAVILION
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ANGELA JANE PAVILION
Inspection Results For:

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ANGELA JANE PAVILION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to three complaints completed on March 11, 2019, it was determined that Angela Jane Pavilion was not in compliance with the following requirements for Long Term Care Facilities, and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Licensure Regulations, as it relates to the health portion of the survey process.






 Plan of Correction:


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

Based on a review of clinical records, medication error reports, select incident and accident reports and staff interviews, it was determined that the facility failed to ensure that a resident was free from a significant medication error, which compromised the resident's clinical condition and resulted in the resident's transfer to the hospital for medication overdose following the medication error for one of 18 residents reviewed (Resident R92).

Findings include:

Review of Resident R92's clinical record revealed that the resident was admitted to the facility on January 25, 2019, with diagnoses including right CVA (Cerebral Vascular Accident -stroke, brain hemorrhage) A Fib (Atrial Fibrillation -irregular and rapid heartbeat) and Gastro-Intestinal bleeding. Continued review of the clinical record revealed a physician's order to start Eliquis (anticoagulant-blood thinner- used to prevent blood clots), 5 milligrams, twice daily to be administered to the resident when the INR (International Normalized Ratio-blood test that determines the thinness of the blood. The average normal range of INR for a person taking certain blood thinning medications is 2.00-3.00) was less than 2.0.

Review of laboratory results for Resident R92 revealed on February 13, 2019, an INR level of 2.5; February 14, 2019, an INR level of 3.0; February 15, 2019, an INR level of 2.3 and on February 16, 2019, and an INR level of 2.2. Review of the Medication Administration Record (MAR) revealed that nursing staff had administered the medication Eliquis on February 14, 2019, at 9:00 a.m., February 15, 2019, at 5:00 p.m., and February 16, 2019, at 9:00 a.m. and 5:00 p.m. Continued review of Resident R92's MAR revealed that nursing staff had erroneously administered the Eliquis medication for four of six scheduled doses over a three day period beginning on February 14, 2019, and extending through February 16, 2019

Review of the facility "Incident/Accident Report" dated February 16, 2019, at 5:30 p.m. revealed that "Hematuria (blood in the urine) was observed in the Foley drainage bag. On investigation, Pt. received 4 doses of Eliquis with INR > (greater than) 2.0." Eliquis, 5 milligrams, was to be given twice a day when the INR < (less than) 2.0 and that Eliquis was administered 2/14, 2/15, 2/16 when INR > 2.0.

Review of the "Medication Error Report" dated February 16, 2019, at 5:30 p.m. revealed an Administrative Error (Any error as it relates to how the medication was incorrectly given or not given by the nurse). The medication as it was intended to be or should have been administered as described above. The immediate action was to address and or correct this error was "Eliquis discontinued. MD notified and pt sent to ER for evaluation of hematuria."

Additional information on the Medication Error Report revealed "Gross hematuria observed in pts Foley bag. Checked MAR for anticoagulants ordered. Noted order for Eliquis and administration instructions. PT/INR drawn today. INR=2.2." Further review on the Medication Error Report revealed that the error was not self-reported and that the resident received too many doses, specifically four doses.

Documentation for Education: Individual Clinical Referral Form, dated February 27, 2019, revealed that Employee E13, Licensed Practical Nurse (LPN) was educated for a "Medication Error: Documentation of Critical Medication (Eliquis) given while parameters are to be held if patient INR is greater than 2.0. Medication given 2/15/19 @ 5 p.m." Further review of education also revealed "Review 5 rights of Medication Safety - Patient, Drug, Dose, Route, and Time. Also review any specific parameters in medication orders, i.e. lab results, BP parameters."

Additional Documentation for Education: Individual Clinical Referral Form, dated February 28, 2019, revealed that Employee E18, LPN, was educated for a "Medication Error: Documentation of Critical Medication (Eliquis) given while parameters are to hold if patient INR is greater than 2.0. Medication given at 9:00 a.m. on 2/14 and 2/16 by nurse (INR 2.2 on 2/16/19." Further review of education also revealed "Review 5 rights of Medication Safety-
Patient Drug, Dose, Route, and Time. Also review any specific parameters in medication orders, i.e. lab results, BP parameters, insulin coverage."

Review of Hospital records dated February 16, 2019, revealed that the Resident R92 was admitted for a primary diagnosis of UTI (urinary tract infection) and a secondary diagnosis of Hematuria (the presence of blood in the urine). Further review of hospital records on February 16, 2019, also revealed that upon admission into the emergency room the resident's INR level was elevated at 3.4 at 19:06 (7:09 p.m.), contributing to the resident's hematuria.

Interview with Employee E1, Nursing Home Administrator and Employee E2, the Director of Nursing, on March 7, 2019, at approximately 2:30 p.m. confirmed that the Licensed Practical Nurses, Employee E13 and Employee E18, violated the rights of medication administration when taking care of Resident R92 on August 2, 2017.

The facility failed to ensure that one resident was protected from a serious medication error resulting in harm to the resident and requiring transport to the hospital for an emergent evaluation and treatment following a medication error.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 07/25/18, 02/01/17

28 Pa. Code 201.18(b)(3) Management

28 Pa. Code 211.9(a)(1) Pharmacy services

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 01/04/18, 02/01/17

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 02/01/17





 Plan of Correction - To be completed: 04/16/2019

Resident's are Free of Significant Med Errors
1. Resident R92's physician was contacted and resident transferred to hospital for evaluation.
2. A chart audit was completed by DON of all residents receiving Anti-coagulants to ensure compliance with physician's orders.
3. All nurse's received 1:1 in-servicing by DON and/or Staff Educator on the facility Anti-Coagulant Policy & Procedure and The Rights of Medication Administration with specific focus on observing all parameters and responsibility to self-report. All new orders for Anti-Coagulant's will be reviewed by DON/designee to ensure clarity of orders. Daily review of Anti-Coagulant log will be done by DON to ensure labs are done and INR recorded. Daily audit of Medication Administration Record for all residents receiving Anti-Coagulants will be done Unit Manager to ensure parameters are followed per physician order.
4. Results of daily audits will be reported to Administrator daily by DON for 3 months. The need for continued audits will be reassessed at that time. All medication errors will be reported at monthly QAPI meeting.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on observations, interview with staff and residents and clinical record review, it was determined that the facility failed to update and revise a care plan for one of one resident reviewed regarding hypoglycemia (Resident R244).

Findings include:

An interview with Resident R244 on March 4, 2019, at 11:30 a.m. revealed that she is at the facility for rehabilitation due to syncope (dizziness - can include falling). The resident stated that the other day, she was not sure of the date, she woke up in bed surrounded by nursing staff and 911 emergency personnel. They informed her that her blood sugar was extremely low. She stated that her blood sugar began to increase after she was treated by nursing staff and did not need to go to the hospital.

A review of Resident R244's clinical record revealed that the resident was admitted to the facility on February 24, 2019, with a diagnosis of syncope with collapse (dizziness with falling), hypoglycemia (low blood sugar) and a history of a myocardial infarction (heart attack).

A review of Resident R244's clinical record, specifically the nurse's notes, revealed that on February 26, 2019, the resident was unable to be aroused at 8:20 a.m. An Accu-Chek (a machine used to check a person's blood sugar) was done and recorded at 43 (normal blood sugar 80 - 100). An injection of Glucagon one milligram was given. An Accu-Chek was done and revealed a blood sugar of 34. A second injection of Glucagon one milligram was given. A recheck of an Accu-Chek revealed a blood sugar of 96. The physician had been called and ordered the resident to be sent to the hospital. 911 personnel were present and left without the resident and stated to call again if this reoccurred. The physician and family were notified and the physician stated to monitor the resident.

A review of the resident's care plan titled Diabetes had not been updated to include that the resident had a hypoglycemic episode and an identification of the goals and approaches.

An interview with the Director of Nursing on March 7, 2019, at 10:30 a.m. confirmed that the care plan had not been updated to include the hypoglycemic event and what goals and interventions should be in place.

The facility failed to update a care plan in regards to a hypoglycemic episode and care.

Refer to F684.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 01/04/18, 02/01/17

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 02/01/17














 Plan of Correction - To be completed: 04/16/2019

1. Care plan of Resident R244 was updated to include hypoglycemic episode and protocols for hypoglycemia.
2. All care plans were audited by DON, Staff Educator and Unit Manager to ensure care plans include revisions for any recent incidents/change in status and/or unusual events.
3. All nurses and IDCP Team were in-serviced by the Staff Educator on care planning with focus on importance of timely revisions. Staff Educator or Unit Manager will audit 2 care plans per week x 3 months.
4. Results of audits of timeliness of care plan revisions will be presented by Unit Manager at monthly QAPI meeting.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on observation, review of clinical records and interview with residents and staff, it was determined that the facility failed to obtain, clarify and/or follow physician's orders related to wound treatments, weights and Foley catheters for three of 18 residents reviewed (Residents R144, R242 and R244).

Findings include:

Review of the clinical record for Resident R144 revealed that the resident was admitted to facility on February 21, 2019, with diagnoses including, but not limited to, congestive heart failure (excessive body fluid caused by weakened heart muscle), chronic kidney disease (kidneys unable to filter blood effectively) and chronic venous stasis ulcer (wound on leg or ankle due to damage veins). Continued review of Resident R144's clinical record revealed a physician's order for the administration of Eucerin creme (moisturizer) to feet and legs daily on 7-3 shift. Additionally, there was an order for Ace wrap (elastic bandage) from toes to knees; apply in a.m., may be removed when patient is in bed. Daily at 8:00 a.m. and 9:00 p.m.

Observation of the resident on March 4, 2019, at 12:18 p.m. revealed that the resident was sitting up in a wheelchair. Both legs were noted wrapped in Kling Gauze bandage from the ankle to the knees, which was dated 3/3/19, and the resident was wearing non-skids socks on both feet. Interview with the resident at the time of the observation revealed that the resident had venous ulcers on both legs and edema (swelling from excess fluid) of both legs and feet.

Observation of wound care on March 4, 2019, at 1:04 p.m. by Employee E16, Licensed Practical Nurse (LPN), removed the Kling gauze wrap bandage on the resident's left leg; cleaned and packed two open areas on the left knee then applied Eucerin cream to the left leg. The leg was redressed with Kling gauze wrap then an Ace wrap was applied. Continued observation of Resident R144's wound care revealed that Employee E16 did not remove the dressing from the right leg. The dated bandage to the right leg was noted off and the Kling gauze was loose around the knee. When the resident inquired if the nurse was going to treat the right leg, Employee E16 replied, "no treatment was ordered" then added "maybe the next shift will change it."

Interview with Resident R144 on March 5, 2019, at 9:45 a.m. revealed that the dressing on the right leg was not changed yesterday.

Interview on March 5, 2019, with Employee E17, regional nurse, confirmed that both of Resident R144's legs were to be treated with Eucerin creme and an Ace wrap was to be applied to both legs in the morning and removed at night.

Further review of R144's clinical record revealed that on February 28, 2019, the physician ordered that the resident be weighed daily and to notify the physician of a weight gain or loss of 2 pounds in 24 hours or 5 pounds in one week (schedule 6:00 a.m.). Continued review of the clinical record for Resident R144 revealed that only two of the five daily weights were completed as ordered by the physician on February 21 and March 5, 2019

A review of Resident R242's clinical record revealed that the resident was admitted to the facility on February 28, 2019, with a diagnosis of urinary retention (the inability to empty the bladder of urine) and a Foley catheter (a thin tube inserted into the penis to empty urine from the bladder).

A review of Resident R242's physician's orders dated February 2, 2019, revealed to straight cath (catheterize-insert a hollow tube to empty the bladder and obtain a urine sample) the patient and if urine output is greater than 100 milliliters (approximately 3.4 ounces), to leave the Foley catheter in.

Further review of the physician orders dated February 28, 2019, revealed an order for Foley catheter care, wash with soap and water every shift and to measure and record the urine output every shift. There was no documentation available for review regarding the size of the Foley catheter, when it should be changed and what amount of normal saline is needed to fill the anchoring balloon.

Review of physician's orders dated February 28, 2019, revealed an order for Foley catheter care, wash with soap and water every shift and to measure and record urine output every shift. There was no documentation available for review regarding the size of the Foley catheter, when it should be changed and what amount of normal saline (salt solution) is needed to fill the anchoring balloon (once the thin tube is inserted into the penis then advanced into the bladder, a small amount of normal saline in filled into a small balloon on the tube to help hold the Foley catheter in place).



Interview with the Director of Nursing on March 7, 2019, at 10:30 a.m. confirmed that there was no physician's order for the size of the Foley catheter, when it is to be changed and how much normal saline to fill the balloon for Residents R242 and R92.

A review of Resident R244's clinical record revealed that the resident was admitted to the facility on February 24, 2019, with a diagnosis of syncope with collapse (dizziness with falls) and hypoglycemia (low blood sugar). A review of nurse's notes dated February 26, 2019, revealed that the staff were unable to arouse Resident R244 at 8:20 a.m. An Accu-Check (a machine used to test a person's blood sugar) was performed and the resident's blood sugar was 43 (normal blood glucose 80-100). The nurse injected the resident with Glucagon (a hormone used to treat severe low blood sugar) one milligram. Another Accu-Check was done, and the resident's blood sugar was 34. The nurse injected another one milligram of Glucagon. The blood sugar was rechecked and was recorded at 96. The physician was called and ordered the resident be transferred to the hospital for further evaluation.

A review of Resident R244's physician orders for February 2019, revealed no physician's order for the administration of Glucagon. An interview with the Director of Nursing on March 7, 2019, at 10:30 a.m. confirmed that there were no physician orders for the Glucagon.

The facility failed to ensure that physician orders were followed, obtained and/or clarified for three of 18 records reviewed.


Quality of Care
CFR(s): 483.25 - Previously cited 01/04/18, 02/01/17

28 Pa. Code 211.5(f)(h) Clinical records

28 Pa. Code 211.9(d) Pharmacy services

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

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 01/04/18, 02/01/17

28 Pa. Code 211.12(d)(3)(5) Nursing services
Previously cited 01/04/18




 Plan of Correction - To be completed: 04/01/2019

1. A clarification order was obtained for treatment to Resident R144 bi-lateral lower extremities. Resident R144 weights were reviewed by Unit Manager to ensure daily weight was captured.
Resident 242 was discharged to hospital and returned home. Care plan of Resident R244 was updated to include hypoglycemic episode and protocols for hypoglycemia.
2. All Physician Orders were reviewed by DON, Staff Educator and Unit Manager to ensure clarity and compliance. Chart audits were conducted by the DON, Staff Educator and Unit Manager for all residents with physician orders for daily weights, Foley catheters and/or treatment orders to ensure weights are obtained daily, Foley catheter orders are complete and treatment orders followed. The DON will review all new physician orders daily to ensure physician orders are carried out.
3. The Staff Educator and DON will provide 1:1 in-servicing to all nurses on ensuring physician's orders are followed with focus on daily weights, Foley catheter orders and treatment orders.
The Staff Educator will conduct 2 chart audits and 1 treatment observation weekly to ensure physician orders are followed.
4. Status of compliance with following physician orders for daily weights, Foley catheter care and treatments will be reported at monthly QAPI meeting by Staff Educator for 3 months. The need for continued audits will be re-evaluated at that time.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on observation, review of the clinical records and interviews with residents and staff, it was determined that the facility failed to keep one of two residents reviewed safe from falls (Resident R94).

Findings include:

Review of the clinical record for Resident R94 revealed that the resident was admitted to the facility for rehabilitation on November 27, 2018, with a non-displaced left hip fracture due to a fall at home. Resident was being treated for recurrent kidney infections from December 1, 2018, through to January 28, 2019. Secondary diagnoses included diabetes (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), macular degeneration in the right eye (loss of vision) and anxiety (persistent worry and fear). Review of the Minimum Data Set assessment (a periodic assessment of resident's needs) dated December 4, 2018, indicated that the resident required extensive assistance with one person physical for bed mobility, transfers, dressing, toilet use and limited assist with one person for personal hygiene.

Review of nurse's notes revealed that on January 18, 2019, the resident had an unwitnessed fall at approximately 8:10 a.m. The nurse wrote that the resident denied hitting her head. The resident states the wheelchair became unlocked and one side rolled from under her at the bathroom sink as she was washing. Review of the "Incident and Accident Report" dated 1/18/19, revealed that the resident was in the bathroom in the wheelchair, lock on right side became loose and resident slid from wheelchair to the floor landing on her buttocks, denies hitting head. No apparent injuries. The resident physical status prior to the fall unsteady gait, impaired mobility and transfers. The nurse aide assigned to the resident for care stated that the resident was washing up at the sink, when she returned the resident was on the floor. The resident said the break had come loose.

An interview with the Nursing Home Administrator on March 7, 2019, at approximately 2:00 p.m. confirmed that Resident R94 should not have been left alone in the bathroom.

The facility failed to keep a resident safe and free of falls.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 07/25/18, 02/01/17

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 01/04/18, 02/01/17

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 02/01/17












 Plan of Correction - To be completed: 04/16/2019

1. Resident R94 had been discharged from facility.
2. The transfer and ADL status of each resident was reviewed with Unit Manager by the Rehab Director to determine bathroom safety. The Fall Risk Assessment for each new admission will be reviewed at the daily clinical meeting with the IDCP team.
3. The transfer and ADL status of each resident was reviewed with resident's Nursing Assistant and in-servicing was provided by the Unit Manager. C.N.A. care plans were updated accordingly. The Unit Manager will update C.N.A. care plan with current transfer & ADL status after weekly Utilization Review meeting. All incident reports are reviewed at daily clinical meeting and care plan interventions updated accordingly. A system change was implemented to include review and revisions of C.N.A. care plans by the Unit Manager with the current transfer and ADL status after weekly Utilization Review meeting. Any change in condition will be noted on walking rounds at the beginning of shift change.
4. Falls data will be presented at monthly QAPI meeting by Director of Nursing. Fall data will be monitored for incidents of similar nature to make sure solutions are sustained. Information will be monitored for 6 months then reassessed.

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 observations, staff interviews and review of the facility policy, it was determined that the facility did not maintain acceptable standards of infection control practice related to handwashing technique during wound care for one of one residents observed during wound care (Resident R144).

Findings include:

Review of the facility policy "Handwashing and Hand Hygiene" dated October 31, 2013, revealed that the policy stated that the purpose is to prevent cross contamination. To remove gross soil and to decontaminate hands. The procedure specified: wet hands, apply soap, rub hands together covering all surfaces of the hands and fingers for 20 seconds, rinse hands with water, dry thoroughly with paper towel and use towel to turn off faucet. Indications for Handwashing/Hygiene: After removing gloves.

Observation on March 4, 2019, at 1:04 p.m. prior to performing Resident R144's wound care, Employee E16, Licensed Practical Nurse-LPN, washed her hands for approximately 15 seconds then donned two pairs of gloves. During wound care, Employee E16 used a pair of scissors from the treatment cart to cut gauze dressing to the size of the wound. The scissors were not cleaned with a disinfectant wipe before or after the procedure. After the procedure, Employee E16 did not wash her hands.

Interview with Employee E3, Infection Preventionist on March 7, 2019, at approximately 10:15 a.m. revealed that staff were inserviced (educated) to wash hands with soap and water for 20 seconds.

The facility failed to implement adequate standard infection control procedures related to hand hygiene during wound care.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 07/25/18, 02/01/17

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(c)(d)(2) Nursing services

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 01/04/18, 02/01/17

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 02/01/17










 Plan of Correction - To be completed: 04/16/2019

Infection Prevention & Control
1. Employee E16 was re-educated on hand hygiene and proper procedure for wound treatment/ disinfecting scissors.
2. All nursing staff received in-servicing on hand hygiene and proper procedure for wound treatment/disinfecting scissors.
3. 2 random audits will be done weekly by Staff Educator to make sure solutions are sustained.
4. Results of audits will be reported at monthly QAPI meeting by Staff Educator to make sure solutions are sustained. The need for continued audits will be reassessed at that time for compliance.

211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.
Observations:

Based on closed clinical record review and interview with staff, it was determined that the facility failed to document the disposition of medication for two of two closed records reviewed (Residents R42 and R3).

Finding include:

A review of Resident R42's closed clinical record revealed that the resident was admitted to the facility on December 7, 2018, and discharged on December 15, 2018. Further review revealed no documentation available for review of the disposition of the residents' medications at the time of discharge.

A review of Resident R43's closed clinical record revealed that the resident was admitted to the facility February 13, 2019, and discharged to the hospital on February 21, 2019. Further review revealed no documentation available for review of the disposition of the residents' medications.

Interview with the Director of Nursing on March 7, 2019, at 2:00 p.m. confirmed that there was no disposition of medications available for review for Residents R42 and R43.








 Plan of Correction - To be completed: 04/16/2019

1. Pharmacy was contacted for documentation of medications returned for Residents R42 & R43.
2. A closed record audit of disposition of medications was completed by Medical Records Director of residents discharged in the past 30 days.
3. All nurses were in-serviced on Policy & Procedure for recording disposition of resident's medication at time of discharge. Charts of discharged resident's will be reviewed daily at clinical meeting to confirm that medication disposition is properly recorded in closed record.
4. Medical Records Director will continue to audit and report status at monthly QAPI meeting for 3 months to make sure solutions are sustained.


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