Nursing Investigation Results -

Pennsylvania Department of Health
MASONIC VILLAGE AT ELIZABETHTOWN
Patient Care Inspection Results

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MASONIC VILLAGE AT ELIZABETHTOWN
Inspection Results For:

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MASONIC VILLAGE AT ELIZABETHTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated survey in response to a complaint completed on January 24, 2019, it was determined that Masonic Village at Elizabethtown was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Licensure Regulations as they related to the Health portion of the survey process.



 Plan of Correction:


483.25 REQUIREMENT Quality of Care:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
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 policy review, clinical record review, and staff interview, it was determined that the facility failed to communicate the results of Resident CL1's PT/INR screening to the physician. This placed one out of three residents reviewed (Resident CL1) in an immediate jeopardy situation with the continued administration of an anticoagulant medication, which resulted in Resident CL1 developing an abnormal hemoglobin level requiring a transfer to the hospital via emergency services, critical INR levels of above 15.6, and requiring transfusion of two units of blood and intravenous Vitamin K.

Findings include:

Review of the facility policy, Change in Condition, effective date January 8, 2018, revealed that nursing was to notify the physician when there is a need to alter the resident's medical treatment significantly.

Review of the facility policy, Anticoagulation Therapy (medication used as blood thinners), undated, revealed that the anticoagulation management provider will review each INR (laboratory test used as a standard for monitoring the effects of anticoagulant treatment) result within 8 hours. The provider may adjust anticoagulant dosing if the INR is above or below the therapeutic range specified. The facility must seek physician orders for initiating or stopping anticoagulant therapy.

Review of Resident CL1's diagnosis list revealed diagnoses including, but not limited to, CVA (cerebrovascular accident - stroke) and atrial fibrillation (irregular heart beat that can put residents at increased risk for blood clots).
Review of Resident CL1's November 2018 physician's orders revealed that there was an order for an anticoagulant medication, Jantoven 2.5 mg (milligrams) daily. Further review of the November 2018 orders revealed an order dated November 5, 2018, for PT/INR screening on November 9, 2018.

Review of Resident CL1's INR screening results from November 9, 2018, revealed the resident's INR was 3.3 (therapeutic range is between 2-3).

Review of Resident CL1's "Medical Provider Communication Form" dated November 9, 2018, revealed the physician was notified that the resident's INR was 3.3. The physician responded with an order to hold the resident's Jantoven on November 9, 2018, and to recheck the resident's INR on November 10, 2018.

Review of Resident CL1's physician's orders revealed an order dated November 9, 2018, for Jantoven (blood thinner used to prevent blood clots) 2.5 milligrams (mg) daily. Next PT/INR on November 10, 2019.

Review of Resident CL1's INR results from November 10, 2018, revealed that the resident's INR was documented on the resident's electronic clinical record flow sheet as "3.1."

Review of Resident CL1's clinical record failed to reveal documented evidence that the resident's physician was notified of the resident's elevated INR on November 10, 2018.

Review of Resident CL1's medication administration records from November 2018 to December 2018 revealed that the resident continued to receive Jantoven 2.5 mg daily until December 1, 2018.

Review of the physician's progress notes dated November 21, 2018, and November 26, 2018, revealed no documented evidence that the resident's anticoagulant medication and PT/INR levels were reviewed.

Review of Resident CL1's progress notes revealed a nurse's note on December 1, 2018, at 3:45 p.m. stating, "Family in to visit today and concerns about [resident] not feeling well. Per family/POA wife this has been a few days and today his speech is worse and color is pale and jaundice looking. [Vital signs stable] O2 sats [oxygen saturation] hard to get due to poor circulation in his fingers, but 98% when finally gotten." Nurse's note further stated Resident CL1 "feels like he is having generalized muscle pain all over and in his buttock from sitting ...New orders noted to get stat CBCD (complete blood count) and CMP (comprehensive metabolic panel) to start with today."

Further review of the progress notes revealed a note on December 1, 2018, at 6: 55 p.m. stating, "Report received from Lab with critical values reviewed with family, [resident], and on call MD ...new order to send to [emergency room] to evaluate low and critical labs. 911 called at [6:35] and arrived on unit at 6:42."

Review of Resident CL1's labs from December 1, 2018, revealed the resident's hemoglobin was 5.1 (low - normal is 14-18), hematocrit was 15.6 (low - normal is 42-52), and red blood cell count was 1.61 (low - normal is 4.6-6.2).

Review of emergency hospital records revealed that Resident CL1 was found with a critical hemoglobin level of 5.1, an INR above 15.6, and an 11 cm x 3 cm x 14 cm right gluteal hematoma (collection of blood outside the blood vessels.) The resident required 2 units of packed red blood cells (blood transfusion) and 10 units of intravenous vitamin K (vitamin which aids in blood clotting.)

Interview with the NHA and DON on January 15, 2018, at approximately 4:20 p.m. confirmed that there was no documented evidence that Resident CL1's PT/INR values of November 10, 2018, were communicated to the resident's physician.

Interview with the Director of Quality Assurance, Employee E3 on January 22, 2019, at 3:10 p.m. confirmed that the resident continued to receive Jantoven 2.5 mg daily until the resident's hospitalization on December 1, 2018.

Interview with facility physician on January 24, 2018, at 12:15 p.m. confirmed that it was expected for the resident's physcian to be notified of the PT/INR values as ordered. It was further stated during interview that if the values were not received within 24 hours, the facility should check for the values. In addition, it was expected for the licensed nursing staff to know the facility anticoagulant policy.

The facility failed to communicate the results of Resident CL1's PT/INR screening of November 10, 2018, to the physician and to ensure the proper monitoring of Resident CL1's PT/INR, which placed Resident CL1 in an immediate jeopardy situation. The failure to properly monitor Resident CL1's PT/INR levels resulted in Resident CL1 developing an abnormally low hemoglobin level, transfer to the hospital via emergency services, and critical INR levels of above 15.6, requiring 2 units of blood and intravenous vitamin K.

Immediate Jeopardy was identified on January 22, 2019, at 3:39 p.m. for the facility's failure to properly monitor Resident CL1's PT/INR values. An immediate action plan was requested at this time to immediately put systems in place to ensure residents on anticoagulant medications have received proper laboratory test follow ups to ensure medications are within a proper therapeutic level.

The facility submitted and implemented an action plan which included an audit of all residents currently receiving Jantoven, education of licensed nursing staff on the policies for anticoagulation therapy and changes in resident condition, establishing a protocol for changes in level of care (short term to long term care) and more frequent monitoring when residents are on antibiotics, and ensuring that the registered nurse on the unit will be responsible for placing the orders on the medical record and recording lab results received and having a second registered nurse sign the results to ensure proper follow up with the physician has been completed. Furthermore, the facility will audit 100% of residents on anticoagulants which require laboratory monitoring weekly for four weeks and then monthly for three months. The results will be shared with the quality assurance committee for further follow up and recommendations.

Immediate Jeopardy was removed on January 24, 2019, at 2:00 p.m. based on the facility's implementation of an acceptable plan of action.

Review of Resident R2's electronic diagnosis list revealed a diagnosis of atrial fibrillation (irregular and rapid heart beat) and long term use of anticoagulants. Review of November 2018 physcian's orders confirmed that Resident R2 had an order for the anti-coagulant medication, Jantoven 2 milligrams three times per week. Review of the "Medical Provider Communication Form" dated November 7, 2018, revealed the resident's physician was notified about the INR of 2.2 and the physician ordered that the resident continue to receive the "same coumadin" and INR in one month. Review of the resident's clinical record revealed no documented evidence that the INR screening was completed in the month of December 2018. The next available INR screening completed was not until Janaury 16, 2019. Interview with the Director of Quality Assurance, Employee E3 confirmed that the resident did not have an INR screening completed in December 2018.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 08/10/18

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 08/10/18

28 Pa. Code 211.5(f) Clinical records
Previously cited 08/10/18

28 Pa. Code 211.5(h) Clinical records

28 Pa. Code 211.10(c) Resident care policies
Previously cited 07/17/17

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 08/10/18, 07/17/17

28 Pa Code 211.12(d)(3) Nursing services




















 Plan of Correction - To be completed: 02/15/2019

1. Resident CL1 is no longer a resident at this facility.

The PT/INR for resident R2 was obtained on January 16, 2019 and had a result of 2.2. This is within therapeutic limits and no change to the medication dose was required. The resident is on monthly PT/INR draws and has one schedule for February.

2. On January 23, the facility completed an audit on residents with orders for anticoagulant medication which needs to be monitored with appropriate blood work. Residents included in the audit had the appropriate PT/INR screenings in place or had additional labs ordered if necessary.

3. The facility has updated its policy on Anticoagulant Therapy to ensure that the appropriate follow up will be completed on residents that need lab monitoring. Residents will have a lab drawn at least monthly but will have more frequent labs if required by the resident's current medical condition. Education has been provided to the staff on the policy changes. A directed in-service will be completed by an approved provider on Anticoagulant Therapy, timely notification of the physician of laboratory results and a review of symptoms related to the use of anticoagulant therapy. The medical practitioner staff will also review the policy changes and the current system of notification for lab results.

4. The facility will continue to audit 100% of residents on anticoagulants therapy which requires lab monitoring, weekly for four weeks and then monthly for three months. The director of nursing and nursing home administrator will review the findings and make any additional recommendations for system change if required. The audit findings will be communicated to the quality assurance committee for review and further recommendations.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident's physican reviewed the licensed pharmacist's report for a medication irregularity for one of 10 residents reviewed. (Resident R2)

Findings include:

Review of the facility policy titled, "Medication Regimen Review," dated July 1, 2017, revealed that the findings and recommendations are reported to the Director of Nursing and the attending physican and to the appropriate Medical Director and/or Adminsitrator.

Review of Resident R2's clinical record revealed diagnoses including but not limited to: congenital hypothyroidism without goiter (condition due to deficiency in the thyroid hormone resulting in decreased body metabolism without an enlarged thyroid gland), unspecified atrial fibrillation (irregular and rapid heart beat), unspecified heart failure (heart muscle does not pump properly)

Review of a monthly drug regimen review completed by the consultant pharmacist on October 25, 2018, revealed a recommendation of "Resident's TSH (thyroid stimulating hormone) level on 10/16/18 was 9.19. Consider increasing her Levothyroxine Dose to 75 mcg daily and recheck her level in 8 to 12 weeks." Further review of Resident R2's clinical record failed to reveal documented evidence that the resident's physician was aware of or responded to this pharmacy recommendation.

Review of a monthly drug regimen review completed by the consultant pharmacist on November 21, 2018, revealed a recommendation of "Resident's TSH level on 10/16/18 was 9.19. Resident's level on 10/30/18 was 7.22. Consider increasing her Levothyroxine Dose to 75 mcg daily and recheck her level in 8 to 12 weeks." Further review of Resident R2's clinical record failed to reveal documented evidence that the resident's physician was aware of or responded to this pharmacy recommendation.

An interview with the Assistant Director of Nursing on January 24, 2018, at 11:00 a.m. confirmed that the physician did not respond to or act upon the above pharmacy recommendations. The interview also revealed the expectation that the physician should have responded to the pharmacy recommendations.

28 Pa. Code 211.5(f) Clinical records
Previously cited 08/10/18

28 Pa. Code 211.5(h) Clinical records

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

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services.
Previously cited 08/10/18, 07/17/17

28 Pa. Code 211.12(d)(3) Nursing services





 Plan of Correction - To be completed: 02/15/2019

1. The physician has addressed the pharmacy recommendation for resident R2.

2. The facility will review the pharmacy recommendations from the December reviews to ensure that recommendations have been responded to by the physician and have been documented.

3. The facility will communicate with the medical staff via email or through a communication folder on the neighborhood, depending on physician preference. The physician will then complete the review in the electronic medical record. Re-eduction will be provided to the medical providers. DON will review the next month's recommendation to ensure follow up was completed.

4. The facility will audit the pharmacy recommendations monthly, starting with the January reviews, for three months to ensure that a medical practitioner has addressed the concerns in a timely manner. Follow up with the medical practitioners will occur if warranted. The findings of the audit will be forwarded to the quality assurance committee for review and further recommendations.

483.70 REQUIREMENT Administration: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.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:

Based on review of position descriptions, clinical records, and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to monitor and supervise staff performance to ensure the health and safety of the residents.

Findings include:

The position description of the Nursing Home Administrator (NHA) last revised March 2017 revealed that the NHA has responsibility for ensuring that the operation of the entire skilled nursing facility delivers high quality health care.

The position description for the Director of Nursing (DON) last revised February 2017 revealed that the DON has responsibility for the overall management of the healthcare center nursing department.

The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Care 483.25 revealed that the NHA and DON failed to supervise subordinate staff to assure that laboratory results for a resident on anticoagulation medication were communicated to the resident's physician, resulting in subsequent hospitalization requiring a blood transfusion, placing the health and safety of the residents in Immediate Jeopardy.

Refer to F684.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 08/10/18

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 08/10/18

28 Pa. Code 211.12(c)(d)(1) Nursing services
Previously cited 08/10/18, 07/17/17

28 Pa. Code 211.12(d)(3) Nursing services

























 Plan of Correction - To be completed: 02/15/2019

1. There were no specific residents cited for this deficiency.

2. The DON and NHA have reviewed the initial audit findings and have used that information to update policies, educate staff and set up our related quality assurance audit, related to anticoagulant therapy.

3. The DON and NHA will review together each set of audit findings for the Quality of Care deficiency. Any concerns will be addressed immediately, and any policy updates and/or staff education required, will be initiated as appropriate. The DON and NHA will also meet on a weekly basis to review any systematic concerns that may exist for the facility. Additionally, they will review the findings from our quality assurance software reviews to ensure that any concerns are being addressed.

4. The DON and NHA will make a joint presentation at the monthly Quality Assurance meeting to review any systematic issues that have been identified and to review any changes that have been made due to those findings. The quality assurance committee will review those concerns and make any recommendations it finds necessary.


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