Nursing Investigation Results -

Pennsylvania Department of Health
PARKHOUSE REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PARKHOUSE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  77 surveys for this facility. Please select a date to view the survey results.

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PARKHOUSE REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and an Abbreviated Survey in response to seven complaints completed on March 8, 2019, it was determined that Parkhouse Rehabilitation and Nursing Center 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(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is the most serious deficiency and was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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(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 a review of clinical records, facility policies and procedures, and facility documentation, and interviews with residents and staff, it was determined that the facility failed to maintain a safe environment related to fire drills and failed to ensure that adequate fire safety training was provided to agency nursing staff. This failure of not training agency nursing staff on fire safety placed a threat to the health and safety of all residents at the facility related to a lack of knowledge on emergency procedures if a fire or a related disaster occurred at the facility. These conditions resulted in an Immediate Jeopardy situation. In addition, the facility failed to provide adequate supervision for a resident who eloped and sustained an injury which resulted in actual harm to the resident who sustained a fractured hip (Resident R441).

Findings Include:

Review of facility policy titled "Emergency Procedure - Fire" dated October 4, 2016, revealed that the facility had a designated procedure for fires and explosions that shall be followed if such an emergency arises. Staff receive training at least annually on fire procedures and the use of fire extinguishers.

A request was made to the Nursing Home Administrator (NHA) on March 4, 2019, for a list of agency personnel who worked in the facility in the past four months as well as evidence of their education on hire. The list provided by the NHA on March 7, 2019, included 73 agency personnel, which included nursing assistants, registered nurses and licensed practical nurses. A review of the personnel files for the agency personnel revealed no facility fire safety training.

Interview on March 6, 2019, at 9:40 a.m. with Employee E7, Registered Nurse (RN), who is an outside agency personnel, stated that she did not receive facility fire safety training prior to her first day of providing care to residents.

Interview on March 6, 2019, at 9:50 a.m. with Employee E6, Licensed Practical Nurse, who is an outside agency personnel, stated that she wasn't sure/couldn't recall if she received facility fire safety training prior to her first day of providing care to residents.

Review of the facility document "Parkhouse Fire Alarm/Drill Summary" dated March 22, 2018, revealed very poor staff performance. Doors shut to rooms without checking for fire.

Review of the facility document "Parkhouse Fire Alarm/Drill Summary" dated April 22, 2018, very weak supervised staff needs to talk to their staff.

Review of the facility's Safety Committee Meeting dated April 25, 2018, revealed
Must work better on fire drills - fire safety in-service and education facility wide. Employee E8, Security Supervisor/Fire Safety Educator - follow up.

Review of the facility's Safety Committee Meeting dated May 8, 2018, revealed "Fire Drills/Disaster Drills: True" with no other documented evidence for mention of the fire drills.

Review of the facility's Safety Committee Meeting dated June 28, 2018, revealed " ... Fire Drills - spoke w/security and was informed that if a fire drill is done and if it doesn't go well security wants to educate unit and redo fire drill within days to see if there is a better outcome. The obstacle comes with revolving staff (agency) and, at the present time, they are unable to move forward with this plan. Security stated that each month before a drill, they inform the unit that a drill is coming up, but even doing this, the staff are still confused about what they should do. (Further review of the document revealed the following information)
- Fire Drills - Training.
- Develop a one page training for "what to do" during a fire drill.
- How do we educate agency staff on fire drill process?
- Post something at nurses' station
- Increase info during safety fair
- follow up 30/60/90 - for new hires
- Go back to old fire drill model -
- monthly unit based."

Review of the facility document "Parkhouse Fire Alarm/Drill Summary" dated June 29, 2018, revealed that the Supervisor did education with nursing concerning using proper entry to assist with fire/emergencies.

Review of the facility's Safety Committee Meeting dated July 26, 2018, revealed "Fire Drills/Disaster Drills: True" with no other mention of fire drills.

Review of the facility document "Parkhouse Fire Alarm/Drill Summary" dated August 9, 2018, revealed that unit staff need to work on an effective routine for fire drills. This drill was very unorganized on the unit.

Review of the facility's Safety Committee Meeting dated August 22, 2018, revealed "Fire Drills Disaster Drills: True" with no other mention of fire drills.

Review of the facility's Safety Committee Meeting dated October 29, 2018, revealed "Fire Drills/Disaster Drills: True" with no other mention of fire drills.

Review of the facility's Safety Committee Meeting dated November 28, 2018, revealed "Fire Drills/Disaster Drills: True" with no other mention of fire drills.

Review of the facility's Safety Committee Meeting dated December 19, 2018, revealed that Security and Maintenance are working on fire drill response training and disaster training for managing staff. Roll out 2-1-19.

Review of the facility document "Parkhouse Fire Alarm/Drill Summary" dated December 20, 2018, revealed Wheelchair blocking fire door, slow response by 8 North Nursing unit staff.

Review of facility document "Parkhouse Fire Alarm/Drill Summary" dated January 9, 2019, revealed " ... Unit response was slow."

Review of the facility's Safety Committee Meeting dated January 16, 2019, revealed the fire department is supposed to come awaiting completion and roll out of fire drill training roll out was supposed to be 1/1/19 new date - 2-1-19.

Interview on March 6, 2019, at 11:00 a.m. with Employee E8, Security Supervisor/Fire Safety Educator, where he acknowledged the above mentioned fire drill deficient areas. Employee E8, Security Supervisor/Fire Safety Educator, attributed the fire drill deficiencies on agency staff and their lack of knowledge regarding the facility's fire safety program. Employee E8, Security Supervisor/Fire Safety Educator, stated part of his responsibilities include
in-servicing new hires, that are not agency personnel, on the facility fire safety plan. Employee E8, Security Supervisor/Fire Safety Educator, stated that he was under the impression that the facility's educator was responsible for orientating new agency hires.

Interview with the NHA on March 7, 2019, at 1:30 p.m. where she confirmed that agency personnel are not oriented on hire regarding the facility's fire safety program. The NHA stated that regular non-agency staff do receive fire safety training on hire, but agency staff do not receive training.

An Immediate Jeopardy situation was identified to the NHA and the Director of Nursing (DON) on March 7, 2019, at 6:04 p.m. related to the facility not ensuing that a safe environment was maintained regarding fire drills related to a lack of fire safety training for agency nursing staff. This failure of not training agency nursing staff on fire safety placed a threat to the health and safety of all residents at the facility related to the facility's agency staff lack of knowledge on emergency procedures if a fire or a related disaster occurred at the facility.

The corrective action plan included the following interventions:

1. Parkhouse provided fire safety education to 43 agency staff that were in the building the past 24 hours.
March 7, 2019 - 3:00 p.m. - 11:00 p.m. shift and 11:00 p.m. - 7:00 a.m. shift
March 8, 2019 - 7:00 a.m. - 3:00 shift was completed on this date.
March 8, 2019 - 3:00 p.m. - 11:00 p.m. shift

2. 21 Agency staff are scheduled: 4 RN's, 10 LPN's, 7 CNA's. 16 of the above referenced agency staff have worked within the past 24 hrs. and have received the fire safety training, the remaining 5 will receive training upon arrival to the facility before being assigned to a unit.

3. All contracted agencies were contacted on March 7, 2019, and advised that their assigned staff reporting to Parkhouse must complete fire safety education prior to being assigned to a unit.

4. Parkhouse staffing coordinator reached out to the five agency staff scheduled for 3:00 p.m. - 11:00 p.m. on March 8, 2019, to reiterate they must arrive prior to their scheduled shift to take part in fire safety education and will then be assigned a unit.

5. Unit Managers/ADON will conduct the fire safety education with agency upon arrival on March 8, 2019.

6. They will ensure fire safety education is completed and documented in log/binder which will be kept in the Nursing office.

7. Process will continue for proceeding shifts throughout the weekend, and thereafter.

8. Staffing Coordinator will identify first time agency staff, provide a list to Nursing Supervisor or designee, they will ensure fire safety education is completed and documented in log/binder which will be kept in the Nursing office.

Monitoring visits were conducted on March 7, 2019, and March 8, 2019, to verify the implementation of the immediate action plan and to review staff re-education documentation. On March 8, 2019, 43 agency staff that were in the building in the past 24 hours received fire safety education. All contracted agencies were contacted and advised that they would need fire safety training prior to being assigned a unit. Fire safety education is completed and documented in log/binder. Staffing coordinator will identify first time agency staff, provide a list to Nursing Supervisor/designee, they will ensure fire safety education is completed and documented in log/binder. The Immediate Jeopardy was lifted on March 8, 2019, at 1:06 p.m.

Review of the clinical record for Resident R441 revealed that the resident was admitted to the facility from an acute care hospital on February 15, 2019, with diagnoses including dementia (progressive, degenerative brain disease that resulting in problems with thinking, behavior, and memory), multiple fractures of ribs, right side, from fall at home, and bronchitis (inflammation of the lining of the lungs). Review of a nursing admission "Nursing Evaluation," dated February 15, 2019, indicated that the resident was oriented to self and time of day, and that the resident was not ambulatory or self mobile in wheelchair and therefore not an elopement risk. Further review of the same assessment indicated that the resident was disoriented times one, had a history of one or two falls in the past three months, had a balance problem while standing/walking, and had decreased muscular coordination/jerking movements, was on prescribed medications that could cause decreased balance, and was diagnosed with conditions that could also affect balance and muscular movements, and therefore resident was at risk for falls.

Review of the Interdisciplinary Team discussion of resident's functional abilities on February 18, 2019, at 12:46 p.m. indicated that Resident R441's functional abilities and goals were discussed and the performance codes for self-care indicated that Resident R441 required partial or moderate assistance of staff person for personal hygiene, lower body dressing and putting on footwear, and transfers including chair/bed to chair and toileting; supervision only for oral hygiene and upper body dressing; and set-up only for eating. The Interdisciplinary Team discussion also indicated that performance codes for walking were "not attempted, due to medical condition or safety concern," and also noted that the resident "does not use a manual wheelchair as a mode of transportation."

Review of the nursing progress notes for Resident R441 on February 16, 2019, at 5:29 a.m. revealed that the resident woke up "confused and disoriented looking to call sister." The same note of February 16, 2019, stated that the resident was reoriented to room and that safety was to be maintained at all times. Further review of the nursing progress notes indicated that on February 16, 2019, at 12:11 p.m. resident was alert with confusion, and non-compliant with transfers." Review of nursing note of February 17, 2019, at 7:39 p.m. stated that resident was assist of one staff person with walker for ambulation. Review of the nursing care plan for Resident R441, dated as initiated February 17, 2019, noted that the resident was an elopement risk/wanderer, no goal was specified, but the intervention was to "notify appropriate department of resident risk for elopement, also dated as initiated February 17, 2019. Review of an "Elopement Evaluation," dated February 17, 2019, at 7:37 p.m. indicated that resident was "cognitively impaired, with poor decision making skills or with pertinent diagnosis, that resident had a history of wandering, and the intervention was to "notify appropriate departments of Resident Risk for elopement." Clinical record or facility documentation did not reveal why resident was assessed and identified as an elopement risk on February 17, 2019. Also, the clinical record or facility documentation did not reveal if the "appropriate departments" were notified of Resident R441's risk for elopement.

Further review of of the nursing progress notes revealed that on February 18, 2019, at 2: 36 a.m. resident was confused and "demanding to leave, and wanted roommate removed from room." Also noted was that the resident was redirectable. Nursing note of February 18, 2019, at 10:53 a.m. further indicated that the resident was non-compliant and "does not call for nursing assistance with transfers."

Review of an activity progress note of February 18, 2019, at 12:37 p.m. revealed that Resident R441 was "concerned about personal affairs not being taken care of" while resident was in facility, such as paying bills. Review of nursing progress note of February 18, 2018, at 1:29 p.m. indicated that the resident was assist of one and made attempts to get up without assistance. Review of physician's progress note of February 18, 2019, revealed that resident was "insisting that he needed to leave today or tomorrow, that he had very important things to do at home."

Review of nursing progress note of February 18, 2019, at 8:35 revealed that a nursing assistant stated that the resident was not in his room and was unable to be found on the nursing unit. The note stated that the licensed nurse "approached security and looked out ambulance entrance, heard someone yelling and found resident leaning against dietary dock." The same nursing note indicated that Resident R441 stated "he fell and to call an ambulance because his hip was broken." The note also indicated that blood was noted on resident's pants from a laceration to right thumb base, which measured 1.5 centimeters by 0.5 centimeters. Resident was then "escorted back to clinical unit via wheelchair." The nursing progress note further stated that an assessment of the resident was completed, and it was noted that the "right leg was shorter and outwardly rotated, and unable to completely straighten without much discomfort." Result of X-ray ordered by physician found a right femoral neck fracture (right hip) and physician ordered resident to be transferred to acute care hospital emergency department.

Review of the facility's investigation revealed that the nursing assistant entered Resident R441's room on February 18, 2019, at 8:35 p.m. and resident's roommate informed the nursing assistant that the resident put his baseball cap on his head and told the roommate "I'm leaving." The roommate also stated that the nursing assistant came into room within five minutes of resident leaving and he informed her that resident had left. The nursing assistant, Employee E14 reported to the licensed nurse, Employee E17, that resident was missing, who reported it to Employee E16, the nursing supervisor. Review of the statement by the nursing assistant indicated that the last time the she had seen the resident was 7:25 p.m. when he was in his room and "refused to get ready for bed." Review of the statement by the licensed charge nurse, Employee E17, indicated that the last time she saw resident was at 8:05 p.m. when he was observed sleeping in bed with the walker at the foot of the bed.

Review of the statement by Employee E18, licensed nurse, revealed she was on a break at approximately 8:35 p.m. "out back and heard a man's voice yelling" and Employee E16, nursing supervisor, came outside looking for the resident. The statement stated that Employee E16 and Employee E18 heard yelling and followed the voice which was coming from the dietary loading dock. Resident R441 was found leaning against the dock, and he stated that he fell and hit his head and that he had pain in right hip. Employee E16 asked resident where he was going and he answered, "to my house." Resident was dressed with sneakers on his feet.

Review of Resident R441's record revealed he was admitted to the short term unit of the facility for rehabilitation. Observation of the location of the resident's room on the day of the elopement, February 18, 2019, found that the room was located approximately ten feet away from double doors that led to the dietary department via a hallway approximately ten feet in length leading to a second set of double doors leading directly into the dietary department. There was a door to the outside of the building off the hallway which was not equipped with an alarm when opened. The door to the outside of the building was approximately 80 feet from the dietary loading dock where the resident was found. During the interview with the resident following the elopement by Employee E16, he was unable to remember how he got to the loading dock.

Interview with the Nursing Home Administrator on March 7, 2019, at approximately 12:15 p.m. confirmed that the resident was not properly supervised and monitored which resulted in an elopement and injury to the resident.

The facility failed to ensure that the residents' environment was safe and free of accident hazards by not ensuring that all agency staff received adequate fire safety education and failed to monitor one resident who eloped from the facility resulting in actual harm to the resident who sustained a fractured hip.

Refer to F726, F838, F865.

Free of Accident Hazards/Supervision/Devices
CFR(s): 483.25(d)(1)(2) - Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/18

28 Pa. Code 201.20(c)(d) Staff development

28 Pa. Code 211.5(f)(h) Clinical records
Previously cited 05/07/18

28 Pa. Code 211.5(g) Clinical records

28 Pa Code 211.11(d) Resident care plan
Previously cited 05/07/18

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 05/07/18

























 Plan of Correction - To be completed: 03/08/2019

1.No actual harm occurred in regards to facility fire safety training, facility immediately trained all agency staff that were in the building.
2. First time agency staff continue to take part in fire safety education prior to being assigned a unit.
3.Staffing Coordinator will identify first time agency staff, provide a list to Nursing Supervisor or designee, they will ensure fire safety education is completed and documented in log/binder which will be kept in the Nursing office.
4. Daily audits conducted by NHA or designee to review agency staff that worked vs education log
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.
1. Facility secured and alarmed the door to the outside of the building off the hallway. Resident R441 is currently in the facility being monitored and receiving care.
2.No additional residents were impacted.
3.Facility educated nursing staff on elopement risk evaluation and appropriate follow thru.
4.Audits will be performed on residents who are identified as, at risk, for appropriate follow thru by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:


Based on staff interviews, review of facility documentation, and facility policy and procedure, it was determined that the facility failed to ensure that the agency nursing staff (individuals hired through a staffing company), licensed nurses and nursing assistants, had demonstrated appropriate competencies and skills sets to provide nursing care and services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Findings include:

A request was made to the Nursing Home Administrator (NHA) on March 4, 2019, for a list of agency personnel who worked in the facility in the past four months as well as evidence of their education on hire. The list provided by the NHA on March 7, 2019, included 73 agency personnel, which included nursing assistants, registered nurses and licensed practical nurses. A review of the personnel files for the agency personnel revealed that the agency personnel had completed an "Orientation Manual" which included mandatory in-service subjects of "Client confidentiality/Patient Rights; Infection Control & Safety; Abuse - Adult/Child; and HIPPA."

Interview with the NHA on March 6, 2019, at approximately 1:30 p.m. revealed that agency personnel are screened for employment as required by regulations, but do not receive the required inservice education including competency skill sets, which include fire safety and the resident service and care needs as identified in the facility assessment. The facility assessment, updated January 30, 2019, included person centered care, nursing skills, management of medical conditions, and mental health and behaviors. The NHA revealed that the agency staff do not receive the required inservices until the regular staff inservices in the specific areas are scheduled throughout the year, by the facility educator. During the same interview on March 6, 2019, the NHA stated that the agency personnel must complete the "Orientation Manual" as previously noted. Review of the agency personnel files did reveal that the "Orientation Manual" including the mandatory inservice subjects, were completed by each agency individual. Review of the regular staff inservices and competency skill sets revealed that they were completed by regular staff upon orientation and annually as required.

The facility failed to ensure that agency nursing staff demonstrated knowledge, competency, and skill sets in fire safety, person centered care, nursing skills, management of medical conditions, and mental health and behaviors.

Refer to F838, F865.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28. Pa. Code 201.18(a) Management

28 Pa. Code 201.18(b)(3) Management
Previously cited 05/07/18

28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 201.20(a)(c)(d) Staff Development

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 05/07/18















 Plan of Correction - To be completed: 04/12/2019

1.There were no residents effected as a result of this practice.
2.The facility will ensure thru self assessment and education that agency nursing staff have the appropriate knowledge, competency, and skill sets in fire safety, person centered care, nursing skills, management of medical conditions, and mental health and behaviors.
3 Facility will provide education to agency nursing staff to regarding knowledge, competency, and skill sets in fire safety, person centered care, nursing skills, management of medical conditions, and mental health and behaviors.
4.Audits will by ADON or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended

483.75(a)(2)(h)(i) REQUIREMENT QAPI Prgm/Plan, Disclosure/Good Faith Attmpt:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.75(a) Quality assurance and performance improvement (QAPI) program.

483.75(a)(2) Present its QAPI plan to the State Survey Agency no later than 1 year after the promulgation of this regulation;

483.75(h) Disclosure of information.
A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section.

483.75(i) Sanctions.
Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.
Observations:


Based on staff interviews, review of facility documentation, and review of the facility quality assurance and performance improvement plan, it was determined that the facility failed to implement and maintain an effective Quality Assurance program to identify and correct ongoing recruitment and retention problems of nursing staff to ensure that resident centered care and services were provided to meet the physical, mental, and psychosocial needs residents.

Findings include:

Review of the facility's QAPI (Quality Assurance and Performance Improvement) Plan for 2019 revealed that the goals for the QAPI plan were to continuously improve the quality of services to residents through accountability. The plan stated that the objective of the QAPI plan was to provide the highest quality of care to the residents. The QAPI plan also stated that each resident was entitled to a dignified existence, self determination and the provision of care and services in a manner and environment that promotes the maintenance or enhancement of the resident's quality of life. The plan also stated that the QAPI Committee was designed to objectively and systematically monitor and evaluate the quality of all aspects of the policies and procedures to ensure quality of care and the protection and promotion of resident rights.

An interview with the Nursing Home Administrator on March 5, 2019, at approximately 1:00 p.m. revealed that the facility was utilizing nursing staffing agencies on a daily basis to provide sufficient nursing staff (licensed nurses and nursing assistants), as identified in the Facility Assessment, updated January 30, 2019, to provide care and services to the residents. The Nursing Home Administrator confirmed during the same interview of March 5, 2019, that there was an ongoing problem with nursing recruitment and retention. The Nursing Home Administrator also confirmed that the nursing recruitment and retention issue was never identified as a problem for the QAPI Committee, that the issue was previously addressed by marketing personnel.

Federal and state deficiencies cited in this report demonstrated that the facility failed to maintain an effective Quality Assurance Committee to ensure that the concerns related to quality of care and safety needs of the residents were identified.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.18(a) Management

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/08

28 Pa. Code 201.18(e)(3)(4)Management

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18











 Plan of Correction - To be completed: 04/12/2019

1.No residents were cited in reference to QAPI meeting agenda with regards to recruitment and retention.
2. Facility will develop a recruitment and retention subcommittee as part of the QAPI process PIT- Performance Improvement Team. Facility will implement and maintain an effective Quality Assurance program to identify and correct ongoing recruitment and retention problems of nursing staff to ensure that resident centered care and services are provided to meet the physical, mental, and psychosocial needs of residents.
3. Facility will educate staff on QAPI Program and goals of the PIT in regards to recruitment and retention.
4. Audit will be performed by NHA or designee 3x/wk for 4 weeks then weekly for 2 months of attendance sheet and minutes from PIT committee meeting to access progress.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended

483.70(e)(1)-(3) REQUIREMENT Facility Assessment:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:

Based on a review of the Facility Assessment, the facility failed to assess the knowledge, skills, abilities, behaviors and other characteristics needed to ensure that the agency staff were able to perform work roles to meet the residents' needs during both day-to-day operations and emergencies. This failure resulted in an immediate jeopardy situation when the facility failed to ensure a safe environment was maintained regarding fire drills related to a lack of fire safety training for agency nursing staff, and the facility failed to ensure that agency nursing staff received mandatory inservice education and evaluations for competency in nursing skill sets.

Findings include:

Review of the Facility Assessment tool, updated January 30, 2019, revealed the facility would determine what resources were necessary to provide competent care for the typical resident population, including staff and staff training/education and competencies. The Facility Assessment further specified the service and care offered based on the identified residents needs and identified the facility resources needed to provide competent support and care to the resident population every day and during emergencies.

Further review of the facility assessment revealed no information was provided related to the types of staff education, training or competencies required by agency personnel to provide the appropriate level of care to their resident population. No information was provided regarding required in-service training to the agency personnel including fire safety, person-centered care, nursing skills, management of medical conditions, and mental health and behaviors, as required.

Based on the findings of the survey completed on March 8, 2019, which identified multiple areas of regulatory non-compliance, including an Immediate Jeopardy situation and harm level deficiency, it was determined the Nursing Home Administrator and the Director of Nursing failed to conduct, document and maintain a facility assessment which identified the proper use of agency personnel and resources necessary to competently and safely care for the residents of the facility during both day-to-day operations and emergencies.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.18(a) Management

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/08

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18























 Plan of Correction - To be completed: 04/12/2019

1.There were no residents effected as a result of this practice.
2.The facility will ensure thru self assessment and education that agency nursing staff have the appropriate knowledge, competency, and skill sets in fire safety, person centered care, nursing skills, management of medical conditions, and mental health and behaviors.
3.Nurse educator or designee will educate nursing agency staff on the appropriate knowledge, competency, and skill sets in fire safety, person centered care, nursing skills, management of medical conditions, and mental health and behaviors.
4.Audits will be performed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended


483.10(f)(10)(iii) REQUIREMENT Accounting and Records of Personal Funds: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.
483.10(f)(10)(iii) Accounting and Records.
(A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
(B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.
(C)The individual financial record must be available to the resident through quarterly statements and upon request.
Observations:

Based on interviews with residents and staff, and the review of facility documentation, it was determined that the facility failed to ensure that resident's financial records were made available through quarterly statements for 12 of 13 residents reviewed (Residents R36, R63, R72, R87, R108, R118, R163, R169, R188, R196, R251, R286).

Findings include:

During a group meeting with 13 alert and oriented residents, 12 residents (Residents R36, R63, R72, R87, R108, R118, R163, R169, R188, R196, R251, R286) reported that they were not provided with any financial statements notifying them of their account activity when asked.

During an interview with the Nursing Home Administrator on March 6, 2019, at approximately 2:15 p.m. it was reported that the quarterly statements are sent out to the resident's Power of Attorney's only and that one is not provided to each individual resident.

The list of twelve residents who reported that they were not receiving their quarterly statements was reviewed by Employee E9, during an interview on March 7, 2019, at approximately 3:00 p.m. and Employee E9 confirmed that all twelve resident's had funds that came directly to the resident's accounts at the facility.

The facility failed to ensure that resident's financial records were made available through quarterly statements for twelve residents.

Accounting and Records of Personal Funds
CFR(s): 483.10(f)(10)(iii) - Previously cited 10/25/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28. Pa. Code 201.18(a) Management

28 Pa. Code 201.18(b)(3) Management
Previously cited 05/07/18

28. Pa. Code 201.18(f) Management
Previously cited 10/25/18










 Plan of Correction - To be completed: 03/11/2019

1. Residents R36, R63, R72, R87, R108, R118, R163, R169, R188, R196, R251, R286 were provided their 4th qtr financial records for review,
Resident financial records were obtained, for the 4th Qtr 2018 and made available for residents review.
2.Facility will ensure that resident's financial records are made available to residents for their review each quarter in addition to mailing them to their resident POA.
3. Business office was educated on PNA Qtrly statements being made avail to residents.
4.Audits will be done quarterly for 2 Qtrs by NHA or designee, then randomly.
5. Result of Audits will be reported at QA meeting for 2qtrs with follow up as recommended for 1 additional qtr.

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

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to develop a comprehensive person-centered care plan, with measurable objectives and goals, related to breathing therapy for three of 45 residents reviewed (Residents R278, R397, R395).

Findings include:

Review of Resident R278's clinical record revealed the resident was admitted to the facility on March 29, 2018, with diagnoses to include chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and sleep apnea (a serious sleep disorder, in which the breathing stops and starts repeatedly).

An observation on March 4, 2019, at 11:30 a.m. revealed that Resident R278 had a breathing machine with a mask and tubing on the bedside table next to the resident's bed.

A review of Resident R278's medical record revealed a physician's order for a BiPAP (Bilevel Positive Airway Pressure-a machine which uses pressurized air through a mask to keep the throat muscles from collapsing and reducing obstructions by acting as a splint) with a large full mask, use every evening for sleep apnea, apply at HS (hour of sleep) and remove in the morning. A review completed on March 5, 2019, of Resident R278's care plan revealed no care plan developed for the resident related to the resident's use of a BiPAP machine.

Interview on March 8, 2019, at approximately 1:30 p.m. with Employee E3, the Assistant Director of Nursing, confirmed that no care plan was developed for Resident R278 related to his use of a BiPAP machine used to treat his sleep apnea.

Review of the clinical record for Resident R397 revealed the resident was admitted to the facility on February 22, 2019, with a diagnoses including, but not limited to, sleep apnea. Review of a physician's order dated January 22, 2019, indicated staff were to apply Resident R395's BiPAP at bedtime for a diagnosis of sleep apnea.

Observation on March 6, 2019, at approximately 8:45 a.m. revealed that Resident R397 had a breathing machine with a mask and tubing on the bedside table next to the resident's bed.

Further review of the clinical record revealed no documentation that a care plan was developed related to the use of a BiPAP machine for Resident R397.

Interview on March 8, 2019, at approximately 1:30 p.m. with Employee E3, the Assistant Director of Nursing, confirmed that no care plan was developed for Resident R397 related to the resident's use of a BiPAP machine.

Review of an undated facility policy, "Continuous Positive Airway Pressure [CPAP] Use," indicated that CPAP provides constant pressure to the airways to help hold the airway open and generally ease the work of breathing.

Review of the clinical record for Resident R395 revealed the resident was admitted to the facility on January 17, 2019, with a diagnoses including, but not limited to, sleep apnea. Review of a nursing progress note dated January 17, 2019, at 10:28 p.m. indicated that Resident R395 used a CPAP at night. Review of a physician's order dated January 22, 2019, indicated staff were to apply Resident R395's CPAP at bedtime and remove in the morning for a diagnosis of sleep apnea. Further review of the clinical record revealed no documentation that a care plan was developed related to the resident's use of a CPAP machine.

Interview on March 8, 2019, at approximately 1:30 p.m. with Employee E3, the Assistant Director of Nursing, confirmed that no care plan was developed for Resident R395 related to the use of a CPAP machine used to treat the resident's sleep apnea.

The facility failed to ensure that a comprehensive person-centered care plan was developed for three residents related to the use of a BiPAP and CPAP machine.

Develop/Implement Comprehensive Care Plan
CFR(s): 483.21(b)(1) - Previously cited 10/25/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/18

28 Pa. Code 211.10(c) Resident care policies
Previously cited 05/07/18, 03/01/17

28 Pa. Code 211.10(d) Resident care policies
Previously cited 03/01/17

28 Pa Code 211.11(d) Resident care plan
Previously cited 05/07/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17






 Plan of Correction - To be completed: 04/12/2019

1, R395 is no longer residents at the facility, R278 and R397 are currently residing in the facility. Care plan has been updated to reflect use of BiPAP.
2. Resident's with C-PAP and BiPAPS have been identified and care planned appropriately.
3. Nurse Educator or designee will re-educate all licensed staff on proper development and implementation of residents care plans with measurable objectives and goals, related use of BiPAP and CPAP machines.
4. Audits will be performed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations and interviews with staff, it was determined that the facility failed to maintain a homelike environment on two of nine nursing units (North 3 and North 2 Nursing Units).

Findings include:

Observation on March 5, 2019, at 12:10 p.m. of North 3 Nursing Unit dining room revealed ten residents were served their meals on trays, where the trays remained with the residents throughout the meal.

Observations of North 3 Nursing Unit on March 4, 5, 6, and 7, 2019, revealed that each time the stairwell door to the nursing unit was opened a loud alarm sound would be emitted, which could be heard from one end of the nursing unit to the other end of the nursing unit.

The above mentioned findings were brought to the Nursing Home Administrator's attention on March 6, 2019, at 2:45 p.m.

Observation on North 2 Nursing Unit on March 4, 2019, at approximately 3:20 p.m. revealed a strong foul odor of feces apparent near rooms 201-203 and the opposite side of the hallway rooms 223-224. This area has a "Women's Bathroom" that passes through (for access to both sides of the hallway). Entrance to the "Women's Bathroom" is directly across room 203 on one side, and room 223 on the other side.

Additional observation of North 2 Nursing Unit on March 5, 2019, at 9:16 a.m. revealed the same strong foul odor of feces at the same location (apparent near rooms 201-203 and opposite side of hallway rooms 223-224).

The facility failed to maintain a comfortable homelike environment on North 2 and North 3 Nursing Units with regard to a homelike dining experience, loud noises and odors.

28 Pa. Code 201.18(b)(3) Management
Previously cited 05/07/18

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







 Plan of Correction - To be completed: 04/12/2019

1.North 3 Unit resident meals served in the dining room are being taken off the trays.
2.Facility dining room meals will be removed from the trays when being served.
3. Staff will be educated that dining room meals are not served on trays.
4.Audits will be completed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.
1.North 3 Unit stairwell alarm volume was lowered by in-house maintenance staff.
2. Stairwell alarms have been lowered in volume.
3. Staff have been educated that the volume of the stairwell alarms has been lowered, but still need to remain attentive to the alarm.
4. Audits will be completed by the ADON or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.
1.North 2 Women's bathroom was cleaned and deodorized immediately.
2. No additional foul orders were present on the unit.
3.Staff were re-educated on the cleaning schedule and deodorizing process for the bathrooms.
4. Audits will be performed by housekeeping director or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on observations and staff interviews, it was determined that the facility failed to accommodate the residents' needs by failing to provide staff knowledgeable of the resident's preferences regarding turning and positioning for one of 41 residents reviewed (Resident R309).

Findings include:

Review of Resident R309's clinical record revealed the resident was admitted to the facility on June 6, 2016, with a diagnosis to include contracture of muscle, left lower leg, and contracture of muscle, right lower leg (a contracture deformity is the result of stiffness or constriction in the connective tissues of your body). The resident's care plan included that the resident had an activities of daily living (ADL) care self-care performance deficit related to limited mobility, limited range of motion, musculoskeletal impairment, and pain bilateral hips.

During an initial tour of the facility on March 4, 2019, it was observed that Resident R309's bilateral legs were contracted laterally, where walking would not be possible. Further, a strong body odor was emitting from the resident. The resident stated that he only feels comfortable with certain staff turning and repositioning him related to pain he experiences. Resident R309 stated that the facility utilizes agency personnel who are not aware of his preference on how to be turned and repositioned to perform ADL care.

Interview on March 5, 2019, at 1:30 p.m. with Employee E5, Registered Nurse, where she confirmed that the resident does not feel comfortable with agency staff, who are not familiar with the pain he experiences with turning and repositioning him to perform ADL care.

The facility failed to accommodate the residents' needs by failing to provide staff knowledgeable of the resident's preferences regarding turning and positioning.

Reasonable Accommodations Needs/Preferences
CFR(s): 483.10(e)(3) - Previously cited 05/07/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.14(b) Responsibility of licensee
Previously cited 05/07/18

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/18

28 Pa. Code 201.29(j) Resident rights
Previously cited 05/07/18

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17














 Plan of Correction - To be completed: 04/12/2019

1.R309's preferences regarding turning and repositioning are reflected on the care plan and assignment sheet for staff knowledge.
2. Bedfast resident needs and preferences regarding turning and repositioning will be evaluated and noted on the care plan and assignment sheet.
3.Staff will be educated on following the assignment sheet /care plan which will reflect resident preferences regarding turning & repositioning.
4.Audits will be completed by the ADON or designee 3x/wk for 4 weeks then weekly for 2 months.
5.Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.

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 reviews of clinical records and facility documentation and interviews with staff, it was determined that the facility failed to follow physician's orders related to bowel protocols for one resident (Resident 192) and failed to ensure one resident received treatment and care in accordance with professional standards of practice related to falls for one resident (Resident CL2) of 41 residents reviewed.

Findings include:

Review of Resident R192's clinical record revealed the resident was admitted to the facility on April 10, 2017, with diagnoses to include vascular disorder of the intestine (the arteries supplying oxygen-rich blood and nutrients to your intestines become narrowed) gastroparesis (condition in which your stomach cannot empty itself of food in a normal fashion).

Review of Resident R192's clinical record revealed physician orders for January 2019 for an order for milk of magnesia (administered to treat constipation), give 30 ml orally every 12 hours as needed for Constipation. Review of Resident's R192's clinical record revealed the resident didn't have a documented bowel movement on January 22 through January 28, 2019.

Further, review of Resident R192's clinical record revealed no documented evidence that milk of magnesia was administered to the resident for the resident not having a documented bowel movement on January 22 through January 28, 2019.

Interview on March 6, 2019, at 12:10 p.m. with Employee E5, Registered Nurse (RN), where she confirmed that Resident R192 didn't have a documented bowel movement on January 22 through January 28, 2019, and Employee E5, RN, confirmed the resident was not administered milk of magnesia as needed for constipation.

The facility failed to follow physician's orders related to bowel protocols.

Review of the facility's policy titled, Neurological Check List, effective 2019, revealed nursing evaluates each patient's neurological status after an unwitnessed fall. On-going neurological checks will be completed as follows:

Every 15 minutes for one hour
Every 30 minutes for two hours
Every hour for four hours
Every 8 hours for 9 shifts.

Review of Resident CL2 clinical record revealed he was admitted to the facility on February 6, 2019, diagnosed with a Urinary Tract Infection, Muscle Weakness, Difficulty in Walking, and Lack of Coordination. The facility documented the resident cognition as alert with confusion. Review of the facility's clinical documentation revealed Resident CL2 sustained three falls:

1. An unwitnessed fall occurred on February 11, 2019, at 11:00 a.m. when nursing staff found Resident CL2 on the floor, next to his bed.

2. The same day, on February 11, 2019, at 2:45 p.m. an unwitnessed fall occurred when nursing found Resident CL2 on the men's restroom floor. The resident was noted with abrasions to the top of his nose and small abrasions to the forehead.

3. An unwitnessed fall occurred on February 16, 2019, at 12:30 p.m. when nursing found Resident CL2 on the floor, near the doorway to his room. The resident complained that his head and chest hurt.

Further review of Resident CL2 clinical records revealed the facility failed to ensure the resident received completed neurological assessments for the three falls the resident sustained on February 11 and February 16, 2019. This was confirmed with the Assistant Director of Nursing (Employee E1) on March 7, 2019, at 3:30 p.m.

The facility failed to ensure one resident received treatment and care in accordance with professional standards of practice relating to neurological assessments for three unwitnessed falls.

Quality of Care
CFR(s): 483.25 - Previously cited 05/07/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/18

28 Pa. Code 211.5(f)(h) Clinical records
Previously cited 05/07/18

28 Pa. Code 211.5(g) Clinical records

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17

28 Pa. Code 211.12(d)(2) Nursing services
Previously cited 05/07/18, 03/01/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 05/07/18























 Plan of Correction - To be completed: 04/12/2019

1.R192 is currently residing in the facility and received no ill effect.
2. Residents BM tracking will be reviewed x1wk lookback to ensure compliance of protocol.
3 Nurse Educator or designee will educate nursing staff on bowel protocol, to notify the physician if resident does not have a BM within 72 hrs.
4..Audits will be performed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.
1.CL2 is no longer a resident at the facility.
2. Unit Managers or designee will review falls x1 wk lookback to ensure resident's received treatment and care in accordance with professional standards of practice relating to neurological assessments.
3. Nurse educator or designee will re-educate nursing staff on Neuro check policy and documentation requirements.
4.Audits will be performed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.


483.25(h) REQUIREMENT Parenteral/IV Fluids:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to provide adequate assessment and monitoring for care and maintenance of intravenous (IV-tube inserted through the skin into a vein to administer fluids and medications) catheters for two of 45 residents reviewed (Residents R64, R278).

Findings include:

Review of facility policy, "IV-Intravenous [tube inserted into a vein to administer fluids and medications] Therapy Guidelines," dated last revised March 7, 2012, revealed that staff would change the dressing over a PICC line (Peripherally Inserted Central Catheter-type IV inserted for long-term use) every seven days and as warranted, and that the external length of the catheter would be measured in centimeters from insertion site to hub (amount of catheter tubing that is visible, outside the body, from the plastic end of the catheter) with each dressing change.

Review of an online document, "American Nurse Today (official journal of the American Nurse's Association)," Volume 8, Number 11, dated November 2013, revealed a complication of a PICC line includes, but is not limited to, catheter-tip migration (assessed by external length of the catheter-amount of catheter tubing that is visible outside of the vein moves from original insertion and may cause medical complications).

Review of the clinical record for Resident R64 revealed that the resident was readmitted to the facility on October 19, 2018, with diagnoses including, but not limited to, pneumonia (infection in one or both lungs). Review of a procedure note from a consultant IV insertion nurse dated December 7, 2018, revealed the licensed nurse consultant inserted a PICC line in Resident R64's left upper arm, that the external length of the catheter to the hub was one centimeter, and that the PICC was successfully inserted as ordered for facility staff to administer IV antibiotic medication.

Review of a nursing progress note revealed on December 14, 2018, at 3:37 p.m., revealed Resident R64's left upper arm PICC line dressing was changed and the external length of the catheter was "about 12 cm" (11 cm longer length exposed than original insertion by the consultant IV nurse on December 7, 2018), that the resident had an X-ray performed (due to the discrepancy in the external length and possible complication of catheter-tip migration), that a certified registered nurse practitioner (CRNP) was made aware of the X-ray results, that no new orders were given by the CRNP, and that staff would continue to monitor the resident's PICC line.

Review of a nursing progress note dated December 17, 2018, at 7:28 p.m., revealed that the dressing over Resident R64's PICC line was changed and that the external length of the catheter was 11 cm (one centimeter less in length than documented on December 14, 2018).

Review of a nursing progress note dated December 21, 2018, at 8:40 p.m. revealed that Resident R64 was seen by a hospice (end of life care to support resident and family) nurse who recommended to discontinue the resident's PICC line stating, "maybe [Resident R64] has low grade T [temperature] because of PICC." Review of a hospice consultant communication/physician orders form dated December 21, 2018, stated, "Please discontinue LUE [left upper extremity-arm] PICC line," and that the hospice licensed nurse "previously discussed" this with Resident R64's physician who was in agreement to discontinue the resident's PICC line.

Review of an "Orders-Administration Note" dated December 24, 2018, at 8:04 p.m. revealed that the transparent dressing over Resident R64's PICC line was changed, with no documented measurement of the external length of the catheter.

Review of a nursing progress note dated December 26, 2018, at 3:01 p.m. revealed the licensed nurse pulled (removed) Resident R64's PICC line.

Further review of the clinical record for Resident R64 revealed no documentation that nursing staff notified the physician regarding the documented one centimeter difference in external catheter length on December 17, 2018, ("about 12 cm" on December 14, 2018, and 11 cm on December 17, 2018,) and no documentation of the assessment of the external length of the resident's PICC line catheter upon a dressing change on December 24, 2018, and no documentation regarding reason for the facility's delay in removing the resident's PICC line from recommendation by the hospice nurse on December 21, 2018, to documented removal on December 26, 2018, a total of five days.

Interview with Employee E3, Assistant Director of Nursing, on March 6, 2019, at approximately 2:15 p.m. confirmed there was no documentation that nursing staff notified the physician regarding the documented one centimeter difference in external catheter length on December 17, 2018, ("about 12 cm" on December 14, 2018, 11 cm on December 17, 2018,) and no documentation of the assessment of the external length of the resident's PICC line catheter upon dressing change on December 24, 2018, and no documentation regarding reason for the facility's five day delay in removing the resident's PICC line after recommendation by the hospice nurse.

Review of Resident R278's clinical record revealed the resident was admitted to the facility on March 29, 2018, with diagnoses to include dementia (long-term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning) with behavioral disturbance (disturbances are seen at some time in the course of dementia and are mainly caused by the underlying neurochemical changes associated with dementia diseases), personal history of venous embolism (obstruction of an artery, typically by a clot of blood or an air bubble) and thrombosis (the formation of a blood clot inside a blood vessel).

An observation on March 4, 2019, at 11:30 a.m. revealed Resident R278 had a Mid-Line catheter (a 3"-8" catheter inserted into the peripheral veins of the upper arm usually used for 1 - 4 weeks) on the resident's right upper extremity (RUE, arm).

Review of Resident R278's physician orders revealed a February 4, 2019, physician order to change transparent dressing on PICC line every 7 days as needed for soilage or lifting of dressing, and with each transparent dressing change in the evening every 7 day(s) measure arm circumference, measure midline length, and change the cap and document measurements measure arm circumference on admission (or post insertion), with weekly dressing change, and PRN (as needed).

A review of Resident R278's clinical record revealed a procedure note for new 4 French single lumen 20 cm total original catheter length Mid-Line placed on February 28, 2019, at 8:19 p.m. in the right upper arm with 18 cm placed in the resident and 2 cm external length to hub,
Mid-arm circumference was 25 cm. Further review of Resident R278's clinical record revealed a nursing progress note dated March 4, 2019, at 11:19 p.m. which stated, RUE midline in place. Stat-lock (suture-free device for securing catheters) in place and down from insertion site 2.5 cm. External length to hub 12 cm. Mid-arm circumference 26 cm.

Interview on March 6, 2019, at 2:10 p.m. with Employee E3, the Assistant Director of Nursing (ADON), where the above-mentioned findings were reviewed and who stated that the measurements did not appear to be correct for the above residents.

The facility failed to ensure that each resident achieved the highest possible level of functioning and well-being by not providing the necessary care and services based on the findings of the residents' comprehensive assessments and plans of care.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/18

28 Pa. Code 211.5(f)(h) Clinical records
Previously cited 05/07/18

28 Pa. Code 211.5(g) Clinical records

28 Pa. Code 211.10(c) Resident care policies
Previously cited 05/07/18, 03/01/17

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 05/07/18







 Plan of Correction - To be completed: 04/12/2019

1.R64 and R278 are currently in the facility receiving care with no ill effects.
2.Facility will review current residents with a PICC or Mid line to ensure adequate assessment and monitoring for care and maintenance.
3.Education to be completed with nursing staff to ensure adequate assessment and monitoring for care and maintenance of intravenous catheters
4.Audits will be performed on residents with IV catheters to ensure assessment and maintenance by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.

483.40 REQUIREMENT Behavioral Health Services: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.
483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on observations, review of clinical records and interviews with staff, it was determined that the facility failed to adequately monitor, assess, and provide the necessary and timely behavioral health care and services for residents exhibiting psychological and/or physical distress for two of 45 residents reviewed (Residents R391, R329).

Findings include:

Review of the clinical record for Resident R391 revealed the resident was originally admitted to the facility on February 17, 2019, with diagnoses including aspiration pneumonitis (lung injury from inhalation of stomach contents) and history of falls. Review of a nursing progress note dated February 17, 2019, at 9:00 p.m. indicated that Resident R391 was difficult to communicate with due to being very hard of hearing and that every time the nurse attempted to ask questions, the resident said, "I don't hear what you're saying." Review of nursing progress notes revealed on February 18, 2019, at 2:29 a.m. Resident R391 was awake, alert and oriented times two (accurate knowledge of person and place); that the resident had a Foley catheter (tube inserted into the bladder used to drain urine); that the resident attempted to pull on the catheter tubing; and was trying to "climb up in bed." The nursing progress note went on to state that the licensed nurse attempted to redirect the resident from pulling at the Foley catheter and climbing out of bed, but the resident stated, "I am old already I wanted to die and I have been to war, just let me go, take this off on [sic] my penis. I don't want it in me, please. I can't sleep I wanna sit." Review of a nursing progress note dated February 19, 2019, at 2:47 p.m. revealed Resident R391 attempted to get out of the wheelchair and fell, and that the resident's physician assessed the resident who ordered an X-ray of the resident's right knee and hip due to complaints of right knee pain. Review of a nursing progress note dated February 19, 2019, at 9:00 p.m. revealed that Resident R391 was being transferred to an acute care hospital for evaluation. Review of a nursing progress note dated February 19, 2019, at 11:54 p.m. revealed that Resident R391 was admitted to an acute care hospital for a diagnosis of right hip fracture post fall.

Review of a nursing progress note dated February 22, 2019, at 10:49 p.m. revealed Resident R391 was readmitted from the acute care hospital with a diagnosis of surgical repair of right hip fracture; with the licensed nurse noting the resident had eight staples to the right hip surgical incision, six staples to the right lateral (outer side) femur (thigh bone), and seven staples to the right lateral knee. Review of a nursing progress note dated February 23, 2019, at 2:30 p.m. revealed Resident R391 "continues to scream help and c/o [complains of] pain to the right knee throughout the shift. PRN [medical abbreviation for as needed] Percocet [narcotic pain medication] given but the yelling continues." Review of a nursing progress note dated February 25, 2019, at 4:08 a.m. revealed that Resident R391 "continues to scream throughout the night." Review of a nursing progress note dated February 25, 2019, at 3:27 p.m. revealed Resident R391 refused to eat breakfast and lunch. Review of an activity progress note dated February 26, 2019, at 1:32 p.m. revealed Resident R391 was very hard of hearing and "continued to focus on 'Why I am Here?'" Review of a care plan note dated February 27, 2019, at 12:42 p.m. revealed Resident R391 was readmitted to the facility after a fall and fracture of the right hip and was "adjusting to the unit with some difficulty, as he states he does not know why he is here. Seemed to be focused on going home most of this week. He is very HOH [hard of hearing]... Family was called to complete activity assessment/leisure interests as res. [resident] does not understand why he is here. He is spending time in bed, calling out when in pain, nursing addresses with some positive results."

Review of an eMediCall message (texted message by nursing staff to a facility physician) dated March 2, 2019, at 6:09 a.m. revealed "Resident still has significant pain from right hip fracture and keep [sic] on yelling out this shift and asking for some pain pill and something to sleep prn Tylenol given and was ineffective. Resident [sic] Percocet was ordered for 7 days only and fell out [order was completed] this midnight. Is it ok to order? Please advise [sic]." The documented response by the physician was a reorder of Percocet.

Observation on March 4, 2019, at 2:59 p.m. revealed Resident R391 yelling constantly from his room, while lying in bed, repeating the words, "Help" "Help me!" and "Hey!" over and over. Several staff members were observed to walk past the room without engaging the resident or asking what he may need.

Observation on March 5, 2019, at approximately 9:00 a.m. revealed Resident R391 in his room, resting in bed. Approximately 15 minutes later, two rehabilitation staff members (Employee E12, Physical Therapy Assistant and Employee E13, Occupational Therapist) went in the room to assist the resident with getting dressed and transferring from the bed to the wheelchair. After assisting the resident, and upon wheeling the resident out of his room to go to the therapy gym, the resident was observed rubbing his right knee and stated out loud, "See, this is the one that smarts!" Further observation on March 5, 2019, at approximately 11:30 a.m. revealed the resident was taken into the dining/activity room on North 2 Nursing Unit where music from the 1940's era was playing. Resident R391 appeared to be engaged with listening to the music which was playing and with reading a magazine that was on the table in front of him, but as soon as the staff member in the room walked out of his line of sight, he began to yell, "Hey!" again.

Observation on March 6, 2019, at approximately 1:00 p.m. revealed Resident R391 continuing with the same similar verbalizations of "Hey!" and "Help!" not directed towards any specific person.

Observation on March 7, 2019, at approximately 8:00 a.m. in the presence of the Assistant Director of Nursing, revealed Resident R391 was in bed in preparation for transport to an outside medical appointment, was extremely hard of hearing, and had a pad of paper on his bedside table for staff to use to communicate with him.

Further review of the clinical record revealed no documentation that from the original admission to the facility on February 17, 2019, and from the readmission after falling and sustaining a right hip fracture, that staff assessed the resident's ongoing verbal outbursts to determine the reasoning behind why the resident may exhibiting these behaviors (ex. pain management, loneliness, depression, dementia, boredom, frustration of being severely hard of hearing), and no documentation that Resident R391 was evaluated by professional psychiatric services to help staff assess the resident for his behaviors and what possible interventions could be put into place to address these behaviors.

Interview with the Nursing Home Administrator on March 8, 2019, at approximately 1:15 p.m. confirmed there was no documentation that Resident R391, a resident who was a recent admission and sustained a hip fracture requiring surgical repair, was adequately assessed and monitored for behaviors and evaluated by a psychiatric practitioner in a timely manner.

Review of the clinical record for Resident R329 revealed that the resident was admitted to the facility on January 4, 2019, with diagnoses that included dementia (a group of symptoms that together affect the memory, normal thinking, communicating and reasoning ability of a person), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest, affects how you feel, think and behave and can lead to a variety of emotional and physical problems), and Parkinson's Disease (a progressive nervous system disorder that affects movement).

During observations on the unit where Resident R329 resided, the resident could be heard yelling "Help" on March 4, 5, and 6, 2019, at various times throughout each day of the listed dates.

Review of Resident R329's nursing notes revealed documentation of behaviors from the resident since the resident's admission date of January 4, 2019, to January 31, 2019. The resident's behaviors that were documented by staff included documentation by nursing staff on January 20, 2019, which stated, "calls out frequently during the night." On January 27, 2019, review of a nursing notes revealed the resident stated that she is calling out because "I am lonely." On January 29, 2019, a nursing noted documented "Constantly calling out when needs are met. On January 30, 2019, a nursing note stated, "Resident tearful and anxious at moments throughout the shift."

Review of Resident R329's nursing notes from February 1, 2019, to March 6, 2019, revealed documentation of Resident R329's behaviors that included documentation on February 7, 2019, that "Resident continues to call out after all needs are met." An additional nursing note on February 7, 2019, stated, "Resident is tearful in the AM when her husband not on unit." On February 13, 2019, nursing documentation revealed "resident in bed occasionally calling out, increased anxiety noted. Reassurance given." Review of nursing note from February 27, 20189, revealed "Resident R329 left the unit for a follow up appointment, continues to cry and call out frequently for her husband, wanting to go home. unable to console." Review of additional nursing notes for February 2019 documented the resident yelling for her husband, yelling "help" and crying. On March 6, 2019, the resident was documented as yelling off and on during the night, calling for her husband and wanting to go home.

During an interview with the resident's husband on March 6, 2019, at approximately 10: 00 am. the resident's husband reported that Resident R329 had been making comments about wanting to die and wanting a divorce from him for the past two weeks. The resident's husband stated that he notified the Unit Manager (Employee E19) about the above comments that Resident 329 had been making and reported "nothing has been done about it. "During an interview with Employee E19 on March 6, 2019, at approximately 12:55 p.m. Employee E19 stated that the resident's husband had never spoken to her about this. Employee E19 stated that the resident is having problems adjusting to the facility and the floor that she is on.

Review of the physician orders for March 2019 revealed an order dated January 4, 2019, and monthly thereafter, for "Psychiatry consult and treat as needed."

Review of a social services noted dated January 30, 2019, regarding the resident's care plan meeting, stated that the resident had anxiety and that a psychiatric consult had been ordered. Review of the resident's clinical record did not show evidence that Resident R329 was evaluated by professional psychiatric services, per the physician's order, to help staff assess the resident for behaviors and what possible interventions could be put into place to address the resident's behaviors, and this was confirmed during an interview with the Employee E19 on March 6, 2019, at approximately 12:55 p.m.

The facility failed to provide the necessary behavioral health care and services to attain or maintain each residents' highest practicable physical and psychosocial well-being.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/18

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17

28 Pa. Code 211.16(a) Social services














 Plan of Correction - To be completed: 04/12/2019

1 R391 and R329 were seen by behavioral health services.
2. No additional residents were identified as being affected. Facility will adequately monitor, assess, and provide the necessary and timely behavioral health care and services for residents exhibiting psychological and/or physical distress.
3. Nurse Educator or designee will do education with nursing staff on assessing and documenting behaviors exhibiting psychological and/or physical distress.
4.Audits will be performed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.

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 observation and staff interview, it was determined that the facility failed to implement procedures to promote accurate identification of residents during medication administration for two of five residents observed (Residents R203, R289).

Finding include:

A request was made to the Assistant Director of Nursing (ADON) on March 6, 2019, at 2:35 p.m. for a facility protocol related to properly identifying resident's prior to administering medications. The ADON provided a document titled "Safe Medication Administration Practices, General" revealed " ... confirm the patient's identity using at least two patient identifiers to minimize the potential for a medication error related to patient misidentification. Compare the information with the regular or electronic medication administration record."

Observation of Medication Administration on March 6, 2019, at 8:30 a.m. revealed Employee E7, a Registered Nurse (RN), did not confirm the resident's identity using at least two patient identifiers before administering medications to Resident R203.

Observation of Medication Administration on March 6, 2019, at 8:45 a.m. revealed Employee E6, a Licensed Practical Nurse (LPN), did not confirm the resident's identity using at least two patient identifiers before administering medications to Resident R289.

Interview on March 7, 2019, at 11:55 a.m. with the ADON where he confirmed the facility's protocol is to confirm the resident's identity using at least two patient identifiers.

The facility failed to implement procedures to promote accurate identification of residents during medication administration.

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17

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














 Plan of Correction - To be completed: 04/12/2019

1. R203/ R289 had no ill effects, both residents are still residing in the facility receiving care according to standard practice.
2.E7, and E6 received education and competency for medication administration
3. Agency staff will be educated regarding procedures to promote accurate identification of residents during medication administration.
4.Audits will be performed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on observation of medication administration, review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure the medication error rate was less than five percent. Need a Universe

Findings include:

The facility's medication error rate was 10.34 percent based on observation of 29 medication administration opportunities with three medication errors observed.

Review of undated facility policy, "Safe Medication Administration Practices, General," revealed that nursing staff would ensure the right medication was administered to each resident via the right route of administration.

Observation of medication administration on March 6, 2019, at approximately 9:17 a.m. revealed Employee E10, Registered Nurse (RN), preparing morning medications for Resident R288. Employee E10 obtained a blister pack (card containing tablets, each individually separated, which easily allows to pop a tablet through the card) with Resident R288's name on the blister pack, which was labeled, "Levothyroxine Sodium 112 mcg [micrograms]" (medication used to treat hypothyroidism-condition due to deficiency in the thyroid hormone resulting in decreased body metabolism) from a drawer in the medication cart. Employee E10 was observed to pop one Levothyroxine Sodium 112 mcg tablet from the blister pack into a white paper souffle medication cup. Employee E10 then obtained a stock medication bottle (multi-dose bottle used for multiple residents) from a drawer in the medication cart containing chewable Aspirin (over-the-counter medication used for its blood-thinning properties) 81 mg (milligrams) and poured one tablet into the same white paper souffle medication cup containing the Levothyroxine Sodium 112 mcg tablet. Employee E10 was then observed to crush both medications, add the powder residue into a plastic drinking cup, mixed it, then draw up the solution into a 30 mL (milliliter) syringe. Employee E10 promptly proceeded to administer both medications via syringe into Resident R288's feeding tube (tube inserted into the stomach to administer fluids and liquid nourishment).

Review of the clinical record for Resident R288, directly after the medication pass observation, revealed a physician's order dated February 21, 2019, instructing staff to administer Aspirin Tablet Chewable 81 mg, one tablet by mouth one time a day for a diagnosis of heart prophylaxis (prevent blood clots from forming); and Levothyroxine Sodium 112 mcg, one tablet by mouth one time a day for a diagnosis of hypothyroidism. Further review of the physcian's orders revealed no instructions to administer either the Aspirin or the Levothyroxine Sodium via Resident R288's feeding tube.

Review of the Medication Administration Record (MAR) for Resident R288 revealed that for the Levothyroxine Sodium, the administration time was documented as scheduled for 6:00 a.m. daily. Review of the MAR revealed that for March 6, 2019, another licensed nurse documented administration at 6:00 a.m. of Resident R288's Levothyroxine Sodium. Further review of the MAR revealed Employee E10 documented administration of Aspirin 81 mg and Lacosamide 200 mg (medication used to treat seizure activity), not Aspirin 81 mg and Levothyroxine Sodium 112 mcg as observed during the medication pass.

Interview with Employee E10 on March 6, 2019, after clinical record review, confirmed that Employee E10 administered two medications to Resident R288 through the resident's feeding tube and the physician's orders instructed to administer the medications orally; and confirmed that Employee E10 administered Levothyroxine Sodium 112 mcg instead of Lacosamide 200 mg in error.

Interview with Employee E11, North 2 Nursing Unit Manager, directly after the observation and clinical record review confirmed Resident R288 was not receiving any medications or nutrition through the resident's feeding tube, that staff were only flushing the tube with water to keep it from clogging, and that all medications were to be administered orally to the resident per physician's orders. Further interview with Employee E11 confirmed documentation on Resident R288's MAR revealed Levothyroxine Sodium was administered by another licensed nurse at 6:00 a.m. on March 6, 2019, which would mean Resident R288 received double the dose (Levothyroxine Sodium 112 mcg administered at 6:00 a.m., and again during medication administration observation at approximately 9:17 a.m.).

The facility failed to ensure that it was free of a medication error rate of five percent.

Refer to F760.

Free of Medication Error Rates Five Percent or More
CFR(s): 483.45(f)(1) - Previously cited 05/07/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/18

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

28 Pa. Code 211.10(c) Resident care policies
Previously cited 05/07/18, 03/01/17

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17










 Plan of Correction - To be completed: 04/12/2019

1 R288 had no ill effects, is currently residing in the facility and receiving care according to standard practice. No additional residents were identified
2.E10 received education and competency for medication administration.
3. Agency Nursing staff in addition to facility nursing staff will be educated on medication administration.
4.Audits will be performed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended

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

Based on observation, review of clinical records, facility policy and procedures, and facility documentation, and interviews with the staff, it was determined that the facility failed to ensure residents were free of any significant medications errors for one of five residents observed (Resident R288).

Findings include:

Review of undated facility policy, "Safe Medication Administration Practices, General," revealed that nursing staff would ensure the right medication was administered to each resident at the right time.

Observation of medication administration on March 6, 2019, at approximately 9:17 a.m. revealed Employee E10, Registered Nurse (RN), preparing morning medications for Resident R288. Employee E10 obtained a blister pack (card containing tablets, each individually separated, which easily allows the nurse to pop a tablet through the card) with Resident R288's name on the blister pack which was labeled, "Levothyroxine Sodium 112 mcg [micrograms]" (medication used to treat hypothyroidism-condition due to deficiency in the thyroid hormone resulting in decreased body metabolism) from a drawer in the medication cart. Employee E10 was observed to pop one Levothyroxine Sodium 112 mcg tablet from the blister pack into a white paper souffle medication cup. Employee E10 was then observed to crush the medication, add the powder residue into a plastic drinking cup, mixed it, then draw up the solution into a 30 mL (milliliter) syringe. Employee E10 promptly proceeded to administer the medication via syringe into Resident R288's feeding tube (tube inserted into the stomach to administer fluids and liquid nourishment).

Review of the clinical record for Resident R288, directly after the medication pass observation, revealed a physician's order dated February 21, 2019, instructing staff to administer Levothyroxine Sodium 112 mcg, one tablet by mouth one time a day for a diagnosis of hypothyroidism.

Review of the Medication Administration Record (MAR) for Resident R288 revealed that the Levothyroxine Sodium administration time was documented as scheduled for 6:00 a.m. daily. Review of the MAR revealed that for March 6, 2019, another licensed nurse documented administration at 6:00 a.m. of Resident R288's Levothyroxine Sodium. Further review of the MAR revealed Employee E10 documented administration of Lacosamide 200 mg (medication used to treat seizure activity), not Levothyroxine Sodium 112 mcg as observed during the medication pass.

Interview with Employee E10 on March 6, 2019, after clinical record review, confirmed that Employee E10 administered Levothyroxine Sodium 112 mcg instead of Lacosamide 200 mg in error.

Interview with Employee E11, North 2 Nursing Unit Manager, directly after the observation and clinical record review confirmed documentation on Resident R288's MAR revealed Levothyroxine Sodium was administered by another licensed nurse at 6:00 a.m. on March 6, 2019, which would mean Resident R288 received double the dose (Levothyroxine Sodium 112 mcg administered at 6:00 a.m. and again during medication administration observation at approximately 9:17 a.m.).

The facility failed to ensure that it was free of significant medication errors.

Residents Are Free of Significant Medication Errors
CFR(s): 483.45(f)(2) - Previously cited 05/07/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 10/25/18, 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/07/18, 03/01/17

28 Pa. Code 201.18(b)(3)(e)(1) Management
Previously cited 05/07/18

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

28 Pa. Code 211.10(c) Resident care policies
Previously cited 05/07/18, 03/01/17

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/07/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 05/07/18, 11/21/17, 03/01/17










 Plan of Correction - To be completed: 04/12/2019

.R288 is currently residing in the facility receiving care and treatment in accordance with professional standards and free of any significant medication errors.
2.Medication administration will be completed per physician's orders.
3.Nurse educator or designee will educate nursing agency staff on medication administration.
4.Audits will be performed by Unit Manager or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended

201.18(b)(1)-(3) LICENSURE Management.:State only Deficiency.
(b) The governing body shall adopt and enforce rules relative to:

(1) The health care and safety of the residents.

(2) Protection of personal and property rights of the residents, while in the facility, and upon
discharge or after death.

(3) The general operation of the facility.
Observations:
Based on review of clinical records and interviews with staff, it was determined that the facility failed to provide a disposition of personal belongings upon discharge for two of four closed clinical records reviewed (Residents R395 and R396).

Findings include:

Review of the closed clinical record for Resident R395 revealed that the resident was admitted to the facility on January 17, 2019, and was discharged from the facility in the care of the resident's responsible party on January 31, 2019. Review of a Resident's Clothing List form revealed an attached handwritten itemized list of clothing, shoes, and other personal belongings upon admission to the facility on January 17, 2019. Further review of the Resident's Clothing List form, under the "RECEIPT FOR PERSONAL ARTICLES" section at the bottom of the form, revealed no documentation of a signature from the resident's responsible party that all of Resident R395's personal belongings were accounted for and taken upon discharge.

Review of the closed clinical record for Resident R396 revealed that the resident was admitted to the facility on January 17, 2019, and was discharged from the facility in the care of the resident's responsible party on January 31, 2019. Review of a Resident's Clothing List form revealed an attached handwritten itemized list of clothing, shoes, and other personal belongings upon admission to the facility on January 17, 2019. Further review of the Resident's Clothing List form, under the "RECEIPT FOR PERSONAL ARTICLES" section at the bottom of the form, revealed no documentation of a signature from the resident's responsible party that all of Resident R396's personal belongings were accounted for and taken upon discharge.

Interview with the Nursing Home Administrator and the Assistant Director of Nursing on March 8, 2019, at approximately 1:00 p.m. confirmed that there was no signature by the responsible party on the clothing list form for Residents R395 and R396 that all personal items originally brought to the facility were taken with them upon their discharge on January 31, 2019.





 Plan of Correction - To be completed: 04/12/2019

1.Facility reached out the family of R395 & R396, reviewed the list of belongings that were originally brought into the facility and those that were picked up upon discharge.
2. Residents personal belonging sheet will be reviewed x1wk look back to ensure compliance of procedure.
3 Nurse Educator or designee will educate nursing staff on disposition of personal belongings upon discharge, to obtain a signature from the resident or responsible party that all personal belongings are accounted for and taken upon discharge.

4..Audits will be performed by ADON or designee 3x/wk for 4 weeks then weekly for 2 months.
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.


209.7(a) LICENSURE Disaster preparedness.:State only Deficiency.
(a) The facility shall have a comprehensive written disaster plan which shall be developed and maintained with the assistance of qualified fire, safety and other appropriate experts. It shall include procedures for prompt transfer of casualties and records, instructions regarding the location and use of the alarm systems and signals and fire fighting equipment, information regarding methods of containing fire, procedures for notification of appropriate persons and specifications of evacuation routes and procedures. The written plan shall be made available to and reviewed with personnel, and it shall be available at each nursing station and in each department. The plan shall be reviewed periodically to determine its effectiveness.
Observations:

Based on a review of clinical records, facility policies and procedures, and facility documentation, and interviews with residents and staff, it was determined that the facility failed to ensure that a safe environment was maintained regarding response to a fire emergency related to a lack of fire safety training for agency nursing staff.

Findings Include:

Review of facility policy titled "Emergency Procedure - Fire" dated October 4, 2016, revealed that the facility has a designated procedure for fires and explosions that shall be followed if such an emergency arises. Staff receive training at least annually on fire procedures and the use of fire extinguishers.

A request was made to the Nursing Home Administrator (NHA) on March 4, 2019, for a list of agency personnel who worked in the facility in the past four months as well as evidence of their education on hire. The list provided by the NHA on March 7, 2019, included 73 agency personnel, which included nursing assistants, registered nurses, and licensed practical nurses. A review of the personnel files for the agency personnel revealed no facility fire safety training.

Interview on March 6, 2019, at 9:40 a.m. with Employee E7, Registered Nurse (RN), who is an outside agency personnel, stated that she did not receive facility fire safety training prior to her first day of providing care to residents.

Interview on March 6, 2019, at 9:50 a.m. with Employee E6, Licensed Practical Nurse, (LPN), who is an outside agency personnel, stated that she wasn't sure/couldn't recall if she received facility fire safety training prior to her first day of providing care to residents.

Interview on March 6, 2019, at 11:00 a.m. with Employee E8, Security Supervisor/Fire Safety Educator, where he acknowledged the above mentioned fire drill deficient areas. Employee E8, Security Supervisor/Fire Safety Educator, attributed the fire drill deficiencies on agency staff and their lack of knowledge regarding the facility's fire safety program. Employee E8, Security Supervisor/Fire Safety Educator, stated part of his responsibilities include inservicing new hires, that are not agency personnel, on the facility fire safety plan. Employee E8, Security Supervisor/Fire Safety Educator, stated that he was under the impression that the facility's educator was responsible for orientating new agency hires.

Interview with the NHA on March 7, 2019, at 1:30 p.m. where she confirmed that agency personnel are not oriented on hire regarding the facility's fire safety program. The NHA stated that regular non-agency staff do receive fire safety training on hire, but agency staff do not receive training.

The facility failed to ensure that a safe environment was maintained regarding response to a fire emergency related to a lack of fire safety training for agency nursing staff.








 Plan of Correction - To be completed: 03/08/2019

1.No actual harm occurred in regards to facility fire safety training, facility immediately trained all agency staff that were in the building.
2. First time agency staff continue to take part in fire safety education prior to being assigned a unit.
3.Staffing Coordinator will identify first time agency staff, provide a list to Nursing Supervisor or designee, they will ensure fire safety education is completed and documented in log/binder which will be kept in the Nursing office.
4. Daily audits conducted by NHA or designee to review agency staff that worked vs education log
5. Result of Audits will be tracked and trended at QA meeting for 1qtr with follow up as recommended.


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