Nursing Investigation Results -

Pennsylvania Department of Health
HILLSDALE PARK REHAB CENTER
Patient Care Inspection Results

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HILLSDALE PARK REHAB CENTER
Inspection Results For:

There are  76 surveys for this facility. Please select a date to view the survey results.

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HILLSDALE PARK REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an incident survey completed on February 22, 2019, it was determined that Hillsdale Park Rehab 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:


483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for one of two residents reviewed (Resident 1), which resulted in Resident 1 becoming unresponsive and requiring medical intervention to correct a dangerously low blood sugar level.

Findings include:

The facility's medication administration policy, dated June 15, 2018, indicated that medications were to be administered in a safe and effective manner. Staff were to review the five rights (the right resident, right medication, right dose, right time, and right route) three times, and prior to removing the medication package/container from the cart/drawer they were to check the Medication Administration Record (MAR)/Treatment Administration Record (TAR) for the order, and check the label against the order on the MAR.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 22, 2018, indicated that the resident was confused and had diagnoses that included diabetes (disease that interferes with blood sugar control). The resident's care plan, dated June 19, 2018, revealed that staff were to administer diabetes medications as ordered by the physician.

Physician's orders for Resident 1, dated February 12, 2019, at 9:11 a.m. included orders for the resident to receive 5 units of Novolog insulin (fast-acting insulin), 100 units/milliliter (concentration) before meals. The order was changed on February 12, 2019, at 10:56 p.m. and should have read that the resident was to receive 5 units of Humalog (fast-acting insulin), 100 units/ml before meals; however, the order was transcribed (written into the record) for the resident to receive 100 units of Humalog (fast-acting insulin), 100 units/ml before meals, and 5 units of Humalog (100 units/ml) before meals.

A medication error report, dated February 19, 2019, revealed that on February 15, 2019, at 7:00 a.m. the physician's order for Humalog insulin was transcribed wrong and Licensed Practical Nurse 1 administered 100 units of Humalog insulin to Resident 1.

Nursing notes for Resident 1, dated February 15, 2019, indicated that Licensed Practical Nurse 1 misinterpreted the Humalog order and 100 units of insulin was administered to Resident 1 at 7:52 a.m. Licensed Practical Nurse 1 then returned to the resident's room at a documented time of 11:35 a.m. and found the resident unresponsive. The resident's blood sugar reading was 10 milligrams per deciliter (mg/dL) (normal blood sugar for a person with diabetes is 70 to 100 mg/dL before meals). Licensed Practical Nurse 1 called the registered nurse and stated that the resident was "crashing." At this time the resident was assessed by the registered nurse and was lethargic, hard to arouse, and cold and clammy. Licensed Practical Nurse 1 stated that one tube of Glucagon (a gel administered orally to raise blood sugar) was given, and the resident's blood sugar was rechecked and the reading was 38 mg/dL. The resident was cold and clammy and would respond by opening his eyes when his name was called, and chest rub was applied. Another tube of Glucagon was given at this time, and the resident's blood sugar was checked 10 minutes later and was 47 mg/dL. The physician was updated at 11:40 a.m., and orders were received to administer 1 mg of Glucagon intramuscularly (IM - injected into the muscle), every 15 minutes for a blood sugar less than 60 mg/dL, if the resident had symptoms and was unable to take anything by mouth. At 11:43 a.m. the resident received IM Glucagon for a blood sugar result of 38 mg/dL and at 12:02 p.m. for a blood sugar result of 24 mg/dL. The physician was notified, and new orders were received for 1 ml of Dextrose (medication used to raise blood sugar levels) IM to be given, and the Dextrose was administered at 12:20 p.m. with blood sugar response of 78 mg/dL.

Interview with the Director of Nursing on February 22, 2019, at 3:14 p.m. confirmed that Resident 1's insulin order was entered into the electronic clinical record incorrectly and Licensed Practical Nurse 1 administered 100 units of Humalog insulin to Resident 1.

28 Pa. Code 201.29(d) Resident rights.

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

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 9/6/18.

28 Pa. Code 211.12(d)(1)(3) Nursing services.
Previously cited 1/24/18, 8/9/17.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/6/18, 1/24/18, 8/9/17.















 Plan of Correction - To be completed: 04/05/2019

R1's insulin order was corrected to read Humalog Solution 100 unit per milliliter, inject 5 units subcutaneously before meals- Hold for blood sugar less than 100 milligrams per deciliter per MD order.

The Director of Nursing (DON) audited insulin orders to ensure that other residents were not affected by deficient practices. DON added to two resident orders notification of MD of parameters less than 70 milligrams per deciliter and greater than 400 milligrams per deciliter per facility's Abnormal Laboratory Values (Panic Lab Values) Policy. Insulin orders are reviewed by the interdisciplinary team during morning clinical rounds to ensure accuracy and completeness.

Agency Licensed Practical Nurse (LPN) who administered incorrect dose of insulin is no longer welcomed to work at facility. Staff Educator reviewed the importance of order entry with License Practical Nurse responsible for the transcription error.

Facility's Staff Educator completed an in-service on with facility licensed personnel that addressed facility's Physician Orders Telephone and Oral Policy. This policy reviews physician order clarification of orders perceived as unsafe or contraindicated with the ordering practitioner prior to acting upon the order.

Facility has executed a contract with a health consultant agency for a directed in-service. Licensed professional staff will receive training regarding the preparation and administration of medications and biologicals, including information regarding following physician's orders, manufacturer's specifications, and accepted professional standards and principles that apply to medication administration. This training will also include information regarding medication errors and examples of medication errors, including errors caused by transcribing and/or entering physician's orders incorrectly. This training will include available types of insulin and the normal doses for each type.

Director of Nursing or designee will audit monthly for three months insulin orders to ensure accuracy and completeness. Director of Nursing or designee will perform random medication administration competencies with licensed professional staff monthly for three months to ensure that medications perceived as unsafe or contraindicated are being clarified prior to administration.
Results of the audits and competencies will be reported and trended to the facility's Quality Assurance Steering Committee, which is the Centers for Medicare & Medicaid Services (CMS) recommended structure for Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).




483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to notify the physician in a timely manner following a change in condition for one of two residents reviewed (Resident 1).

Findings include:

The facility's policy regarding physician notification, dated June 15, 2018, indicated that nursing staff were expected to notify the registered nurse supervisor about significant changes in a resident's condition warranting further evaluation, and physician notification was based on the urgency of the situation. Staff were to call the physician during an emergency and the physician would address the situation at the time of the call.

A nursing note for Resident 1, dated February 15, 2019, at 11:40 a.m. revealed that Licensed Practical Nurse 1 called and stated that Resident 1 was "crashing." The insulin orders were misinterpreted, and 100 units of Humalog was administered to Resident 1. Upon entering the resident's room, the resident was hard to arouse, and Licensed Practical Nurse 1 stated that one tube of Glucagon (a gel administered orally to raise blood sugar) was given 10 minutes prior. The resident's blood sugar was rechecked, and the reading was 38 mg/dL (normal blood sugar for a person with diabetes is 70 to 100 milligrams/deciliter (mg/dL) before meals). The resident was cold and clammy and would respond by opening his eyes when his name was called, and chest rub was applied. Another tube of Glucagon was given, the resident's blood sugar was checked 10 minutes later and was 47 mg/dL.

A nursing note dated February 15, 2019, at 1:00 p.m. revealed that Licensed Practical Nurse 1 misinterpreted a Humalog order and 100 units of insulin were administered to Resident 1 at 7:52 a.m. Licensed Practical Nurse 1 returned to the resident's room at 11:35 a.m. and the resident was found unresponsive. The resident's blood sugar reading was 10 milligrams/deciliter (mg/dL). At this time the resident was assessed and found to be lethargic, hard to arouse, and cold and clammy.

There was no documented evidence that the physician was notified when Resident 1's blood sugar was 10 mg/dL.

Interview with the Director of Nursing on February 22, 2019, at 3:14 p.m. confirmed that Resident 1's physician was not notified that the resident's blood sugar was 10 mg/dL, and the physician should have been notified at that time.


28 Pa. Code 211.12(d)(1)(3) Nursing services.
Previously cited 1/24/18, 8/9/17.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/6/18, 1/24/18, 8/9/17.







 Plan of Correction - To be completed: 04/05/2019

Physician was notified of resident's critically low blood sugar after agency licensed practical nurse (LPN) gave resident glucagon gel on 2/15/19.

An audit was completed by the Director of Nursing on residents with documented blood sugars obtained to ensure that appropriate physician notification of parameters less than 70 milligrams per deciliter or greater than 400 milligrams per deciliter were completed.

Licensed professional staff were educated by Staff Educator on Notification of Changes Policy, Physician Notification Guidelines Policy as well as Panic Lab Values Abnormal Laboratory Results Policy. These policies address when the physician needs notified of changes in condition and abnormal lab values including a blood glucose of less than 70 milligrams per deciliter or greater than 400 milligrams per deciliter unless physician orders otherwise. A copy of abnormal laboratory values that require physician notification were placed at the nurses station as a quick reference for licensed professional staff.

Interdisciplinary team will review daily progress notes to ensure that changes in resident conditions are addressed with resident's physician. Director of Nursing or designee will audit monthly for three months randomly selected diabetic residents with blood glucose orders to ensure licensed professional staff are notifying physician when blood sugars parameters are less than 70 milligrams per deciliter or greater than 400 milligrams per deciliter.

Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee, which is the Centers for Medicare & Medicaid Services (CMS) recommended structure for Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders for one of two residents reviewed (Resident 1).

Findings include:

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

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 22, 2018, indicated that the resident was confused and had diagnoses that included diabetes (disease that interferes with blood sugar control). The resident's care plan, dated June 19, 2018, revealed that staff were to administer diabetes medications as ordered by the physician.

Physician's orders for Resident 1, dated February 12, 2019, at 9:11 a.m. included orders for the resident to receive 5 units of Novolog insulin (fast-acting insulin), 100 units/milliliter (concentration) before meals. The order was changed on February 12, 2019, at 10:56 p.m. and was transcribed (written into the record) for the resident to receive 100 units of Humalog (fast-acting insulin), 100 units/ml before meals, and 5 units of Humalog (100 units/ml) before meals.

Resident 1's Medication Administration Record (MAR) for February 2019 indicated that the resident was to receive 100 units of Humalog insulin before meals on February 13 and 14, 2019, at 7:00 a.m., 11:00 a.m., and 5:00 p.m.

A medication error report, dated February 19, 2019, revealed that on February 15, 2019, at 7:00 a.m. Licensed Practical Nurse 1 administered 100 units of Humalog insulin to Resident 1 because the physician's order was transcribed incorrectly.

A nursing note for Resident 1, dated February 15, 2019, at 1:00 p.m. revealed that Licensed Practical Nurse 1 misinterpreted the Humalog order and administered 100 units of insulin to Resident 1 at 7:52 a.m. Licensed Practical Nurse 1 returned to the resident's room at 11:35 a.m. and found the resident unresponsive.

There was no documented evidence that the physician's order of February 13, 2019, to give 100 units of Humalog insulin before meals was clarified with the physician.

Interview with Registered Nurse 3 on February 22, 2019, at 2:20 p.m. confirmed that she did not follow the order to give Resident 1, 100 units of Humalog and administered 5 units; however, she did not clarify the order with the physician.

Interview with Licensed Practical Nurse 2 on February 22, 2019, at 2:26 p.m. revealed that she thought that Resident 1's order for 100 units of Humalog insulin did not make sense, but she never clarified the order with the physician.

Interview with the Nursing Home Administrator on February 22, 2019, at 2:07 p.m. confirmed that the physician should have been notified to clarify whether Resident 1 was to receive 100 units of Humalog insulin.

42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 1/24/18, 8/9/17.

28 Pa. Code 211.12(d)(1)(3) Nursing services.
Previously cited 1/24/18, 8/9/17.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/6/18, 1/24/18, 8/9/17.






 Plan of Correction - To be completed: 04/05/2019

R1's insulin order was clarified with physician by Registered Nursing (RN) Supervisor when agency License Practical Nurse made RN Supervisor aware of unsafe insulin order on 2/15/19.

Director of Nursing completed an audit of insulin orders to make certain insulin orders were correct and did not require clarification. No other residents were affected.

Staff Educator or designee educated licensed staff with regards to facility's Physician Orders Telephone and Oral Policy. This policy addresses questioning and/or clarifying orders perceived as unsafe or contraindicated.

Interdisciplinary team will review daily physician orders to ensure that the orders are complete and correct, making certain that the orders do not require clarification and if clarification is necessary it will be completed. Director of Nursing or designee will audit monthly for three months insulin orders to ensure accuracy and completeness. Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee, which is the Centers for Medicare & Medicaid Services (CMS) recommended structure for Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents who displayed signs and symptoms of hypoglycemia (low blood sugar) were provided with timely treatment in accordance with hypoglycemic procedures for one of two residents reviewed (Resident 1).

Findings include:

The facility's policy and procedure regarding the treatment of hypoglycemia, dated June 15, 2018, indicated that signs and symptoms of hypoglycemia, which were usually of sudden onset, included irritability, bizarre change in behavior, tachycardia (increased heart rate), paleness, cool and moist skin, blurred or impaired vision, stupor, convulsions, slurred speech, numbness of the tongue or lips, headache, trembling, and coma. For residents who were symptomatic, unresponsive, and or unable to swallow, staff were to obtain a blood glucose (sugar) measurement, and if it was less than 70 milligrams per deciliter (mg/dL) or there were other low parameters established by the physician, staff were to immediately administer 1 mg of Glucagon (used to raise blood sugar levels) intramuscularly (IM).

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 22, 2018, indicated that the resident was confused and had diagnoses that included diabetes (disease that interferes with blood sugar control). A nursing note for Resident 1, dated February 15, 2019, at 11:40 a.m. revealed that Licensed Practical Nurse 1 called and stated that Resident 1 was "crashing." An insulin order was misinterpreted and 100 units of Humalog (fast acting insulin) was administered to Resident 1. Upon entering the resident's room, the resident was hard to arouse, and Licensed Practical Nurse 1 stated that one tube of Glucagon (a gel administered orally to raise blood sugar) was given 10 minutes prior. The resident's blood sugar was rechecked, and the reading was 38 mg/dL (normal blood sugar for a person with diabetes is 70 to 100 milligrams/deciliter before meals). The resident was cold and clammy and would respond by opening his eyes when his name was called, and chest rub was applied. Another tube of Glucagon was given, the resident's blood sugar was checked 10 minutes later and was 47 mg/dL.

A nursing note for Resident 1, dated February 15, 2019, at 1:00 p.m. revealed that Licensed Practical Nurse 1 misinterpreted the Humalog order and administered 100 units of insulin to Resident 1 at 7:52 a.m. Licensed Practical Nurse 1 returned to the resident's room at 11:35 a.m. and the resident was found unresponsive. The resident's blood sugar reading was 10 mg/dL. At this time the resident was assessed and was lethargic, hard to arouse, and cold and clammy. The physician was updated, and orders were received to administer 1 mg of Glucagon intramuscularly (IM - injected into the muscle) every 15 minutes for a blood sugar less than 60 mg/dL, if the resident had symptoms and was unable to take anything by mouth.

There was no documented evidence that Licensed Practical Nurse followed the facility's hypoglycemic procedure when Resident 1 was hard to arouse and had a blood sugar of 10 mg/dL. Nursing notes indicated that oral Glucagon gel was administered instead of IM Glucagon for blood sugar levels that were below 70 mg/dL.

Interview with the Director of Nursing on February 22, 2019, at 3:14 p.m. confirmed that Licensed Practical Nurse 1 did not follow the facility's hypoglycemic procedures.

42 CFR 483.25 Quality of Care.
Previously cited 8/9/17.

28 Pa. Code 201.29(d) Resident rights.

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

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 1/24/18, 8/9/17.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/6/18, 1/24/18, 8/9/17.





 Plan of Correction - To be completed: 04/05/2019

Director of Nursing or designee will review progress notes and Point of Care documentation through the facilities clinical rounds process to ensure staff are appropriately capturing when signs or symptoms of hypoglycemia are present. Clinical rounds is the system where the interdisciplinary team round each unit and discuss orders, notes, change in conditions for residents.

Staff Educator in-serviced licensed professional staff with regards to facility's Hypoglycemic Protocol.

Staff Educator educated Certified Nursing Assistant (CNA) staff on what the signs and symptoms of hypoglycemia are. This protocol includes signs and symptoms of hypoglycemia that include sweating, facial pallor, shakiness/tremors, increased appetite, nausea, dizziness/lightheadedness, sleepiness, weakness, rapid heart rate, headache, tingling of mouth or tongue, change in level of consciousness and seizures. A copy of the hypoglycemia protocol with signs and symptoms of hypoglycemia were posted at each nurses station as a quick reference for nursing staff.

The Director of Nursing or designee will complete random audit of diabetic progress notes monthly for three months to monitor that the corrective action is achieved and sustained.

Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee, which is the Centers for Medicare & Medicaid Services (CMS) recommended structure for Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).

483.50(a)(1)(i) REQUIREMENT Laboratory 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.
483.50(a) Laboratory Services.
483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.
Observations:


Based on clinical records reviews and staff interviews, it was determined that the facility failed to obtain physician-ordered laboratory tests in a timely manner for one of two residents reviewed (Resident 1).

Findings include:

A nurse practitioner's (a registered nurse with advanced training) note for Resident 1, dated February 11, 2019, indicated that the resident was seen for green penile drainage after his indwelling urinary catheter was removed over the weekend. An order was received to obtain a culture and sensitivity (C&S - laboratory test to check for the presence of infection) of the penile drainage. A nursing note dated February 12, 2019, at 2:38 a.m. revealed that the registered nurse reported that the culture of the penile drainage was obtained, and they were awaiting the results.

A nursing note for Resident 1, dated February 14, 2019, at 9:19 p.m. revealed the resident had a copious amount of thick green, very foul-smelling drainage from his penis, and his incontinent brief was saturated, and another large amount was noted in the toilet. There were no results yet from the C&S that was obtained earlier in the week.

A nursing note for Resident 1, dated February 15, 2019, at 9:19 a.m. indicated that a call was placed to the laboratory for the results of the C&S of the penile discharge, and the laboratory indicated that they had no record of the culture being sent. At 10:25 a.m. a C&S of the penile drainage was obtained.

Laboratory results for Resident 1, dated February 18, 2019, revealed that the penile drainage was positive for methicillin-resistant staphylococcus aureus (MRSA - a bacteria that is resistant to multiple commonly used antibiotics) infection and an order was received to start 500 milligrams (mg) of Levaquin (an antibiotic) daily for three days.

Interview with the Nursing Home Administrator on February 22, 2019, at 2:07 p.m. confirmed that the culture and sensitivity for Resident 1 was not obtained timely.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 1/24/18, 8/9/17.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/6/18, 1/24/18, 8/9/17.






 Plan of Correction - To be completed: 04/05/2019

R1's penile drainage was sent to Indiana Regional Medical Center for a culture and sensitivity the morning of 2/15/19.

Director of Nursing audited laboratory orders to ensure that other residents were not affected by deficient practices. No other residents were affected.

Staff Educator completed in-service with licensed professional staff. In-service included education on Laboratory Services Policy and the requirement to send laboratory specimens in a timely manner.

The facility will have a meeting with the laboratory provider to identify the root cause of how the specimen was not delivered.

Registered Nurse (RN) Supervisor will implement a laboratory tracking form to ensure that laboratory tests are completed, sent to the laboratory and results are collected in a timely manner. The Director of Nursing or designee will audit lab cultures for the month for three months to ensure completeness and timeliness.
Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee, which is the Centers for Medicare & Medicaid Services (CMS) recommended structure for Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and 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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of two residents reviewed (Resident 1).

Findings include:

The facility's policy regarding medication administration, dated June 15, 2018, revealed that after staff administered medications they were to document the administration in the Medication Administration Record (MAR) or Treatment Administration Record (TAR).

A nursing note for Resident 1, dated February 15, 2019, at 11:40 a.m. revealed that Licensed Practical Nurse 1 called and stated that Resident 1 was "crashing." An insulin order was misinterpreted and 100 units of Humalog (fast-acting insulin) were administered to Resident 1. Upon entering the resident's room, he was hard to arouse, and Licensed Practical Nurse 1 stated that one tube of Glucagon (a gel administered orally to raise blood sugar) was given 10 minutes prior. The resident's blood sugar was rechecked, and the reading was 38 mg/dL (normal blood sugar for a person with diabetes is 70 to 100 milligrams/deciliter (mg/dL) before meals). The resident was cold and clammy and would respond by opening his eyes when his name was called, and chest rub was applied. Another tube of Glucagon was given, and the resident's blood sugar was checked 10 minutes later and was 47 mg/dL.

A nursing note for Resident 1, dated February 15, 2019, at 1:00 p.m. revealed that Licensed Practical Nurse 1 misinterpreted the Humalog order and administered 100 units of insulin to Resident 1 at 7:52 a.m. Licensed Practical Nurse 1 returned to the resident's room at 11:35 a.m. and the resident was found unresponsive. The resident's blood sugar reading was 10 mg/dL. At this time the resident was assessed and was lethargic, hard to arouse, and cold and clammy. The physician was updated, and orders were received to administer 1 mg of Glucagon intramuscularly (IM - injected into the muscle) every 15 minutes for a blood sugar less than 60 mg/dL, if the resident had symptoms and was unable to take anything by mouth. At 11:43 a.m. the resident received IM Glucagon for a blood sugar result of 38 mg/dL and at 12:02 p.m. for a blood sugar result of 24 mg/dL. The physician was notified, and new orders were received for 1 ml of Dextrose (medication used to raise blood sugar levels) IM to be given, and the Dextrose was administered at 12:20 p.m. with blood sugar response of 78 mg/dL.

Resident 1's MAR for February 2019 revealed that there was no evidence that staff documented the administration of the Glucagon gel, the Glucagon injection, or the Dextrose injection on the MAR on February 15, 2019.

Interview with the Director of Nursing on February 22, 2019, at 3:14 p.m. confirmed that Resident 1's MAR did not include the administration of Glucagon gel, Glucagon injection, or Dextrose injection.

28 Pa. Code 211.5(f) Clinical records.







 Plan of Correction - To be completed: 04/05/2019

Hypoglycemic orders were entered into resident R1's orders when he returned from his hospitalization.

The Director of Nursing completed audit to ensure residents ordered insulin also had hypoglycemic protocol orders in place. Physician was contacted for residents that did not have the hypoglycemic protocol orders and new orders were obtained.

Staff Educator completed in-service with licensed professional staff. Hypoglycemic protocol was educated on and it was emphasized that residents who are ordered insulin must also have hypoglycemic orders initiated.

Licensed staff were also educated on facility's Electronic Signature Policy in which users are required to review their entries for completeness and accuracy prior to electronically signing the progress notes, assessments, electronic medication administration record and electronic treatment administration record.

Director of Nursing or designee will audit monthly for three months insulin orders to ensure accuracy and completeness.
Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee, which is the Centers for Medicare & Medicaid Services (CMS) recommended structure for Quality Assurance Performance Improvement Plan (QAPI). The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).


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