Nursing Investigation Results -

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

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COURTYARD GARDENS NURSING AND REHABILITATION CENTER
Inspection Results For:

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

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
COURTYARD GARDENS NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure and Civil Rights and an Abbreviated survey in response to a complaint completed on March 7, 2019, it was determined that Courtyard Gardens Nursing and Rehabilitation 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on review of facility policies, observations, and interviews it was determined that the facility failed to ensure food and beverages were stored in accordance with professional standards for food safety in the kitchen, one of one dining rooms (the Healthcare Dining Room), two of two pantries (A/B and C/D pantries), and one of one lounge (A/B lounge).

Findings include:

Review of facility Policy for Storage of Goods, revised December 12, 2018, revealed the following: date and rotate goods on a "first in, first out" basis; remove goods from storage for which the expiration date has passed; and all foods must be labeled and dated.

Observations on March 5, 2019, at approximately 8:50 AM in the walk-in freezer in the kitchen revealed three five pound (LB- unit of measure) bags of ground bacon didn't contain a received or use by date, and one 5lb bag of beef cubes didn't contain a received or use by date.

During an interview with the Food Service Director 1 (FSD 1) on March 5, 2019, at approximately 8:50 AM it was revealed that the bags of ground bacon and beef cubes should contain a received by date.

Observation of the inside of the ice machine in the main kitchen on March 5, 2019, at approximately 09:04 AM revealed a pinkish black film along the bottom edge of the white plastic ice deflector (a plastic shield where the ice falls down into the bin). The FSD 1 took a cloth and wiped the substance off the edge of the ice deflector, the substance wiped off easily and looked to be moist and slimy.

During an interview with FSD 1 revealed that the ice machine was serviced recently, and that it is serviced every 6 months. It was also revealed that the Dietary Department and/or Maintenance Department doesn't clean the ice machine between the times of service. The expectation was revealed that the moist pinkish black substance should not be there.

Review of the invoice for service of ice machine revealed it was last serviced on September 28, 2018, at that time the ice machine in the kitchen was cleaned and recommended replacing the dump valve. Previous service of ice machine in the kitchen was April 9, 2018.

Observation in the Health care Dining Room on March 5, 2019, at approximately 9:16 AM revealed in the reach-in refrigerator a tray with nine dessert bowls of puree doughnuts that didn't contain a label or a date and the cart didn't contain a date, and one container of cranberry raspberry juice open with contents partially removed and didn't contain an open or use by dated.

During an interview with FSD 1 on March 5, 2019, at approximately 9:16 AM revealed that the dessert dishes were puree doughnuts and that the tray or the cart should contain a date, and that the cranberry raspberry juice should contain an open date.

Observation in the C/D station pantry on March 5, 2019, at approximately 9:20 AM revealed one container grape juice, and one container nectar thick cranberry juice were open with contents partially removed and didn't contain an open date or use by date.

During an interview with Food Service Director on March 5, 2019, at approximately 9:20 AM it was revealed that the aforementioned items should have been dated when they were opened.

Observation in the A/B station pantry on March 5, 2019, at approximately 9:32 AM revealed one container of honey thick cranberry cocktail open with contents partially removed and didn't contain a use by date

During an interview with Food Service Director on March 5, 2019, at approximately 9:32 AM revealed that the honey thick cranberry cocktail should contain an open date.

Observation in the A/B station lounge refrigerator on March 5, 2019, at approximately 9:40 AM revealed a block of sliced American cheese wrapped in clear plastic wrap dated with a used by date February 28 th; one store bag that contained a turkey pretzel sandwich with a paper labeled with staff name, 11-7 shift and a phone number, and three boxes of pizza with a total of 8 slices that is not labeled with a name or date.

During an interview with FSD 1 on March 5, 2019, at approximately 9:40 AM it was revealed that the sandwich and the pizza belong to staff and should be in the staff refrigerator, not the lounge refrigerator.

During an interview with the Nursing Home Administrator on March 6, 2019, at approximately 11:24 AM revealed the expectation that all open food and beverages should contain an open date, all food that belongs to staff should be stored in the staff lounge refrigerator, items past their use by date should be discarded.

Pa Code 211.6(b)(d) Dietary Services











 Plan of Correction - To be completed: 04/09/2019

Food items which were not properly labeled and dated were immediately discarded.

Ice machine in the kitchen was immediately cleaned and sanitized.

Re-education will be completed regarding labeling and dating to all Food Service staff by the Director of Food Services.

Standard labels were established and will be used to identify 'use by' date when food items are opened. A reference tool is provided to identify safe shelf life, this reference was provided to all dietary and is posted on the back of all nourishment doors as well as in the main kitchen.

Routine cleaning and preventative maintenance checklists have been updated to include weekly cleaning and sanitizing of ice machine.

Re-education will be completed regarding safe food handling procedures for all dietary staff.

Audits of freezer, walk ins refrigerators. Daily/1 week starting 3/21/19, 3X wk/month starting 3/28/19, 1x wk/month 4/26/19, monthly for 3months starting May 2019.

Audit for ice machine same as above.

Audits and reports to QAPI for further review and or recommendations.

483.90(d)(3) REQUIREMENT Resident Bed: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.
483.90(d)(3) Conduct Regular inspection of all bed frames, mattresses, and bed rails, if any, as part of a regular maintenance program to identify areas of possible entrapment. When bed rails and mattresses are used and purchased separately from the bed frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible.
Observations:


Based on facility policy review, surveyor observation, record review and staff interview, it was determined that the facility failed to conduct regular inspections of bed rails/enabler bars to identify areas of possible entrapment for six of six residents reviewed (Residents 5, 26, 34, 60, 67, and 74).

Findings include:

Review of facility policy titled, "Side Rail Safety," dated June 2018, revealed "Maintenance will keep separate policy regarding FDA safety zone assessments."

Review of Resident 5's clinical record revealed diagnoses that included urinary tract infection and hypertension (high blood pressure).

Observation of Resident 5's bed on March 5, 2019, at 01:08 PM revealed the presence of bilateral enabler bars on the resident's bed.

Review of Resident 5's clinical record revealed no evidence that inspections of bed rails/enabler bars were conducted to identify areas of possible entrapment.

Review of Resident 26's clinical record revealed diagnoses that included muscle weakness (a lack of muscle strength), essential hypertension (high blood pressure that doesn't have a known secondary cause), low back pain and bone cancer.

Observation of Resident 26's bed on March 6, 2019, at 10:00 AM revealed the presence of bilateral enabler bars on the resident's bed.

Review of Resident 26's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails/enabler bars were conducted to identify areas of possible entrapment.


Review of Resident 34's clinical record revealed diagnoses that included essential hypertension (high blood pressure that doesn't have a known secondary cause) and muscle weakness (a lack of muscle strength).

Observation of Resident 34's bed on March 6, 2019, at 10:46 AM revealed the presence of a one side rail up on the resident's bed.

Review of Resident 34's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails/enabler bars were conducted to identify areas of possible entrapment.

Review of Resident 60's clinical record revealed diagnoses that included flaccid hemiplegia affecting left non dominant side (illness characterized by weakness or paralysis and reduced muscle tone without other obvious cause) and muscle weakness (a lack of muscle strength).

Observation of Resident 60's bed on March 5, 2019, at 9:02 AM revealed the presence of one side rails up on the resident's bed.

Review of resident 60's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails/enabler bars were conducted to identify areas of possible entrapment.

Review of Resident 67's clinical record revealed diagnoses that included a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) and paraplegia (paralysis of the legs and lower body). Surveyor observation on March 5, 2019, at 9:47 AM revealed bilateral enabler bars attached to Resident 67's bed.

Review of Resident 67's clinical record revealed a safety assessment for the enabler bars was done on January 21, 2019, and Resident 67 provided informed consent for the enabler bars on January 22, 2019. Further review of Resident 67's clinical record failed to reveal evidence that the facility conducted an inspection of the bed frame, mattress and enabler bars to identify areas of possible entrapment.

During an interview with the Director of Nursing on March 6, 2019, at 1:55 PM she revealed that to her knowledge they do not complete any measurements on enabler bars but she would verify.

During an interview with the Maintenance Director on March 6, 2019, at 2:30 PM he stated that he does measurements of the enabler bars and mattresses but he does not document it anywhere. He stated that he inspected all of the beds last month but was unable to provide any documentation that this was done.

Review of facility policy titled, "Side Rail Safety," dated June 2018, revealed "Maintenance will keep separate policy regarding FDA safety zone assessments."

Review of Resident 74's clinical record revealed diagnoses that included muscle weakness (a lack of muscle strength) and hyperlipidemia (elevated blood cholesterol level).

Observation of Resident 74's bed on March 6, 2019, at 10:00 AM revealed the presence of bilateral enabler bars on the resident's bed.

Review of Resident 74's clinical record revealed no evidence that ongoing evaluations or inspections of bed rails/enabler bars were conducted to identify areas of possible entrapment.

28 PA Code 201.18(b)(1) Management





 Plan of Correction - To be completed: 04/09/2019

The facility provided to the Department of Health a copy of the Side Rail Policy updated in June 2018.

The facility also provided to the Department of Health a copy of the tool used to measure as referenced in Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.

The facility re-checked measurements of side rails/enablers to confirm compliance including Residents 5, 26, 34, 60, 67, and 74.

Maintenance Department has been re-educated regarding documentation of measurements, which will be done annually, and upon admission of any resident who uses enablers.

The Director of Maintenance or designee will continue to conduct routine room/bed inspections 7 days/week.
Any bed dimensions will be addressed and documented.

The Director of Nursing or designee will conduct an audit of 5 rooms/bed inspection weekly x1month, then 5 residents per month x3months.

Audit results and performance improvement will be tracked and reported through Quality Assurance Process Improvement (QAPI).




483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:


Based on review of resident council meeting minutes, and resident and staff interviews, it was determined that the the facility failed to demonstrate a response to grievances from resident council on five of five months reviewed (October, November and December 2018, January and February 2019).

Findings include:

Review of the resident council meeting minutes for October 2018, through February 2019, indicated the following concerns:

October 2018; "Residents continue to express concern about nursing staff telling residents when answering their call bells that they are not on their assignments."
November 2018; " Residents continue to express concern about nursing staff telling residents that they are not on their assignments."
December 2018; "Resident continue to express concern about nursing staff telling residents that they are not on their assignment."
January 2019; "Resident continue to express concern about nursing staff telling residents that they are not on their assignment."
February 2019; "Residents expressed concern about nursing staff-shortages, call bells not being answered more timely which may be impacted by staff assisting residents with their meals."

During the Resident Group Interview conducted on March 6, 2019, at 10:30 AM, with five resident participating revealed that their biggest concern was that when they ring their call light staff will come in and turn off light and tell them they are not assigned to them and then then they have to wait awhile. The residents also revealed that this has been a problem for a long time and has not been resolved.

Review of the resident council meeting minutes did not reveal documentation that the facility resolved the repeated reported concerns made by the resident council or any documentation that any interventions had been planned and/or attempted.

During an interview with Director of Nursing (DON) on March 7, 2019, at approximately 9:45 AM, the DON revealed that she was probably new in her current position when this concern first came up, was not able to determine if this had been specifically addressed with staff. DON revealed that there are meetings with staff where they are encouraged "To work together as a team."

During an interview with Activities Representative (ACT 1), ACT 1 revealed that at some point a meeting had been scheduled to address this concern with Nursing Aides. ACT 1 revealed that this meeting had been cancelled, she believed that there had been some changes in management positions during that time frame and that somehow the follow-up had been "lost."

During an additional interview with DON on March 7, 2019, at approximately 11:30 AM, no further information was provided to document follow-up and/or resolution of residents' concern.

28 Pa Code: 201.18(a)(b)(1)(3)(e)(1)(2)(3)(6) Management















 Plan of Correction - To be completed: 04/09/2019

A monthly summary of resident's concerns is provided to the Director of Nursing and all Department Directors subsequent to every monthly Resident Council Meeting.

The Director of Therapeutic Recreation or designee will provide documented follow-up and explanation to Resident Council.

Education will be provided at April health center staff meeting. Resident concerns of staff telling residents they are not on their assignments, along with other resident council concerns will be addressed.

A nursing designee will be attending the next resident council meeting to discuss resident concerns.

Social Services Director educated the RN supervisors and LPNs regarding the resident council concern about staff stating that the residents are not on there assignment.

RNs & LPNs educated the CNA's.

The Grievance Officer or designee will audit resident council minutes monthly to verify follow-up of resident concerns and report to QAPI for further review and or recommendations.


483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:


Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure each resident's right to formulate an advance directive for two 18 residents reviewed (Residents 84 and 289).

Findings Include:

Review of facility policy titled, "Advance Directives-Guidelines for Completion," with a review date of February 2016, revealed "It is the policy of this facility that all residents or responsible parties will be offered a PA-POLST [Pennsylvania Orders for Life-Sustaining Treatment] form for completion on admission."

Review of Resident 84's clinical record revealed an admission date of February 13, 2019, and diagnoses that included hypertension (elevated blood pressure) and Type 2 Diabetes Mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment). Further review of Resident 84's clinical record on March 5, 2019, at 10:35 AM revealed that there was no advanced directive form, no POLST form, and no physician order designating the code status for Resident 84.

Review of Resident 84's admission summary progress note, dated February 13, 2019, revealed that Resident 84 "has no POLST or Advanced Directive established at this time."

Review of Resident 84's clinical record revealed a progress note dated March 5, 2019, at 12:19 PM stating "Res. and Husband were explained the choices to make on the POLST. Res. signed the POLST."

On March 5, 2019, at 2:03 PM a POLST form was provided to the surveyor completed and signed by Resident 84, indicating she wanted CPR. The POLST form was not dated nor signed by the physician.

Review of Resident 289's clinical record revealed an admission date of February 18, 2019, and diagnoses that included hyperlipidemia (high level of fats in the blood) and chronic kidney disease (damaged kidneys unable to filter blood like they should). Further review of Resident 289's clinical record on March 5, 2019, at 10:35 AM revealed that there was no advanced directive form, no POLST form, and no physician order designating the code status for Resident 289.

Review of Resident 289's admission summary progress note dated February 19, 2019, revealed that Resident 289 "has no POLST/Advanced Directive established at this time." Review of progress note dated March 5, 2019, at 12:19 PM revealed "Res. was explained the POLST, res. signed the POLST."

On March 5, 2019, at 2:03 PM the surveyor was provided a copy of Resident 289's POLST which was signed by Resident 289, indicating he wished to be a DNR (Do Not Resuscitate). The POLST form was not dated or signed by the physician.

During staff interview on March 6, 2019, at approximately 11:30 AM the Director of Nursing stated that the facility tries to get a POLST filled out as close to the admission as possible and that code status is a sensitive subject and some Residents are not ready to talk about it. She stated that Residents are a Full Code until a POLST is completed.

During an additional interview with the Director of Nursing on March 7, 2019, at 11:05 AM she stated that sometimes Residents/families don't make the decision on a code status right away because it is a big decision. However, she was unable to find documentation that a discussion about formulating an advanced directive was discussed with Resident 84 or Resident 289 or their responsible parties prior to March 5, 2019.

28 Pa. Code 211.5 (f) Clinical records.

28 Pa. Code 211.12(d)(1)(5) Nursing services




 Plan of Correction - To be completed: 04/09/2019

The POLST for resident's #84 and #289 were signed and dated on March 5, 2019.

An audit was immediately conducted to confirm that any resident who wishes to execute a POLST was provided this opportunity and that the POLST is fully executed.

Future residents or responsible parties, if applicable will continue to be offered a POLST and have the option for advanced directives to be completed.

Residents and families are advised upon admission that until a POLST is signed by a physician, the resident will remain a full code.

Admissions and licensed nursing staff were educated on POLST completion.

The Medical Record/Unit Secretary or designee will audit POLST completion for new admissions weekly x3 months and report to QAPI for further review and or recommendations.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:



Based on clinical record review and staff interview it was determined the facility failed to ensure each resident is informed of items and services that the facility offers for which the resident may be charged for two of four resident beneficiary notice forms reviewed (Residents 8 and 235).

Findings Include:

Review of Resident 8's Beneficiary Protection Notification Review form revealed a last covered day by Medicare A services of September 28, 2018.

Review of Resident 8's clincal record revealed she was not notified of the cost per day of services provided via the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form.

Review of Resident 235's Beneficiary Protection Notification Review form revealed a last covered day of Medicare A skilled services of February 22, 2019.

Review of Resident 235's clincal record revealed he was not notified of the cost per day of services provided via the SNFABN form.

An interview with the Social Worker (SW 1) on March 5, 2019, at 2:44 PM revealed she is not familiar with the SNFABN form and therefore residents had not been provided the notice upon the termination of Medicare A skilled services.

28 Pa. Code 201.29 (b) Resident rights










 Plan of Correction - To be completed: 04/09/2019

Resident #8 was discharged on 9/29/18
Resident #235 was discharged on 2/23/19.

An audit was immediately conducted to re-confirm all residents on Medicare A services.

Director of Social Services immediately printed ABN instructions from the CMS website. This information was shared with her department.

Upon termination of Medicare A skilled services, residents will be notified of the estimated cost per day of services provided via the SNF ABN form.

Upon termination of Medicare A benefits, the resident's chart will be reviewed for verification that an ABN notice was received by resident.

Audit will be completed for 3 months.

The Medical Record/Unit Secretary or designee will audit and report to QAPI for further review and or recommendations.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of resident's admission for one of 21 residents reviewed (Resident 67).

Findings Include:

Review of Resident 67's clinical record revealed an admission date of January 18, 2019, and diagnoses that included stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) and paraplegia (paralysis of the legs and lower body). Review of Resident 67's baseline care plan revealed that only a bowel incontinence care plan was developed for Resident 67 within the first 48 hours of Resident 67's admission. Further review of Resident 67's care plan revealed that a pressure ulcer care plan was not developed until January 23, 2019.

During staff interview on March 6, 2019, at 2:00 PM. the Director of Nursing confirmed that bowel incontinence was the only care area addressed on Resident 67's baseline care plan.

28 Pa. Code 211.5(f) Clinical records.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.









 Plan of Correction - To be completed: 04/09/2019

Resident # 67 care plan was re-reviewed to confirm accuracy.

Admissions for the prior 30 day period were reviewed to confirm that a baseline care plan was developed.

The Director of Nursing or designee will re-educate nursing supervisors and members of the interdisciplinary team that a baseline care plan is to be developed within 48 hours of admission.

Audits on new admissions will be completed by the Director of Nursing or designee for compliance of baseline care plan completion weekly x3 months.

Audit results will be reported to QAPI for further review and or recommendations.



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


Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 21 residents reviewed (Resident 67).

Findings Include:

Review of Resident 67's clinical record revealed an admission date of January 18, 2019, and diagnoses that included stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle) and paraplegia (paralysis of the legs and lower body).

Review of Resident 67's comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs), dated January 25, 2019, identified mood as an area of concern for Resident 67. Further review of the assessment revealed that it was coded to indicate the facility planned to create a plan of care addressing Resident 67's mood. Review of Resident 67's current care plan failed to reveal that a mood care plan was developed.

During an interview with the Director of Nursing on March 6, 2019, at 2:00 PM she confirmed that Resident 67 did not have a mood care plan developed and she stated that one should have been developed.

28 Pa. Code 211.11(d) Resident care plan









 Plan of Correction - To be completed: 04/09/2019

Resident #67 care plan was updated.

MDS Assessments for the prior 30 day period were reviewed to confirm that care plans are updated.

Re-education on the Care Area Assessment (CAA) will be provided to all members of the interdisciplinary team who participate in completion of the MDS and care planning.

Care Area Assessment (CAA) completion and care planning will be audited.

The Director of Nursing or designee will audit 3 MDS per week for 3 months.
Any concerns found will be discussed and reviewed with the team member.

Audit results will be reported to QAPI for further review and or recommendations.


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of clinical records and staff interviews it was determined that the facility failed to review and revise the resident plan of care for two of 28 residents reviewed (Residents 46 and 56).

Findings include:

Review of Resident 46's clinical record revealed diagnoses that included Dysphagia (difficulty swallowing) and Hypertension (high/elevated blood pressure).

Observation on March 5, 2019, at 9:39 AM revealed Resident 46 without fluids at the bedside. Resident 46 stated that he gets fluids whenever he wants and plenty with meals. there was no cup at the bedside as observed with all other residents on the wing.

Observation on March 5, 2019, at 2:55 PM revealed Nurse Aide 3 pushing the hydration cart on Resident 46's. The staff person was asked if Resident 46 was on a fluid restriction and she responded "yes". This writer ask Nurse Aide 3 how she knew that Resident 46 was on a fluid restriction and at first she stated their diet is listed on the form on the cart, but when the cart form was reviewed the residents diet was listed but nothing about fluid restriction. Then she stated she stops at the nurses station and they inform her if residents can't have the fluids.

During an interview with Nurse Aide 4 on March 5, 2019, at 3:11 PM stated that a tear drop should be present on wall above Resident 46's bed that indicates fluid restriction. There was no teardrop observed and Nurse Aide 4 did check behind the bed on the floor to make sure it hadn't fallen off of the wall.

During observation on March 5, 2019, reveal Resident 46 drinking ginger ale cup which was provided from the hydration cart.

During an interview with Licensed Practical Nurse (LPN) 1 on March 6, 2019, at 9:08 AM she revealed that Resident 46 has 2 liter fluid restriction per the computer screen due to his cardiac history. She stated that the Fluid restriction documented on care plan flows to physician orders but doesn't flow to Medication Administration Record or the Treatment Administration Record. She also stated that the Nurse Aides monitor the residents intake in the Task section of the electronic medical record. LPN and this writer open the task section but intake was not being monitored.

A review of Resident 46's care plan does state fluid restriction initiated August 9, 2019. The Care plan also included an intervention to encourage Robert to drink fluids of his choice, dated September 14, 2019, and to follow fluid restriction. Additionally, the care plan states ensure Resident 46 has access to cold water whenever possible, dated February 15, 2018.

During an observation of Resident 46 on March 6, 2019, at 10:00 AM revealed a cup of water at the bedside. Resident 46 states that it is in his way and that and he rarely drinks water.

During an interview with the Director of Nursing (DON) on March 6, 2019, she was requested to clarify hydration status of Resident 46. The DON stated she will provide a response after review of the record and notification of the physician.

During an interview with the DON on March 6, 2019, at approximately 2:30 PM she stated that she spoke with physician and Resident 46 is not on fluid restriction. The DON was asked to provide physcican orders that initiated any fluid restriction but they were never presented.

During an interview with Resident 46's physician on March 7, 2019, he stated that Resident 46 is not on fluid restrictions and was unable to recall if he was on fluid restriction in the past.

During an interview with the DON on March 6, 2019, at approximately 11:00 AM she confirmed that Resident 46's care plan should have been revised when the fluid restriction ended.


Review of Resident 56's clinical record revealed diagnoses that included dysphagia (difficulty swallowing) and Chronic Obstructive Pulmonary Disease (lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible).

Review of Resident 56's current active Care Plan on March 6, 2019, revealed the care Focus Area "unintentional weight loss due to dementia; dysphagia; low body weight" and revealed Interventions including "Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss" with an initiation date of April 19, 2016. Review of facility protocol for weight loss (last revised July 29, 2016) revealed processes which included guidelines for obtaining initial weights and for frequency based on findings including "If, within a month the resident's weight is 5 or more pounds higher or lower than the last recorded weight, notify the charge nurse and re-weigh the resident."

Review of Resident 56's current active physician orders revealed the order "Palliative care-no weights or labs" with a start date of December 26, 2017. Further review of resident's clinical record revealed that weights were not being obtained.

During an interview with DON on March 7, 2019, at 8:15 AM, the DON revealed that the care plan should not have included doing weights.

28 Pa. Code 211.11(d) Resident care plan
Previously cited 4/05/18

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 4/05/18







 Plan of Correction - To be completed: 04/09/2019

Resident #46 and 56 care plans were updated.

Care plans have been reviewed for accuracy.

Re-education regarding updating care plans will be provided to the interdisciplinary team.

The Director of Nursing or designee will audit 3 care plans for accuracy per week for 3 months.

Any concerns found will be discussed and reviewed with the team member.

Audit results will be reported to QAPI for further review and or recommendations.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on surveyor observation, facility policy review, and staff interview, it was determined that the facility failed to discard expired biologicals for one of two medication carts observed (C hall med cart), failed to refrigerate medications in one of one medication rooms observed (B hall med cart), and failed to place "opened dates" on medications in one of one medication room observed (Station 1 medication room) and one of two medication carts observed (B hall medication cart) .

Findings Include:

During an observation of C hall medication cart on March 6, 2019, at 10:03 AM revealed one container of Resource ThickenUp (a commercial thickener for foods and beverages that provides them with a consistency that meets National Dysphagia Diet standards) with an expiration date of October 4, 2018.

During an interview with the Director Of Nursing on March 7, 2019, at 1:35 PM revealed that although the facility does not have a specific policy stating such, she expects supplements to be properly disposed of after they are beyond their expiration date.

Review of facility policy, Medication Ordering, Receiving and Storage, in the section labeled, "General Guidelines", with an effective date of 2009 states, "Medications requiring refrigeration must be stored in a refrigerator location in the medication room at the nurses' station or other secured location."

Review of Levemir web site revealed "Unopened Levemir should be kept in the refrigerator at temperature range between 36 and 46 degrees F."

During an observation of B hall medication cart on March 6, 2019, at 10:27 AM revealed one Levemir Flextouch Pen (device filled with and used to dispense insulin) that was unopened and unrefrigerated.

Review of the Lantus Solostar Pen (device filled with and used to dispense insulin) package insert revealed in the section labeled, "How to store your opened Lantus Solostar Pen", "after 28 days, throw your opened Lantus away- even if it still has insulin in it."

Observation of B hall medication cart on March 6, 2019, at 10:27 AM revealed one Lantus Solostar Pen that was opened with nothing indicating what date it was opened, this was verified with Licensed Practical Nurse 1 (LPN)1.

Review of Sanofi Pasteur Tubersol (Tuberculin Purified Protein Derivative) package insert revealed "A vial of Tubersol which has been entered and in use for 30 days should be discarded."

Observation of Station 1 medication room on March 6, 2019, at 10:40 AM revealed one vial of Tubersol solution opened with no markings indicating a date on which it was opened, this was also verified with LPN1.

Interview with Director of Nursing on March 7, 2019, at 1:35 PM revealed that she expects that the facility's policies and manufacture's guidelines would have been followed and the medications would have been stored accordingly.

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

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

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.






 Plan of Correction - To be completed: 04/09/2019

0761
Drugs and biologicals were dated or discarded as necessary.

All medication areas were checked for unlabeled, expired, or improperly stored items.

Unlabeled/ expired items were disposed of properly.

Medications have been audited for dating when opened.

Re-education provided to all licensed staff by Director of Nursing or designee regarding policy for labeling and storing of drug and biologicals.

Medication storage area audits will be completed weekly x3 months by Director Nursing or designee.

Audit results will be reported to QAPI for further review and or recommendations

483.60(i)(3) REQUIREMENT Personal Food Policy: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.
483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.
Observations:


Based on policy review, observations, and interviews it was determined that the facility failed to implement a policy for the use and storage of foods brought to residents by family/visitors to ensure safe and sanitary storage, and consumption in one of one lounge refrigerator observed (A/B lounge).

Findings include:

Review of the facility Policy for Food Brought By Family/Visitors, reviewed Jan 8, 2018, revealed in 7, "All food items must be labeled with resident's name and date it was brought in and/or opened."

Observation in the A/B station lounge refrigerator on March 5, 2019, at approximately 9:40 AM revealed one container with a red beet egg, one container with one slice of apple pie, one custard cup of parmesan cheese, one container of blueberry cream cheese with a manufacture expiration/use by date of February 11, 2019.

During an interview with FSD 1 on March 5, 2019, at approximately 9:40 AM revealed resident food should be labeled with a resident's name and use buy date, and expired food should be disposed of.

During an interview with the Nursing Home Administrator on March 6, 2019, at approximately 11:25 AM it was revealed that resident's food should be labeled with a name and date, and expired food should be disposed of.

28 Pa Code 211.6(c) Dietary services.





 Plan of Correction - To be completed: 04/09/2019

Food items which were not properly labeled and dated were immediately discarded from all refrigerators.

Re-education will be completed regarding labeling and dating of food for all Nursing staff.

The Director of Food Services or designee will provide re-education regarding labeling and dating of food to all Food Service staff.

Education will be provided to families and residents upon admission as well as at Family Council Meetings. Labels and pens/markers will be available for use in the nourishment rooms for anyone that is bringing in food or opening a new container of food/drink.

The Dietician or designee will conduct an audit of the labeling and dating of refrigerated item, Daily/1 week, then 3X wk/month, then 1x wk/month, then monthly for 3months.

The Director of Nursing or designee will complete audits daily in the Nursing department refrigerators.

Report to QAPI for further review and or recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to medication administration for one of four residents observed during medication administration (Resident 66).

Findings Include:

Observation on march 5, 2019, at 9:03 AM, Licensed Practical Nurse (LPN) 2 was observed administering medications. LPN 2 removed the medications from the drawer and 3 pills fell out of the medication pouch and onto the top of the medication cart. LPN 2 then picked up the pills with her ungloved hands and put them into a medication cup. She emptied the remaining medications into the medication cup and administered them to Resident 66.

During an interview with the Director of Nursing on March 7, 2019, at 11:29 a.m. she stated that the LPN should have replaced the pills instead of picking them up off the cart.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.




 Plan of Correction - To be completed: 04/09/2019

There were no adverse outcomes for Resident 66.

There were no other incidents noted.
Re-education regarding medication administration and information was provided to the staff member.

Re-education will be provided to all licensed staff at the April Nursing staff meeting regarding medication administration and infection control.

The Infection Preventionist or designee will audit 2 medication administrations per hall and infection control technique weekly x3 months.

Results of the audits will be reported to the QAPI Committee for further review and or recommendations.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:


Based on clinical record review and interview it was determined that the facility failed to obtain past history of vaccine, and failed to document refusal date of the influenza or document the reason why the resident refused both the influenza and pneumonia vaccines for one of five residents reviewed (Resident 26).

Findings include:

Review of Resident 26's clinical record revealed diagnoses that included muscle weakness (a lack of muscle strength), essential hypertension (high blood pressure that doesn't have a known secondary cause), low back pain and bone cancer.

Review of the clinical record revealed consent forms dated May 22, 2018, signed by R 26's spouse to administer both the pneumococcal and the influenza vaccine.

Review of the clinical record revealed that Resident 26 was admitted to the facility on May 22, 2018. There was no documented history of a previous flu or pneumococcal vaccine in the clinical record.

A review of the influenza and pneumococcal administration site in the electronic medical record stated that that both the Prevnar 13 and the Influenza vaccine were refused June 6, 2018.

An additional form without a title was presented that stated the resident refused but the form is not dated and doesn't indicate what was refused.

During an interview with the Director of Nursing on March 7, 2019, she was unable to provide a past history of the Resident 26's immunizations, or any documented attempts to obtain the information, or any documentation of why the resident refused both immunizations and no documentation that the resident was reapproached to administer the vaccines.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.5(h) Clinical records

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(5) Nursing services





 Plan of Correction - To be completed: 04/09/2019

Resident #26 was provided education, informed consent of risks and benefits, and refused the Influenza and Pneumococcal vaccines.

Upon request from DOH, the resident was re-approached and once again refused the Influenza and Pneumococcal vaccines.

Confirmation that current residents and responsible party, if applicable received education upon admission with documentation in the file.

Documentation from the vaccination administration log will be placed in the residents' medical records.

Facility will continue to provide education, informed consent of risks and benefits of the Influenza and Pneumococcal vaccines.

Re-education to be provided to Director of Admissions or designee to confirm that all residents upon admission receive education regarding Influenza and Pneumococcal vaccines. Reeducation given to licensed staff who administer Influenza and Pneumococcal vaccines to document administration and/or refusal in the clinical record.

Facility will continue to honor resident's right to refuse vaccinations and will document in the EHR.

The Director of Nursing or designee will audit five new admissions and vaccination administration logs weekly for 4 weeks and then monthly for 3 months.

Results of audit will be reported to QAPI for further review and or recommendations.



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