Nursing Investigation Results -

Pennsylvania Department of Health
WILLOWS OF PRESBYTERIAN SENIORCARE
Patient Care Inspection Results

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WILLOWS OF PRESBYTERIAN SENIORCARE
Inspection Results For:

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WILLOWS OF PRESBYTERIAN SENIORCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated survey in response to three complaints completed on January 24, 2019, it was determined that Willows Of Presbyterian Seniorcare 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 for the Health portion of the survey process.



 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 facility policy, observation and staff interview, it was determined the facility failed to make certain food was prepared in a sanitary manner in the main kitchen.

Findings include:

Review of the facility "Dietary Sanitation" policy last reviewed on June 2018, indicated that bare hand contact with food is prohibited. If gloves are contaminated they must be changed between tasks.

During an observation of the main kitchen, Dietary Aide Employee E4 and Dietary Cook Employee E5 were placing lettuce on plates and serving pans with gloved hands after touching the outer surfaces of the lettuce bags with same gloved hands creating the potential for cross contamination.

During an interview on 1/24/19, at 10:00 a.m. the above observations wee reviewed with the Nursing Home Administrator.


28 Pa. Code: 211.6(c)(d)(f) Dietary services.


 Plan of Correction - To be completed: 03/04/2019

The salad was discarded after this was brought to the facility's attention. Bagged food items that need to be portioned will be handled without direct contact with gloved hands that opened the bag. Food contents will be poured into a sanitized container, hands will be washed and regloved, then food will be portioned with gloved hand or tongs. Dining services staff will be in-serviced on this procedure by the dining services director or designee. Observations to audit compliance will be conducted daily for two weeks then five times per week for two weeks. The results of these audits will be reviewed with the QAPI committee.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 the facility policies and clinical records, observations and resident family and staff interviews, it was determined that the facility failed to implement infection control measures to prevent the potential spread of infection on four of four nursing units (First, Second, Third and Fourth Floor nursing units), failed to have an effective infection control plan in place for one of two residents with suspected Norovirus (Resident R1) and failed to store clean linen properly on one of four nursing units (Second floor).

Findings include:

Review of the facility "Nursing-Isolation categories" policy last reviewed on June 2018, indicated that Transmission Based Precautions will be used when caring for residents who are documentated or suspected to have a communicable disease that can be transmitted to others.

During an interview on 1/24/19, at 8:10 a.m. Assistant Director of Nursing Employee E1 stated that there were two residents currently in precautions for the Norovirus. Other residents in isolation were for other reasons.

Review of the facility "Norovirus - Prevention/Control" policy last reviewed June 2018, indicated that strict infection control practices are implemented. That included residents being placed on Contact Precautions and soap and water are used for hand hygiene after providing care or having contact with suspected or confirmed cases.

Review of the facility "Contact Precautions" policy last reviewed June 2018, indicated that gloves and handwashing would occur, gowns are to be worn upon entering room and cubicle and signs to alert staff of isolation are to be used.

During observations of all nursing units on 1/24/19, from 7:50 a.m. through 10:30 a.m. and from 12:15 p.m. through 1:15 p.m. signs indicating a Norovirus outbreak were on the walls and at all nurses stations.

The linen cart in the 2300 hall was uncovered.

Resident R1 and Resident R6 were identified as the two residents currently with the Norovirus on the First floor.

During an observation on 1/24/19, at 8:00 a.m. there was no signage or isolation equipment at the entrance of Resident R1's room

During an observation on 1/24/19, at 8;00 a.m. there was no signage or gowns on the equipment cart at the entrance of Resident R6's room

During observation of the second floor nursing unit on 1/24/19, from 7:45 a.m. through 8:05 a.m. the following occurred:

Resident R10 was in isolation for Clostridium Difficile (a bacterial infection from overuse of antibiotics causing diarrhea and abdominal pain). There was no signage to alert staff and visitors of the infection.

Resident R9, who was not listed as needing isolation. had isolation signage at the door indicating isolation was required but had no isolation equipment.

During an observation of the first floor nursing unit on 1/24/19, from 8:17 a.m. through 8:45 a.m. the following occurred:

During an observation on 1/24/19, at 8:22 a.m. Nurse Aide (NA) Employee E2 entered room 1319 with a food tray, assisted the resident into chair, came out of the room and went to food cart and took a food tray to the resident in room 1326 without washing their hands between tray service or touching the resident in room 1319.

During an observation on 1/24/19, at 8:25 a.m. an opened container of orange juice was sitting on a stand between two chairs in hall and an unused incontinence pad was sitting on top of two novels under the table between the two chairs.

Interview with a private duty resident caregiver on the third floor on 1/24/19, at 8:45 a.m. indicated that she has had to return plates and silverware to the kitchen due to food particles still being present.

During an observation of the fourth floor nursing unit on 1/24/19, at 9:05 a.m. NA Employee E3 was observed assisting the resident in room 4415 with gathering soiled linens and clothing. NA Employee E3 then took the residents bowl of food and heated at the country kitchen area, went back into the resident room, made the residents bed, left the room and went into resident room 4412 and asked resident if she was ready to get cleaned up. NA Employee E3 did not perform hand washing between any of these tasks.

28 Pa. Code:201.14(a) Responsibility of licensee.

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

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

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

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.






 Plan of Correction - To be completed: 03/04/2019

The certified nursing assistant was immediately in-serviced on proper hand hygiene procedures.
There was an immediate audit done for all residents requiring isolation. For those residents, the proper signage/equipment was displayed and/or removed.
Environmental rounds were done to ensure items in common areas are meeting the community's standards i.e. briefs and other items removed from common area, linen carts covered.
The DON or designee will provide education to the nurse aides and nursing team on the community's policy and/or practice for the timing and technique for hand hygiene, environmental standards, including no briefs in common areas and linen carts covered, as well as proper isolation equipment and signage.
Dishes and silverware will be audited by dining services director or designee before being transported to the neighborhood for distribution daily for two weeks. Spot checks will be done daily as a practice daily thereafter to ensure ongoing compliance.
The Director of Nursing or designee will complete random audits of personnel and the timing and technique of hand hygiene procedure. These audits will occur 5 days per week for 6 weeks.
The Director of Nursing or designee will audit all residents needing isolation for proper isolation signage/equipment 5 days per week for 6 weeks.
The Director of Nursing or designee will perform an environmental round 5 times per week for 6 weeks to audit for environmental hygienic standard, to include no briefs in common areas, linen carts covered.
This plan of correction will be monitored by the QAPI committee until such time consistent substantial compliance has been met.
483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:
Based on review of facility policy and clinical record and staff interview, it was determined that the facility failed to provide medications as ordered by the physician for seven of nine residents (Resident R1, R2, R3, R4, R6, R7 and R9).

Findings include:

Review of the facility "Medication Administration" policy last reviewed June 2018, indicated that the facility shall maintain a medication administration record of all medications administered. Documents must include reason why a medication was not administered or refused.

During a review of Resident R1's Medication Administration Record (MAR) dated November 2018, indicated:

Ampyra ER 10mg (milligram) (given for Multiple Sclerosis) every 12 hours was not documented as given on 11/28/18 at at 12:00 p.m. or at 10:30 p.m and on 11/29/18, at 12:00 p.m. dose due to pharmacy not delivering. The family had to supply the medication after it was not delivered by the pharmacy.

Atorvastatin 20 mg, 2 tabs (given for high cholesterol) at bedtime was not given on 11/27/18 at bedtime without a documented reason.

Methanamine 1 Gm (given as antibiotic for urinary tract infection) every 12 hours was not given on 11/27/18 at 10:30 p.m. without a documented reason

Myrbetriq 50mg (given for an overactive bladder) at bedtime was not given on 11/27/18, at 10:30 p.m. without a documented reason.

During a review of Resident R2's MAR dated December 2018, and January 2019, indicated:

Donepezil 10 mg (given for dementia) at bedtime was not given on 12/6/18, or 12/7/18, as they were awaiting delivery from the pharmacy.

Rosuvastatin 5mg (given for high cholesterol) at bedtime was not given on 12/6/18, without a documented reason.

Lidocaine patch (used for arthritic pain) applied topically daily to lower back was not given on 1/12/19, and 1/14/19 as they were awaiting delivery from the pharmacy.

During a review of Resident R3's MAR dated 12/18, indicated:

Keflex 500mg (Antibiotic given for Urinary Tract Infection) every 12 hours for 5 days was not given on 12/20, 12/21, or 12/22, evening dose as they were awaiting delivery from the pharmacy.

During a review of Resident R4's MAR dated 1/19, indicated:

Toujeo Insulin 31 units (given for Diabetes) injection at bedtime was not given on 1/23/19, with no documented reason.

Singulair 10mg (given for asthma)at bedtime was not given on 1/23/19, with no documented reason.

Mucinex 600 mg (given for COPD) every 12 hours was not given evening dose with no documented reason.

Sertraline 50 mg (given for depression) twice a day was not given evening dose with no documented reason.

During a review of Resident R6's MAR dated 12/18, indicated:

Atorvastatin 10mg (high cholesterol) at bedtime was not given on 12/7, reason indicated as they were awaiting delivery from the pharmacy.

During a review of Resident R7's MAR dated 1/19, indicated:

Atorvastatin 80 mg (given for high cholesterol) at bedtime was not given on 1/17/19, with no documented reason.

Aricept 5mg (given for dementia) at bedtime was not given on 1/17/19, with no documented reason.

Mirtazapine 45mg(given for depression) at bedtime was not given on 1/17/19, with no documented reason.

During a review of Resident R9's MAR dated 12/18, indicated:

On 12/16/18, Lantaprost eye drops (given for glaucoma) one drop right eye at bedtime was not given with reason of unable to find in medication cart. On 12/14/18, documented as not given with no documented reason.

During an interview on 1/24/19, at 2:40 p.m. Nursing Home Administrator was made aware that Residents R1, R2, R3, R4, R6, R7 and R9 did not receive the medications as ordered by the physician.

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 211.9(a)(1)(k)(l)(1)(2)(3)(4) Pharmacy services.

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


 Plan of Correction - To be completed: 03/04/2019

This Plan of Correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. The medical records of all affected residents were reviewed to check for adverse effects. There were no untoward consequences from the missed medications.
The community will begin to utilize a dropship delivery from a retail pharmacy for medication orders received after hours and late admissions. Expected turnaround time for this service is approximately 4 hours. This practice will be used in conjunction with our medication vending machine (Cubex). The medication policy has been reviewed and process has been updated to reflect the current practice. The Director of Nursing inserviced the Willows nurses on the following: the dropship delivery process, shared a list of the drugs that are available from the Cubex machine, and reeducated the nursing staff on the appropriate way to follow up on missed medications.
Neighborhood managers and shift supervisors will audit the missed medication report every shift for 6 weeks and will follow up on any missed medications.
Audit results will be reviewed by the QAPI committee until such time consistent substantial compliance has been achieved as determined by the committee.


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