Pennsylvania Department of Health
QUINCY RETIREMENT COMMUNITY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

QUINCY RETIREMENT COMMUNITY
Inspection Results For:

There are 92 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.


QUINCY RETIREMENT COMMUNITY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights survey completed on March 7, 2024, it was determined that Quincy Retirement Community 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:

483.20(g) REQUIREMENT Accuracy of Assessments:

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.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Plan of Correction - To be completed: 04/02/2024

Resident #8, #19, #49, #56, #76 MDS were
modified and corrected during
the survey.

Current resident MDS's were audited
for coding accuracy for hypoglycemics, wounds and infections.
If an error was found, the MDS was modified
and corrected.

Education was provided to
the RNAC staff relating to coding
infections, wounds and hypoglycemics accurately
on the MDS

Random audit of 3 resident
MDS's receiving hypoglycemics, wounds
and/or infections will be audited
for four weeks then monthly
for two months to assure accuracy
of the MDS. Results of audits will
be reported to the Quality
Assurance Process improvement
Committee

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§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 staff interviews, facility policy review, and review of facility legionella guidelines, it was determined the facility failed to implement a Water Management Program for the prevention, detection, and control of water-borne contaminants, such as Legionella (a bacteria that may cause Legionnaires' Disease (a serious type of pneumonia)); and failed to maintain accurate infection control data.

Findings include:

A review of the facility policy, titled "Anticipated Increase in Legionellosis Cases Due to Seasonality", dated June 12, 2023, failed to address any baseline or annual testing in the facility for water-borne contaminants, such as Legionella.

A review of the facility policy, titled "Surveillance for Health-Care Associated Infections (HAI)", last reviewed February 22, 2024, stated, "The purpose of the surveillance of infections is to identify both individual cases and trends in the transmission of epidemiologically significant organisms and Healthcare-Associated Infections, to permit interventions to try to slow or stop the transmission of such infections."

A review of the facility guidelines (toolkit developed by CDC-Centers for Disease Control), titled "Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings", determined the need for a water management program based on risk analysis. The facility risks, based on analysis, included being a healthcare facility where residents stay overnight and have acute or chronic problems and weakened immune systems; Residents are primarily older than 65 years; and the building has multiple rooms (housing units) with a centralized hot water system.

During an interview with the Nursing Home Administrator (NHA) on March 6, 2024, at 11:00 AM, the NHA was unable to show evidence of routine environmental sample results of Legionella testing. The NHA added that the facility was having difficulty finding a local service provider to perform Legionella testing.

A review of the facility infection control (IC) monthly log (data that should minimally include a resident identifier, room location, confirmed type and area of infection, treatment), dated January 2024, revealed 26 residents were listed as suspected for an infection and 8 are listed as confirmed, but the IC logs were not updated for the 26 residents to show confirmation of an infection with microbiology (laboratory/x-ray reports that confirm infection, type of bacteria, and recommended antibiotic), or that the infection was ruled out.

A look back at previous months of IC data revealed the same as above.

Further review of the January 2024 infection control (IC) data log revealed Resident 56 was documented as being admitted January 31, 2024. Resident 56 was actually admitted May 11, 2022. Resident 56's infection was listed as suspected, but was actually confirmed with microbiology reports for both infections in the blood and urinary tract. The organism (type of bacteria or treatment) was never documented on the IC log.

During an interview with the Infection Control Preventionist (ICP) on March 7, 2024, the ICP stated that the system marks all residents as suspected and only those residents who are reported to the state reporting system are marked as confirmed; therefore, the logs do not reveal all of the confirmed infections and accuracy for tracking infections.

During an interview with the Nursing Home Administrator (NHA) on March 7, 2024, at approximately 11:30 AM, the NHA agreed that IC data should be accurate.

28 Pa. Code 201.18(b)(1)(3) Management

Plan of Correction - To be completed: 04/02/2024

Resident 56 had correction to infection log to reflect correct type of infection. No ill effects from not testing for Legionella. Current residents with infection have been audited to ensure that an accurate infection tracking UDA is present and completed to include any organism/x-ray results. Current licensed staff will be educated on requirements of F 0880 with attention to Defining Infections in the Elderly. Current team involved with Water testing will be educated. Baseline Legionella testing completed. The DON/designee will complete an audit of 3 random residents with infection /antibiotic ordered weekly for 4 weeks, then 3 random residents monthly for 2 months to ensure accurate infection documentation. Results of audits and trends from these audits will be submitted and reviewed in the quarterly QAPI committee.

483.25 REQUIREMENT Quality of Care:

§ 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 facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 18 residents reviewed (Resident 19).

Findings include:

Review of facility policy, titled "Wound Care", with a last approved date of December 12, 2023, revealed, in part: "Care of wounds is provided in accordance with current research and practice guidelines in order to facilitate healing and/or provide comfort and symptom control as appropriate."

Review of Resident 19's clinical record revealed diagnoses that included diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high), ischemic cardiomyopathy (the decreased ability of the heart to pump blood properly due to heart damage caused by blockages of blood vessels supplying the area), and polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body).

Observation of Resident 19 on March 4, 2024, at 1:38 PM, revealed the presence of dressings to their bilateral (both) lower legs.

Review of Resident 19's physician orders revealed the following orders: cleanse open areas to lower legs, cover with Xeroform (a non-adherent type dressing), ABD (absorbent type dressing), and kling (a gauze type wrap) then apply ACE wraps (elastic type wrap), change every three days and as needed for soiling/lifting, dated January 22, 2024; and an order to cleanse open areas to lower legs, cover with Xeroform, ABD, and kling then apply ACE wraps change every three days and as needed for soiling/lifting, dated November 29, 2023.

Review of Resident 19's clinical record under section titled "Skin Condition", revealed it did not include any identified areas to their legs.

Review of Resident 19's clinical record nurses notes from November 29, 2023, through March 5, 2024, at approximately 9:30 AM, revealed that there were various notes indicating that their dressings were intact or changed, but the notes failed to include any description of Resident 19's actual skin appearance.

Review of Resident 19's physician progress note dated February 8, 2024, revealed that it did not include any assessment or documentation of Resident 19's skin condition on their bilateral lower extremities.

Review of Resident 19's care plan revealed a problem for a chronic skin condition of dry skin that flakes off and exposes wounds, dated February 19, 2024, with no identified goal, and one intervention to apply treatment to legs as ordered, dated February 19, 2024.

During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Assistant Director of Nursing (ADON) on March 6, 2024, at 11:55 AM, the aforementioned concerns were shared for further follow-up and additional information was requested.

During an interview with the ADON on March 6, 2024, at 2:02 PM, she indicated that she does not follow Resident 19 on her weekly wound rounds. She said that the nurses assigned to Resident 19 complete the dressing changes. Again, the concern was shared that there was no documentation of an assessment or evaluation of the condition or appearance of Resident 19's legs to identify if or what was present on their legs. ADON then indicated that the physician would be in tomorrow and could take a look at them to see what they are. It was, again, shared that there was no documentation of any assessment of Resident 19's skin condition to their bilateral lower legs from November 2023, through present.

Email communication received from NHA on March 6, 2024, at 4:01 PM, included a copy of a progress note dated March 6, 2024, that indicated it was a late entry from March 4, 2024.

This progress note indicated that Resident 19's treatment was provided to their bilateral lower legs. In addition, the note indicated that Resident 19's bilateral lower legs remained reddened with multiple scattered open areas from the top of right foot to their mid lower right thigh, and left leg from mid shin to upper knee; both with scattered open areas draining small serosanguinous (thin, slightly yellow fluid with a pink tinge) drainage.

During an interview with the NHA and ADON on March 7, 2024, at 12:08 PM, the ADON indicated that they do not do skin sheets for chronic skin conditions. The concern was shared that the March 6, 2024, nurse's note indicated multiple scattered open areas with no measurements. She indicated that Resident 19 has a chronic skin condition in which skin flakes off and creates open areas, some of which could be very small in nature. She confirmed that there was no documentation of the size of the identified multiple open areas, and that she would expect staff to document a full evaluation or an assessment of these areas in their notes with dressing changes so that the effectiveness of the treatments could be determined and appropriate follow-up completed.

As of March 7, 2024, at 1:15 PM, the facility had provided no other additional information.

28 Pa. Code 201.18(b)(1) Management
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: 04/02/2024

Resident 19 has consult with wound clinic for evaluation of chronic skin condition.
2. Current residents with chronic skin conditions have been reviewed for accurate documentation of skin conditions
3. Nursing staff have been re-educated on requirements of F684 with attention to wound documentation.
4. The DON/designee will complete an audit of 3 residents with chronic skin conditions for wound documentation weekly for 4 weeks, then 3 residents monthly for 2 months to ensure accurate skin condition documentation. Results of audits and trends from these audits will be submitted and reviewed in the quarterly QAPI committee.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

§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 facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for three of 21 residents reviewed (Residents 8, 19, and 56).

Findings include:

Review of facility policy, titled "Care Planning", with a last review date of December 7, 2023, revealed, in part: "Presbyterian Senior Living will comprehensively evaluate and re-evaluate a resident's need for service and develop a plan to promote their highest practicable level of functioning as set forth by our Mission Statement as well as State and Federal guidelines... 10. The care plan will be updated electronically as needed; and 11. The care plan will be reviewed and evaluated for intervention effectiveness no less than quarterly."

Review of Resident 8's clinical record revealed diagnoses that included chronic kidney disease (CKD - longstanding disease of the kidneys leading to renal failure) and diabetes mellitus type II (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin).

Review of Resident 8's care plan revealed a care plan problem for a pressure ulcer related to a deep tissue injury to the left heel, dated February 5, 2024.

Further review of Resident 8's clinical record revealed that their pressure ulcer was resolved on February 20, 2024.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on March 6, 2024, at 11:50 AM, the above care plan concern was shared for further follow-up.

An email communication received from the NHA on March 6, 2024, at 2:01 PM, confirmed that the care plan should have been revised when the pressure ulcer resolved.

Review of Resident 19's clinical record revealed diagnoses that included ischemic cardiomyopathy (the decreased ability of the heart to pump blood properly due to heart damage caused by blockages of blood vessels supplying the area) and the presence of an automatic (implantable) cardiac defibrillator (pacemaker).

Review of Resident 19's physician orders revealed an order to completed a pacemaker device remote check, dated September 19, 2023.

Review of Resident 19's care plan failed to reveal any documentation of the presence of the defibrillator/pacemaker, the intervention of testing, or any safety measures needed.

During an interview with the NHA on March 7, 2024, at 9:30 AM, the above concern was shared for further follow-up.

During a follow-up interview with the NHA and Employee 2 (Registered Nurse Assessment Coordinator [RNAC]) on March 7, 2024, at 12:04 PM, Employee 2 confirmed that the pacemaker was not care planned and the care plan had been revised. The NHA confirmed that she would expect care plans to be comprehensive.

Review of Resident 56's clinical record on March 5, 2024, at 2:00 PM, revealed diagnoses that included obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract, causing urine to back up into the kidney) and bacteremia (bacteria in the bloodstream).

Further review of Resident 56's clinical record revealed Resident 56 was hospitalized January 27, 2024, until January 31, 2024, for bacteremia due to complicated urinary tract infection (UTI).

Review of Resident 56's hospital discharge summary revealed urine culture results dated January 29, 2024, showing Resident 56's urine was positive for multidrug resistant Enterobacter cloacae complex (MDRO [multi-drug resistant organism] - a type of bacterium associated with healthcare-related infections).

Review of Resident 56's comprehensive plan of care revealed the facility failed to update the comprehensive care plan to include the new identification and diagnosis of an MRDO in the urine.

During a staff interview March 7, 2024, at 12:02 PM, with the NHA and Employee 2, Employee 2 revealed Resident 56's care plan had been reviewed and updated.

Email communication March 7, 2024, at 12:28 PM, with the NHA revealed it is the facility's expectation that the care plan would have been updated timely.

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

Plan of Correction - To be completed: 04/02/2024

Resident 8's care plan was updated during the survey And pressure ulcer care plan was resolved. Resident 19's
Care plan was updated during the survey to include Pacemaker presence and the testing or any safety measures
Needed. Resident #56 care plan was updated during The survey to include MRDO in the urine. An audit of current resident's care plans will be
reviewed for appropriate care plans in place for Pacemakers, wounds and MRDO will be Reviewed to assure accurate care plans. Education to licensed nursing staff and RNAC staff Related to updating Care plans for changes in wounds, pacemakers And MRDO. Random audit of 3 resident care plans with wounds, pacemakers And MRDO will be completed weekly for four weeks then monthly
For two months to assure care plan revisions have Been updated as appropriate. Results of audit will be
Reported to the Quality Assurance Process Improvement Committee.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary:

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(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.

Plan of Correction - To be completed: 04/02/2024

1. Residents #83 & #85 discharged. No ill effects noted. Request for Nurse Practitioner to correct discharge Summary including inaccurate diagnosis.
2. Discharge Summaries of last 10 days reviewed for recapitulation of resident stay.
3. Physician and NP will be educated on regulatory documentation.
4. Random audit by DON or designee of three residents discharge summaries weekly for 4 weeks. Audited for recapitulation of resident stay. Continued Audited for four weeks then monthly for two months. The results of these will be reviewed during Quality Assurance process.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:

§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services for urinary catheters consistent with the resident's comprehensive plan of care for one of six residents reviewed for urinary catheters (Resident 63).

Findings include:

Review of Resident 63's clinical record on March 4, 2024, at approximately 1:00 PM, revealed diagnoses that included chronic kidney disease (CKD - decreased ability of the kidneys to filter toxin from the blood and produce urine) and osteomyelitis (infection of the bone) with sepsis (life threatening condition that results in dysfunction of the immune system entering the blood stream and causing inflammation in organs through out the body).

Review of Resident 63's clinical record revealed Resident 63 utilized a urostomy (surgical opening to the bladder through the skin) with a catheter for urine elimination.

Review of Resident 63's comprehensive plan of care revealed that Resident 63 had a care plan with the identified problem of, "[Resident 63] has an ostomy to divert urine [related to] urostomy."

Review of the goal of care plan revealed the goal was, "[Resident 63] will have urinary diversion managed appropriately: drainage appropriate amount, type, color, odor, stoma correct size, pink free of breakdown and infection, surrounding skin free of breakdown, rash and infection."

Review of the care plan interventions revealed one of the interventions for nursing staff were to, "Check/record drainage (amount, type, color, odor). Observe for leakage."

Review of Resident 63's clinical record revealed that staff were not recording the characteristics (amount, type, color, odor) of the urine drained from the urostomy bag.

During a staff interview on March 7, 2024, at approximately 11:15 AM, Nursing Home Administrator confirmed that staff were not recording Resident urine characteristics and added that there was no physician order to do so.

28 Pa code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 04/02/2024

Resident # 63 was discharged on 3/12/24, had no ill effects due to missing documentation. All current residents with an indwelling catheter care plans have been reviewed and updated per physician order. Current licensed staff will be educated on selection of care plan interventions to match physician orders. Random audit of three residents with indwelling catheter will be audited for four weeks then monthly for two months to ensure documentation of abnormalities. Results of these audits will be forwarded to QAPI for review.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents were free of unnecessary psychotropic medications for one of six residents reviewed for unnecessary medications (Resident 61).

Findings include:

Review of facility policy, titled "Management of Behavioral or Psychological Symptoms of Dementia-BPSD with or without Antipsychotic", with a last approved date of December 22, 2023, revealed the following, in part: "The FDA [Food and Drug Administration] Black Box Warning Regarding Atypical & Conventional Antipsychotic in Dementia states, 'Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo; Residents/families/representatives should be involved in discussions about potential approaches to address behaviors and about the potential risks and benefits of a psychopharmacological medication (e.g., FDA black box warnings), the proposed course of treatment, expected duration of use of the medication, use of individualized approaches, plans to evaluate the effects of the treatment, and pertinent alternatives. The discussion should be documented in the resident's record; and D. Monitoring of behaviors/antipsychotic use through community At Risk committee at least annually with IDT to include pharmacist reviews of medication use. 1. Include gradual dose reduction attempts and results.'"

Review of facility policy, titled "Medication Orders: IB3: Stop Orders", with a last review date of December 7, 2023, indicated, in part: "A. The following medications, whether the order is for routine or as needed (PRN) use, are stopped automatically after the indicated number of days, unless the prescriber specifies a different number of doses or duration of therapy to be given. 7) PRN psychotropic medication orders - 14 days."

Review of Resident 61's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning); anxiety (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in daily activities).

Review of Resident 61's current physician orders on March 6, 2024, at approximately 10:15 AM, revealed an order for haloperidol (an antipsychotic medication), give 1 milligram as needed every 12 hours for behaviors, dated February 8, 2024, with no stop date indicated.

During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON), on March 6, 2024, at 11:48 AM, the concern was shared that an antipsychotic medication was ordered PRN with no 14-day stop date implemented or documentation as to why the order was extended beyond 14 days. Additional information was requested.

Email communication received from the DON on March 6, 2024, at 12:53 PM, indicated that Resident 61's routine Haldol was discontinued on February 8, 2024. The DON further indicated that Resident 61 had a history of significant behaviors, but that the facility staff and Resident 61's hospice provider felt that the routine dose could be discontinued and the PRN Haldol could be added in case it was needed to support hospice philosophy for end of life comfort. She further indicated that the PRN Haldol was used only once in February 2024 since the time the routine dose was discontinued.

Review of Resident 61's February 2024 Medication Administration Record revealed that they received a PRN dose of the Haldol on February 27, 2024, at 8:42 PM; a total of 20 days after the order was originally written.

Review of Resident 61's physician's progress note dated February 12, 2024, failed to include any documentation of Resident 61 being on Haldol or a rationale for continuing the PRN Haldol past the 14 day threshold.

Email communication received from DON on March 6, 2024, at 1:19 PM, indicated that she would get the physician to put it in their progress note.

Follow-up email communication sent to the DON on March 6, 2024, at 1:34 PM, reiterated the concern that this had not occurred at the time the medication was originally ordered, or at the 14-day point.

Review of Resident 61's March 2024 Medication Administration Record on March 6, 2024, at 1:40 PM, revealed that they have not received any PRN doses of the Haldol thus far in March.

Email communication was sent to the NHA on March 6, 2024, at 5:00 PM, requesting a copy of Resident 61's consent for the use of the antipsychotic medication (Haldol) or information to indicate that the resident's responsible party was educated on the risks versus benefits of the medication and their Abnormal Involuntary Movement Scale (a rating scale designed to measure involuntary movements known as tardive dyskinesia that can occur with the use of antipsychotic medications) screening results.

During an interview with the NHA on March 7, 2023, at 9:19 AM, she indicated that they did not have any other documentation to provide. She said that there were no AIMS screenings completed and that there was no consent or documentation of risk versus benefit education with Resident 61's responsible party for the use of the Haldol at any point. She further indicated that they have processes in place for these to occur, but that they were missed for Resident 61, possibly because they were on hospice.

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

Plan of Correction - To be completed: 04/02/2024

1. Resident 61 AIMS assessment was completed on 3/7/24, antipsychotic consent form was completed 3/9/24 and the order to d/c prn Haldol was completed 3/10/24
2. Current PRN antipsychotics will be audited for a 14day stop date. Audit will also include if an AIMS assessment is current and presence of antipsychotic consent forms.
3. All licensed staff and prescribing providers will be educated on the policy for prn antipsychotic medications including the completion of AIMs at initiation and then quarterly, the antipsychotic consent form completed prior to initiation of the antipsychotic and the 14day stop for all PRN antipsychotic.
4. Audits for PRN antipsychotics will be audited for a 14day stop date. Audit will also include if an AIMS assessment is current and presence of antipsychotic consent forms will continue weekly for 4 weeks, monthly for 2 months. Audits and findings will be submitted in the Quarterly QAPI committee meetings

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview, state regulation review, and review of the facility's Infection Control Meeting attendance record, the facility failed to ensure that one of the required nine multidisciplinary members were present at the Infection Control meetings (maintenance personnel).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the Medical Care Availability and Reduction of Error (Mcare) Act, Chapter 4, Section 403(1) Infection Control plan stated, "A health care facility... shall develop and implement an internal infection control plan that shall include...a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members include Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, a community member, laboratory personnel, pharmacy staff, and infection control team members.

Review of the facility's Infection Control Committee Attendee signature page for January 2024, July 2023, and October 2023, failed to reveal that a maintenance personnel was in attendance.

During an interview with the Nursing Home Administrator (NHA) on March 6, 2024, at approximately 11:30 AM, the NHA confirmed that maintenance personnel never attended the Infection Control Meetings.

Plan of Correction - To be completed: 04/02/2024

No affect on residents regarding attendance of meetings. Assure proper attendees are on the invites for upcoming meetings. Necessary Environmental Services attendees educated on need for attendance.
Audit of attendees at meetings completed. The results of these will be reviewed during Quality Assurance process.

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