Nursing Investigation Results -

Pennsylvania Department of Health
QUADRANGLE, THE
Patient Care Inspection Results

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QUADRANGLE, THE
Inspection Results For:

There are  49 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.
QUADRANGLE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey and State Licensure Survey, completed on June 7, 2019, it was determined that The Quadrangle, was not in compliance with 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 related to the health portion of the survey process.




 Plan of Correction:


483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on interviews with resident representatives, interviews with staff, and clinical record review, it was determined that the facility failed to implement restorative nursing services for one of 27 residents reviewed (Resident R24).

Findings include:

Interview on June 4, 2019, at 4:10 p.m., Resident R24's Representative revealed that the resident has had two falls recently and stated that Resident R24 does not receive restorative nursing services that would help her maintain her strength or prevent falls.

Clinical record review for Resident R24 revealed a Physical Therapy Discharge summary, dated March 11, 2019, which revealed "An updated restorative nursing program has been provided for AAROM (assisted active range of motion) of BUE/BLE (bilateral upper extremities/bilateral lower extremities) in order to maintain her current functional abilities, to maintain quality of life, and to reduce the risk of falling."

Continued clinical record review for Resident R24 revealed a Monthly Evaluation, dated March 20, 2019, which indicated that the resident was not on a restorative program.

Continued clinical record review for Resident R24 revealed another Monthly Evaluation, dated April 19, 2019, which indicated that the resident was not on a restorative program.

Review of Resident R24's quarterly MDS assessment (Minimum Data Set - a mandatory periodic resident assessment tool), dated April 18, 2019, revealed that the resident did not receive any physical, occupational or speech therapies within the previous seven days nor any restorative nursing programs within the previous seven days of the assessment.

Further clinical record review for Resident R24 revealed another Monthly Evaluation, dated May 19, 2019, which indicated that the resident had two falls, one while walking on May 10, 2019, and another where she slid out of her wheelchair on May 12, 2019. The May 2019 Monthly Evaluation also revealed that Resident R24 was not on a restorative program.

Review of Resident R24's care plan, dated last reviewed April 29, 2019, revealed that there was no indication or instructions for the restorative program as recommended by Physical Therapy.

Review of Resident R24's nurse aide Kardex revealed that there was no indication or instructions for the restorative program as recommended by Physical Therapy.

Continued record review revealed that there was no documentation available in the record to indicate if a restorative program was being performed, how often it was being done, the resident's tolerance and progress, and if the resident maintained, improved or declined in her range of motion.

Interview on June 6, 2019, at 1:30 p.m., the Director of Nursing confirmed that there was no documentation available to indicate if Resident R24 received restorative nursing services.

The facility failed to implement restorative nursing services.

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/9/17

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



 Plan of Correction - To be completed: 07/17/2019

Resident R24 will be re-screened by therapy for upper and lower range of motion to be completed by 6/21/19.

The resident will receive functional nursing restorative services based on results of the screen beginning 7/1/19.

Long stay residents will be screened for restorative program participation by the Therapy team to be completed by 6/21/19.

A Functional Nursing Restorative Program will be initiated for individual residents, as appropriate, in accordance with screening outcomes, beginning 7/1/19
Individual resident functional nursing restorative programs will be reviewed/audited by Therapy and the DNS /designee weekly for 3 weeks and monthly thereafter for 2 months to confirm efficacy and appropriateness.

The outcome of the reviews/audits will be documented in Monthly Evaluations by the ADNS/designee.

In addition, quarterly screens will be reviewed/audited by the ADNs or designee to confirm that the functional status of the resident was captured and active therapy or functional restorative activity was initiated if indicated.

In order to confirm that the processes outlined above are sustained: The Director of Nursing or designee and Therapy Director will report the audit findings to the QAPI committee for 3 months.

During and at the conclusion of each month, the QAPI committee will re-evaluate and initiate necessary action or extend the review period.

The Executive Director/Skilled Nursing Administrator is responsible for confirming the implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.






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


Based on observation, staff interviews and review of clinical records, it was determined that the facility failed to monitor the peripherally inserted central catheter (PICC) for two out of two residents reviewed with a peripherally inserted central catheter. (Resident R30 and R159).

Findings include:

A review of Resident R30's clinical record revealed that the resident was admitted to the facility on April 25, 2019, with a diagnosis of Charcot's joint (refers to progressive degeneration of a weight bearing joint), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose) and Osteomyelitis of the right foot (inflammation of the bone caused by infection, generally in the legs, arm, or spine).

Further review of Resident R30's clinical record revealed that the resident was independent in decision making skills and needed assistance to move about the facility in a wheelchair.

A review of physician's orders dated April 25, 2019, revealed an order for Vancomycin (an antibiotic used to treat infections) solution, 750 milligram intravenously, two times a day for osteomyelitis of the right ankle via the PICC line (peripherally inserted central catheter- it is a thin, soft, and long catheter that is inserted into a vein in the arm, leg or neck, the tip of the catheter is positioned in a large vein that carries blood to the heart. The PICC line is used for long term intravenous antibiotic). Further review of the physician's order revealed that the external catheter length will be measured on admission, with each dressing change, and as needed. The upper arm circumference will be measured on admission, with each dressing change, and as needed.

A review of the order form for the insertion of the PICC line revealed that it was inserted on April 25, 2019, and the total length of the PICC line was 36 centimeters and the arm circumference was 47 centimeters.

A review of Resident 30's clinical record revealed no evidence available for review that the external length of the catheter was being measured (measured to confirm that the PICC line is not coming out of the residents arm or that the catheter is moving more inward) and no evidence available for review that the arm circumference was being measured (measured to confirm that there is no swelling).

In an interview with the Director of Nursing on June 5, 2019 at 11: 00 a.m. it was confirmed that the facility was not measuring the PICC line length or the arm circumference.

The facility failed to monitor the PICC line length or arm circumference of one resident with a PICC line.

Resident R 159 was admitted to the facility May 28, 2019 with a right foot infection which required intravenous antibiotics for a six week period. The PICC ( peripherally inserted central catheter) was inserted prior to admission on May 28, 2019. Observations on June 4th and June 5th revealed that the PICC line dressing was dated May 28, 2019.

Review of clinical record revealed that "Central Line Catheter Protocol" stipulates that the PICC line dressing change should be done within 24 hours post catheter insertion and every 5-7 days and PRN for established lines.

Review of physician's orders are as follows: change intravenous dressing; needleless connector (caps)and measure the external catheter length and circumference of arm 3 centimeters above intravenous insertion site every seven days.

Review of the Medication Administration Record for May and June of 2019 revealed that the dressing change and PICC line measurements were not completed until it was brought to the Unit Supervisor's attention on June 5, 2018 at 9:25 AM on the eighth day.

The facility failed to change the intravenous dressing and measure the PICC line length per protocol and physician's order.

28 PA. Code:211.12 (d)(1)(5) Nursing services.



 Plan of Correction - To be completed: 07/17/2019

Resident 30 physician order stated that the external catheter length and that the upper arm circumference will be measured on admission, with each dressing change and as needed.
During the survey (6/5), measurements were completed per order and documented.
Resident was discharged from the facility on 6/13/19.

Resident 159 physician order stated to change the intravenous dressing; needless connector (caps) and measure the external catheter length and circumference of arm above intravenous insertion site every 7 days.
During the survey (6/5), measurements were completed per order and documented.
Resident was discharged from the facility on 6/12/19
Assistant Director of Nursing has completed an audit of residents within the community with a PICC line on 6/10/19.
Measurements, including circumference, have been documented and physician orders confirmed.
Director of Nursing/Assistant Director of Nursing will conduct refresher training regarding Intravenous Therapy and compliance with physician orders with the nurses by 7/12/19
The Director of Nursing/Assistant Director of Nursing will audit residents receiving IVABT via a PICC line weekly for 3 months to confirm compliance with physician orders.
Issues identified will be addressed and resolved and refresher training initiated as needed.

The results of the audits will be submitted and reviewed during monthly QAPI meetings for 3 months.

During and following the 3 months, the QAPI team will re-evaluate and initiate necessary action or extend the review period, as needed based on issues identified or trends observed.

The Skilled Nursing Administrator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.




483.70(o)(1)-(4) REQUIREMENT Hospice Services:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.70(o) Hospice services.
483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in 418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at 483.24.
Observations:

Based on observations, interviews with resident representatives, interviews with staff, clinical record review, review of facility documentation and review of facility policies, it was determined that the facility failed to ensure that adequate communication was maintained between a hospice (end of life care to support resident and family) provider and the facility, for one of 27 records reviewed (Resident R23).

Findings include:

Review of facility policy, "Hospice Services," dated April 25, 2018, revealed that nursing staff are responsible for "Names and contact information for hospice personnel involved in hospice care of each patient ... Review of the resident's record for pertinent documentation regarding the delivery of hospice care."

Review of facility documentation, "Hospice Services Agreement," dated June 18, 2015, revealed that, "Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each hospice patient."

Observation on June 4, 2019, at 1:30 p.m., revealed a hospice aide providing companionship to Resident R23.

Interview on June 4, 2019, at 4:00 p.m., Resident R23's Representative stated that he did not like the way the hospice aide positioned the resident this morning in her chair and indicated that he had to show the hospice aide how to properly position the resident. Resident R23's Representative also stated that he was unsure if the hospice staff communicate with facility staff related to the care and services provided.

Review of Resident R23's care plan, dated initiated April 15, 2019, revealed that the resident will receive hospice services from her preferred hospice provider.

Review of Resident R23's Hospice Plan of Care, dated April 15, 2019, revealed that the resident will receive skilled nursing visits once or twice per week and nurse aide visits five to seven times per week.

Review of Resident R23's hospice documentation that was available in the facility, revealed that there were no nursing notes, no nurse aide notes and no hospice staff schedule available.

Interview on June 6, 2019 at approximately 11:00 a.m., the Nursing Home Administrator confirmed that above documentation was not available and indicated that she would obtain it from the hospice provider.

Continued review of hospice documentation, received by the facility on June 6, 2019, at 12:32 p.m., revealed a nurse's note, dated April 25, 2019, which indicated, "Hospice aide schedule will be faxed to facility and emailed to family each week. White board to be placed in room for facility staff to leave notes and allow patient to know who is caring for her each day."

Observation on June 7, 2019, at 8:51 a.m., revealed that there was no indication on Resident R23's white board in her room of the hospice staff names, schedules or communication notes.

Follow-up interview on June 7, 2019 at approximately 9:00 a.m., the Nursing Home Administrator confirmed that the hospice aide documentation and hospice staff schedules were still not available and indicated that she would obtain them from the hospice provider.

Continued review of hospice documentation, received by the facility on June 7, 2019, at 10:05 a.m., revealed one week of hospice aide documentation from May 26, 2019, through June 1, 2019, and a schedule of hospice aides for June 8, 2019 through June 14, 2019. There was no additional hospice aide documentation or hospice staff schedules available for review.

The facility failed to ensure that adequate communication was maintained between a hospice provider and the facility.

28 Pa. Code 211.5(f) Clinical records
Previously cited 6/9/17

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




 Plan of Correction - To be completed: 07/17/2019

Resident #23 is stable and comfortable at this time and continues to receive Hospice services.


Resident #23 has been included in a Hospice Binder by the Unit Manager.
The Binder contains communication and progress notes between the Hospice Provider and Facility Staff.

Hospice provider binders are located in the nursing station (1st and 2nd floor).
The binders will continue to include: communication notes, and Hospice nurse and nurse aide progress notes.

Hospice providers will be in-serviced on the binders, along with the facility staff, by the Director of Nursing/Assistant Director of Nursing by 7/12/19.

The in-service will include training on documentation, communication between the Hospice Provider and facility staff, and coordination of care plans.

The Skilled Nursing Administrator or designee will audit the Hospice Binders weekly for 3 months to confirm that residents on Hospice have a binder and that communication between the hospice provider and the facility staff and progress notes are documented, accessible, and available; and will confirm Hospice care plans are current.
During and following the 3 months, the QAPI team will re-evaluate and initiate necessary action or extend the review period, as needed based on issues identified or trends observed

The Skilled Nursing Administrator is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur

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