Nursing Investigation Results -

Pennsylvania Department of Health
ROSEMONT CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ROSEMONT CENTER
Inspection Results For:

There are  73 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.
ROSEMONT CENTER - 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, State Licensure and an Abbreviated survey in response to two complaints, completed on May 24, 2019, it was determined that Rosemont Center was not in compliance with the 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:


483.60(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 observations of the Food and Nutrition Department's kitchen and interview with dietary staff, it was determined that the facility failed to store, prepare distribute and serve food in accordance with professional standards for food service safety.

Findings include:

Observation of the kitchen, during the initial tour on My 21, 2019, revealed that the flooring needed repair. The dish room and three compartment sink area flooring contained extensive water damage. Water damage was also noted in
the flooring in the food preparation areas throughout the kitchen. The grouting between the floor tiles was missing creating grooves between the ceramic tiles.

Continued observation of the dietary kitchen revealed that the wall area located behind the ice machine had been damaged. The condensation pump located behind the ice machine that was used to condense the excess water was not functioning properly. Water was observed spilling onto the floor and creating a puddle underneath the ice machine.

Further observation of the dietary kitchen revealed that the light from the ceiling light fixtures was dim. The lighting was not adequate for dietary staff to perform their job duties efficiently and adequately within the kitchen. According to the Servsafe Manual, National Restaurant Association, 2012, good lighting makes it easier to clean things in the food service operation. Local jurisdictions require food preparation areas to be brighter than other areas of the facility. This allows staff to recognize the condition of the food. Interview with Employee E8, Dietary Employee, at the time of the observation, indicated that it was difficult to read diet slips and recipes with the dim lighting in the kitchen.

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

28 Pa. Code: 205.13(b) Flooring.

28 Pa. Code: 207.2(a) Administrator's responsibility.







 Plan of Correction - To be completed: 07/05/2019

No residents were harmed based on this practice. Any resident that eats food prepared in the facility's kitchen has the potential to be harmed.

The lighting has been repaired. The grouting will be repaired. The wall behind the ice machine will be repaired. An audit will be conducted weekly fore a period of 12 weeks to ensure the floor, walls, and lighting are in good repair. Results of this audit will be taken to the quality assurance performance improvement committee for discussion and recommendations. The director of food services will be responsible for this audit.
483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(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, observations and interviews with staff and residents, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet each residents' needs for three of twenty-eight residents reviewed (Residents R31, R53, R62).

Findings include:

Review of the comprehensive Minimum Data Set (MDS-assessment of resident care needs) dated 12/18/2018 indicated that Resident R53 weighed 154 pounds. The comprehensive assessment dated March 29, 2019 indicated that the resident weighed 138 pounds. A weight decrease of 16 pounds over a three month period of time was recorded which represented a significant weight loss. The comprehensive assessment MDS dated April 26, 2019 for Resident R53 indicated that this resident's cognition was moderately impaired.

Interview with Resident R53 on May 22, 2019 at 11:10 a.m., revealed that the resident was trying to eat as much as possible and that this resident was interested in between meal supplemental foods to meet nutritional needs for weight gain.

A review of the resident's food consumption documented in the clinical record for breakfast, lunch and dinner during April 25, 2019 through May 21, 2019, revealed that this resident had poor food intake for the breakfast meal. Continued review of Resident R53's clinical record revealed no documentation to indicate that a care plan had been developed and implemented to address the resident's poor food consumption.

Review of the dietitian's progress note dated April 24, 2019 revealed that Resident R53 had poor intake and the resident was scheduled for an abdominal PEG (tube placed surgically through the abdomen into the stomach used for feeding) tube placement on May 13, 2019. Interview with Employee E2 director of nursing, on May 21, 2019 at 1:00 p.m., revealed that the resident did not have the tube surgically placed..

Interview with Employee E4, dietitian, on May 22, 2019 at 9:00 a.m., confirmed that there was no nutritional care plan developed and implemented for Resident R53's poor food consumption as documented by the nursing staff for April 25, 2019 through May 21, 2019.

Review of the clinical record for Resident R31 revealed a comprehensive Minimum Data Set (MDS-an assessment of resident care needs) dated January 2, 2019, which indicated that the resident required extensive assistance of two staff persons for bed mobility (how a resident moves to and from lying position, turns side to side and positions body while in bed). The MDS also indicated that this resident was exhibiting physical behavioral symptoms directed toward others (hitting, kicking, pushing scratching, grabbing) and that this resident was incontinent of bowel and bladder).

Continued review of the clinical record revealed a comprehensive MDS assessment dated March 25, 2019 which indicated that the resident had a history of a fall with injury (skin tear, abrasion, laceration). The resident was severely cognitively impaired, non-ambulatory (unable to walk) and totally dependent on the assistance of one staff for locomotion (how the resident moves between locations in his/her room or corridor). The assessment also indicated that the resident had no functional limitations of the upper and lower extremities and that Resident R31 was incontinent of bowel and bladder.

Clinical record review further indicated that Resident R31 had two falls (March 13, 2019 and October 14, 2018), that required a hospital evaluation. On March 13, 2019 Resident R31 fell from bed while one staff member was providing incontinence care. Clinical record documentation indicated that the resident was resistive with care at that time. Further review of Resident R31's clinical record revealed there was no care plan developed and implemented for Resident R31 related to bed mobility and behavioral symptoms.

Clinical record documentation for October 14, 2018 indicated that a staff member was transporting Resident R31 in a high-back wheelchair, when the resident impulsively fell forward out of the chair resulting in a laceration to the forehead. The clinical record indicated that after this fall, the resident was to use a wheelchair (Broda), that was to be reclined during transporting the resident to prevent further falls. Observation of Resident R 31 being transported by staff in the hallway at 1:30 p.m., on May 23, 2019, revealed that the resident was not reclined as care planned to prevent accidents and injury.

Interview with Employee E5, occupational therapist, on May 24, 2019 at 9:30 a.m., revealed that the reclining ability of the chair was not functioning properly on May 23, 2019. The interview further revealed that the therapist had adjusted/tightened the resident's wheelchair (Broda) on May 23, 2019. The occupational therapist confirmed during the interview that the care plan had not been implemented as planned for Resident R31.

Review of the clinical record and the hospital record for Resident R62 revealed that the resident admitted to the facility on April 22, 2019, with a diagnosis of complete traumatic amputation (loss of limb) of the right great toe complicated by osteomyelitis (infection of the bone). Observations of Resident R62 on May 21, 2019 at 11:30 a.m., revealed that the resident had a left upper extremity PICC (peripherally inserted central catheter) line. Further review of clinical record indicated a physician order dated April 22, 2019, which directed staff to change the double lumen PICC line every seven days.

Review of the facility policy for the care of a peripherally inserted central catheter (PICC) line dated March 2019 was to have the PICC dressing changed twenty-four hours after insertion, then have the PICC dressing changed every five to seven days, or sooner, if the dressing becomes soiled, wet or not intact. The policy further indicated that the PICC site was to be assessed for complications and possible migration or malfunction.

A review of Resident R62's clinical record revealed no documentation that the facility had developed a comprehensive care plan for the assessment and monitoring for the care and maintenance of PICC line. Interview
with Employee E2, Director of Nursing, at 2:45 p.m. on May 24, 2019, confirmed the finding.

28 Pa. Code: 211.11(a)(b)(c) Resident care plan.

28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services.
Previously cited 6/29/18.








 Plan of Correction - To be completed: 07/05/2019

Resident R53 has been seen by the facility's registered dietitian, interventions have been discussed with the resident, and a care plan is in place.

Resident 31 has been reviewed by the therapy department, the care plan has been reviewed, and staff will be educated on the resident's care plan interventions.

Resident R62 has been successfully discharged from the facility.

An audit will be conducted for all residents that have had a significant weight loss as defined by the MDS, to ensure appropriate interventions are in place. An audit will be conducted for all residents that have a PICC line, to ensure a care plan is in place for the care of the PICC line. An audit will be conducted for all residents that have had a fall in the last 60 days, to ensure an appropriate care plan is in place.

Audits will continue for interventions for residents that have had a significant weight loss as defined by the MDS, have a PICC line, or have had a fall, for the next 12 weeks, to ensure the intervention(s) is appropriate and being followed as care planned.

Results of the audits will be taking to the quality assurance performance improvement committee for discussion and recommendations. The director of nursing or designee will be responsible for these audits.
483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on review of clinical records, observation and staff interview, it was determined that the facility failed to accommodate the needs of one of 28 residents (Resident R8) reviewed.

Findings include:


A review of the clinical record indicated that Resident R8 was admitted to the facility on November 13, 2018. The Minimum Data Set (MDS- periodic assessment of care needs) dated February 20, 2019, revealed diagnoses included Huntington's Disease (Huntington's disease is an inherited disease. It causes the breakdown of nerve cells in the brain. People with Huntington's disease can experience chorea symptoms such as involuntary jerking or writhing), and Depression (a state of low mood and aversion to activity. It may feature sadness, difficulty in thinking and concentration). MDS Section C0200-C0500, a Brief Interview for Mental Status for Resident R8 revealed a score of 3 out of 15, which indicated that the resident is with severely impaired cognition.

A review of the care plan for the Resident R8 revealed that the resident is at risk of potential skin tear or injury related to Chorea. (Chorea is a movement disorder that causes involuntary, unpredictable body movements. Chorea symptoms can range from minor movements, such as fidgeting, to severe uncontrolled movements of the arms and legs.) In the care plan, on April 9, 2019, intervention for chorea was indicated as ' head board padded for safety'.

Review of the progress note for Resident R8, dated April 20, 2019, revealed as follows: 'resident noted with abrasion to nose 0.2 x 0.5 cm, abrasion to forehead 0.3 x 0.3 cm, and open area to left side of head 0.5 x 0.5 cm. No bleeding or swelling noted. Resident denied falling, or hitting her head, when she was asked : what happened, she replied : I have no idea. MD and RP notified'.

On May 22, 2019 and May 23, 2019, observed the Resident R8 in her bed in her room, without any head board padded for safety. At the time of observation on May 22, 2019, approximately 1:25 p.m., the charge nurse, Employee E7, confirmed that the Resident R8 had no head board for safety.

During an interview on May 22, 2019 at 1:28 p.m., the charge nurse, Employee E7, confirmed that the facility failed to accommodate the needs for Resident R8.

28 Pa. Code: 201.29 (j) Resident rights.
Previously cited 6/29/2018.






 Plan of Correction - To be completed: 07/05/2019

Resident R8 has had the head of the bed padded, as per care plan.

Residents with chorea symptoms may be at risk for injury. Residents with a diagnosis of Huntington's disease will be evaluated to ensure individualized interventions are in place to reduce potential injuries from involuntary movement.

Interventions put into place for residents with Huntington's disease will be monitored and audited weekly for a period of 12 weeks. Interventions will be monitored for efficacy, and altered as necessary. The results of the audits will be taking to the Quality assurance performance improvement committee for discussion and recommendations.

The director of rehabilitation, or designee, will be responsible for this audit.
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 review of clinical records and interviews with staff, it was determined that the facility failed to ensure that the resident's wishes, as indicated in Advance Directives (one's wishes on life-sustaining medical or surgical treatment), was reflected accurately in the clinical record, for one of 28 residents reviewed (Residents R45).

Findings include:

Review of the electronic clinical record for Resident R45 on May 21, 2019, revealed a physician order for Advance Directives as Full Code (A Full Code means a person will allow all interventions needed to get their heart started). The same electronic clinical record for R45 revealed code status as DNR also (Do Not Resuscitate, it instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating).

Interview with the Assistant Director of Nursing on May 21, 2019, at 12:26 p.m., confirmed that Resident R45 did have an incomplete physician order for Advance Directives.

The facility failed to ensure accurate documentation was maintained regarding one resident's wishes for resuscitation upon life-threatening medical conditions.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 6/29/18.

28 Pa. Code 201.29(i) Resident rights.
Previously cited 6/29/18.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 6/29/2018.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 6/29/18.

28 Pa. Code 211.12(d)(5) Nursing services.
previously cited 6/29/18.








 Plan of Correction - To be completed: 07/05/2019

The electronic clinical record for resident R45 has been correct.

An audit will be conducted for all current residents to ensure the desire to have or not have resuscitation efforts aligns with physician orders.

An audit will be conducted for all new orders to ensure resuscitation orders match physician orders. This audit will continue for a period of 12 weeks. Results of this audit will be taken to the quality assurance performance improvement committee for review and recommendation.

The social services professional or designee will be responsible for this audit.
483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on clinical record review, review of facility policies and procedures and staff interview, it was determined that the facility failed to thoroughly investigate an incident of potential neglect for one of 28 residents reviewed (Resident 33).

Findings include:

The policy entitled "Abuse , Neglect and Exploitation" created on November 2017, revealed that the facility would protect individuals from neglect. The investigation will be initiated immediately. Components of an investigation may include: (a) Interview the involved resident, if possible, and document all responses. (b) If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident. (c) Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. (d) Document the entire investigation chronologically.

Clinical record review for Resident R33 revealed nursing progress note dated February 25, 2019, at 8:50 p.m., indicating that the facility received a phone call from Romed Transportation. Facility immediately initiated the elopement protocol and Resident R33 was found at the front of the building on the opposite side of the stop sign on the corner.

Further review of the clinical records revealed that the facility had not obtained interview statements from Resident R33, the resident's family or the responsible party. There were no interview statements from the room mates, and residents of adjoining rooms. The available witness statements of two Certified Nursing Assistants (CNA) , one Licensed Practical Nurse (LPN), and a staffing Coordinator do not present a clear picture how Resident R33 eloped (left the facility without permission) or how long Resident R33 was outside the building.

On May 24, 2019, at 1:41 p.m., the Assistant Director of Nursing confirmed these findings.

The facility failed to thoroughly investigate potential neglect for one of 28 residents reviewed.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 6/29/18.

28 Pa. Code 201.18(b)(1)(e)(1) Management.
Previously cited 6/29/18.

28 Pa. Code 201.29(c)(d) Resident rights

28 Pa. Code 211.10(d) Resident care policies
Previously cited 6/29/18.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 6/29/18.






 Plan of Correction - To be completed: 07/05/2019

Resident R33 did not receive any injuries from the elopement. Any resident that attempts to elope, or does elope, is at risk.

Education will be provided for staff related to our elopement policy, and our Abuse, neglect, and exploitation policy.

An audit will be conducted for any incidents replated to Abuse, Neglect, and Exploitation; or elopement, to ensure the policy is correctly followed, and witness statements are obtain. This audit will continue for a period of 12 weeks. The results of the audit will be forwarded to the quality assurance performance improvement committee for review and recommendations. The administrator or designee will be responsible for this audit.
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 review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented, and that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for two of three residents reviewed (Residents R57 and Resident R62).

Findings include:

Review of facility policy "care plans-baseline", dated December 2016, revealed "To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission". Further review of the policy revealed that "The resident and their representative will be provided summary or can view a copy of the baseline care plan".

A review of Resident R57's clinical record revealed that resident was admitted to the facility on April 10, 2019, with diagnosis, including but not limited to, Cerebral Infraction (Stoke or brain hemorrhage) and muscle weakness. Continued review of the clinical record revealed no documented evidence that a baseline line care was developed within 48 hours of resident's admission and resident and/or the resident's representative received a written summary of the baseline care plan.

A review of Resident R62's clinical record revealed that the resident was admitted to the facility on April 22, 2019, with diagnosis, including but not limited, to complete traumatic amputation (removal of limb) of the right great toe and osteomyelitis (bone infection). Continued review of the clinical record there was no documented evidence that a baseline line care was developed within 48 hours of resident's admission and resident and/or the resident's representative received a written summary of the baseline care plan.

Interview with Employee E2, Director of Nursing, on March 22, 2019, at 1:30 p.m. confirmed that there was no documented evidence that a baseline care plan was developed and implemented within 48 hours of admission and no evidence that the resident and/or the resident's representative received a written summary of the baseline care plan for Resident R57 and Resident R62.

28 Pa. Code 211.11(e) Resident care plan.







 Plan of Correction - To be completed: 07/05/2019

Resident R62 was not harmed from this practice and has been successfully discharged home.

Resident R57 was not harmed from this practice. Resident R57 and resident's representative will be given a copy of the most recent care plan.

All newly admitted residents have the potential to be affected by this deficient practice.

An audit will be conducted for all newly admitted residents who have been admitted since April 1, 2019, and are still in the facility, and will be given a copy of the most recent care plan, and one will be sent to the responsible party.

An audit will be conducted for all newly admitted residents to ensure the care plan is completed and copies are given to the resident and responsible parties. This audit will be conducted for a period of 12 weeks. Results of the audit will be taken to the Quality assurance performance improvement committee for review and recommendations. The MDS coordinator or designee will be responsible for this audit.
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.
Observations:

Based on clinical record review and interview with staff, it was determined that the facility failed to complete a discharge summary for two of three residents reviewed (Residents R64, and 114).

Findings include:

Review of the clinical record for Resident R64 revealed that the resident was admitted to the facility on February 7, 2019 with diagnoses, including but not limited to, Fracture (broken bone) of unspecified Pubis (pair of bones forming the two sides of the pelvis), Thyrotoxicosis (overactive thyroid gland) and Malignant Neoplasm of Colon (Cancer of the Colon, located at the digestive tract's lower end). Resident R64 was discharged from the facility on February 26, 2019.

Review of the physician discharge summary for Resident R64 indicated that the facility failed to complete a full summary of Resident R64's stay and course of treatment in the facility including Prognosis, Physician Orders for Immediate Care, and Discharge Diagnoses.

Interview with Employee E1, nursing home administrator, on May 24, 2019, at 11:25 a.m., confirmed that the facility failed to complete a full Physician Discharge Summary for Resident R64.

Review of the clinical record for Resident R114 revealed that the resident was admitted to the facility on December 9, 2017 with diagnoses, including but not limited to, end stage kidney disease ( kidney failure), bipolar disorder
(mental condition marked by alternating periods of elation and depression), anemia (a reduction of red blood cells) and Alzheimer's disease (irreversible progressive degenerative disease of the brain). Resident R114 was discharged from the facility on April 7, 2019.

Further review of the clinical record revealed that the facility failed to document a discharge summary of Resident R114's stay and course of treatment in the facility.

Interview with Employee E1, nursing home administrator, on May 24, 2019 at 11:15 a.m., confirmed that the facility failed to document a recapitulation of the Resident R114's stay. The administrator reported that the facility's policy stipulated that records of discharged residents shall be completed within 30 days of discharge and that clinical information pertaining to a resident's stay shall be centralized in the resident's record.


The facility failed to include or complete a discharge summary for two of three residents reviewed.

28 Pa. Code: 211.5(d) Clinical records.
Previously cited 6/29/18.







 Plan of Correction - To be completed: 07/05/2019

The physician for resident R64 has been contacted to complete the discharge summary. The interdisciplinary team will complete the discharge summary for resident R114.

An audit will be completed for all residents that have been discharged in the last 60 days to ensure a discharge summary is in place.

An audit will be conducted for all discharged residents for the next 12 weeks, to ensure a discharge summary has been completed. Results of the audits will be taken to the quality assurance performance improvement committee for discussion and recommendations.

The social services manager or designee will be responsible for this audit.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on review of clinical records, facility policy and staff interviews, it was determined that the facility failed to address a significant weight loss for two of six residents reviewed (Resident R42 and R62).

Findings include:

A review of facility policy "Resident Weight Policy" dated April 1, 2019, indicated that "Weight changes are calculated through the use of PCC (Electronic medical record) or manually by the Registered Dietitian (RD). A significant weight change is indicated by any of the following: 5% X 30 days (loss of 5% body weight over thirty days), 7.5% X 90 days, 10% X 180 days. The RD assesses each resident with a significant weight change, makes appropriate recommendation to physician(s) and update the residents plan of care. Nursing notifies the C.N.A and the RD of changes in weight frequency, such as a physician's order for weekly weights".

A review of Resident R42's clinical record revealed that the resident was admitted to the facility on July 5, 2018, with diagnoses including Unspecified Dementia (broad category of brain diseases that cause a long-term and often gradual decrease in the ability to think and remember that is great enough to affect a person's daily functioning), Paroxysmal Atrial Fibrillation (abnormal heart rhythm characterized by rapid and irregular beating), constipation and Anxiety Disorder (a group of mental disorders characterized by significant feelings of anxiety and fear). Review of Resident R42's care plan dated July 11, 2018 revealed that resident was identifed as at potential for nutritional risk.

Continued review of the clinical record for Resident R42's revealed the resident's weights were as follows: December 1, 2018, the resident weighed 96.9 lbs. (pounds), on January 2, 2019, the resident weighed 96.9 lbs., on February 1, 2019 the resident weighed 93.7 lbs., on March 1, 2019, the resident weighed 92.9 lbs. on April 17, 2019, the resident weighed 88.3 lbs., on May 1, 2019, the resident weighed 84.3 lbs., which indicated an overall weight loss of 12.6 pounds in six months. (-13.00 %) loss.

Further review of the clinical record for Resident R42 revealed no documented evidence that the facility had developed effective interventions to address Resident R42's significant weight loss.

Interview with Employee E4, Registered Dietician, on May 24, 2019, approximately at 10:05 a. m., confirmed Resident R42's significant weight loss.

A review of Resident R62's clinical record revealed that the resident was admitted to the facility on April 22, 2019, with diagnoses, including but not limited to, complete traumatic amputation (loss of limb) of the right great toe and osteomyelitis (infection of the bone). Review of the resident's care plan dated April 26, 2019 revealed that the resident had been identifed as at potential for nutritional risk.

The clinical record revealed that Resident R62's weights were as follows: On April 22, 2019, the resident weighed 191.8 lbs. (pounds). On May 07, 2019, the resident weighed 180.5 pounds which is was 11.5 pounds (-5.89 %) loss.

Further review of the clinical record for Resident R62 revealed no evidence that the facility had developed interventions to address the resident's weight loss and/or conducted an assessment by Registered Dietician or Physician to further evaluate the resident's weight loss.

Interview with Employee E4, Registered Dietician, on May 24, 2019 at approximately 10 a.m. confirmed that Resident R62's significant weight loss was not addressed, no assessment was completed and no interventions were initiated.

The facility failed to address a significant weight loss for two residents.

42 CFR 483.25(g)(1) Assisted nutrition and hydration.
Previously cited 6/29/2018

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 6/29/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 6/29/18

28 Pa. Code 211.6(d) Dietary services.





 Plan of Correction - To be completed: 07/05/2019

Resident R62 has been discharged from the facility and was not harmed.

Resident R42 will be reviewed by the facility's registered dietitian, and if necessary, appropriate interventions will be put into place.

A review will be conducted for all residents that have had a significant weight loss, as defined by the MDS, and interventions will be care planned.

A monthly audit will be conducted for three months, to determine if any resident has had a signficiant weight loss as defined by the MDS, and has appropriate interventions. Results of the audit will be taken to the quality assurance performance improvement committee for discussion and recommendations. The dietitian or designee will be responsible for this audit.
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 observations, reviews of clinical records and review of facility policies and procedures, it was determined that the facility failed to provide adequate treatment, assessment and monitoring for the care and maintenance of an intravenous catheter in accordance with professional standards of practice for one of 28 residents reviewed (Resident R62).

Findings include:

Review of the facility policy for the care of a peripherally inserted central catheter (PICC) line, dated March 2019 revealed that the PICC dressing should be changed twenty-four hours after insertion, then changed every five to seven days or sooner if the dressing becomes soiled, wet or not intact. The policy also indicated that the PICC line site was to be assessed for complications and possible migration or malfunction.

According to the standards of nursing practice guidelines in the Journal of the American Nurse's Association, dated November 2013, complications of a PICC line includes, but is not limited to catheter-tip migration (assessed by external length of the catheter-amount of catheter tubing that is visible outside of the vein moves from original insertion and may cause medical complications).

Clinical record review indicated that Resident R62 was admitted to the facility on April 22, 2019, with a diagnosis of complete traumatic amputation (loss of limb) of the right great toe complicated by osteomyelitis (infection of the bone). Resident R62 was admitted for continued antibiotic therapy for osteomyelitis. Review of Minimum Data Set (MDS-periodic assessment of resident's care needs) assessment, dated April 29, 2019 indicated that resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in in determining cognitive impairment) score of 14 which indicated that the resident was cognitively intact.

Continued review of resident R62's clinical record revealed that the physician ordered Daptomycin (antibiotic) to be administered intravenously (IV- through a vein) starting April 23, 2019 and to continue the antibiotic therapy until June 03, 2019. Further review of clinical record indicated a physician order dated April 22, 2019, to change the double lumen PICC line every seven days, evening shift on Mondays. Resident R62's clinical record lacked a physician order to monitor and/or to assess the PICC line insertion site during dressing change for complications and/or possible migration or malfunction.

Observation of Resident R62 at 11:15 a.m., on May 21, 2019 revealed that the resident had a left upper extremity PICC line insertion. The transparent dressing appeared loosened above the PICC insertion site and appeared visibly soiled. There was no documentation on the dressing indicating the date and time the dressing was last changed. Resident R62 stated that the dressing was not changed for more than two weeks. Interview with Employee E3, Licensed Practical Nurse, who was present at the time of the observation, confirmed the finding.

A review of the treatment administration record (TAR) in the Electronic medical record on May 21, 2019 at approximately 11:30 a.m. indicated that the PICC line dressing was changed on May 06, 2019, and May 20, 2019. There was no evidence in the clinical record that the PICC line dressing was changed as ordered by the physician on May 13, 2019. There was no documentation of the reason for not changing resident R62's PICC line dressing. Interview with Employee E2, Director of Nursing, on May 22, 2019 at approximately 2:45 pm confirmed that there was no documented evidence in the clinical records that the PICC line dressing was changed on, May 13, 2019 as ordered. Employee E2 also stated that the PICC line dressing was not changed on May 20, 2019, as indicated in the clinical record.

There was no documentation to indicate that the nursing staff assessed the PICC line, while performing a dressing change and measured the external length of the catheter and the resident's arm circumference every seven days according to the standards of practice. The lack of documentation, monitoring and assessment for Resident R62's PICC (peripherally inserted central catheter) line for April 22, 2019 through May 20, 2019 was confirmed with the Director of Nursing Services on May 24, 2019 at 2:45 p.m..

The facility failed to provide adequate treatment, assessment and monitoring for the care and maintenance of a Peripherally inserted central line catheter.

28 PA. Code: 211.10 (a)(b)(c)(d) Resident care policies.

28 PA. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services.
Previously cited 6/29/18.





 Plan of Correction - To be completed: 07/05/2019

Resident R62 has been discharged from the facility.

An audit for all residents with dressing changes will be conducted to ensure physician orders and care plans are in place.

An audit will be conducted for all residents requiring dressing changes, to ensure dressings are changed according to physician orders and care planned, for a period of 12 weeks. Results of this audit will be taken to the quality assurance performance improvement meeting for review and recommendations. The director of nursing or designee will be responsible for this audit.
483.40(d) REQUIREMENT Provision of Medically Related Social Service: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.
483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to provide medically-related social services to meet the physical, mental and psychosocial needs of one of twenty-eight residents reviewed (Resident R5).

Findings include:

Review of the admission Minimum Data Set (MDS-an assessment of resident care needs) assessment dated February 8, 2019 revealed that the resident was admitted to the facility on February 1, 2019 was cognitively intact (awake, alert and oriented). The assessment also indicated that the resident was independently ambulatory (able to walk without assistance) throughout the inside of the facility and required no assistive devices for ambulation.

Review of nursing progress notes dated February 23, 2019 indicated that Resident R5 had physical and verbal agitation. The resident was noted as refusing to eat and cursing during a telephone call with a family member. The nursing progress note indicated that Resident R5 wanted to smoke outside the facility grounds with supervision.

Nursing progress notes on March 1, 2019 indicated that that Resident R5 no longer wanted to stay at the nursing home. The nursing note indicated that his family was in agreement with the resident's desire to be discharged to another facility that could meet his needs.

Nursing progress notes on March 12, 2019 indicated that Resident R5 was requesting to go outside on the facility porch. The nursing note indicated that the receptionist was monitoring the whereabouts of the resident.

The nursing progress note dated April 6, 2019 indicated that Resident R5 was allowed outside of the facility to sit on the porch; while the receptionist was planned to monitor the resident. The resident left the facility without the facility being aware that the resident had done so. Resident R5 eloped (left the facility without permission) from the facility on April 6, 2019 and was found walking the streets at a busy traffic area several blocks from the facility. The resident reported again, a desire to live in a boarding home or a place where smoking was allowed.

Nursing progress notes on April 8, 2019 indicated that this resident was sitting near the exit doors expressing to the nursing assistant a desire to leave the nursing home. The resident expressed a desire to have a place to live outside the nursing facility.

The psychiatrist evaluated Resident R5 on April 12, 2019. The psychiatrist noted that Resident R5 again reported a desire to go outside the building (facility) for some air and would like to go and live in the community.

Nursing progress notes dated May 24, 2019 indicated that Resident R5 stated that this nursing home was not the place for him, it was too strict. The resident desired the freedom to go for a walk or to smoke.

Continued review of Resident R5's clinical record revealed no documentation that the resident was provided social services to assist the resident with a transition in care and/or services (assisting the resident with identifying community placement options, arranging intake for home care services for residents returning home or assisting with transfer arrangements to other facilities) to another facility.

Interview with Employee E1, administrator, on May 24, 2019 confirmed that the facility had not provided Resident R5 with social services to meet the resident's physical, mental and psychosocial well-being.


28 Pa. Code: 211.16(b) Social services.

28 Pa. Code: 201.18(a)(b)(1)(3) Management.
Previously cited 6/29/18.






 Plan of Correction - To be completed: 07/05/2019

The social services manager will meet with resident R5 to determine if this resident still wishes to be discharged.

Social services director will attempt to find suitable placement for any resident wishing to be discharged from the facility, based on individual resident needs, and document in the resident's health record.

During care plan meetings, in conjunction with the MDS process and associated assessments, the social worker or designee will discuss discharge planning, and document in the resident's health record. An audit will be conducted for a period of 12 weeks, to ensure discharge planning is discussed and documented. Results of these audits will be taken to the quality assurance performance improvement committee for review and discussion. The social services manager or designee will be responsible for these audits.
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 observation and staff interview, it was determined that the facility failed to ensure that medications were stored at the proper temperature in one of one medication refrigerators and to failed to discard expired medications for one medication cart inspected (the second-floor medication cart).

Findings include:

Observation of the second-floor medication storage room with Employee E7, Licensed Nurse, on May 22, 2019, at 11:30 a.m., revealed that the temperature log sheet for the medication refrigerator in the medication storage room was incomplete with gaps for the months of February, March, April, and May 2019.

Interview with Employee E7, Licensed Nurse, on May 22, 2019, at the time of the observation, confirmed that the temperature log sheets for the medication refrigerator in the medication storage room was incomplete with gaps and that the facility failed to monitor the medication room refrigerator temperatures daily.
.
On May 22, 2019, at 11:45 a.m.,Observation of the second-floor medication cart with Employee E7, Licensed Nurse, on May 22, 2019, at 11:45 a.m., revealed the following:

Three opened 15 ML (milliliter) bottles of Lubricant Eye Drops which were dated expired on March 2019.

An opened 15 ML bottle of Systane Lubricant Eye Drops with no indication of the date the bottle had been opened.

An opened Refresh Lacri-lube Eye Ointment, with no indication of any opened date.

Interview with Employee E7, Licensed Nurse, on May 22, 2019, at the time of the finding, confirmed that the expired medications should have been discarded.

The facility failed to ensure that medications were stored at the proper temperature in medication refrigerator and that all drugs used in the facility were not expired.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 6/29/18.

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

28 Pa. Code 211.9(g)(h) Pharmacy services

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 6/29/18.







 Plan of Correction - To be completed: 07/05/2019

No residents were injuried from this practice. Any resident that takes refrigerated medications or expired medications have the potential to be affected.

Expired medications and opened medications without a date have been removed and discarded.

Refrigerator temperatures are being documented, and are within acceptable limits.

A weekly audit will be conducted for a period of 12 weeks to verify temperatures are being taken for the medication refrigerators, and are at acceptable temperatures. A weekly audit will be conducted for a period of 12 weeks to ensure that there are no expired medications in the medication carts, and that all opened medications are dated. The director of nursing or designee will be responsible for this audit.
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 observation, review of facility policies and procedures, review of clinical records and staff interview, it was determined that the facility failed to ensure that appropriate infection control practices were implemented to reduce the potential spread of infection for one of two sampled residents with an infection. (Resident 33)

Findings include:

Review of the facility policy entitled "Infection Control" dated, January 2019, revealed that residents with infections with sentinel/epidemiologic important bacteria including Staph aureus both resistant and sensitive to Methicillin(antibiotic) (MRSA) require contact isolation precaution (Process of seperating infected persons from non-infected persons). The policy also stated that, "it is the responsibility of the unit manager and the supervisor to be aware of culture reports, confirming the presence of potentially transmissible, antibiotic resistant organisms including MRSA". Further review of the policy indicated that "the medical director is notified when the ability to provide care, due to an infectious disease or process, is in question".

Review of the Clinical record and hospital record revealed that Resident R62 was admitted to the facility on April 22, 2019, with diagnoses, including but not limited to, traumatic amputation (loss of limb) of the right great toe complicated by osteomyelitis (infection of the bone). Resident R62 was admitted for continued antibiotic therapy for osteomyelitis.

A review of Resident R62's hospital records indicated a wound swab culture (A test to find germs or bacteria) result dated April 20, 2019, revealed the presence of MRSA (Methicillin Resistant Staph Aureus- bacteria which has developed resistance to treatment with certain antibiotics). Further review of clinical record revealed an undated admission Nurse to Nurse report sheet indicated "isolation precaution- MRSA wound". Nurses notes dated April 22, 2019 also indicated that isolation precaution was indicated for Resident R62.

Continued review of Resident R62's clinical record revealed no evidence that contact precautions were initiated after admission. The clinical record contained no documented evidence that the physician was contacted to address the need for isolation precautions, or a physician order was obtained. Interview with Employee E2, Director of Nursing, on April 24, 2019 at approximately 2:45 p.m. confirmed the finding.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 6/29/18.





 Plan of Correction - To be completed: 07/05/2019

Resident R62 has been dischaged home. An audit will be completed for all residents in the facility with an infection, to determine what precautions are necessary. Any precautions identified will be care planned, and physician orders will be obtained.

An audit will be conducted for all residents with an infection. This sample will include newly admitted residents with an existing infection, as well as current residents that may acquire an infection. The audit will include ensuring the resident has proper precautions in place, and is appropriately care planned, and physician orders have been obtained. Results of the audit will be taken to the quality assurance performance improvement committee for discussion and recommendations. The director of nursing will be responsible for this audit.
211.12(f)(1) LICENSURE Nursing services.:State only Deficiency.
(f) In addition to the director of nursing services, the following daily professional staff shall be available:

(1) The following minimum nursing staff ratios are required:

Census Day Evening Night
59 and under 1 RN 1 RN 1 RN or 1 LPN
60/150 1 RN 1 RN 1 RN
151/250 1 RN and 1 LPN 1 RN and 1 LPN 1 RN and 1 LPN
251/500 2 RNs 2 RNs 2 RNs
501/1,000 4 RNs 3 RNs 3 RNs
1,001/Upward 8 RNs 6 RNs 6 RNs



Observations:

Based on review of nursing staffing schedules, it was determined that the facility failed to meet the Pennsylvania State Required minimum nursing staffing ratios on one of 21 days reviewed.

Findings include:

Review of the nursing staffing schedules for the three non-consecutive weeks of: 5/17/19- 5/23/19, 3/11/19-3/17/19 and 12/25/18-12/31/18 revealed that on Saturday May 17, 2019, the facility failed to ensure that a registered nurse was assigned to the 3-11 shift. The resident census for May 17, 2019 was 63. Further review of the nursing staffing schedules for May 17, 2019, revealed that two licensed practical nurses and six nursing assistants worked on the 3-11 shift.





 Plan of Correction - To be completed: 07/05/2019

The facility will review time cards for May 17, 2019, to identify RN staffing levels on this date.

Facility staffing sheets will be reviewed daily, for a period of 12 weeks, to ensure proper staffing levels. The results of the audit will be taken to the quality assurance performance improvement committee for discussion and recommendations. The administrator or designee will be responsible for this audit.

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