Nursing Investigation Results -

Pennsylvania Department of Health
ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are  136 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.
ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on March 11, 2019, it was determined that St. Francis Center for Rehabilitation & Healthcare 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 as they relate to the Health portion of the survey process.






 Plan of Correction:


483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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(c) Menus and nutritional adequacy.
Menus must-

483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

483.60(c)(2) Be prepared in advance;

483.60(c)(3) Be followed;

483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

483.60(c)(5) Be updated periodically;

483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:

Based on observation and resident interviews, it was determined that the facility failed to follow the information written on residents' meal tickets for eight of eight residents reviewed (Residents R34, R48, R94, R102, R131, R161, R188, and R193).

Findings include:

During observations of the noon meal on February 25, 2019, at 12:00 p.m. it was revealed that food items listed on the residents' meal tickets were missing.

Resident R94's meal ticket stated that the resident was to be on a Regular Ground Diet (all food items are minced into small pieces) and to allow Regular Textured Snacks. Resident R94's meal ticket specifically listed Ground Pork Fry and Sauteed Spinach and onions. Observation of the resident's meal tray revealed that his food was in a pureed (a paste, pudding or thick liquid) form.

Observations of Resident R167, who was eating in her room, revealed the resident's meal ticket listed Tropical Fruit and Orange Sherbet. Both items were not on the resident's meal tray. Resident R167 stated that she would really like to have the orange sherbet.

Observations of Resident R188 revealed her meal ticket listed Juice and Skim Milk. Both items were missing from her tray.

Interview with seven alert and oriented residents (Residents R34, R161, R102, R131, R48, R193 and R188) in a group setting, on February 26, 2019, at 10:30 a.m. unanimously stated that they are occasionally missing food items on their meal trays that are listed on the meal ticket.

These observations were relayed to Employee E12, dietitian and the Nursing Home Administrator.

The facility failed to ensure that meal menus were followed as developed and that each resident received all the food items as listed on their menu for eights residents.

Menus Meet Resident Needs/Prepared in Advance/Allowed
CFR(s): 483.60(c)(1)-(7) Previously cited 11/30/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/30/18, 04/23/18, 08/23/17, 03/20/17, 01/04/17

28 Pa. Code 201.18(b)(3) Management
Previously cited 11/30/18, 04/23/18, 08/23/17, 01/04/17

28 Pa. Code 201.18(b)(2) Management
Previously cited 11/30/18














 Plan of Correction - To be completed: 05/01/2019

All meal tickets were reviewed for accuracy within the meal ticketing software. Errors have been corrected.
Dietary and nursing employees will be in-serviced regarding the importance of the accuracy to the tray tickets.
Daily and weekly audits will be conducted to ensure meal ticket is correct.
Food Service Director or Designee will conduct weekly audits for four weeks then monthly X3 to ensure accuracy. Results will be forwarded to Quality Assurance and Performance Improvement Committee for review.

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 and interviews with staff, it was determined that the facility failed to maintain the physical environment of the department in accordance with professional standards for food service safety.

Findings include:

Initial tour of the Food and Nutrition Department on February 25, 2019, at approximately 9:30 a.m. with the Assistant Director of Dietary, revealed that the baseboard in the area by the dish room and by the fourth freezer box and in other areas around the perimeter of the floor, had large chunks of missing tile and grout.

Observations of the walls throughout the dish room area revealed that the walls had brown substances on them. A ceiling tile in the dish room area had a black like substance on it. There also appeared to be chips of a material, resembling paint, on the ceiling tile.

Observation of the Utility Closet revealed a brown substance on the walls, standing water on the floor
and debris in the drain.

Interview with the Assistant Director of Dietary on February 25, 2019, at approximately 10:00 a.m. confirmed the observations noted during the initial tour of the Food and Nutrition Department.

The facility failed to maintain the dietary kitchen in a safe and sanitary manner.

Food Procurement, Store/Prepare/Serve-Sanitary
CFR(s): 483.60(I)(1)(2) Previously cited 03/20/17

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/30/18, 04/23/18, 08/23/17, 03/20/17, 01/04/17

28 Pa. Code 201.18(a) Management
Previously cited 08/23/17

28 Pa. Code 201.18(b)(3) Management
Previously cited 11/30/18, 04/23/18, 08/23/17, 01/04/17









 Plan of Correction - To be completed: 05/01/2019

All missing tile and grout have been replaced. Dish room walls have been cleaned, dirty ceiling tiles have been changed. Utility closet walls, floor and drain have been cleaned.
Dietary staff to be in serviced on performing their cleaning assignments.
Dietary supervisor/ designee will audit all cleaning schedules weekly X4 Monthly X3. Results will be forwarded to Quality Assurance and Performance Improvement Committee for review

483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:

Based on review of facility policy and procedure and staff interview, it was determined that the facility failed to ensure the development of a comprehensive policy for abuse prohibition and investigation.

Findings include:

Review of the facility's policy and procedure titled "Abuse," dated September 1999, revealed that the protocols lacked details for the following components to prevent abuse.

Review of the first "Abuse" policy and procedure, number AD154, on February 22, 2019, at 11:00 a.m. revealed that the "Abuse" policy and procedure did not include the required component about how the facility would "Protect" residents from physical and psychosocial harm during and after the investigation.

Review of three additional "Abuse" policies and procedures numbered 155, 156 and 358, provided to the surveyor on February 26, 2019, at 10:30 a.m. indicated that the additional "Abuse" policies provided for review were not updated with the name of the current Nursing Home Administrator and the Director of Nursing and phone numbers. Further review of the "Abuse" policies and procedures revealed they were not complete with the required areas as indicated in the Federal and State regulations. In addition, the policies and procedures did not have the correct definitions related to the types of "Abuse."

The facility Nursing Home Administrator confirmed in an interview on February 26, 2019, at 2:15 p.m. that the facility "Abuse" policy and procedure contained incorrect information and needed to be revised and updated.

Continued review of the facility "Abuse" policy and procedure revealed they did not have a procedure in place for completing FBI background checks when required. An interview with the Nursing Home Administrator on February 26, 2019, at 2:15 p.m. confirmed that the "Abuse" policy and procedure did not indicate anything about FBI background checks.

The facility failed to develop a comprehensive, systematic procedure to address Abuse prevention related to Screening, Training, Prevention, Identification, Investigation, Protection and Reporting/Response.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/30/18, 04/23/18, 08/23/17, 03/20/17, 01/04/17

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 11/30/18, 04/23/18, 08/23/17, 01/04/17

28 Pa. Code 201.18(b)(2) Management
Previously cited 11/30/18

28 Pa. Code 201.29(a) Resident rights
Previously cited 01/04/17

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

28 Pa. Code 211.10(b) Resident care policies

28 Pa. Code 211.10(d) Resident care policies
Previously cited 10/16/17, 08/23/17, 01/04/17


















 Plan of Correction - To be completed: 05/01/2019

A comprehensive Policy for abuse prohibition and investigation was developed which includes FBI background checks, and approved at the March QA meeting
Staff re-educated on the revised abuse policy.
NHA/ Designee will do random audits of employees monthly x 3 to ensure comprehension of Abuse policy.
Any trends and findings will be reported in QA.

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 observation, review of facility documentation and interview with facility staff, it was determined that the facility failed to accommodate a resident's preferences related to hot beverages for one of 39 residents reviewed (Resident R155).

Findings include:

Review of documentation submitted by the facility on January 22, 2019, indicated that Resident R155 sustained a burn on January 19, 2019, from a hot beverage.

During the lunch observation on February 21, 2019, which began at approximately 12:30 p.m. and concluded at 1:15 p.m. it was revealed that Resident R155 was not served any hot beverages during the lunch meal.

At the end of the lunch observation, an interview with Employee E3, Nurse Aide, confirmed that Resident R155's dietary meal ticket indicated a preference for hot tea and/or hot chocolate as a beverage during the lunch meal.

Employee E3 further indicated that Resident R155 is not allowed to have hot beverages served to her because of a recent burn to the back of her left thigh.

An interview with Employee E4, Physical Therapist Director, on February 23, 2019, at 2:00 p.m. indicated no reason why Resident R155 could not drink hot tea and/or hot chocolate from the hot beverage mugs that are used by the Dietary Department.

The facility failed to ensure that resident preferences were honored related to being served hot beverages during meals.

Reasonable Accommodations Needs/Preferences
CFR(s): 483.10(e)(3) Previously cited 11/30/18, 10/16/17

28 Pa. Code 201.29(j) Resident rights
Previously cited 11/30/18, 04/23/18, 01/04/17

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 11/30/18, 04/23/18, 10/16/17, 08/23/17, 010/4/17

















 Plan of Correction - To be completed: 05/01/2019

Resident 155 is now offered preferred beverage as per meal ticket.
Staff educated on accommodating residents' preferences
NHA/Designee will do random audits of meal tickets to ensure resident preferences are being honored.
Audits done weekly x 4 than monthly x 3
Any trends and findings will be reported in QA.
This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

483.12(a)(3)(4) REQUIREMENT Not Employ/Engage Staff w/ Adverse Actions: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(a) The facility must-

483.12(a)(3) Not employ or otherwise engage individuals who-
(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
(ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
(iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff.
Observations:

Based on review of facility policies and procedures, personnel records and interviews with staff, it was determined that the facility failed to implement and operationalize policies and procedures for screening potential employees to prevent abuse for one of five newly hired employees reviewed (Employee E11).

Findings include:

Review of the facility policy, "Abuse- Screening, Reporting, Protecting, Investigation and Correcting Issues Related to Abuse," dated September 1999, revealed that the facility will not employ individuals who have been convicted of abusing, neglecting or mistreating individuals nor will it employ any individuals excluded by Criminal Background Check.

Review of the facility policy, "Abuse Prevention Program," dated October 2017, revealed that the facility will conduct employee background checks and will not knowingly employ persons who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.

Review of the personnel record for Employee E11, Assistant Administrator, revealed a hire date of January 28, 2019, and that the employee resided in New Jersey within the past two years. Further review of the personnel record revealed no documentation that a Federal Bureau of Investigation (FBI) criminal background check was initiated until February 18, 2019, and that it had not been completed yet.

An interview with the Nursing Home Administrator (NHA) on February 26, 2019, at approximately 2:15 p.m. confirmed that an FBI background check for Employee E11 was not initiated until February 18, 2019, and not been completed yet. The NHA also confirmed that the "Abuse" policy and procedure did not indicate anything about FBI background checks.

The facility failed to operationalize and implement policies and procedures for screening employees to prevent abuse.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/30/18, 04/23/18, 08/23/17, 03/20/17, 01/04/17

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 11/30/18, 04/23/18, 08/23/17, 01/04/17

28 Pa. Code 201.19 Personnel policies and procedures














 Plan of Correction - To be completed: 05/01/2019

The FBI Criminal Background check was completed for E11
The revised Abuse Policy was approved by the QA committee on March 18, 2019
Staff will be in-serviced on the revised Abuse Policy and Procedure.
HR will educate on conducting appropriate background checks prior to employment.
NHA/ Designee will audit new employee applications to ensure those who reside outside of PA for two years will receive a FBI criminal background check.
Audits will be done biweekly times one month then monthly x 3.
Any trends and findings will be reported in QA.

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 a review of clinical records, review of facility polices, review of facility documentation and interview with staff, it was determined that the facility failed to complete a comprehensive investigation of an injury related to a burn for one of 39 residents reviewed (Resident R155).

Findings include:

Review of facility documentation submitted on January 22, 2019, revealed that on January 19, 2019, Resident R155 sustained an injury, indicated as a burn, related to a spill of a hot beverage.

Review of facility policy and procedure titled "Accident and Incidents" dated November 10, 2018, indicated that "Incident/Accident reports will be reviewed by the Interdisciplinary Care Plan Team for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities."

Review of Resident R155's clinical record revealed a physician order dated February 1, 2019, which indicated the following diagnoses: dementia without behaviors, (psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia. They include symptoms such as depression, anxiety psychosis, agitation, aggression, disinhibition, and sleep disturbances), hypertension, (elevated blood pressure), mild cognitive impairment and abnormal gait and mobility.

Continued review of Resident R155's clinical record revealed a quarterly Minimum Data Set assessment (MDS - periodic assessment of needs), dated November 2, 2018, which indicated that Resident R155 was cognitively impaired and required set up assistance with eating.

Review of Resident R155 progress notes revealed a nursing note dated January 19, 2019, written at 11:45 p.m. which indicated that "Resident R155 was observed with a large blister to left thigh measuring 9 centimeters by 6 centimeters." "Blister had burst and skin sloughed away (outer layer of skin removed)." "Resident reported to nurse she spilled tea that afternoon."

An interview with Employee E13, Licensed Nurse, on February 21, 2019, at 11:15 a.m. indicated that Resident R155 was not able to clearly communicate thoughts and feelings. Employee E13 further indicated Resident R155 would not be able to communicate she spilled tea on herself.

Observation of Resident R155's left thigh on February 22, 2019, at 9:20 a.m. in the presence of Employee E10, Registered Nurse, Certified Wound Nurse, it was revealed that "The hot water, puddled underneath Resident R155's left thigh, causing a second degree burn."

Review of facility documentation titled "Incident Accident Report" dated January 19, 2019, indicated that Resident R155 sustained an open blister measuring 9 centimeters by 6 centimeters as a result of hot tea spilling on Resident R155.

Interview with the Director of Nursing on February 25, 2019, at 10:30 a.m. confirmed that the facility did not complete a comprehensive investigation of an injury related to a burn. The Director of Nursing further indicated that the IDT (Interdisciplinary Care Plan Team- staff members from various departments) never reviewed the burn that occurred to Resident R155.

Additionally, during the interview the Nursing Home Administrator confirmed that the facility never came to a comprehensive conclusion of how Resident R155 sustained the second degree burn to the back of her left thigh.

The facility failed to complete a comprehensive investigation of an injury related to a burn.

Investigate/Prevent/Correct Alleged Violation
CFR(s): 483.12(c)(2)-(4) Previously cited 11/30/18, 04/23/18, 01/04/17

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/30/18, 04/23/18, 08/23/17, 03/20/17, 01/04/17

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 11/30/18, 04/23/18, 08/23/17, 01/04/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 11/30/18, 08/23/17, 01/04/17

28 Pa. Code 201.29(a) Resident rights
Previously cited 01/04/17

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.10(d) Resident care policies
Previously cited 10/16/17, 08/23/17, 01/04/17

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 11/30/18, 04/23/18, 10/16/17, 08/23/17, 01/04/17




















 Plan of Correction - To be completed: 05/01/2019

The accident and incident report for R155 was reviewed by the IDT to ensure comprehensive investigation was conducted and appropriate interventions put in place.
IDT re-educated to review all incidents and accidents at clinical meeting and review at weekly risk meeting and ensure notes are written and investigation complete.
NHA/ Designee will do audits weekly x 4 then Monthly x 3.
Any trends and findings will be reported in QA.

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

Based on a review of clinical records, review of facility documentation and interviews with staff, it was determined that the facility failed to develop and implement comprehensive care plans related to bed mobility, alcohol use and intravenous therapy for three of 39 residents reviewed (Residents R86, R120, and R350).

Findings include:

Clinical record review for Resident R86 revealed a quarterly Minimum Data Set assessment (MDS - a mandatory periodic resident assessment tool) dated January 2, 2019, indicating that the resident was admitted to the facility on January 7, 2013, with diagnoses including but not limited to, encephalopathy (brain damage), aphonia (loss of ability to speak), contractures (permanent shortening of a muscle or joint), respiratory failure, a feeding tube, and a tracheostomy (a surgically created hole in the trachea that allows for breathing). Continued review of the MDS revealed that Resident R86 was severely cognitively impaired, had impaired range of motion in all four extremities, and required the physical assistance of two or more persons for bed mobility, transfers and toileting.

Review of documentation submitted by the facility on February 5, 2019, at 1:43 p.m. revealed that on February 5, 2019, at 1:25 a.m. Employee E8, a nurse aide, was giving care to Resident R86 when the resident rolled over the side of the bed and landed on the floor mat. Review of facility documentation related to the incident revealed a witness statement from Employee E8 which indicated that she had turned Resident R86 onto her side to change the bed sheets and as she was putting a clean fitted sheet on the bed, the resident rolled over the side of the bed onto the floor mat.

Review of Resident R86's care plan on February 22, 2019, at 10:47 a.m. indicated that the last care plan review was completed on January 8, 2019. Continued review of the care plan revealed a focus area dated as initiated on February 3, 2013, and revised on November 6, 2015, which stated that the resident "has potential for skin breakdown related to immobility as evidenced by unspecified coma resulting in need for total assist of two for bed mobility." Continued review of the care plan revealed a focus area stating that the resident "is at risk for falls with injury" with an intervention dated February 5, 2019, for "Resident to have two persons assist for ADL (activities of daily living) care."

Interview on February 25, 2019, at 10:00 a.m. with Employee E5, Unit Manager, revealed that Resident R86's care plan was updated after the fall to include two person assistance with care.

Nurse aide documentation from February 6, 2019, through February 25, 2019, was reviewed with Employee E5 related to bed mobility for Resident R86. The documentation revealed that physical assistance of only one person was provided on 31 out of 53 shifts and occurred at least daily. Employee E5 was unable to explain why Resident R86 was still only receiving the assistance of one staff person and confirmed that the resident should receive the assistance of two staff persons during care.

An interview on February 25, 2019, at 10:06 a.m. with Employees E6 and E7, nurse aides, revealed that the nurse aide care plan (written instructions for nurse's aides which describes the specific care needs for each residents) does not indicate that Resident R86 requires the assistance of two staff members for care. Both nurse aides agreed that the resident's nurse aide care plan should include that information.

Interview on February 25, 2019, at 10:10 a.m. with the Assistant Director of Nursing (ADON) confirmed that the nurse aide care plan does not direct the nurse aides to provide two-person assistance with care and confirmed that Resident R86 required the assistance of two staff persons for care.

Clinical record review for Resident R120 revealed a quarterly MDS dated January 11, 2019, indicating that the resident was admitted to the facility on May 18, 2017, and was cognitively intact and had diagnoses, including but not limited to, anxiety, bipolar disorder (a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), schizophrenia (mental illness associated with loss of reality contact, delusions and hallucinations), and alcohol abuse.

Continued record review for Resident R120 revealed a physician's order dated December 28, 2017, indicating that the resident may not have alcohol and an order dated July 23, 2018, instructing staff "If observed to be using alcohol or acts intoxicated send to emergency room for alcohol level."

Review of progress notes dated October 19, 2018, at 6:11 p.m. revealed that Resident R120 was "noted to be intoxicated" and that he "declined being sent out for evaluation." The next note relating to Resident R120's behavior was dated October 20, 2018, at 4:10 p.m. approximately 22 hours later, and indicated that the resident was not exhibiting any behavioral problems.

Continued review of progress notes dated January 25, 2019, at 1:49 p.m. revealed that around 12 noon Resident R120 was observed by staff to be loud, with slurred speech, face red and "appears to be intoxicated." The next note relating to Resident R120's behavior was dated January 26, 2019, at 11:44 a.m. approximately 22 hours later and indicated that the lab work for a blood alcohol level could not be completed because the resident was not in his room.

Continued review of progress notes dated February 3, 2019, at 8:55 p.m. revealed that Resident R34 accused Resident R120 of touching her inappropriately on her arm. Review of social work notes dated February 4, 2019, revealed that Resident R34 reported to the social worker that Resident R120 "was intoxicated" when he touched her.

Review of a psychiatry evaluation dated February 5, 2019, revealed that the psychiatrist recommended to "encourage alcohol sobriety."

Continued review of progress notes dated February 12, 2019, at 8:45 a.m. and 10:00 a.m. revealed that Resident R120 refused drug and alcohol testing and that social work spoke with the resident regarding receiving assistance from Alcoholics Anonymous.

Review of Resident R120's care plan on February 25, 2019, at 10:30 a.m. with the Assistant Director of Nursing (ADON) confirmed that there was nothing in the care plan related to the resident's suspected alcohol use, his behaviors when he appears intoxicated and his refusals of drug and alcohol testing.

Clinical record review of physician's order dated February 9, 2019, revealed that Resident R350 was admitted to the facility with a PICC line in the right upper arm, and it was documented, from the hospital, that the PICC line catheter length was 42 cm (centimeters - 1 inch = 2.54 centimeters).

Further review of physician's order dated February 10, 2019, revealed diagnoses that included Sepsis (infection of the blood stream) due to Methicillin Susceptible Staphylococcus Aureus (MSSA- type of bacterial infection in the blood stream resistant to certain antibiotics), and Osteomyelitis (bone infection) of the vertebra (spinal column).

Continued review of Resident R350's physician order's revealed an order written on February 14, 2019, for Resident R350 to measure arm circumference every six hours as needed for discomfort. Measure arm circumference four inches above IV insertion site on admission, weekly with each dressing change and as needed if any discomfort. Further orders say to measure arm circumference every evening shift every seven days. Measure arm circumference four inches above IV insertion site on admission, weekly with each dressing change and prn if any discomfort; and measure external Catheter Length on admission, then with weekly dressing change every evening shift every seven days.

Review of Resident R350's care plans on February 26, 2019, at 2:00 p.m. revealed that the facility failed to develop a comprehensive care plan related to the proper monitoring and assessment of a PICC line that included changing, flushing, and measuring the PICC line.

The facility failed to develop and implement comprehensive care plans related to bed mobility, alcohol use and intravenous therapy.

Develop/Implement Comprehensive Care Plan
CFR(s): 483.21(b)(1) Previously cited 10/16/17

28 Pa. Code 211.5(f) Clinical records
Previously cited 04/23/18, 08/23/17, 04/20/17, 01/04/17

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


















 Plan of Correction - To be completed: 05/01/2019

R86 Care plan was updated to include assist 2 for Bed Mobility
R120 Care plan updated to address alcoholism.
R 350 Care Plan updated to include PiCC measurements and monitoring. PICC line discontinued.
Staff educated to update comprehensive care plan and ensure Nurse Aid Kardex reflects the interventions on care plan.
An audit of residents who are assist of 2 for bed mobility, alcohol use and IV therapy will be completed to ensure care plans are in place.
DON/designee will do random audits of residents care plans to ensure comprehensive care plans are updated and in place. Weekly x 1 than Monthly x 3.
Any trends and findings will be reported in QA.

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 review of clinical records, facility documentation, facility policy and procedure and staff interview, it was determined the facility failed to provide adequate assessment and monitoring for the care and maintenance of intravenous (IV- tube inserted through the skin into a vein to administer fluids and medications) catheter for one of 39 residents reviewed (Resident 350).

Findings include:

Review of the facility policy and procedure titled, "Central Vascular Dressing Change," (PICC- peripherally inserted central catheter - a form of intravenous access that can be used to administer medications or fluids for a prolonged period of time) dated 11/2018, indicated that dressings must stay clean, dry, and intact and that documentation of the date and time dressing are changed was to be recorded in the resident's medical record. Further review of the policy revealed that the arm circumference of residents with PICC lines was to be monitored; the external PICC line was to be measured weekly; report any signs and symptoms of complications to physician, supervisor and oncoming shift and to intervene as necessary.

Review of physician's order dated February 9, 2019, revealed that Resident R350 was admitted to the facility with a PICC line in right upper arm, and it was documented from the hospital that the PICC line catheter length was 42 cm (centimeters - 1 inch =2.54 centimeters).

Further review of physician's order dated February 10, 2019, revealed diagnoses that included Sepsis (bloodstream infection) due to Methicillin Susceptible Staphylococcus Aureus (MSSA- type of infection that is resistant to certain antibiotics), and Osteomyelitis (bone infection) of the vertebra (spinal column).

Continued review of Resident R350's physician's order revealed an order written February 14, 2019, for Resident R350 to measure arm circumference every six hours as needed for discomfort. Measure arm circumference four inches above IV insertion site on admission, weekly with each dressing change and as needed if any discomfort. Further orders indicated to measure arm circumference every evening shift every seven days. Measure arm circumference four inches above IV insertion site on admission, weekly with each dressing change and prn if any discomfort; and measure external Catheter Length on admission, then with weekly dressing change every evening shift every seven days.

Review of the Treatment Administration Records (TAR's- documentation that nursing completes indicating that a treatment was completed as ordered by the physician), revealed no indication that nursing was monitoring the length of the PICC line. There were no values in centimeters documented on the TAR for the length of the PICC line. Review of nurse's notes for February 10, 2019, did not reveal documentation that nursing was measuring the external PICC line every seven days as ordered by the physician.

Continued review of the clinical record revealed there were no comprehensive care plans developed for Resident R350 to specifically address the care of a PICC line.

Interview with Employee E9, Registered Nurse, on February 26, 2019, at 11:15 a.m. confirmed that there was no documentation of proper monitoring and assessment of the PICC line.

The facility failed to provide the necessary care and services related to proper assessment and monitoring of a PICC line for one resident.

28 Pa. Code 211.5(f) Clinical records
Previously cited 04/23/18, 08/23/17, 04/20/17, 01/04/17

28 Pa. Code 211.5(h) Clinical records

28 Pa. Code 211.10(c) Resident care policies
Previously cited 08/23/17

28 Pa. Code 211.11(c)(d) Resident care plan

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 11/30/18, 04/23/18, 10/16/17, 08/23/17, 01/04/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 11/30/18, 08/23/17, 01/04/17
























 Plan of Correction - To be completed: 05/01/2019

R350 PICC discontinued
Staff will be educated on the facility policy for proper assessment and monitoring of PICCs.
DON/ Designee will complete audits of residents receiving IV therapy via PICC audits will be done Weekly x 1 then Monthly x 2
Any trends and findings will be reported in QA.

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to maintain effective communication with a dialysis provider for one of five dialysis residents reviewed (Resident R84).

Findings include:

Clinical record review for Resident R84 revealed a physician's order dated December 11, 2018, for the resident to attend an outside dialysis provider (the process of removing waste products and excess fluid from the body) every Monday, Wednesday and Friday. Review of progress notes revealed that the resident attended dialysis three times every week, for a total of 34 dialysis visits. Review of the dialysis communication binder revealed six completed dialysis summaries and seven incomplete log entries.

During an interview on February 26, 2019, at 9:36 a.m. Employee E5 confirmed that Resident R84's dialysis communication log was incomplete.

The facility failed to maintain communication with a dialysis provider.

28 Pa. Code 211.5(f) Clinical records
Previously cited 04/23/18, 08/23/17, 04/20/17, 01/04/17

28 Pa. Code 211.12(c) Nursing services
Previously cited 08/23/17, 01/04/17

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 11/30/18, 08/23/17, 01/04/17






 Plan of Correction - To be completed: 05/01/2019

R84 dialysis summaries obtained and placed on chart
Staff educated to maintain communication with dialysis provider.
DON/ designee will do random audits of communication books will be done weekly x1 month then monthly x 3
Any trends and findings will be reported in QA.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on review of clinical records, observations, and resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurate for two of 25 resident records reviewed (R47 and R129).

Findings include:

Review of Resident R47's clinical record revealed diagnoses including Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), unspecified psychosis (a mental disorder characterized by a disconnection from reality), cerebra vascular accident (damage to the brain from interruption of its blood supply).

On February 22, 2019, at 9:32 a.m. review of R47's electronic physician order dated February 8, 2019, revealed an order for 'Full Code' (full code would prompt immediate life-saving emergency procedure - cardiopulmonary resuscitation -CPR). Review of R47's paper chart (medical record stored at the nursing station) revealed a POLST (Pennsylvania Orders for Life-Sustaining Treatment- a form that specifies the types of medical treatment that a patient wishes to receive towards the end of life) dated February 18, 2019, which read "DNR" (Do Not Resuscitate, or allow natural death).

Review of Resident R129's clinical record revealed diagnoses including unspecified psychosis, chronic kidney disease, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).

On February 22, 2019, at 11:41 a.m. review of R129's electronic physician order dated February 27, 2017, revealed an order for 'full code.' Review of R129's hard chart (medical record stored at the nursing station) revealed a POLST, undated that read 'DNR.'

Interview with the Assistant Director of Nursing on February 22, 2018, at approximately 10:05 a.m. revealed that the facility expectation was that all code status information would be updated and should match both in the electronic record and the hard charts.

The facility failed to maintain complete and accurate clinical records for two residents.

Resident Records - Identifiable Information
CFR(s): 483.70(i)(1)-(5) Previously cited 04/23/18, 08/23/17, 04/20/17

28 Pa. Code 211.5(f) Clinical records
Previously cited 04/23/18, 08/23/17, 04/20/17, 01/04/17











 Plan of Correction - To be completed: 05/01/2019

Residents 47 and 129 charts updated to reflect current code status.

Staff will be educated to ensure clinical records reflect the current code status of residents
Social Service/designee will audit residents' charts to ensure current code status is reflected.
During care conferences social services will update chart with any changes.
NHA/designee will do random audits following comprehensive assessments weekly x 1 month then Monthly x 3.


205.26(e) LICENSURE Laundry.:State only Deficiency.
(e) Equipment shall be made available and accessible for residents desiring to do their personal laundry.
Observations:

Based on interviews with residents and staff, it was determined that the facility failed to make equipment available and accessible for residents desiring to do their personal laundry.

Findings include:

Observation on February 26, 2019, at approximately 12:15 p.m. revealed that Resident R34
was visibly upset that she was not able to do her own laundry. Her clothes were now being sent to the facility laundry and she expressed that it was taking to long to have her clothes returned to her.

Interview with the resident at the time of the observation revealed that the laundry facility was located on a unit that was now closed and that residents do not have access to or were not informed about being able to use the laundry facility if available.

This was confirmed by the Nursing Home Administrator on February 26, 2019, at approximately 1:30 p.m.

The facility did not ensure that laundry equipment was made available to residents interested in
doing their personal laundry.











 Plan of Correction - To be completed: 05/01/2019

Laundry services will be made available for residents.
Resident council will be informed for the next 3 meetings that a washer and dryer have been made available to those interested and deemed safe to do their own laundry. R34 is president of resident council.
Audits of resident council minutes will be audited X3 to insure notification is made to residents



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