Nursing Investigation Results -

Pennsylvania Department of Health
TEL HAI RETIREMENT COMMUNITY
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
TEL HAI RETIREMENT COMMUNITY
Inspection Results For:

There are  46 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.
TEL HAI RETIREMENT COMMUNITY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey and a reportable event completed on March 5, 2019, it was determined that Tel Hai Retirement Community was not in compliance with the following requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.



 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on observation, clinical record review and staff interview, it was determined that the facility failed to maintain an environment that was hazard-free during medication pass on one out of two nursing units ( First floor nursing unit)

Findings include:

Review of clinic record for Resident, R50 revealed diagnoses of but not limited to: Vascular dementia with behavioral disturbances ( common form of dementia \ caused by impaired blood supply to brain which can lead to inappropriate behaviors) and Alzheimer's (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

Observations conducted during the initial tour of the First floor nursing unit, C wing on February 27, 2019, at approximately 4:55 p.m. revealed that Employee E3, Licensed Nurse, was exiting the Heather Gardens dining room with arms laden with treatment supplies and placing the supplies into the drawer of the treatment cart, which was positioned against wall outside of dining room. Surveyor observed Resident R50 propelling self haphazardly around the Health Gardens dining room. On a table near the door approximately 10 feet away from Resident R50, was a plastic medication cup.

Standing in the doorway of the Heather Gardens dining room with their back to the resident in the dining room was non-licensed Employee, E4. As non-licensed Employee, E4 started to walk out into hallway, licensed Employee, E3 turned to non-licensed Employee, E4 and ask that she watch medication cup in dining room.

Licensed Employee, E3 then re-entered Heather Gardens dining room, picked up clear plastic medication cup and proceeded to walk across the hallway to room C111, where he administered the medications to Resident R29.

Interview conducted with licensed nursing staff Employee, E3 on February 27, 2019 at approximately 5:00 p.m. confirmed that the clear plastic medication cup observed on a table in the Health Gardens contained medications mixed with applesauce. Employee E3 indicated that he just poured them. Employee E3 confirmed medications in the clear plastic cup were Coumadin 3mg (blood thinner to treat/prevent clots), Edecrin tablet 50mg ( for treating edema), and Ascorbic Acid 250mg (helps to maintain levels of vitamin C).

The facility failed to maintain an environment that was hazard-free during medication pass.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 3/1/18, 1/31/17

28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 1/31/17

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

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 1/31/17, 3/1/18





















 Plan of Correction - To be completed: 04/05/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed in accordance with Federal and State Law requirements

Resident R50's environment will remain hazard-free during medication pass,

Facility staff will ensure the environment for all residents will remain hazard-free during medication pass.

Licensed nursing staff will be educated to provide an environment free of hazards during medication pass.

Staff Development nurse or designee will conduct random environment audits weekly to ensure the environment is free of potential hazards during medication pass. Audit results will be forwarded the Quality Assurance Performance Improvement Committee until such time that committee determines compliance had been successfully demonstrated.

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 upon review of facility policy and procedures and observation, it was determined that the facility failed to maintain appropriate transmission based precautions for one of one resident reviewed (Resident #51).

Findings include:

Review of facility policy and procedure entitled "Clostridium Difficile (C-Diff)", revised November 2018 revealed "Residents with Clostridium Difficile [C-Diff - a contagious internal bacteria that causes chronic diarrhea] shall be placed on contact isolation." Further review of this policy revealed "Wear gowns and gloves when entering the resident's room even to care for the roommate the whole room is an isolation room."

Further review of this policy revealed "Employees shall wash their hands after resident and/or room contact".

Review of facility policy and procedure entitled "Transmission-based Precautions" revealed "Transmission-based isolation precautions will be used for residents with uncontained or suspected infectious material or communicable diseases that can be transmitted by airborne or droplet transmission or by contact with skin or contaminated surfaces. Transmission based isolation precautions are to be used in addition to Standard Precautions."

Further review of this policy revealed "Isolation precautions encompass the entire room due to the risk of potential exposure while in the room. Even if not working with the infected individual, but with the roommate." Further review of this policy revealed "Remove gloves before leaving the room and wash hands immediately or use a waterless antiseptic agent" and "wear a gown (clean, nonsterile) when entering room; remove the gown before leaving the resident's environment."

Review of Resident #51's diagnosis list revealed a diagnosis of Clostridium Difficile (C-diff).

Observation on February 28, 2019 at 9:53 a.m. of Resident #51's room revealed a housekeeper cleaning the residents' bathroom without wearing a cover gown. Further observation revealed the housekeeper left Resident's #51's room, removed the used, contaminated gloves in the hallway and entered another resident's room across the hall without washing hands.

Further observation on February 28, 2019 at 9:55 a.m. revealed a caregiver assisting Resident #51's roommate with getting dress. This observation further revealed that the caregiver was not wearing a cover gown or gloves while in the residents' room.

The facility failed to maintain appropriate transmission-based precautions while caring for a resident on contact isolation precautions.



28 Pa. Code 211.10(d) Resident Care Policies

28 Pa. Code 211.12(c) Nursing services
Previously cited 3/1/18

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




 Plan of Correction - To be completed: 04/05/2019

Resident 51's transmission-based precautions were discontinued on March 5, 2019

Facility staff will ensure appropriate transmission-based precautions are maintained while providing care for residents on contact isolation precautions.

Nursing staff and housekeeping staff will be educated on ensuring appropriate transmission-based precautions are maintained for residents on contact isolation.

Infection Preventionist or designee will conduct random on residents on contact isolation to ensure appropriate transmission-based precautions are maintained weekly. Audits will be forwarded to the Quality Assurance Performance Improvement Committee until such time that committee determines compliance had been successfully demonstrated.

201.29(k) LICENSURE Resident rights.:State only Deficiency.
(k) The resident shall be permitted to retain and use personal clothing and possessions as space permits unless to do so would infringe upon rights of other residents and unless medically contraindicated, as documented by his physician in the clinical record. Reasonable provisions shall be made for the proper handling of personal clothing and possessions that are retained in the facility. The resident shall have access and use of these belongings.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure documention regarding the disposition of resident's personal property for one of three closed clinical records reviewed. (Residents #116).

Findings include:

Review of the Resident #116's closed clinical record revealed that the resident was admitted on November 16, 2018, and was discharged on November 29, 2018. There was no documented evidence in the resident's closed clinical record to indicate the disposition of the residents personal belongings when discharged.

Interview with the administrator on March 5, 2019, at 11:30 AM confirmed that there was no documentation of the disposition of the residents belongings in Resident #116's clinical record.










 Plan of Correction - To be completed: 04/05/2019

Resident 116's family was contacted and confirmed residents belongings were in their possession.

All residents that discharge from the facility will have the disposition of personal property documented in the clinical record.

Licensed nurses and social services will be education that all discharged residents will have the disposition of personal property documented in the clinical record.

Social Service Coordinator of designee will conduct random audits to ensure discharged residents have the disposition of personal property documented in the clinical record. Audit results will be forwarded the Quality Assurance Performance Improvement Committee until such time that committee determines compliance had been successfully demonstrated

211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.
Observations:

Based on closed clinical record review and staff interview, it was determined that the facility failed to document the quantity and disposition of resident's medication following discharge from the facility for two of three residents reviewed (Residents #61 and #116).

Findings include:

Review of Resident #61's closed clinical record revealed that the resident expired in the facility on February 24, 2019. There was no documented evidence in the resident's closed clinical record to indicate the quantity of non-narcotic medications and their disposition following the resident's death.

Review of the Resident #116's closed clinical record revealed that the resident was discharged on November 29, 2018. There was no documented evidence in the resident's closed clinical record to indicate the quantity of non-narcotic medications and their disposition following the resident's discharge.

Interview with the administrator on March 5, 2019, at 11:30 a.m. confirmed that the quantity and disposition of Residents #61 and #116's non-narcotic medications were not included in the closed clinical records.

Facility failed to ensure that all medications at the time of discharge from the facility were counted and the method of disposition was indicated in the closed clinical record.












 Plan of Correction - To be completed: 04/05/2019

Residents 61 and 116 have discharged from the facility.

All residents discharged from the facility will have the quantity and disposition of the residents medications documented in the residents clinical record.

Licensed nursing staff will be educated on the proper documentation of the disposition of medications upon discharge.

The DON on designee will conducted audits weekly for discharged residents to ensure the quality and disposition of medications are documented in the resident's medical record. Audit results will be forwarded the Quality Assurance Performance Improvement Committee until such time that committee determines compliance had been successfully demonstrated


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