Nursing Investigation Results -

Pennsylvania Department of Health
TWINBROOK HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
TWINBROOK HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  66 surveys for this facility. Please select a date to view the survey results.

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TWINBROOK HEALTHCARE AND REHABILITATION CENTER - 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 completed on March 29, 2019, it was determined that Twinbrook Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and 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(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on review of clinical records and the Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual and staff interview, it was determined that the facility failed to ensure that Minimum Data Sets (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status for two of 27 residents reviewed (Residents R146 and Resident R56).

Findings include:

The RAI User's Manual, dated 10/2018, indicated that to complete Section N of the MDS, related to medications, the facility is to identify and code medications received during the seven day look-back period according to all categories/classifications assigned to the medication. The USP Pharmacological Classification of Drugs, a reference for identifying drug classifications referenced in the RAI Manual, indicates that Hydroxyzine is classified as an antihistamine (drug classification for allergies), anxiolytic (drug classification for anxiety) and antiemetic (drug classification for nausea/vomiting).

Resident R146's Admission MDS, dated 3/12/19, revealed an admission date of 3/05/19, with diagnoses including but not limited to anxiety, Parkinson's disease (a progressive nervous system disorder that affects movement), and depression. Section N0410B of the MDS, related to the number of days that an anti-anxiety medication was administered during the assessment period, indicated that Resident R146 did not receive medications for anxiety on any day during the assessment period.

Resident R146's clinical record revealed a physician order dated 3/05/19, for Hydroxyzine, 25 milligram (mg) tablets, 0.5 (1/2) tablet every 12 hours as needed for anxiety. The March 2019 Medication Administration Record revealed that Resident R146 received Hydroxyzine for symptoms of anxiety on two days during the assessment period (3/06/19 and 3/07/19).


The RAI Manual, dated 10/2018, indicated that to complete Section M of the MDS, related to pressure ulcers/injuries (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure), the facility is to review the medical record, including skin care flow sheets or other skin tracking forms, nurses' notes, and pressure ulcer/injury risk assessments and speak with direct care staff to confirm conclusions from the from the medical record review to identify the presence and assessment findings related to pressure ulcers/injuries.

Resident R56's Quarterly MDS, dated 2/07/19, revealed an admission date of 5/17/18, with diagnoses including but not limited to diabetes, obesity and respiratory failure. The MDS further indicated that Resident R56 had one unhealed Stage III pressure ulcer (full thickness skin loss).

Resident R56's clinical record included wound team notes that indicated during the 2/07/19, look-back period, Resident R56 had two Stage III pressure ulcers to the right heel, one to the lateral (side) and one to the inferior (lower) area.

During an interview on 3/28/19, at 2:30 p.m., Registered Nurse Assessment Coordinator Employee E7 confirmed that Resident R146's Admission MDS, dated 3/12/19, and Resident R56's Quarterly MDS, dated 2/17/19, were not correctly coded to reflect the residents' current condition.

483.20(g) Previously cited state deficiency 2/02/18

28 Pa. Code 211.5(g)(h) Clinical records
Previously cited 2/02/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 2/02/18

















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

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations, the center has taken or is planning to take the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been or are to be corrected by the date or dates indicated.

Resident #146 minimum data set was reviewed by the RNAC (Registered Nurse Assessment Coordinator) to accurately reflect the use of Hydroxyzine for anxiety. It was not coded as antianxiety due to classification of anti-histamine when doing the minimum data sets. The modification was completed and submitted.

Resident #56 most recent minimum data sets dated 2/7/19 was reviewed by the RNAC for accuracy regarding wound status. The MDS was modified and submitted by the RNAC to accurately reflect resident status.

An audit was completed by Nursing of assessments for residents who receive Hydroxyzine and residents who have wounds to ensure their most recent MDS accurately reflects their current status.

Regional MDS/Designee will in-service the RNAC (Registered Nurse Assessment Coordinator)in regards to Accuracy of Assessments.

A random weekly audit of 2 MDS will be completed by RNAC/designee from assessments submitted one month prior, weekly x4 then monthly x2, to ensure accuracy of MDS coding

Findings will be reviewed monthly x3 months at QAPI with IDT for further recommendations.

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 clinical records and facility policy and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written summary of the baseline care plan for four of 30 residents (Residents R36, R58, R146 and R345).

Findings include:

The policy entitled, "Care Plans- Baseline" dated August 16, 2018, revealed that a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight and that the resident and/or their representative would be provided a summary of the baseline care plan.

Resident R36's clinical record revealed an admission date of 6/27/18, with diagnoses to include but not limited to delusional disorder, dementia, diabetes and stroke.

The clinical record lacked evidence that Resident R36 or his/her representative were provided a written summary of the baseline care plan including initial goals for the resident, current medications and dietary instructions and services and treatments to be administered by the facility and personnel acting on behalf of the facility.

During an interview on 3/28/19, at 1:05 p.m. the Director of Nursing confirmed that there was no evidence to support that Resident R36 or their representative received a written summary of the baseline care plan.


Resident R58's clinical record revealed an admission date of 8/02/18, with diagnoses including but not limited to heart attack, brain damage due to lack of oxygen supply, high blood pressure, and history of choking on food.

The clinical record lacked evidence that Resident R58 or his/her representative were provided a written summary of the baseline care plan including initial goals for the resident, current medications and dietary instructions and services and treatments to be administered by the facility and personnel acting on behalf of the facility.

During an interview on 3/28/19, at 1:10 p.m. the Director of Nursing confirmed there was no evidence to support that Resident R58 or their representative received a written summary of the baseline care plan.


Resident R146's clinical record revealed an admission date of 3/05/19, with diagnoses including but not limited to Parkinson's disease (a progressive nervous system disorder that affects movement), anxiety and depression.

Resident R146's clinical record lacked evidence that Resident R146 or his/her representative were provided a written summary of the baseline care plan including initial goals for the resident, current medications, dietary instructions, and services and treatments to be administered by the facility and personnel acting on behalf of the facility.

During an interview on 3/28/19, at 1:31 p.m. Registered Nurse Employee E2 confirmed that there was no evidence in the clinical record to support that Resident R146 or their representative received a written summary of the baseline care plan.


Resident R345's clinical record revealed an admission date of 9/09/18, with diagnoses including by not limited to breast cancer, diabetes, cirrhosis of the liver, and high blood pressure.

Resident R345's clinical record review lacked evidence that Resident R345 or his/her representative, were provided a written summary of the baseline care plan including initial goals for the resident, current medications, dietary instructions, and services and treatments to be administered by the facility and personnel acting on behalf of the facility.

During an interview on 3/28/19, at 1:10 p.m. the Director of Nursing confirmed there was no evidence in the clinical record to support that Resident R345 or their representative received a written summary of the baseline care plan.


28 Pa. Code 201.18(a)(2) Management

28 Pa. Code 211.10(d) Resident care policies
Previously cited 2/02/18

28 Pa. Code 211.11(e) Resident care plan











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

Resident #36 #58 #146 #345 care plans were reviewed with the resident and/or family. The resident and/or family were provided a summary of the resident's current plan of care and the acceptance or declination of the copy offered was documented in the resident's medical record.

Residents currently residing in the facility with admission dates of January 1, 2019 to current were audited to ensure each resident and/or responsible party has received a copy of the resident's baseline or a summary of the comprehensive plan of care. In each case of missing entries the careplan or summary was provided and the acceptance or declination was documented in the individual's medical record.

New admissions will be audited the first business day after admission to ensure a baseline careplan has been developed. The resident and/or family will be contacted, encouraged to set up a care conference and if scheduled the copy will be provided during the conference or provided to the resident.

The Nursing Administration team was educated by the Regional Clinical Nurse Consultant regarding the baseline care plan policy.

An audit of 2 admission or care conference charts will be completed by DON to ensure care plans are being reviewed/provided and documentation is in medical records. Audits will be completed weekly x4 weeks then monthly x2, to ensure baseline careplans or summaries are provided and documentation is made.

Findings will be reviewed monthly x3 months at QAPI with IDT for further recommendations

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of clinical records and facility policy and staff interviews, it was determined that the facility failed to ensure a dietary recommendation was acted upon by the physician for one of 27 residents (Resident R71).

Findings include:

The facility policy entitled "Interdepartmental Notification of Diet (Including Changes and Reports), dated 8/16/18, indicated that nursing services will notify the physician and dietitian regarding nutritional problems (such as weight loss, pressure ulcers, eating problems) and shall collaborate with the dietitian and physician to initiate an appropriate process of clinical review of the nutrional problem.

Resident R71's clinical record revealed an admission date of 11/16/18, with diagnoses including but not limited to diabetes, pressure ulcers of the left buttock and sacral area (tailbone), and depression. Included in the clinical record, was a dietary note and "Diet Order and Communication" form, both signed by the facility dietitian and dated 2/01/19, indicating that Resident R71 had increased nutrient needs and recommended a fortified diet; a daily multivitamin with minerals, one by mouth daily; Zinc Sulfate 220 mg (milligrams) for 14 days then discontinue; Vitamin C 500 mg by mouth daily; and Pro Stat (a high protein liquid supplement), one packet three times daily related to Stage III pressure ulcer (full thickness tissue loss) of the sacrum.

Resident R71's clinical record, including current and discontinued physician orders, the "Diet Order and Communication" form, physician progress notes subsequent to the recommendation, and Medication and Treatment Records for February 2019 and March 2019, lacked evidence that Resident R71's physician reviewed the recommendation, or that the recommended diet and medications were instituted. Physician orders reflected Resident R71 was currently receiving a regular diet with a mechanical soft texture (a diet where foods are chopped, mashed or minced for easy chewing), thin/regular fluid consistency and a sugar free health shake twice a day, both with original order dates of 12/05/18.

During an interview on 3/28/19, at 10:43 a.m. the facility dietitian confirmed that he/she had made the recommendation for Resident R71 to receive a fortified diet and the additional medications identified on the communication form and that the clinical record lacked evidence that the physician had reviewed or acted on the recommendations.

During an interview on 3/28/19, at 12:30 p.m. Registered Nurse Employee E2 confirmed Resident R71's clinical record lacked evidence that the dietitian's recommendations dated 2/01/19, were provided to the physician for review.

28 Pa. Code 211.10(c) Resident care policies
Previously cited 2/02/18

28 Pa. Code: 211.12(d)(1(5) Nursing services
Previously cited 2/02/18












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

Resident #71 clinical record was reviewed and a dietician recommendation was noted. The physician office was notified and the order was obtained.

Residents who are identified with weight loss in the last 30 days were reviewed for outstanding dietary recommendations. Any outstanding recommendations were addressed per policy.

Dietician was educated per the Executive Director of Nutrition regarding using a log and providing recommendations/log to Nursing Administration for physician notification and obtaining orders.

Based on the Dietary recommendation log and the weekly weight meeting 2 charts will be audited per week for 4 weeks then 2 charts per unit per month for two months thereafter and as needed by the DON/designee to ensure physician notification and order entry have been documented.

Findings will be reviewed monthly x3 months at QAPI with IDT for further recommendations.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on review of facility policy and clinical records, observations and staff interview, it was determined that the facility failed to provide appropriate treatment to prevent potential complications related to a gastrostomy tube (g-tube - a tube inserted through a small incision in the abdomen into the stomach, used for the administration of liquid nutrition and medications) for one of four residents (Resident R145).

Findings include:

The facility policy entitled "Gastrostomy/Jejunostomy (a tube inserted through a small incision in the abdomen into the mid section of the intestine, used for administration of liquid nutrition and medications) Site Care," dated 8/16/18, indicated that care is to be provided to the gastrostomy or jejunostomy site per physician order to prevent irritation, breakdown and infection. The policy indicated soap and water are to be used to clean around the tube, working in a circular fashion being sure to clean under the bolster (a plastic disc surrounding the tube and adjacent to the skin to prevent migration of the tube).

Resident R145's clinical record revealed an admission date of 3/16/19, with diagnoses including but not limited to dysphagia (difficulty swallowing), Parkinson's disease, and a history of sepsis (a life threatening response by the body to infection). The clinical record also indicated the presence of a g-tube, inserted while in the hospital prior to admission to the facility. Resident R145's current physician orders, dated 3/16/19, included orders for Jevity 1.5 (a high calorie, nutritional liquid product) feedings through the g-tube, but did not include an order for care to the g-tube site. Resident R145's care plans included a "Surgical wound/site" care plan related to the g-tube with an intervention to administer treatment per physician orders and a goal to heal the area without complications.

Observations of Resident R145's g-tube site on 3/26/19, at 1:51 p.m. and on 3/28/19, at 2:33 p.m. revealed the skin under the g-tube bolster to be wet with red-brown drainage.

During an interview on 3/28/19, at 2:35 p.m., Licensed Practical Nurse Employee E6 confirmed that Resident R145's skin was wet under the bolster from drainage at the g-tube site and that there was no order or documentation that care was being provided to the area.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 2/02/18











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

Resident #145 clinical record was reviewed and PEG (Percutaneous Epigastric Tube) site was assessed, physician notified of the need for an order to provide PEG site care and order was obtained.

Residents with PEG (Percutaneous Epigastric Tube) tubes were identified. Their ostomy sites were assessed. Their care plans and orders were reviewed and any variances identified were corrected.

Nursing staff were educated regarding the policy for PEG tube site care by the DON/designee.

Residents admitted/readmitted will be assessed for feeding tubes and tube sites observed for any irritation, breakdown or infection . Their orders will be reviewed to ensure these devices have orders and care plans in place to ensure proper care delivery. Audits will be done weekly x4 weeks then 2x per month for 2 months to ensure ongoing compliance.

Findings will be reviewed monthly x3 months at QAPI with IDT for further recommendations.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on observations, review of clinical records and facility policies and staff interviews, it was determined that the facility failed to provide necessary complete respiratory care for two of 30 residents (Residents R58 and R347).

Findings include:

Review of facility policy "Departmental (Respiratory Therapy)- Prevention of Infection" dated 8/16/18, revealed that the distilled water used in the respiratory equipment must be dated and initialed when opened and discarded after twenty-four hours and that condensate (liquid form of steam or gas, which is considered infectious) must be drained into waste bottles, which must be marked with the resident's name and emptied into the toilet or hopper (industrial sink that enables the safe and hygienic disposal of clinical waste) at the end of the hall every shift.

Resident R347's clinical record revealed an admission date of 3/08/19, with diagnoses including but not limited to respiratory failure, diabetes, infection in the lung, bed sore, and bladder infection.

Observation on 3/26/19, at 12:45 p.m. revealed the distilled water bottle used in the respiratory equipment was not labeled with the date it was opened or initialed, and the condensate waste bottle was not labeled with Resident R347's name.

Observation on 3/28/19, at 11:32 a.m. revealed the distilled water bottle used in the respiratory equipment was not labeled with the date it was opened or initialed, and the condensate waste bottle was not labeled with Resident R347's name.


Resident R58's clinical record revealed an admission date of 8/02/18, with diagnoses including but not limited to heart attack, brain damage due to lack of oxygen supply, high blood pressure, and history of choking on food.

Observation on 3/26/19, at 2:09 p.m. revealed the distilled water bottle used in the respiratory equipment was not labeled with the date it was opened or initialed, and the condensate waste bottle was not labeled with Resident R58's name.

Observation on 3/28/19, at 11:24 a.m. revealed the distilled water bottle used in the respiratory equipment was not labeled with the date it was opened or initialed, and the condensate waste bottle was not labeled with Resident R58's name and was lying in a lined garbage can on the floor.

During an interview on 3/28/19, at 11:51 a.m. RN Supervisor Employee E2 and the DON confirmed that the distilled water bottles used in the respiratory equipment were not labeled with the dates opened or initialed and that the condensate waste bottles were not labeled with Residents R347 and R58's name and the condensate waste bottle should not be in the garbage can.



28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.12(d)(3) Nursing services

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 3/31/17, 1/26/17















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

Resident #347 and resident #58 entire set-up respiratory equipment were changed and labeled per policy. The residents had no signs or symptoms of respiratory distress or infection.

Orders were written to ensure nurses are checking, changing and labeling per policy for the identified residents. No other residents with tracheostomy tubes were identified as residing in the facility at this time.

Licensed nurses were in-serviced regarding the policy for preventing respiratory infections, including labeling components and not placing tubing in waste containers by the DON/designee

Residents admitted/readmitted will be assessed for tracheostomy tubes. Their orders will be reviewed to ensure these devices have orders and care plans in place to ensure proper care delivery. Audits will be done weekly x4 weeks then 2x per month for 2 months to ensure distilled water bottles used in the respiratory equipment and condensate waste bottles are labeled with dates opened or initialed. Also make sure the condensate waste bottles are not placed in the garbage can.

Findings will be reviewed monthly x3 months at QAPI with IDT for further recommendations

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for two of 30 residents (Residents R56 and R347).

Findings include:

The facility policy entitled "Medication Monitoring and Management," and the "Pain Assessment and Management" policies, both dated 8/16/18, indicated that as part of a pain management program, characteristics of pain and underlying causes are identifed, specific strategies identified and utilized for different levels and sources of pain and that when possible, non-pharmacological interventions are considered before initiating a new medication. The policy further indicated that pain documentation is to include adequate detail and in accordance with the pain management program.

During an interview on 3/26/19, at 2:50 p.m. Resident R56 indicated the presence of pain in the lower legs and stated that he/she received pain medication when requested but would like to talk to the doctor about getting scheduled pain medication due to the severity of the pain on occasion.

Resident R56's Significant Change Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), dated 3/07/19, revealed an admission date of 5/17/18, with diagnoses including but not limited to obesity, diabetes, and kidney and respiratory disease. The assessment further indicated that Resident R56 was cognitively intact (normal mental functioning) and indicated that he/she occasionally experienced pain that was rated as an "8" on a scale of "1 to 10" with 10 being the most severe, and that the pain interfered with sleep and daily activities. The assessment also indicated that Resident R56 received scheduled and "as needed" pain medication, but no "non-medication" interventions for pain.

Resident R56's care plan related to pain, last revised 2/26/19, included a goal for pain levels within acceptable limits and less than a six rating (scale of one to ten), after receiving pain medication. Interventions included to administer pain medication per physician orders, educate the resident and family, report gastrointestinal distress secondary to analgesia (the administration of pain medications), and report non-verbal expressions of pain. The care plan included no reference to the type, source or location of Resident R56's pain, no strategy to address pain except the administration of medication and included no reference to non-pharmacological interventions.

Resident R56's current physican orders, dated 3/16/19, included orders for Acetaminophen (Tylenol), 325 milligrams (mg), two tablets every four hours as needed for pain with non-pharmacological interventions of repositioning, back rubs, music, warm/cool compresses, diversional activity and "other-see progress notes;" Gabapentin Capsule (a medication impacting nerves involved with pain), 300 mg, one capsule two times a day for neuropathic (originating from the nerves) pain, swallow whole; and Oxycodone (a narcotic medication for moderate to severe pain), 15 mg tablets, one tablet by mouth every six hours as needed for pain rated as six to ten on a scale of ten.

Resident R56's March 2019 Medication Administration Record (MAR) revealed that from March 1, 2019, through March 28, 2019, Resident R56 received 43 doses of Oxycodone and one dose of Tylenol per physician order. On 37 of the 43 occassions that Resident R56 received Oxycodone, the clinical record lacked documentation related to the location or type of pain, or the use of non-pharmacological interventions prior to the administration of the medication. On the one occasion Resident R56 received Tylenol for pain during the month of March 2019, the record did not include information related to the location or type of pain, and listed six non-pharmacological interventions (reposition, back rub, music, warm/cool compress, diversional activity and "other-progress note," without indication which of the interventions had been implemented.

During an interview on 3/28/19, at 12:15 p.m. Registered Nurse Employee E2 confirmed that Residents R56's pain management program lacked comprehensive assessments of pain, non-pharmacological interventions and specific individualized pain strategies.



Resident R347's clinical record revealed an admission date of 3/08/19, with diagnoses including but not limited to respiratory failure, infection in the blood, diabetes, infection in the lung, and pressure ulcer. Physician's order dated 3/08/19, to give morphine sulfate 20mg/Ml- give 1 mL every four hours as needed for pain.

Resident R347's care plan entitled "Pain/Spasms Related to Immobility" dated 3/08/19, revealed an intervention to "implement non-drug therapies such as: to assist with pain and monitor for effectiveness of interventions" and lacked reference to what the resident specific list of non-drug therapies were.

Resident R347's March 2019 MAR revealed that Resident R347 received morphine once on 3/10/19, 3/14/19, 3/16/19, 3/18/19, 3/23/19 to 3/28/19, twice on 3/11/19, 3/12/19, 3/13/19, and 3/15/19. A numerical rating for pain level ranging from three (mild pain) to nine (severe pain) was documented prior to Resident R347 receiving the "as needed" doses of morphine. The MAR lacked documentation of the type and location of pain and that non-drug therapies were implemented or evaluated for effectiveness prior to administering the morphine as needed for pain.

Progress notes for R347 lacked documentation regarding the type and location of pain, and non-drug therapies implemented or evaluated for effectiveness on 3/10/19, 3/14/19, 3/16/19, 3/18/19, 3/23/19 to 3/28/19, twice on 3/11/19, 3/12/19, 3/13/19, and 3/15/19, prior to administering the morphine as needed for pain.

During an interview on 3/29/19, at 9:00 a.m. the Director of Nursing confirmed that there were no non-drug interventions documented on Resident R347's pain care plan or MAR and that there were progress notes with documentation related to administration of morphine.


28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 2/02/18










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

Resident R56 and Resident R347 orders were reviewed and a comprehensive assessment of pain, non-pharmacological interventions and specific individualized pain strategies were put in place.

Residents with PRN pain medication were identified, a comprehensive assessment of pain, non-pharmacological interventions and specific individualized pain strategies were put in place.

Nursing staff were educated regarding the use of non-pharmacological Interventions in pain management by the DON/designee.

Residents admitted/readmitted will be assessed for pain. Their orders will be reviewed to ensure non-pharmacological interventions and care plans in place to ensure proper care delivery.

Audits will be done weekly x4 weeks then 2x per month for 2 months to ensure
a comprehensive assessments of pain, non-pharmacological interventions and specific individualized pain strategies are in place,findings reviewed monthly x3 months at QAPI with IDT for further recommendations.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to document the rationale for continuing an order for a psychoactive (affecting the mind) medication, ordered on an as-needed (prn) basis, after 14 days for one of six residents reviewed (Resident R146).

Findings include:

The facility policy entitled "Medication Monitoring and Management", dated 8/16/18, indicated that if a medication seems unnecessary or harmful to a resident and a request is sent to the prescriber to evaluate the resident for the continued need for the medication, and the prescriber deems the medication necessary, he/she must document the clinical rationale for the benefit of, or necessity for the medication.

Resident R146's clinical record revealed an admission date of 3/05/19, and diagnoses including but not limited to Parkinson's disease (a progressive nervous system disorder that affects movement), anxiety and depression.

Resident R146's current physician orders included an order dated 3/05/19, for Hydroxyzine (a medication ordered for anxiety, nausea, or allergy relief), 25 milligrams (mg), give one-half tablet every 12 hours as needed for anxiety. The March 2019 Medication Administration Record revealed Resident R146 received six doses of the medication since admission (3/06/19; 3/07/19; 3/13/19; 3/19/19; 3/21/19; and 3/27/19.

Resident R146's clinical record included a "Note To Attending Physician/Prescriber," form from the consultant pharmacist, dated 3/26/19, related to Resident R146's PRN Hydroxyzine, and indicated "If use is greater than 14 days, please provide rationale." The Physician/Prescriber Response section of the form was blank.

During an interview on 3/28/19, at 12:15 p.m. Registered Nurse Employee E2 confirmed that the PRN Hydroxyzine order exceeded 14 days and was not evaluated for ongoing use by the physician.

28 Pa. Code 211.10(d)(1)(3)(5) Nursing services
Previously cited 2/02/18





















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

Resident R146 PRN psychotropic medication was discontinued as it was no longer necessary

An audit of orders was done and it was determined there were no other resident on PRN psychotropic medication

Residents admitted/readmitted with orders of PRN Psychotropic medication will be reviewed for ongoing use by the physician.

Licensed staff were educated regarding the use of PRN psychotropic medication by the DON/designee.

Audits will be done weekly x4 weeks then 2x per month for 2 months to ensure any resident/patient on PRN Psychotropic medication is reviewed within 14 days and evaluated for ongoing use by the physician, findings reviewed monthly x3 months at QAPI with IDT for further recommendations.

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 review of facility policy, observations and staff interviews, it was determined that the facility failed to assure that out-dated medications were discarded in a timely manner on two of five nursing units (South and Southeast Wings).

Findings include:

The facility policy entitled "Vials and Ampules of Injectable Medications", dated 8/16/18, indicated that injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use and disposal. The policy further indicated that staff are to place the date an injectable medication container is opened on the vial.

Manufacturer's recommendations for the use of Lantus (a long-acting injectable insulin administered to control elevated blood sugar levels) indicated that Lantus is not to be used after the expiration date on the medication, or 28 days after opening.

Observation of medication storage on the South Wing on 3/27/19, at 9:00 a.m. revealed a Lantus insulin pen labeled with Resident R38's name and an open date of 2/17/19 (38 days beyond open date), was present in the medication cart drawer.

During an interview at the time of the observation, Licensed Practical Nurse (LPN) Employee E4 confirmed the Lantus insulin pen was past the expiration date and should be discarded.


Manufacturer's recommendations for the use of multi-dose vials of Purified Protein Derivative (PPD - a combination of proteins, injected under the skin to determine exposure to tuberculosis) indicated that PPD is to be discarded one month after use/opening.

Observation of medication storage on the Southeast Wing on 3/28/19, at 9:55 a.m. revealed an open vial of PPD, without an open date on the vial, was present in the wing's medication refrigerator.

During an interview at the time of the observation, LPN Employee E5 confirmed the PPD vial was open and undated and needed to be discarded.

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

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 2/20/18








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

Expired Lantus insulin pen and undated PPD vial were disposed off

Medication storage areas were audited to ensure there were no expired and undated medications

Licensed staff were educated on ensuring proper medication handling and storage of medications by the DON/designee.

Audits will be done weekly x4 weeks then 2x per month for 2 months to ensure there are no expired and undated medications, findings reviewed monthly x3 months at QAPI with IDT for further recommendations


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