Nursing Investigation Results -

Pennsylvania Department of Health
WYNDMOOR HILLS HEALTH CARE & REHAB CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WYNDMOOR HILLS HEALTH CARE & REHAB CENTER
Inspection Results For:

There are  99 surveys for this facility. Please select a date to view the survey results.

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WYNDMOOR HILLS HEALTH CARE & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an abbreviated survey in response to three complaints, completed on April 6, 2019, it was determined that Wyndmoor Hills Healthcare and Rehabilitation Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements For Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.



 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

An initial tour of the Food Service Department was conducted on April 3, 2019 at 9:00 a.m. with Employee E3, Food Service Director (FSD), which revealed the following:

Observations in the receiving area revealed the side sliding black door to the large dumpster was left open, and there was a long florescent light fixture and florescent light bulb lying on the ground next to the dumpster. Further observation in the back hallway near the receiving door was an open door with a missing door closer which lead to a mechanical room that contained several large compressors with running motors that had moving parts with no protective covers.

Observations in the walk-in refrigerator revealed a white plastic Target bag with no label or date containing a hard Tupperware like plastic food container with no label or date which contained what appeared to be rice and pork.

Observations in the dish room revealed a build-up of dust, dirt and food and paper particles on the floor especially under the dish machine including dirty cups and silverware, and the top of the booster heater had a vinyl cover which had a layer of dust and dirt covering the top.

Interview with the FSD on April 3, 2019 at 9:15 a.m. confirmed the above findings and indicated that the unidentified food was likely one of the staff's lunch.

Observations on a follow up visit on April 5, 2019 at 12:12 p.m.to the caged storage area where emergency supplies are stored revealed the room had a cement floor which was covered with dust, dirt and debris including Styrofoam packing material under and around the racks where the emergency food and water were stored.

An interview with the FSD on April 5, 2019 at 12:15 p.m. confirmed the above observations.

The facility failed to store, prepare and serve food in accordance with professional standards for food service safety.


F812 Food procurement, store/prepare/serve-sanitary
CFR(s): 483.609i)(1)(2) previously cited 06/20/2018

28 PA Code: 201.14(a) Responsibility of licensee.
Previously cited 4/11/17, 1/20/17, 6/20/18

28 PA Code: 201.18(e)(1) Management.
Previously cited 4/11/17, 1/20/17, 6/20/18

28 Pa. Code 201.18(b)(3) Management
Previously cited 4/11/17, 1/20/17, 6/20/18



 Plan of Correction - To be completed: 05/15/2019

F812-F
1)Light bulb picked up immediately; sliding door to the dumpster was closed, white plastic bag removed-staff immediately in-serviced; Work order for missing door; dish room deep cleaned; New location for emergency food storage identified; no residents affected by deficient practices. No residents affected by deficient practice
2)Sanitation audit and outside area audit completed to ensure no other sanitation concerns were identified with corrections completed based on the findings.
3)Sanitation In- services completed and will be a part of new employee orientation program to assure compliance
4)Outside area rounds will be a part of daily work assignment as designated by Food Service Director, Complete kitchen audits will be completed daily by supervisors, and submitted to Food Service Director weekly to be reviewed in monthly Quality Assurance Performance Improvement Program times 3 months.
5)Corrective Action will be completed May 15, 2019

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observation, interviews with staff and review of facility documentation, it was determined that the facility failed to maintain an effective infection control program related to cleaning and disinfection of blood glucose monitors.


Findings include:

An observation on April 4, 2019 at approximately 11:35 a.m. with Employee E5, a licensed nurse, revealed Employee E5 preparing to perform an accu-check. Employee E5 disinfected her hands with hand sanitizer and donned clean gloves. Employee E5 then ripped open an alcohol swab and proceeded to wipe the outside of the meter with the disposable alcohol swab.

An interview on April 4, 2019 at approximately 11:45 a.m. with Employee E5 confirmed that Employee E5 did not have antimicrobial disinfectant wipes available on the medication cart and Employee E5 was not aware of the facility policy, "Blood Glucose Monitor /Prothrombin Time Meter Device Cleaning and Disinfecting for Single Resident Use."

An observation on April 5, 2019 at approximately 12:00 p.m. with Employee E6, a licensed nurse, revealed Employee E6 preparing to perform an accu-check. Employee E6 disinfected her hands with hand sanitizer and donned clean gloves. Employee E6 then ripped open an alcohol swab and proceeded to wipe the outside of the meter with the disposble alcohol swab.

An interview on April 5, 2019 at approximately 12:10 p.m.with Employee E6, a licensed nurse, confirmed that Employee E6 did not have antimicrobial disinfectant wipes available on the medication cart and Emplyee E6 was not aware of the facility policy, "Blood Glucose Monitor/Prothrombin Time Meter Device Cleaning and Disinfecting for Single Resident Use."

Review of Facility Policy, "Blood Glucose MonitorProthrombin Time Meter Device Cleaning and Disinfecting for Single Resident Use, created September 2013 and revised February 4, 2019, revealed, " Policy: The Blood Glucose Monitor/Protime equipment will be cleaned between resident use, utilizing a disposable disinfectant cloth. Meter is to be labeled with resident's name and stored in plastic baggie, also labeled withresident's name. Procedure: 1. Wash hands with soap and water, or usehand sanitizer. 2. Put on clean gloves. 3. Remove a disposable disinfectant cloth from the storage container. 4. Wipe the outside of the meter with the disposable disinfectantcloth. Avoidcoming in cotact with the electronic components and/or strip insertion area. 5. Place meteron protective surface and allow the meter to air dry. 6. Remove gloves.
7. Wash hands with soapand water or use hand sanitizer. 8. Repeat steps 1-7after use and prior to placing meter back into baggie.


The facility failed to maintain an effective infection control program related to disinfecting glucometers for two of two observed accu-checks by two licensed nurses.


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






 Plan of Correction - To be completed: 05/15/2019

F880-E
1)Employees E5 & E6 immediately in serviced; No residents affected by deficient practice
2)No other residents affected by deficient practice
3)In-services completed with licensed nurses on the facility blood glucose device cleaning and disinfecting policy and procedure.
4)Education/Competencies in place to be completed during new employee orientation for return demonstration in cleaning glucometer machines. Competencies' will be submitted weekly, along with random audits to Director of Nursing, to be reviewed monthly in Quality Assurance Performance Improvement Program times 3 months.
5)Corrective Action will be completed May 15, 2019


483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

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, facility policies and procedures, and interviews with residents and staff, it was determined that the facility failed to ensure that an alleged allegation involving suspected abuse was reported, as required, to the Department of Health for one of 26 residents reviewed (Residents R210).

Findings include:

Review of the facility policy, "Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property" dated May, 2013, stated that it is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property. Any employee who becomes aware of abuse shall immediately report to the Nursing Home Administrator (NHA), and the NHA or designee will report abuse to the state agency per State and Federal requirements.

Review of the clinical record for Resident R210 revealed an Admission Minimum Data Set assessment (MDS-a periodic assessment of needs) dated March 27, 2019, which revealed the resident had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment. Scores from the BIMS assessment suggest the following distributions: 13-15 cognitively intact; 8-12 moderately impaired; 0-7 severe impairment) score of 13, indicating the resident was cognitively intact.

An interview on April 3, 2019, at 11:05 a.m. with Resident R210 revealed that the resident had concerns about her caregiver, the Nursing Assistant, on the night shift who changed her early on the morning of April 3, 2019, stating that the aide was not very friendly, and when the resident asked the aide to put a pillow under her leg, the aide had a bad attitude and performed the task begrudgingly making the resident feel uneasy. Resident R210 also stated that she never wanted that aide to take care of her again.

During an interview on April 3, 2019, at 11:15 a.m. with Employee E4, Unit Manger for 3rd Floor, the concerns of Resident R210 were discussed and the Unit Manager indicated she would find out who the night shift aid was who had changed Resident R210 that morning and follow up with the resident and Director of Nursing (DON).

A follow-up interview with the Unit Manager on April 5, 2019, at 12:20 p.m. revealed that she had discussed the incident between Resident R210 and the night shift aide with the DON but had not heard back as to who the aide was who changed Resident R210 on the morning of April 3, 2019.

During an interview with the DON on April 5, 2019, at 2:15 p.m. the allegations made by Resident R210 that were presented to the Unit Manager on April 3, 2019 and subsequently followed up with the Unit Manager on April 5, 2019, were discussed with the DON and it was confirmed that aide in question was from an agency. The DON further stated that the agency was contacted and asked not to send that aide to the facility any more.

An interview on April 6, 2019 at 1:15 p.m. with the DON and NHA confirmed that the allegations by Resident R210 were not reported to the State Survey Agency.

The facility failed to report an incident of alleged verbal abuse to the Department of Health as required by federal and state regulation.


42 CFR 483.12(c)(1)(4) Reporting of Alleged Violations
Previously cited 07/10/17, 08/29/16, 04/11/17

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 06/14/16, 08/12/16, 04/11/17

28 Pa. Code 201.14(c) Responsibility of licensee
Previously cited 04/11/17

28 Pa. Code 201.18(b)(1) Management
Previously cited 05/09/16, 06/14/16, 06/24/16, 08/12/16, 04/11/17

28 Pa. Code 201.18(e)(1) Management
Previously cited 04/11/17

28 Pa. Code 201.29(a)(j) Resident rights
Previously cited 04/11/17

28 Pa. Code 211.10(d) Resident care policies
Previously cited 04/11/17

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 04/02/15, 05/09/16, 10/13/16, 04/11/17

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 04/02/15, 05/09/16, 04/11/17
















 Plan of Correction - To be completed: 05/15/2019

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

F609-D
1)R210 Concern form was investigated, allegation of abuse was submitted to and accepted by Department of Health Reporting System; Abuse In-service immediately completed
2)Concern Reports for previous 3 months were reviewed to assure , if any concerns needed to be reported that they were completed; No other residents affected by deficient practice
3)Staff will be educated on the facility abuse policy and reporting alleged allegations involving suspected abuse, as required, to the Department of Health
4)Resident Concerns will be reviewed during stand- up meeting, and allegations, whether unsubstantiated and/or substantiated will be reported to Department of Health as per policy. Concern Logs will be audited weekly by Social Services, audit will be submitted to Nursing Home Administrator and reviewed monthly in Quality Assurance Performance Improvement Program times 3 months
5)Corrective Action will be completed May 15, 2019

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 the clinical records and interviews with staff, it was determined that the facility did not develop a comprehensive person-centered care plan with measurable objectives and goals related to emergency care for bleeding at the access site for hemodialysis (a process of purifying the blood of a person whose kidneys are not working normally) for one of 26 records reviewed (Resident R21).

Findings include:

Review of Resident R21's clinical record revealed the resident was admitted to the facility on January 21, 2019, with a diagnosis to include end stage renal disease (when the kidneys are no longer able to work as they should to meet your body's needs).

A review of Resident R21's care plan completed on April 4, 2019 revealed no interventions listed under the hemodialysis care plan developed for the resident related to emergency treatment for bleeding at the hemodialysis access site.

Interview on April 5, 2019 at 2:00 p.m. with Nursing Home Administrator and Director of Nursing, confirmed that no care plan interventions were developed related to emergency treatment for bleeding or hemorrhage at the hemodialysis access site for Resident R21.

The facility failed to ensure that a comprehensive person-centered care plan was developed for one resident related to emergency care for bleeding at the access site for hemodialysis.

F656 CFR(s): 483.21(b)(1)develop/implement comprehensive care plan
previously cited 06/20/2018

28 Pa Code: 211.11(d) Resident care plan.
Previously cited 6/20/18

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 6/20/18, 4/11/17, 1/20/17



 Plan of Correction - To be completed: 05/15/2019

F656-D
1)Resident R21Comprehensive Care Plan was updated; Resident not affected by deficient practice
2)Hemodialysis comprehensive care plans were audited to assure emergency care were documented; No other residents affected by deficient practice
3) In-Services conducted for nursing staff on developing a comprehensive person-centered care plan with measurable objectives and goals related to emergency care for bleeding at the access site for hemodialysis.
4) Hemodialysis residents care plans will be reviewed in clinical upon admission/re-admission by nursing team to assure accurate completion of comprehensive care plans. Audits will be completed weekly by Unit Manager, submitted to Director of Nursing, and reviewed monthly in Quality Assurance performance Improvement Program times 3 months
5)Corrective Action will be completed may 15, 2019

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

Based on observations, interviews with staff, and a review of clinical records and facility policies, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous (IV-tube inserted into a vein) lines, for one of 26 residents reviewed (Resident R10).

Findings include:

Review of the facility's policy "PICC LINE CARE" dated May 14, 2016, stated it is the policy of Wyndmoor Hills to ensure that appropriate care is provided to all residents with PICC lines (IV tube inserted into a peripheral vein in the arm with the tip extended to the superior vena cave, a large vein returning blood to the heart) based on the current standards of practice.

Review of Resident R10's clinical record revealed that the resident was admitted to the facility on December 14, 2018, with a diagnosis to include acute embolism (obstruction of an artery) and thrombosis (coagulation or clotting of the blood) of deep vein in lower extremity.

Observation on April 3, 2018 at 1:30 p.m. revealed Resident R10 had a peripherally inserted central catheter (PICC) line to the resident's right upper extremity.

Review of Resident R10's physician orders revealed no physician order to measure the mid arm circumference of the resident right upper extremity or to measure the external PICC line at the insertion site to ensure the PICC line did not migrate from its intended position.

Further, review of Resident R10's clinical record on April 4, 2019, revealed no documented evidence that the resident's right upper extremity's arm circumference or the resident's external PICC line at the insertion site was measured.

Interview on January 5, 2018, at 2:00 p.m. with the Director of Nursing and the Nursing Home Administrator, where the above-mentioned findings were reviewed and who stated that they would look into it further.

The facility failed to measure the resident's right upper extremity's arm circumference and the external length of the PICC line at the insertion site.


28 Pa. Code 201.18(b)(1) Management
Previously cited 6/20/18, 04/11/17, 06/20/18

28 Pa. Code 201.18(b)(3) Management
Previously cited 08/12/16, 04/11/17, 06/20/18

28 Pa. Code 211.5(f) Clinical records
Previously cited 10/13/16, 04/11/17, 06/20/18

28 Pa. Code 211.12(c) Nursing services
Previously cited 05/09/16, 04/11/17, 06/20/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 10/13/16, 04/11/17, 06/20/18

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 05/09/16, 04/11/17

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 05/09/16, 04/11/17, 06/20/18





 Plan of Correction - To be completed: 05/15/2019

F694-D
1) R10 PICC Line circumference measurements were obtained and documented; resident not affected by deficient practice
2) Residents with PICC Lines reviewed, no other resident affected by deficient practice
3)In-Service completed with licensed nurses to ensure residents with PICC lines receives care and treatment in accordance with professional standards.
4)Residents with PICC lines will have their orders reviewed to ensure they are receiving care and treatment in accordance with professional standards during the clinical meeting. Unit managers will audit PICC line orders 3 times per week to ensure measurements are being documented. Audits will submitted to Director of Nursing to be reviewed in Monthly Quality Assurance Performance Improvement Program times 3 months
5)Corrective Action will be completed May 15, 2019


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