Nursing Investigation Results -

Pennsylvania Department of Health
TULIP SPECIAL CARE, LLC
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
TULIP SPECIAL CARE, LLC
Inspection Results For:

There are  4 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.
TULIP SPECIAL CARE, LLC - 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, and an Abbreviated survey in response to two complaints completed on April 6, 2019, it was determined that Tulip Special Care, LLC, 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:


483.40(a)(1)(2) REQUIREMENT Sufficient/Competent Staff-Behav Health Needs: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.
483.40(a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with 483.70(e). These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for:

483.40(a)(1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to 483.70(e), and
[as linked to history of trauma and/or post-traumatic stress disorder, will be implemented beginning November 28, 2019 (Phase 3)].

483.40(a)(2) Implementing non-pharmacological interventions.
Observations:

Based on review of medical records, facility documentation, and interviews with staff, it was determined that the facility failed to ensure that licensed nursing staff had completed training upon hire and annually thereafter related to mental and behavioral health.

Findings include:

Interview on April 4, 2019, at 4:30 p.m. with the DON and the Director of Human Resources, revealed that licensed nursing staff do not receive mental or behavioral health training upon hire or annually. Review of training records with the Director of Human Resources, revealed that Employee E7, RN, was hired by the facility on January 17, 2019, and that the Director of Human Resources confirmed that no mental or behavioral health training had been completed by Employee E7. Further interview with the Director of Human Resources revealed that none of the Registered Nurses or Licensed Practical Nurses received mental or behavioral health training upon hire as part of their orientation education.

Review of documentation submitted by the facility, signed by the DON and dated April 2, 2019, revealed that the facility identified having three residents in the facility with behavioral healthcare needs. Continued interview on April 4, 2019, at 4:30 p.m. with the DON indicated that the three residents identified were Residents R5, R21 and R28.


The facility failed to ensure that licensed nursing staff had completed education upon hire and ongoing related to mental and behavioral health.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 201.18(a)(b)(1)(3)(e)(1) Management

28 Pa Code 201.20(a)(c) Staff development

28 Pa Code 211.5(f)(g)(h) Clinical records

28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services














 Plan of Correction - To be completed: 05/24/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

The facilities immediate action plan concerning this I/J was accepted by DOH on April 6, 2019. The plan is outlined by DOH.

It is the goal of this facility to ensure facility staff complete training upon hire and annually related to mental and behavior health and know how to respond to residents expressing desire to die.

R22 no longer resides in the facility.

Full house education has been completed on identifying and acting on mental and behavior health needs.

All residents identified as having anxiety disorder or symptoms will be referred for Psych services. Nursing will be re-educated on behavior monitoring documentation.

The immediate action plan will be audited weekly x 4 months by the DON or designee.

Results to be monitored by the NHA.


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

Based on observations, interviews with residents, interviews with staff, and clinical record review, it was determined that the facility failed to develop a comprehensive person-centered resident care plan related to a wound for Resident R16 and intravenous catheters and mobility for Resident R91 and failed to implement comprehensive person-centered care plans related to medication administration for Resident R12 and communication language preferences for Resident R22 for four of 25 residents reviewed.

Findings include:

Observation of medication administration on April 2, 2019, at 8:34 a.m. for Resident R12 with Employee E8, Licensed Practical Nurse (LPN), revealed the resident being handed a medication cup containing four tablets to take from the nurse (aspirin 81 mg, famotidine 20 mg, folic acid 1 mg and metoprolol tartrate 25 mg tablets). The resident was observed to swallow all four tablets at the same time.

Observation during the medication administration on April 2, 2019, at 8.34 a.m. for Resident R12 with Employee E8, LPN, revealed a sign posted above the resident's bed with the words "take medications whole, one at a time, orally" and this was signed off by the Speech and Language Therapist, dated April 1, 2019.

Review of medical records for Resident R22 revealed a care plan for a language barrier with an intervention of the resident preferring to communicate in Spanish.

Review of medical records for Resident R22 revealed a progress note dated March 29, 2019, at 11:45 p.m. that stated, "Resident was educated on why she was receiving IV. Resident then kept trying to pull at IV tubing. Redirected resident with a positive effect."

Interview with Employee E7, Registered Nurse (RN) on April 4, 2019, at 1:20 p.m. revealed that on March 29, 2019, the nurse received a new order from the physician to hang intravenous fluids for Resident R22. Upon hanging the fluids, the nurse stated that the resident was confused and didn't want the intravenous tubing and that the resident always refused things and had a little problem speaking English. Employee E7 stated that she could not speak Spanish and educated the resident in English even though the resident's preferred language to communicate was Spanish. There was no evidence of any attempt to use a language line or Spanish speaking colleague to educate the resident.

Observation of wound care on April 2, 2019, at 8:50 a.m. revealed Employee E3, Registered Nurse, perform wound care to Resident R16's abdomen. During the observation, Employee E3 described the wound as surgical.

Clinical record review for Resident R16 revealed a skin report which indicated that the resident was readmitted to the facility on January 26, 2019, with a surgical wound to the upper mid abdomen. The report also indicated that on April 1, 2019, the wound measured 1 cm (centimeter) in length by 12 cm in width by 0.2 cm in depth.

Review of Resident R16's care plan on April 3, 2019, at 11:46 a.m., revealed that there was no indication or documentation of Resident R16's surgical abdominal wound on the care plan.

Interview on April 4, 2019, at 9:16 a.m. with the Director of Nursing (DON), confirmed that Resident R16's surgical abdominal wound was not documented on the care plan.

During an interview on April 1, 2019, at 2:15 p.m. Resident R91 stated that she wants to get out of bed to her wheelchair for a few hours each day, but that the staff don't offer to get her out of bed. Resident R91was observed to be in bed during the interview. Observation, at the time of the interview, revealed a sign, written on the whiteboard in the resident's room, to get the resident out of bed daily between 1:00 and 1:30 p.m. and to put the resident back to bed between 3:00 and 4:00 p.m.

Observation of intravenous line care on April 2, 2019, at 10:02 a.m. revealed Employee E4, Registered Nurse, flush Resident R91's midline (peripherally inserted catheter - a thin soft tube inserted in a vein in the arm), then administered antibiotics through the resident's midline.

During a follow-up interview on April 2, 2019, at 10:13 a.m. Resident R91 stated that she did not get out of bed yesterday, that she wanted to, and that staff did not offer to get her out of bed. Observation, at the time of the interview, revealed Employee E5, physical therapist, provided range of motion exercises to Resident R91 while the resident was in bed. Resident R91 asked Employee E5 to get her out of bed, and Employee E5 responded to the resident that the nurse aide should get her out of bed. Then Employee E5 stated to Employee E4, to please make sure that Resident R91 gets out of bed today.

An interview on April 3, 2019, at 10:24 a.m. revealed that Resident R91 again stated that she did not get out of bed yesterday, that she wanted to, and that staff did not offer to get her out of bed.

Review of therapy notes for Resident R91, revealed a physical therapy note, dated April 1, 2019, by Employee E5, which indicated that the resident requested to get out of bed and that the resident was educated by Employee E5 that the nurse aides would get her up. Continued review of therapy notes, revealed another physical therapy note, dated April 2, 2019, by Employee E5, which indicated that Employee E5 notified the nurse that Resident R91 wanted to get out of bed that day.

Review of Resident R91's care plan on April 4, 2019, at 9:38 a.m. revealed that the resident requires a mechanical lift and the assistance of two staff persons for transfers. Continued review of the care plan revealed no indication or documentation related to getting the resident out of bed to her wheelchair daily. Further review of the care plan revealed that there was no indication or documentation of Resident R91's midline on the care plan.

Interview on April 4, 2019, at 12:51 a.m. with the DON, confirmed that no care plan had been developed for Resident R91 related to her midline and for getting out of bed daily to her wheelchair.

The facility failed to develop and implement comprehensive person-centered resident care plans.

28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 211.5(f)(h) Clinical records

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

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services






 Plan of Correction - To be completed: 05/24/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

F0656
The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the department's direction to change conditions which the department alleges are deficient under state and federal regulation relating to long term care. This should not be construed as either a waiver of the facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or admission of wrong doing or admission of past and ongoing violations of state and federal regulation.

It is the goal of this facility to ensure we develop comprehensive person-centered care plans for our residents.

R16 Care Plan was updated with the wound; R91 Care Plan was updated to include IV & Mobility. R12 Care Plan was updated with specific Medication Administration, and R22 no longer resides in the facility.

Care Plan Policy has been educated to the Interdisciplinary team.

Care Plans will be audited weekly x4 months then at each interdisciplinary meeting to ensure all person center needs are addressed.

This will be audited by the RNAC/Designee and reported findings to the DON for corrective action.

The DON will oversee the process and report to the QAPI committee who will determine the need for further audits.

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 review of medical records, facility documentation, facility policy, video camera footage review and staff interview, it was determined that the facility failed to complete a thorough investigation for a resident who died unexpectedly in the facility for one of one resident reviewed (Resident R22).

Findings include:

Review of a facility policy titled, "Accidents and Incidents - Investigating and Reporting" dated April 1, 2018, revealed that all accidents or incidents occurring on the facility premises must be investigated and reported to the administrator. The policy further revealed that injuries of unknown origin must be fully investigated, and all incidents, accidents, unusual occurrences and events and injuries of unknown origin must have witness statements obtained.

Review of a facility policy titled, "Incidents and Accidents Document" dated April 1, 2018, revealed the facility will maintain documentation if incidents and accidents occur. The policy further revealed that incident reports will be completed as appropriate and the analysis, preventative plan, summary, determination and follow-up will be completed in a timely manner.

Review of a facility policy titled, "Incidents and Accidents Reports" dated April 1, 2018, revealed the facility will document all unusual occurrences and events, including injuries of unknown origin.

Review of the medical record for Resident R22 revealed an admission Minimum Data Set assessment (MDS - a mandatory periodic resident assessment tool), dated March 9, 2019, indicating the resident was admitted to the facility on March 2, 2019.

Review of facility documentation for Resident R22 and dated April 3, 2019, at 7:28 p.m. revealed the resident died due to injury, suicide or unusual circumstances while a resident in the facility on March 29, 2019. Review of progress notes revealed Resident R22 was pronounced dead on March 29, 2019, at 8:39 p.m.

Review of facility documentation on April 4, 2019, revealed the facility investigation into the death consisted of the following:
- A timeline created by the Director of Nursing (DON) detailing the events observed from camera footage from 4:00 p.m. until 11:41 p.m. on March 29, 2019;
- Statements from four members of the interdisciplinary care team (Employees E7, Registered Nurse [RN], E9, Licensed Practical Nurse [LPN], E10, Respiratory Therapist [RT] and E11, Nursing Assistant [NA]);
- A front sheet for Resident R22, printed from her electronic health record (EHR), and
- The code sheet (documentation of the life saving measures to try and save the resident during resuscitation).

Review of the facility timeline identified four employees by their initials: Employees E7, RN, E12, NA, E13, RN, and E14, NA. Of these, only Employee E7 had provided a written statement.

A complete listing of staff involved in the care of Resident R22 on March 29, 2019, between 4:00 p.m. and 8:39 p.m. that was provided by the facility on April 4, 2019, revealed:
- E7, RN - Statement obtained, listed on timeline, performed cardiopulmonary resuscitation (CPR - a medical technique for reviving someone whose heart has stopped beating by pressing on their chest and breathing into their mouth);
- E9, LPN - Statement obtained, not on timeline;
- E10, RT - Statement obtained, not on timeline;
- E11, NA - Statement obtained, not on timeline;
- E12, NA - No statement, listed on timeline;
- E13, RN - No statement, listed on timeline;
- E14, NA - No statement, listed on timeline;
- E15, LPN - No statement, not listed on timeline;
- E16, RT - No statement, not listed on timeline, performed CPR;
- E17, RN, Nurse Supervisor - No statement, not listed on timeline, documented the CPR;
- E18, NA - No statement, not listed on timeline, and
- E19, NA - No statement, not listed on timeline.

Interview on April 4, 2019, at 1:20 p.m. with Employee E7, RN, regarding the event the preceded the death of Resident R22 on March 29, 2019, revealed that in response to the question, "can you tell us what you saw when you entered the room to answer the call light?", the employee stated:
- "I entered the room, saw all the blood and ran out of the room to get help."

Review of the camera footage from the northeast hallway camera (the video shows the hallway leading up to Resident R22's room) for March 29, 2019, from 4:00 p.m. to 8:40 p.m., a timeframe that overlapped with the facility's investigation, revealed multiple discrepancies in the official timeline of events with the following being the most significant discrepancy:
- The facility timeline stated that on March 29, 2019, at 7:55 p.m. for Employee E7, RN: "Employee E7 returns to room and is observed running out of room towards nursing station looking for help and nursing staff respond." Review of the camera footage revealed that Employee E7, RN, spent 1 minute and 33 seconds in the room before seeking help.

Review of the facility's investigation timeline revealed that unlike other line items on the facility timeline where events spanned multiple minutes, this line was entered for 7:55 p.m. only. Review of the camera footage revealed that on March 29, 2019, at 7:55 p.m. and 46 seconds, Employee E7, RN, entered Resident R22's room and then at 7:57 p.m. and 19 seconds, Employee E7 exited Resident R22's room to seek assistance. The facility's timeline did not make note of the 1 minute and 33 seconds spent in the room by Employee E7. The facility did not provide any supplemental documentation that accounted for the time Employee E7 spent inside Resident R22's room prior to declaring an emergency situation.

Review of the statement provided by Employee E7, RN, on April 1, 2019, as part of the Nursing Home Administrator's investigation into the death of Resident R22 on March 29, 2019, revealed as stated, "this nurse went to check on resident and met her unresponsive with blood running under right arm. This nurse call for help and started CPR."

Review of medical records for Resident R22 revealed a progress note dated March 30, 2019, at 12:57 a.m. and written by Employee E17, Registered Nurse, Nurse Supervisor, in reference to the course of events leading up to the death of Resident R22 on March 29, 2019, that stated the resident was seen by a NA (nursing assistant) at 7:25 p.m. to 7:30 p.m., all was well and no issues were noted.

Interview with Employee E17, RN, Nurse Supervisor, on April 4, 2019, at 1:37 p.m. revealed that in response to the question, "in your progress note you mentioned a nursing assistant had been with the resident from 7:25 p.m. to 7:30 p.m. Can you tell us who that was?" The employee stated, "when I asked Employee E12 the CNA, what time was the last time you saw the resident, she said she went in, made her more comfortable by positioning her in the bed asked if she needed anything and told me everything was fine. At that time we were getting ready to send someone out to the emergency department, maybe she wasn't exactly right to the minute but she told me she went in at that time."

Interview with Employee E7, RN, on April 4, 2019, at 1:20 p.m. revealed that in response to the question, "in the progress notes it says Employee E12, NA, saw Resident R22 from 7:25 p.m. to 7:30 p.m. and she was OK. Did Employee E12, NA, tell you this?" The employee stated, "Employee E12 (a nursing assistant) saw the resident at that time - she said she went there to check, peeped in and the resident was OK."

Review of the camera footage from the northeast hallway camera (the video shows the hallway leading up to Resident R22's room) for March 29, 2019, from 4:00 p.m. to 7:56 p.m., a timeframe that overlapped with the facility's investigation, revealed as follows:
- Employee E19, NA, entered Resident R22's room at 5:32 p.m. and 14 seconds and remained in the room for 3 seconds.
- Between 5:32 p.m. and 17 seconds and the time Employee E7, RN, entered Resident R22's room at 7:55 p.m. and 46 seconds when she found the resident to be unresponsive and bleeding out, no other nursing assistants entered the resident's room.

Interview with the Director of Nursing on April 4, 2019, at 12:47 p.m. revealed the she had not investigated why Employee E17, RN, Nursing Supervisor, had written in the progress note for Resident R22 that a NA was in the room from 7:25 p.m. to 7:30 p.m. because upon her review of the camera footage she had not seen an NA walk into the room and stated that she knew the nurse must have been mistaken in her progress note documentation.

Interview on April 5, 2019, at 10:30 a.m. with Employee E20, Respiratory Therapy Manager, revealed that Resident R22 received continuous pulse oximetry monitoring (monitoring oxygen levels in the blood) and that the machine stores data for 72-hours. The interview also revealed that immediately after the machine had been cleaned following Resident R22's death, the machine was reassigned to another resident and all data had been written over by the time of interview on April 5, 2019.

Interview on April 5, 2019, at 11:11 a.m. with the Nursing Home Administrator revealed that the pulse oximetry data could have been useful in determining at what time Resident R22 started bleeding out, leading up to her death on March 29, 2019, at 8:39 p.m. The NHA revealed that a pulse oximetry machine located in the room formerly belonging to Resident R22 was a different machine.

The facility failed to thoroughly collect statements or interviews to allow the Nursing Home Administrator (NHA) to determine what actions were necessary (if any) for the protection of residents. Additionally, the facility failed to recognize and thoroughly investigate a significant discrepancy between a written witness statement, a timeline of events and video footage of the same event as well as failed to investigate a false statement indicating that a resident had received care when they had not received care. Furthermore, the facility failed to retain important information for a thorough investigation.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

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

28 Pa. Code 211.5(f)(g)(h) Clinical records





 Plan of Correction - To be completed: 05/24/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of this facility to ensure complete and through investigations of incidents.

R22 no longer resides in the facility.

The incident log will continue to be used to log each incident that occurs, to track completion of investigation, and statements. This log is utilized to track all incidents for all residents.

All Nursing staff will be re-educated on the Incident report process as well as the Resident abuse, involuntary seclusion and misappropriation of property policy.

An audit of incidents will be completed by the DON/Designee weekly for 4 weeksy and findings will be reported to the QAPI committee to determine the need for further audits.

This process will be overseen by the NHA

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers for three of 25 residents reviewed (Residents R6, R16 and R14).

Findings include:

Clinical record review for Resident R6 revealed a nurse's note, dated October 11, 2018, at 8:00 a.m. which indicated that the resident had a low oxygen level and was unresponsive. The resident was sent to the hospital emergency room via 911. There was no further documentation available in the record at the facility at the time of the survey to indicate that the Long-Term Care Ombudsman had been notified of the facility-initiated emergency transfer of Resident R6.

Clinical record review for Resident R6 revealed a nurse's note, dated November 17, 2018, at 8:14 a.m. which indicated that the resident had sepsis (a life-threatening condition caused by an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever). The resident was sent to the hospital emergency room via 911. There was no further documentation available in the record at the facility at the time of the survey to indicate that the Long-Term Care Ombudsman had been notified of the facility-initiated emergency transfer of Resident R6.

Clinical record review for Resident R6 revealed a nurse's note, dated March 8, 2019, at 1:10 a.m. which indicated that the resident had low hemoglobin (a protein in red blood cells that carries oxygen) and the possibility of influenza. The resident was sent to the hospital emergency room via 911. There was no further documentation available in the record at the facility at the time of the survey to indicate that the Long-Term Care Ombudsman had been notified of the facility-initiated emergency transfer of Resident R6.

Clinical record review for Resident R16 revealed a nurse's note, dated January 8, 2019, at 6:00 p.m. which indicated that the resident had a high fever and aspirated (breathed foreign objects into your airways) his feeding tube formula through his tracheostomy (a surgically created hole in your trachea that allows for breathing). The resident developed an unstable heart rate and oxygen saturations and was sent to the hospital emergency room via 911. There was no further documentation available in the record at the facility at the time of the survey to indicate that the Long-Term Care Ombudsman had been notified of the facility-initiated emergency transfer of Resident R16.

Clinical record review for Resident R14 revealed a nurse's note, dated March 22, 2019, at 8:09 a.m. which indicated that the resident experienced an autonomic storm (acute disorders of sympathetic function that result in alterations of body temperature, blood pressure, heart rate, respiratory rate, sweating, and muscle tone), had an elevated temperature and that the facility was unable to obtain prescribed laboratory studies. The physician ordered for the resident to be transferred to the hospital emergency room for evaluation. There was no further documentation available in the record at the facility at the time of the survey to indicate that the Long-Term Care Ombudsman had been notified of the facility-initiated emergency transfer of Resident R14.

During an interview on April 3, 2019, at 11:30 a.m. the Nursing Home Administrator stated that he was unsure if there was a process in place to notify the Office of the State Long-Term Care Ombudsman related to facility-initiated emergency transfers.

During an interview on April 4, 2019, at 9:00 a.m. the Director of Nursing confirmed that no documentation was available and that there was no current process in place to notify the Office of the State Long-Term Care Ombudsman related to facility-initiated emergency transfers.

The facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(2)(3)(e)(1) Management

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.5(f)(g)(h) Clinical records

28 Pa. Code 211.12(c)(d)(1)(3) Nursing services





 Plan of Correction - To be completed: 05/24/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of this facility to ensure we notify the Office of the State Long-Term Care Ombudsman of facility initiated emergency transfers.

The Office of the State Long-Term Care Ombudsman has been notified of the facility initiated transfer of R6, R16, & R14.

A policy and process was developed and educated to the DON/Designee and Social Services. A transfer report will be sent to the Office of the State Long-Term Care Ombudsman including all facility initiated transfers weekly or at a minimum monthly.

This will be audited Monthly by the NHA/Designee and findings reported to the QAPI committee.




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 clinical record review, review of facility policies and interviews with staff, it was determined that the facility failed to properly assess and monitor intravenous therapy (IV - therapy that delivers liquid substances directly into a vein) for one of 25 residents reviewed (Resident R22).

Findings include:

Review of facility policy, "Central Venous Catheter Care and Maintenance" dated April 1, 2018, revealed that routine dressing changes are done every seven days for central venous access devices, PICC lines and midlines (a thin soft tube inserted in a vein with the tip of the tube positioned in a large vein that carries blood to the heart).

Review of the admission MDS assessment (Minimum Data Set - a mandatory periodic resident assessment tool), dated March 9, 2019, revealed that Resident R22 was admitted to the facility on March 2, 2019, and had diagnoses including: kidney failure, low sodium, high potassium, depression, respiratory failure, mood disorder, obstructive hypertropic cardiomyopathy (a condition in which the heart muscle becomes abnormally thick), unspecified psychological development disorder, tracheostomy (a surgically created hole in your trachea that allows for breathing), and gastrostomy (feeding tube).

Clinical record review for Resident R22 revealed a chest xray, dated March 2, 2019, which indicated that the resident had a "right vascular line."

Review of Resident R22's care plan revealed that the resident receives intermittent hemodialysis (the process of removing waste products and excess fluid from the body; dialysis is necessary when the kidneys are not able to adequately filter the blood) related to kidney failure and that the dressing at the resident's access site should be checked and changed daily.

Continued review of Resident R22's care plan revealed that the resident had a right chest wall double lumen PICC and that the dressing should be changed as per policy.

Review of Resident R22's March 2019 Medication Administration Records (MARs) revealed a physician's order, dated March 15, 2019, to "Change double lumen PICC IV dressing, needleless connector (caps), measure external catheter length and circumference of arm 3cm (centimeters) above IV insertion site every week from the day of patient arrival to facility or as needed." The MARs indicated that this was completed on March 15, March 22, and March 29, 2019.

Continued of Resident R22's March 2019 MARs revealed a physician's order, dated March 14, 2019, for "Dressing change per policy for right chest wall dialysis site. Do not flush." The MARs indicated that this was completed on March 14, 21, and 28, 2019.

Continued clinical record review revealed that there was no additional documentation available in the record related to Resident R22's PICC line dressing changes and measurements or the chest wall dialysis site dressing changes.

During an interview on April 5, 2019, at 1:45 p.m. the Director of Nursing stated that there is no specific policy related to the care of permacaths (chest wall dialysis site) and that nurses are instructed to follow the Central Venous Catheter Care and Maintenance policy (as referenced above).

The facility failed to properly assess and monitor intravenous therapy.

28 Pa Code 211.5(f)(h) Clinical records

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

28 Pa Code 211.12(c)(d)(1)(5) Nursing services





 Plan of Correction - To be completed: 05/24/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of this facility to ensure facility staff properly assess and monitors IV Therapy

A Policy for Perma Caths for Dialysis has been put in place . Nurses have been educated on Policy.

R22 no longer resides in the facility.

Nursing staff have been educated that Dialysis Perma Caths are to be monitored daily.

Perma Cath Dressings will be audited weekly x 4 months to ensure dressing changes have been completed.

Residents with physician ordered IV catheters, including PICC lines will be audited weekly x 4 months by Nursing Management then randomly to ensure all elements of order is present and being completed, care planned and documented.

Licensed nursing staff will be re educated by DON/designee on obtaining complete physician orders for IV catheters, including PICC line and also associated documentation and care planning.

Physician orders will be reviewed in morning clinical meeting to ensure physician order is complete.

Any discrepancies will have corrective action and will be reviewed at monthly QAPI who will determine the need the need for further action.

This process will be overseen and monitored by the DON.


483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on interviews with residents, clinical record review, review of facility documentation and interviews with staff, it was determined that the facility failed to ensure that a newly admitted resident received their medications in a timely manner for one of 25 residents reviewed (Resident R87).

Findings include:

During an interview on April 1, 2019, at 11:17 a.m. Resident R87 stated that she was admitted to the facility on March 29, 2019, and that she did not get her medications.

Clinical record review for Resident R87 revealed a progress note dated March 29, 2019, at 5:38 p.m. which indicated that the resident arrived at the facility and was alert and oriented to person, place and time.

Review of Medication Administration Records (MAR) for March 2019 revealed Resident R87 was admitted to the facility on March 29, 2019, with diagnoses including: acute respiratory failure, tracheostomy (a surgically created hole in your trachea that allows for breathing), gastrostomy (feeding tube), chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe), Bipolar disorder (also known as manic depression, is a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior), and suicide attempt.

Continued review of the MAR for March 2019 revealed that the following medications were scheduled to be administered on March 29, 2019, at 9:00 p.m. but were not signed out nor documented as administered:
- Risperidone 2mg (milligrams) (a medication used to manage bipolar disorder)
- Bupropion 75mg (a medication used to treat depression)
- Clonazepam 0.5mg (a medication used to manage bipolar disorder)
- Famotidine 20mg (a medication used to treat reflux)
- Metoprolol 12.5mg (a medication used to treat high blood pressure)

Further review of the MAR for March 2019 revealed that the following medications were scheduled to be administered on March 29, 2019, at 10:00 p.m. but were not signed out nor documented as administered:
- Buspirone 10mg (a medication used to treat anxiety)
- Gabapentin 600mg (a medication used to treat nerve pain)

Continued clinical record review revealed that there was no additional documentation available in the record for review to indicate if the above medications had been administered.

Review of facility documentation related to the storage of emergency medications, revealed that following medications were available in the facility's Omnicell machine (electronic pharmacy machine that dispenses medications in the event a resident's medications are unavailable): risperidone, clonazepam, famotidine, metoprolol, and gabapentin.

Interview on April 4, 2019, at 11:05 a.m. with the Director of Nursing (DON), confirmed that Resident R87's medications were not documented as administered and that she should have received the medications that were available in the Omnicell machine as scheduled.

The facility failed to ensure that a newly admitted resident received her medications in a timely manner.

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

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services








 Plan of Correction - To be completed: 05/24/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of this facility to ensure residents receive their medications in a timely manner.
R87 received all further doses of medications as ordered.

Licensed staff has been reeducated on procedure to follow to ensure residents receive medications if they are not immediately available from Pharmacy.

New Admissions will be audited by Nursing Administration to ensure no missed doses.

Random audits of MARS will be conducted weekly x 4 months to ensure compliance with procedure.

Findings of audits will be reported to the QAPI committee who will determine the need for further audits.

This process will be overseen by the DON

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on observations, medical record review and resident and staff interview, it was determined that the facility failed to ensure that it was free of a medication error rate of five percent or greater.

Findings include:

Observation of medication administration completed on April 2, 2019, revealed 25 medication administration opportunities and two observed medication errors which yielded a medication error rate of 8%.

Review of medical records for Resident R12 revealed a physician order for the following medication:
- Vitamin D tablet 2000 unit give 2000 unit enterally in the morning for supplement, due at 9:00 a.m. every day.

Observation of medication administration with Employee E8, Licensed Practical Nurse (LPN), for Resident R12 on April 2, 2019, at 8:34 a.m. revealed the nurse did not dispense the vitamin D at the medication cart and did not administer vitamin D to Resident R12 when she took the remainder of her morning medications during the medication administration pass. When the nurse gave the resident her medications he only explained to the resident what two out of six tablets were (Vimpat 200 mg and Amox-clav 500 mg/125 mg tablets).

Review of medical records for Resident R12 revealed that Employee E8, LPN, signed out the April 2, 2019, at 9:00 a.m. dose of vitamin D as having been administered to the resident. The medical records also revealed that Resident R12 had a Brief Interview for Mental Status (BIMS - conducted periodically to assess cognition over time) score of 13 which means good cognitive functioning.

Interview with Employee E8, LPN, on April 2, 2019, at 9:36 a.m. revealed Resident R12 had earlier informed the nurse that she didn't want the vitamin D and that it was not given.

Interview with Resident R12 on April 2, 2019, at 12:08 p.m. revealed that she would never refuse vitamin D and assumed she had taken it with her other medications that the nurse had handed to her.

Review of medical records for Resident R19 revealed a physician order for the following medication:
- Fluticasone propionate 50 mcg per actuation spray suspension, one spray in each nostril two times a day for allergies, due at 9:00 a.m. and 9:00 p.m.

Observation of medication administration with Employee E4, Registered Nurse (RN), for Resident R19 on April 2, 2019, at 9:11 a.m. revealed the nurse handed Resident R19 the fluticasone propionate nasal spray and instructed him to spray two sprays in each nostril. The resident was observed performing two sprays in each nostril for a total of four sprays.

Interview with Employee E4, RN, on April 2, 2019, at 11:08 a.m. revealed confirmation that the nurse instructed Resident R19 to spray two sprays of the fluticasone propionate nasal spray in each nostril during the morning medication administration.

The facility did not ensure that it was free of a medication error rate of five percent or greater.

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

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services







 Plan of Correction - To be completed: 05/24/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

It is the goal of this facility to ensure it remains free of medication error rates greater than 5%.

E8 & E4 received 1:1 education. R12 & R19 are receiving medications per Physician orders.

Licensed Nurses have been re-educated on Medication Administration.

Random medication administration competencies will be completed by Nursing Administration weekly x 4 months with corrective actions as needed.

Results of competencies will be reported to the QAPI committee who will determine the need for further audits.

This process will be overseen by the DON/Designee

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 medical record review, video footage review and staff interview, it was determined that the facility failed to maintain complete and accurate medical records related to medication administration documentation and controlled substance records for one of 25 residents reviewed (Resident R22).

Findings include:

Review of the medical record for Resident R22 revealed an admission Minimum Data Set assessment (MDS - a mandatory periodic resident assessment tool), dated March 9, 2019, indicating the resident was admitted to the facility on March 2, 2019.

Review of the medical record for Resident R22 revealed the resident died while a resident in the facility and was pronounced dead on March 29, 2019, at 8:39 p.m.

Review of facility video footage for March 29, 2019, at 6:34 p.m. and 6 seconds revealed Employee E7, Registered Nurse (RN) entering Resident R22's room with intravenous fluids for Resident R22 and exited the room eight minutes and 42 seconds later.

Interview with Employee E7, RN, on April 4, 2019, at 1:20 p.m. revealed that when she went into Resident R22's room on March 29, 2019, with intravenous fluids and connected them to the resident.

Review of the Medication Administration Record (MAR) audit report for Resident R22 revealed that the physician's order for sodium chloride solution 0.9% was not signed off as administered until March 30, 2019, at 1:33 a.m. which was not at the time the medication was administered and was also after the resident had died. The audit report also revealed that the medication was not signed out as administered by the nurse who hung the medication (Employee E7, RN) but was signed out by the nursing supervisor (Employee E17, RN).

Review of the March 2019 MAR for Resident R22 revealed two physician orders for alprazolam 0.25 mg tablets, 1 tablet via tube every six hours as needed for anxiety. The first order was for March 13 to 21, 2019, inclusive and the second order was for March 21 to March 27, 2019, inclusive. Review of the electronic MAR revealed administrations of this medication on three occasions (two administrations on March 14 and one on March 17, 2019).

Review of the paper-based controlled medication utilization record for Resident R22 for March 13 to 27, 2019, revealed nine administrations of alprazolam on:
- March 14, 2019, at 2:00 a.m. (documented in electronic MAR);
- March 14, 2019, at 1:00 p.m.;
- March 14, 2019, at 9:00 p.m. (documented in electronic MAR);
- March 14, 2019, at 4:00 a.m. (duplicate date);
- March 17, 2019, at 4:30 p.m. (documented in electronic MAR);
- March 21, 2019, at 10:47 a.m.;
- March 24, 2019, at 9:00 a.m.;
- March 26, 2019, at 9:00 p.m., and
- March 27, 2019, at 9:00 p.m.

The facility failed to maintain complete and accurate medical records related to medication administration documentation and controlled substance records.

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

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(d)(1)(5) Nursing services







 Plan of Correction - To be completed: 05/24/2019

Preparation and execution of the plan of correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State law.

All nursing professionals have been reeducated on effectively maintaining complete and accurate medical records related to medication administration documentation.

Random audits of MAR's will be conducted weekly x 4 months by the DON or designee.

Findings of audits will be reported to the QAPI committee who will determine the need for further audits.

This process will be overseen by the DON



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