Nursing Investigation Results -

Pennsylvania Department of Health
ROSEWOOD GARDENS REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ROSEWOOD GARDENS REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  86 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.
ROSEWOOD GARDENS REHABILITATION AND NURSING 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 April 26, 2019, it was determined that Broomall Presbyterian Village 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 as they relate to the Health portion of the survey process.



 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on observations, clinical record review and staff interview, the facility failed to ensure residents dignity in one out of four units observed. (E wing)

Findings include:

On April 23, 2019, at 1:38 p.m., Resident #84 was observed in her bed. There was an uncovered urinary bag with yellow urine visible hanging from the side of the bed. At 5:02 p.m., urinary bag of Resident #84 was still observed uncovered.

Observations conducte on April 24, 2019, at approximately 11:03 am, revealed Resident #84 was in her bed, the urinary bag still uncovered with yellow urine, hanging from the side of the bed.

Interview with Employee E3 on April 24, 2019, at 11:07 am indicated that the catheter bag should be covered with a dignity bag and proceeded to place a dignity cover for the urinary bag of Resident #84.

Observation of the evening meal on April 23, 2019 revealed at 5:10 p.m. revealed the meals trays arrived on the E unit. Further observation revealed that by 5:15 p.m. all of the trays were delivered to the resident in the dining room. Residents #65 and Resident #124 sat with the meals in front of them from 5:15 p.m. until they were assisted by staff members to eat at 5:34 p.m. Further observations between 5:10 p.m. and 5:34 p.m. revealed three instanced where the residents who required help with eating were referred to as "feeders" by the staff and once when a clothing protector was referred to as a "bib."

Interview with the Nursing Home Administrator and Director of Nursing on April 26, 2019 at 1:30 p.m. confirmed that the residents were provided care without ensuring their dignity during meal time.

Observation of Resident #62 during all days of the survey revealed a bright neon pink sign posted above the bed stating, "honey thick liquids only provide all liquids by spoon." Interview with Licensed Nursing Employee E6 on April 25, 2019 at 9:20 a.m. confirmed that the sign should not have been posted.

Observation of Resident #111 during all days of the survey revealed a sign posted above the bed stating, "position pillow under Resident 111's left shoulder for extra support - wear splint on left hand 8-10 hours a day - OT (occupational therapy) Dept." Interview with Licensed Nursing Employee E6 on April 25, 2019 at 9:20 a.m. confirmed that the sign should not have been posted.


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

28 Pa. Code 201.29(j) Resident's rights



 Plan of Correction - To be completed: 06/10/2019

Preparation and/or execution of the Plan of Correction does not constitute admission by the providers of the truth of the facts alleged, or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared solely as a matter of compliance with federal and state law.

1. Resident 84 and 111 signage removed from rooms, dignity bag in place for resident 84 on 4/29/19. Resident 65, 124 and other residents identified during meal time did not have any complications related to observations.
2. Current residents in house room checks completed on 4/30/19 all signage removed, residents with Foley catheter have dignity bag in place.
3. All nursing staff to be educated on Dignity, Respect during meal time's room environment signage, and care of residents with Foley Catheters. Rehab staff to be educated on dignity and signage in resident rooms.
4. Weekly audits x4 then monthly audits x 4 of all residents' rooms by DON or designee to ensure no visible signage present, residents with Foley Catheters have dignity bags, and meal observations to ensure residents are treated with dignity and respect during meal time. Results of these audits will be reviewed at QAPI meeting for further recommendation as indicated

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(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 review of facility temperature log guidelines, observation and staff interview, it was determined that the facility failed to maintain the minimum standard holding temperature for hot food items in the main kitchen during tray line.

Findings include:

Review of the facility temperature log guidelines, undated, revealed that the minimum standard holding temperature for hot food items is indicated to be between 140 and 155 degrees Fahrenheit.

Observation of the tray line for the noon meal on April 25, 2019 at 12:30 p.m., when food temperatures were taken by the Director of Dining Services, revealed chicken breasts at a holding temperature of 130 degrees Fahrenheit which was below the minimum standard holding temperature indicated on the facility temperature log guidelines.

The internal temperature of the chicken breast was confirmed by the Director of Dining Services at the time of the observation.

The facility failed to maintain the holding temperature of chicken breasts at the minimum standard holding temperature.

28 PA Code 201.14(a) Responsibility of licensee
Previously cited 3/19/2018

28 PA Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 3/19/2018

28 PA Code 211.6(d) Dietary services
Previously cited 3/19/2018




 Plan of Correction - To be completed: 06/10/2019

1- The piece of chicken breast that was found to be below the proper holding temperature was discarded at that time. No impact on resident safety noted as a result of the temperature of the chicken.
2- Trayline temperatures will be obtained and recorded prior to service and random midway point checks will be completed by the supervisor weekly.
3- Staff will be in-serviced on appropriate standard holding temperature guidelines. Also, staff will be In-serviced on use of holding ovens and batch cooking to maintain proper standard holding temperatures.
4- Weekly audits X4, then monthly X4 of appropriate standard holding temperatures will be conducted by the food service director or designee. Findings will be presented at the QAPI meeting for further recommendations.

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

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

Based on review of the National Fire Protection Agency's (NFPA), observation and staff interview, it was determined that the facility failed to provide an environment free of accident hazards in the main kitchen.

Findings include:

Review of NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations states that open flames are not permitted in health care settings.

Observation of the kitchen tray line on April 25, 2019 at approximately 12:15 p.m., revealed chafing dishes (portable food warmers) being heated by sterno (fuel made from denatured and jellied alcohol) with an open flame used on the tray line.

Interview with the Director of Dining Services at the time of the observation confirmed that the chafing dishes had been used on the tray line since April 22, 2019. The Director of Dining Services further stated that the use of the chafing dishes was "temporary" as the steam table was broken and the replacement would not be available until later on April 25, 2019.

28 PA Code 201.18(b)(1) Management
Previously cited 3/19/2018

28 PA Code 207.2(a) Administrator's responsibility








 Plan of Correction - To be completed: 06/10/2019

1- The Steamtable was fixed on 4/24/19 and is functioning properly. All sternos have been removed from the building.
2- No impact on resident safety noted during the timeframe indicated.
3- All dining staff will be educated that open flames are not permitted in healthcare settings.
4- Discussion and review at QAPI meeting for further recommendations Monthly X4.

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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.
483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical record review and staff interviews, it was determined that the facility failed to complete a quarterly Minimum Data Set assessments timely for 23 of 58 residents reviewed (Residents 1, 3, 8, 9, 11, 12, 15, 16, 17, 19, 20, 21, 22, 27, 35, 37, 38, 39, 44, 45, 46, 47, and 56).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions for completing Minimum Data Set (MDS- assessments (mandated assessments of residents' abilities and care needs), dated October 2017, indicated that a quarterly assessment was to be completed within 92 days of the previous assessment's (any type) reference date.

Review of Resident 1's clinical record revealed that the last assessment was completed on December 3, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 3's clinical record revealed that the last assessment was completed on December 1, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 8's clinical record revealed that the last assessment was completed on December 3, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 9's clinical record revealed that the last assessment was completed on December 11, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 11's clinical record revealed that the last assessment was completed on November 19, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 12's clinical record revealed that the last assessment was completed on November 20, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 15's clinical record revealed that the last assessment was completed on November 21, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 16's clinical record revealed that the last assessment was completed on November 28, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 17's clinical record revealed that the last assessment was completed on November 29, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 19's clinical record revealed that the last assessment was completed on December 3, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 20's clinical record revealed that the last assessment was completed on December 5, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 21's clinical record revealed that the last assessment was completed on December 6, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 22 ' s clinical record revealed that the last assessment was completed on December 6, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 27's clinical record revealed that the last assessment was completed on December 7, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 35's clinical record revealed that the last assessment was completed on December 11, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 37's clinical record revealed that the last assessment was completed on December 14, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 38's clinical record revealed that the last assessment was completed on December 14, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 39's clinical record revealed that the last assessment was completed on December 15, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 44's clinical record revealed that the last assessment was completed on December 19, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 45's clinical record revealed that the last assessment was completed on December 20, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 46's clinical record revealed that the last assessment was completed on December 20, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 47's clinical record revealed that the last assessment was completed on December 21, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 56's clinical record revealed that the last assessment was completed on December 20, 2018. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on April 26, 2018, at 9:55 a.m. confirmed that a quarterly MDS assessment should have been completed for Residents 1, 3, 8, 9, 11, 12, 15, 16, 17, 19, 20, 21, 22, 27, 35, 37, 38, 39, 44, 45, 46, 47, and 56 within 92 days of the completion of their previous assessment.

28 Pa Code 211.5(f) Clinical records
Previously cited 3/19/18


28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 10/11/17









 Plan of Correction - To be completed: 06/10/2019

1- R1, 3, 8, 9, 11, 12, 15, 16, 17, 19, 20, 21, 22, 27, 35, 37, 38, 39, 44, 45, 46, 47, 56. Quarterly MDS assessments will be submitted by 5/10/19.
2- Audits will be done of all residents to assure that Quarterly MDSs assessments at a minimum have been completed.
3- In-services on RAI Manual Guidelines related to Quarterly MDS assessments and time frames will be provided to RNACs by Regional Clinical Specialist/Designee.
4- Audits will be completed by Regional Clinical Specialist/Designee on timely submission of Quarterly assessments, weekly x four, monthly x 3, then Quarterly or until compliance is achieved.

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 staff interviews and clinical record review, the facility failed to provide care and services related to diabetes (a disease characterized by long-term high blood sugar) on one out of 24 residents reviewed (Resident #104).

Findings include:

Interview conducted with Resident #104 on April 24, 2019, at 9:30 a.m. revealed that Resident # 104 went to dialysis (manual removal of waste and toxins from the body) every Monday, Wednesday and Friday. Resident #104 reported that her dialysis took approximately 3-4 hours. Further interview with Resident #104 revealed that there were times that she reminded staff to check her blood sugar, especially on dialysis days.

Review of Resident #104 diagnoses list revealed that that the resident's diagnoses included but was not limited to, diabetes (DM), hypertension (high blood pressure) and end-stage renal disease (ESRD-medical condition in which kidneys no longer function.).

Review of Resident #104 Minimum Data Set (MDS- assessment of resident care needs) dated March 5, 2019 identified the resident with a BIMS ((Brief interview for mental status) score of 15 out of 15 which place the resident as cognitively intact.

Review of Resident #104's physician's order dated March 8, 2019, revealed an order of sliding scale of Humalog U-100 Insulin (fast acting insulin) as follows: Blood sugar <70 or >400 notify MD; 201-250, 2 units; 251-300, 3 units; 301-350, 4 units; 351-400, 5 units three times daily (timed at 9:00 am, 1 pm, and 5 pm).

Review of April 2019 Medication Administration Record (MAR) revealed no documented evidence of the blood sugar results for 5:00 p.m. on the following dates: April 3, 11, 15, 17, 18, 21 and 22, 2019. On April 16, 2019 the blood sugar result was missing for 1:00 p.m.

Reviewof March 2019 MAR revealed missing blood sugar result for 5:00 p.m. on the following dates: March 11, 19, 20,25, 26 and 31, 2019

Interview with Director of Nursing on April 26, 2019 at approximately 1:30 p.m. confirmed that Resident #104's blood sugar monitoring for the 5:00 p.m. on March 11, 19, 20, 25, 26, 31, 2019; April 3, 10, 15, 17, 18, 21, 22 and on April 16, 2019, at 1:00 p.m. was not completed.

28 Pa Code 211.5(f) Clinical records
Previously cited 3/19/18

28 Pa Code 211.12(c)(d)(1) Nursing services
Previously cited 3/19/18



















 Plan of Correction - To be completed: 06/10/2019

1. Resident 104 blood glucose orders have been reviewed with physician and updated on 4/29/19 and are current to the resident's needs
2. Current residents in-house blood glucose results to be reviewed by 5/13/19 that they are complete with notification to physician with omission/refusal by the DON or designee.
3. All nursing staff will be educated on following physician orders and notification to physician with omission/refusal
4. Weekly audits x 4, then monthly audits x 4 of all residents with blood glucose monitoring will be completed by DON or designee to ensure they are complete with proper notification to physician for omission/refusal. Results of these audits will be reviewed at QAPI meeting for further recommendations as indicated.

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 policy review, clinical record review and staff interview, it was determined the facility failed to ensure that clinical records were complete and accurate for one of 24 residents reviewed (Resident 136).

Findings include:

Review of facility policy Weight Assessment and Intervention, effective date February 2019, revealed that when obtaining a resident's weight, staff would reweigh the resident if there was a 5 pound or more difference noted to verify the resident's weight before documenting it in the resident's record.

Review of Resident 136's weights revealed that on April 9, 2019, the resident was documented as weighing 207.4 pounds. On April 23, 2019, the resident was documented as weighing 262.2 pounds, a difference of 54.8 pounds. Further review of Resident 136's record failed to reveal that the resident was reweighed following the April 23, 2019 weight.

Interview with licensed nurse Employee E3 on April 26, 2019 at 9:30 a.m. confirmed that Resident 136's weight of 262.2 pounds on April 23, 2019 was documented in the clinical record incorrectly.

28 Pa. Code 211.5 (f) Clinical records
Previously cited 3/18/18
28 Pa. Code 211.12 (d)(1)(5) Nursing services
Previously cited 3/18/18




 Plan of Correction - To be completed: 06/10/2019

1. Resident 136 did not have any complications, weight updated and current no weight gain noted.
2. Current residents in-house will have weight done as per weight policy; weights will be reviewed for accuracy/completion by DON or designee.
3. All nursing staff will be in-serviced on the weight policy

4. Weekly audits x 4, then monthly x 4 reviewing all weights to ensure weights are timely and accurate by DON or designee. Results of these audits will be reviewed at QAPI for further recommendations as indicated.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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


Based on observations, interview and clinical record review, the facility failed to ensure that infection prevention and control program was maintained in one of four residents reviewed for infection control (Resident #84).

Findings include:

Review of Resident #84's care plan revealed that a care was developed on April 10, 2019 for urinary tract infection.

Observation conducted on April 23, 2019, at 1:38 p.m. of Resident #84 revealed that the resident was in her bed with an uncovered urinary bag hanging from the side of the bed, touching the floor. Further observation conducted on April 23, 2018 at 5:02 p.m. revealed the urinary bag was still observed touching the floor.

On April 24, 2019, at approximately 11:03 a.m., Resident #84 was observed in her bed, the urinary bag still hanging from the side of the bed touching the floor.

Interview with Employee E3 on April 24, 2019, at 11:07 am confirmed that urinary bag of Resident #84 should not be touching the floor.

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












 Plan of Correction - To be completed: 06/10/2019

1. Resident 84 did not have any complications with Foley bag on the floor.
2. Current residents in house will be assessed for proper placement of Foley catheter bag as per infection control policy.
3. All nursing staff will be in serviced on infection control practice with residents with Foley catheters.
4. Weekly audits x 4 then monthly x 4 of all residents in house with Foley catheters to ensure consistent infection control practice by DON or designee. Results of these audits will be reviewed at QAPI for further recommendations as indicated.


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