Nursing Investigation Results -

Pennsylvania Department of Health
ELLEN MEMORIAL HEALTH CARE CENTER-HONESDALE, INC.
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ELLEN MEMORIAL HEALTH CARE CENTER-HONESDALE, INC.
Inspection Results For:

There are  47 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.
ELLEN MEMORIAL HEALTH CARE CENTER-HONESDALE, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a MedicareRecertification, State Licensure, and Civil Rights Compliance Survey completed on February 8, 2019, it was determined that Ellen Memorial Health Care Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


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

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

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

Based on observations during a tour of the dietary department and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for microbial growth in food, which increased the risk of food-borne illness.

Findings include:

During the initial tour of the dietary department on February 5, 2019, at approximately, 9:30 a.m., with the CDM (Certified Dietary Manager), the following sanitation issues, with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

Six broken tiles on the dish room wall;

A box of bacon in the cooler was opened and undated;

The ice machine had two drains, but air gaps were not adequate; water was observed on floor around the ice machine;

Six roll-in cart coolers were observed with multiple calcium deposits around the floors, walls of the coolers were dirty, two coolers were missing metal on the inside of the doors revealing exposed styrofoam with deep gauges;

The fryer had a greasy handle;

There was grease with a floating brown substance on top fryer, which was last used on February 1, 2019. The CDM stated it that the grease should have been changed or discarded by this date;

The cook top on the stove had dirty particles, the insides of the ovens were dirty and greasy with old food items on door and the floor of the stoves all three ovens were not clean;

Streaks and food particles were observed on the inside door and walls of the convection ovens;

There were six 1/2 sheet pans stacked on top of each other and were observed wet on the inside;

The industrial can opener blade was coated with sticky food particles.

An observation on February 7, 2019 revealed that three 1/2 sheet pan were again stored wet on top of each other.

Interview with the Dietary Manager at this time, confirmed that these observations were food safety and sanitation concerns.


28 Pa. Code 211.6 (c)(f) Dietary services.
Previously cited 3/16/18

28 Pa Code 201.18(e)(6) Management
Previously cited 3/16/18






 Plan of Correction - To be completed: 04/09/2019

The issues identified during survey week have been corrected.

To prevent recurrence, dietary staff will be re-educated on appropriate labeling of open food items and cleaning of floors, walls, coolers, freezers, stoves, ovens, and other dietary equipment and when to discard grease. Education will also be given to make sure that sheet pans are not stacked when wet.

The dietician and certified dietary manager (CDM) will be responsible to conduct QA studies twice weekly to ensure that compliance is monitored with sanitation issues.
483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on a review of facility's infection control policies and procedures and staff interview, it was determined the facility failed to fully develop and implement an antibiotic stewardship program.

Findings include:

Review of the facility policy entitled "Antibiotic Stewardship Program" last reviewed by the facility on November 21, 2018, revealed that the facility has a program in place that promotes antibiotic stewardship and includes protocols and a system to monitor antibiotic use. The medical director, consulting pharmacist, nursing and administration and partnering laboratory will participate to provide leadership, support and accountability that focuses on improving antibiotic use by avoiding unnecessary or inappropriate antibiotics.

There were no protocols developed to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and to identify what infection assessment tools or management algorithms are used for one or more infections.

There was no process for periodic review of antibiotic use by prescribing practitioners. No protocols were developed to optimize the treatment of infections by ensuring residents receiving antibiotics are prescribed the appropriate antibiotic.

In an interview on February 7, 2019, at 1:15 PM, the Director of Nursing stated that the facility had not yet developed specific protocols relating to antibiotic use and was unable to provide evidence of a functioning antibiotic stewardship program in the facility at the time of the survey.

Refer F756

28 Pa. Code 211.12 (c) Nursing services
Previously cited 3/16/18

28 Pa. Code 211.10(a)(d) Resident care policies
previously cited 3/16/18



 Plan of Correction - To be completed: 04/09/2019

The facility is unable to correct the issues identified during survey.

To prevent recurrence, the facility policy on antibiotic stewardship will be revised.

Protocols will be included that will address protocols to address clinical signs and symptoms and lab reports to be reviewed to determine if antibiotic use is justified or if an adjustment in therapy should be made.
Management algorithms will be used for direction for treatment of infections. If a physician does not order antibiotics based on the algorithm,the RN supervisor will be responsible to document the physician response and justification.

Antibiotic use by prescribing physicians will be reviewed monthly by DON/designee and QA studies complete to ensure that antibiotics ordered are appropriate based on resident symptoms and algorithm.
483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(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 staff interview, it was determined that the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and the residents' representatives along with a copy of this notice sent to a representative of the Office pf the State Long-Term Care Ombudsman for eight of eight residents reviewed (Residents 69, 71, 77, 13, 74, 91, 85, and 97).

Findings include:

A review of the clinical record revealed that Resident 69 was admitted to the facility on December 19, 2018, and discharged to the hospital and admitted on January 8, 2019 and returned to the facility on January 12, 2019.

Resident 71 was transferred to the hospital on January 9, 2019, at 4:20 PM and returned to the facility at 7:45 PM He was transferred to the hospital again on January 19, 2019, at 12:15 AM and returned the same day at 6:15 AM. He was also transferred to the hospital on February 1, 2019, at 12:30 AM and returned the same day at 5:00 AM.

Resident 77 was transferred to the hospital on January 12, 2019, and returned to facility January 13, 2019.

Resident 13 was transferred to the hospital on January 7, 2019, and returned to facility January 10,2019.

Resident 74 was transferred to the hospital on December 17, 2018, and returned to facility December 20, 2018.

Resident 91 was transferred to the hospital on January 3, 2019, and returned to facility January 18, 2019.

Resident 85 was transferred to the hospital on December 23, 2018 and returned to the facility on December 28, 2018.

Resident 97 was transferred to the hospital on December 4, 2018, and did not return to the facility.

Further review of the clinical records of the above residents revealed no documented evidence that written notice was provided to these residents and their representatives regarding the transfers, that included the reason for the transfer, effective date of the transfer, location to which the resident was transferred, contact and address information for the Office of the State Long-Term Care Ombudsman, and if applicable, information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.

There were also no copies provided to a representative of the Office of the State Long-Term Care Ombudsman.

Interview with the DON (director of nursing) on February 9, 2019, at approximately 9:30 a.m. verified that the facility did not send written notices to the resident and the residents' representatives or representative of the Office of the State Long Term Care Ombudsman of the facility-initiated transfers of the above residents.


28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 8/11/17

28 Pa. Code 201.29 (a)(f)(g) Resident rights
Previously cited 8/11/17, 5/9/18, 7/5/18.






 Plan of Correction - To be completed: 04/09/2019

To correct the issues with residents cited in the survey, written notice of transfer to the hospital and reason for discharge will be provided to residents 69, 71, 77, 13, 74, 91, 85, and CR 97 and their representative.
The Office of the State Long term Care Ombudsman will also be notified.

To prevent recurrence, all residents who are transferred/discharged to the hospital and the resident's representative will receive written notification and reason for the transfer in writing and in a language and manner they can understand.
A representative from the Office of the State Long Term Care Ombudsman will be sent a copy monthly of all residents who were transferred to the hospital.

Education will be provided to licensed nursing staff, social service and business office staff on the facility policy on notification to the resident and their representative upon discharge/transfer to the hospital, and requirement to notify the State Long Term Care Ombudsman.

QA studies will be performed by Director of Social Services or designee weekly on all residents who were transferred/discharged to the hospital to ensure that written notice was provided to the resident and their representative and that the State Long Term Care Ombudsman was notified as per regulations.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and 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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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

Based on a review of clinical records and staff interview, it was determined that the facility failed to attempt dose reductions of psychotropic medications for two of five residents sampled (Resident 11 and 77).

Findings include:

A review of the clinical record revealed that Resident 11 was admitted to the facility on May 24, 2012, and had diagnoses that included anxiety, depression and senile and presenile dementia,

The resident had a physician's order, with an original date of May 27, 2104, for Diazepam (an antianxiety medication) 1 mg twice daily for anxiety; a physician order, originally dated May 8, 2014, for Paroxetine (an antidepressant) 10 mg daily for depression and a physician's order, with an original date of October 1, 2105, for Quetiapine (an antipsychotic medication) 50 mg daily .

A review of pharmacy recommendations dated April 30, 2018, revealed that the pharmacist requested that the physician evaluate the resident's current dose of Diazepam 1 mg twice daily and consider a gradual dose reduction. The physician response was no change "as previous documented adverse reaction to all prior reductions, one resulted in patient harm. Do not ask again." However, the facility was unable to provide documentation or dates of negative effects from a gradual dose reduction of Diazepam.

A review of pharmacy recommendations dated June 12, 2018, revealed that the pharmacist requested that the physician evaluate the resident's current dose of Paroxetine 10 mg daily and consider a (GDR) gradual dose reduction. The physician response was no changes, "prior GDR=adverse effects." The facility was unable to provide documentation or dates of previous GDR, which caused adverse effects.

Further review of the resident's clinical record revealed no evidence of a GDR attempt of the antipsychotic medication Quetiapine 50 mg in the past year.

A review of the clinical record revealed that Resident 77 was admitted to the facility on August 10, 2011, with diagnoses that included dementia with psychosis.

The resident had a physician's order, with an original date of July 24, 2016, for Sertraline (an antidepressant medication) 25 mg daily for dementia with psychosis and a physician order, originally dated May 18, 2016, for Risperidone (an antipsychotic medication) 0.25 mg daily for dementia with psychosis.

A review of pharmacy recommendations dated June 12, 2018, revealed that the pharmacist requested that the physician evaluate the resident's current dose of Sertraline 25 mg daily and consider a (GDR) gradual dose reduction. The physician response was no changes, "depression persists because she is unable to go home."

Further review of the resident's clinical record revealed no evidence that a gradual dose reduction was attempted for the Risperidone. 25 mg in the past year.

During an interview with the Assistant Nursing Home Administrator, and Director of Nursing on February 8, 2019, at 12:05 PM, it was confirmed there was no attempt of gradual dose reductions for the above psychoactive medications for Resident 11 and Resident 77.


28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.5(f)(g)(h) Clinical records
Previously cited 3/16/18

28 Pa. Code 211.9(a)(1)(k) Pharmacy Services

28 Pa. Code 211.12(c)(d)(3)(5) Nursing Services
Previously cited 3/16/18












 Plan of Correction - To be completed: 04/09/2019

The physician for resident 11 and resident 77 will be notified to request a dose reduction in their psychotropic medications.

Medical providers will be provided with regulations on use of psychotropic medication and dose reductions.

To prevent recurrence, all residents who receive psychotropic medications will be reviewed to ensure that reductions were attempted as per CMS guidelines or that appropriate justification is documented by the physicians that includes previous adverse effects of prior reduction and clinical justification for continued use.

QA studies will be completed monthly by DON/designee and Social Services to ensure that compliance is maintained regarding dose reductions or have appropriate clinical justification for continued use.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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.
483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:

Based on a review of clinical records and staff interviews it was determined that the facility failed to ensure that five residents' drug regimens were free of unnecessary drugs out of 20 residents sampled (Residents 1, 65, 14, CR1 and CR2 ).

Findings included:

A review of Resident 1's clinical record revealed an order dated September 30, 2018, to obtain urine culture and sensitivity and start Cipro 500 mg ( an oral antibiotic) by mouth, twice a day for 10 days.

A corresponding culture and sensitivity dated October 3, 2018, indicated that the resident's urinary infection was resistant to the physician ordered Cipro. The physician was contacted on October 3, 2018, and discontinued the Cipro and ordered Macrobid 100 mg, one by mouth twice a day for 10 days, to which the resident's infection was noted to be sensitive.

The medication resident's administration record dated September 2018 and October 2018 revealed that Resident 1 received 6 doses of the antibiotic, drug Cipro.

A review of Resident 65's clinical record revealed an order dated November 2, 2018, to obtain urine culture and sensitivity and start Cipro 500 mg ( an oral antibiotic) by mouth, twice a day for 10 days.

A corresponding culture and sensitivity dated November 2, 2018, indicated that the resident's urinary culture was negative for bacteria. The physician was contacted on November 6, 2018 and the physician discontinued the Cipro.

The medication administration record dated November 2018 revealed that Resident 65 received 8 doses of the antibiotic, Cipro.

A review of Resident CR1's clinical record revealed an order dated August 13, 2018, to obtain urine culture and sensitivity and start Cipro 250 mg ( an oral antibiotic) by mouth, twice a day for 7 days.

A corresponding culture and sensitivity dated August 16, 2018, indicated that the resident's urinary infection was resistant to Cipro. The physician was contacted on August 16, 2018, and discontinued Cipro and ordered Amoxil 500 mg, one by mouth twice a day for 10 days. The culture and sensitivity noted that the resident's infection was sensitive to the Amoxil.

The medication administration record dated August 2018 revealed that Resident CR1 received 5 doses of the antibiotic, Cipro.

A review of Resident CR2's clinical record revealed an order dated September 8, 2018, to obtain urine culture and sensitivity and start Cipro 500 mg ( an oral antibiotic) by mouth, daily for 7 days.

A corresponding culture and sensitivity dated September 10, 2018 indicated that the resident's urinary culture was negative for bacteria. The physician was contacted on September 11, 2018, and discontinued the Cipro related to the urine C & S results.

A review of the resident's medication administration record dated September 2018 revealed that Resident CR2 received 4 doses of the antibiotic, Cipro.

A review of Resident 14's clinical record revealed that the resident was prescribed Bupropion SR 150 mg daily February 2, 2016 and Mirtazapine 15 mg February 19, 2016.

Review of Pharmacy Recommendation dated February 17, 2018, revealed that the pharmacist requested that the physician provide justification for duplicate antidepressant therapy. There was no documentation from the physician showing the clinical justification for duplicate antidepressant therapy.

During an interview with the DON on February 9, 2019, at 11 AM, the DON confirmed that the administration of the above noted antibiotics and duplicate antidepressant therapy were not clinically justified.


Refer F881

211.12(c)(1)(3)(5) nursing services
previously cited 3/16/18

211.9(1) pharmacy services








 Plan of Correction - To be completed: 04/09/2019

The facility is unable to correct the issues cited during survey for Resident 1, CR1 and CR2.

The physician for resident #14 will be notified to consider a GDR or provide justification for continued use of dual antidepressants.

To prevent recurrence, licensed nursing staff will be educated on antibiotic stewardship and symptoms to reported to the medical providers to determine if antibiotic use is indicated. If the prescriber orders an antibiotic before culture results are returned or the antibiotic does not meet criteria, the RN receiving the order is to document the physician response as to the reason the antibiotic is to be initiated.

QA studies will be completed weekly by the DON/designee on all residents who receive antibiotic orders or who have duplicate antidepressant therapy to ensure that medications are clinically justified.
483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 20 sampled (Residents 27 and 44).

Findings include:

Review of the "Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) and identified as the facility's reference for completing Minimum Data Set Assessments, revealed that for the coding of Section H Bladder and Bowel, the facility would check all that apply for section H0100 Appliances.

A review of the clinical record of Resident 27 revealed the resident had a nephrostomy tube (a tube inserted directly into the kidney to drain the kidney of urine) used to relieve urine obstruction.

The resident's admission MDS Assessment dated November 9, 2018, indicated the resident had an external and indwelling catheter. A nephrostomy tube, as per the MDS definition, is an example of an indwelling catheter. Section H0100 was coded inaccurately whereas the section for indwelling catheter was coded along with external catheter.

According to the RAI User's Manual, Section O0500 for Restorative Nursing Program, the facility is to record the number of days each of the following restorative programs was performed (for at least 15 minutes a day) in the last 7 calendar days (enter 0 if none or less than 15 minutes a day).

A review of a clinical record of Resident 44 revealed that she was on a nursing restorative program for Active Range of Motion Bilateral Upper extremities and Bilateral Lower Extremities, 10 reps each.

A review of nurse restorative documentation dated December 2018 indicated that Resident 44 completed the goal of Active Range of Motion 10 reps each per day, 5 of the 7 days in the MDS assessment look back period. The corresponding quarterly MDS Assessment dated December 11, 2018, Section O0500 indicated that this resident did not receive any restorative nursing services for Active Range of Motion during the MDS Assessment look-back period.

Interview with the RNAC on February 5, 2019, at 1:00 PM confirmed that the facility failed to accurately identify the type of catheter present and restorative nursing services performed.


28 Pa. Code 211.5(f) Clinical records
Previously cited 3/16/18

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
Previously cited 3/16/18

















 Plan of Correction - To be completed: 04/09/2019

The MDS was corrected and resubmitted for resident 27.

To prevent recurrence, the RNAC department will be educated to record restorative nursing programs which meet the criteria of 15 minutes a day(as per RAI User Manual) on the MDS, and to accurately identify the type of catheter or appliance in use under Section H0100 on the MDS.

The RNAC will be responsible to conduct audits of MDS's completed to ensure accuracy of coding of restorative nursing programs and type of appliances in use under Section H0100.
483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interviews, it was determined that the pharmacist failed to identify drug irregularities in the drug regimen of one of 20 sampled residents (Resident 11).

Findings included:

A review of the clinical record revealed that Resident 11 was admitted to the facility on May 24, 2012, with diagnoses to include senile and pre-senile dementia.

At the time of the survey ending February 8, 2019, the resident had a current physician order, originally dated, October 2, 2015, for the antipsychotic drug Quetiapine 50 mg daily, for senile and pre-senile dementia.

A review of the monthly "Medication Regimen Reviews" conducted by the pharmacist from January 2018 through January 2019, revealed no indication that the pharmacist identified the absence of an attempt at a gradual dose reduction of the Quetiapine 50 mg daily during the last year.

Interview with the Assistant Nursing Home Administrator on February 8, 2019, at approximately 12;05 PM, confirmed that there was no evidence that the pharmacist had identified the lack of a gradual dose reduction attempt in 2018 and the continued use and dose of this antipsychotic medication.


28 Pa. Code 211.9 (k) Pharmacy services

28 Pa. Code 211.12 (c) Nursing services
Previously cited 3/16/18

































 Plan of Correction - To be completed: 04/09/2019

The facility is unable to go back and correct the issue cited in survey.


To prevent recurrence, the facility met with the consultant pharmacist to review the regulations on identifying lack of GDR's based on CMS regulation.

QA studies will be completed by the DON/designee on residents who are prescribed psychotropic medications every two weeks for two months to ensure that dose reductions are recommended as per regulations.

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