Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-POTTSVILLE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANORCARE HEALTH SERVICES-POTTSVILLE
Inspection Results For:

There are  112 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.
MANORCARE HEALTH SERVICES-POTTSVILLE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification and State Licensure Survey completed on May 10, 2019, it was determined that Manorcare Health Services - Pottsville 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:


483.80(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 the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to fully develop and implement an antibiotic stewardship program.

Findings include:

Review of the facility policy entitled "Antibiotic Stewardship" last reviewed by the facility on October 17, 2018, revealed that the policy failed to include evidence of the development of procedures designed to improve antibiotic use for the safety of residents.

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 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 May 10, 2019, at 11:45 AM, Employee 1, RN, the facility's Infection Control Nurse, stated that the facility had not yet developed specific protocols/procedures 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.





28 Pa. Code 211.12 (c) Nursing services
Previously cited 1/1/19, 5/2/19

28 Pa. Code 211.10(a)(d) Resident care policies
previously cited 1/18/19, 5/2/19















 Plan of Correction - To be completed: 05/27/2019

1. Responsibility of antibiotic stewardship activities is a shared responsibility between the center medical director, director of nursing and infection preventionalist and consultant pharmacist. The medical director will serve as the antibiotic stewardship champion to promote adherence to clinical practice guidelines for antibiotic prescribing, acts as a resource for nurses and other providers; provides education to prescribers regarding antibiotic stewardship. The DON and IP will act as clinical antibiotic stewardship champions to promote nursing assessment, communication and documentation. Consultant pharmacist will serve as antibiotic stewardship champion to review antibiotic utilization and assist the center in evaluating antibiotic patters, make recommendations regarding antibiotic prescribing practices, conducting medication regimen reviews, reviewing microbiology culture results and monitoring adverse drug events. The antibiotic stewardship committee will meet prior to the date of compliance and at least quarterly to review antibiotic utilization, identify trends and develop and monitor improvement through performance improvement plans.
2. New admissions and current residents with infections have the potential to be affected by the deficient practice. Utilizing the "Infection" QAPI tool the DON/designee will audit antibiotics from 5.10.2019 current to ensure compliance with antibiotic stewardship.
The Medical Director will serve as an antibiotic stewardship champion to promote adherence to clinical practice guidelines for antibiotic prescribing.
3. To ensure the deficient practice does not recur the infection preventionist and licensed nurses will be educated on Focus on F-tag 881 and McGeer's criteria. The Infection preventionist, DON, Medical Director and Consultant pharmacist will be educated by the quality assurance consultant on antibiotic stewardship, Focus on F-tag 881, McGeers criteria and the centers antibiotic stewardship committee guidelines.
4. Utilizing the "Infection" QAPI tool residents requiring antibiotics will be audited weekly x4 by the DON/designee to ensure compliance. Results will be reviewed with QA&A.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations and staff interview, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and sanitary environment for two of three nursing units (First and second floor).

Findings include:

An observation on May 8, 2019, at 12:15 PM of the first floor nourishment room revealed a black mold-like substance on the floor of the cabinet under the sink

An observation on May 9, 2019, at 11:30 AM of the first floor nourishment room revealed the floor under the ice machine was littered with paper, debris, and dirt. The ice machine drain pipe, above the drain in the floor, was observed to have black material on the inside and outside of the pipe.

An observation on May 9, 2019, at 11:40 AM of the second floor Arcadia dining and activity room revealed the outside of the cabinets were dirty and the surface was sticky to the touch.

An Interview with the Nursing Home Administrator on May 10, 2019, at approximately 3:00 PM confirmed that the environment was to be maintained in a sanitary manner to provide a clean, comfortable and homelike environment.


28 Pa. Code 207.2 (a) Administrator's responsibility.
Previously cited 1/18/19, 5/2/19









 Plan of Correction - To be completed: 05/27/2019

1. The first floor nutrition room sink was cleaned to remove the black mold-like substance on the floor of the cabinet under the sink. The first floor nourishment the floor under the ice machine was cleaned and the drain pipe black material was cleaned on both the inside and outside. The second floor Arcadia dining and activity room cleaned the outside of the cabinets.
2. Utilizing the "Housekeeping" QAPI tool the NHA/designee will audit all nourishment rooms and dining areas to ensure adequate cleanliness on or before the date of compliance.
3. To ensure the deficient practice does not recur, housekeeping staff and maintenance will be educated by the NHA/designee on the focus on F-tag 584 the federal regulation on or before the date of compliance.
4. Utilizing the "housekeeping" QAPI tool the NHA/designee will audit nourishment rooms and dining rooms 3/weekly x4 week to ensure appropriate cleanliness. The results will be reviewed with QA&A.

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 manufacturer drug information and staff interview it was determined the facility failed to accurately assess clinical need and effectively monitor the use of a neurological drug for three residents (Residents 19, 43 and 26) and failed to the necessity of antibiotic usage for one (Resident 54) out of 28 sampled.

Findings include:

A review of the manufacturer's product information for Nuedexta revealed that this medication has not been tested in other types of emotional lability for example Alzheimer's disease and other dementia's and may cause serious side effects, including possible changes in heart rhythm. Electrocardiographic evaluations should be conducted at baseline and 3-4 hours after the first dose. Neurologic disorder causing involuntary emotional outbursts include crying or laughing episodes, incongruent or exaggerated to patient's inner mood, usually occurs several times per day and the episodes last from seconds to minutes.

A review of the clinical record revealed that Resident 19 had diagnoses of vascular dementia without behavioral disturbances and heart disease.

A review of the clinical record review revealed that on June 11, 2018, Resident 19 was prescribed a medication (Nuedexta) 20-10 mg daily x 7 days then twice daily for 90 days, to treat Pseudobulbar Affect (PBA- a neurological condition characterized by frequent involuntary outbursts of crying and/or laughing). A physician's order, dated September 28, 2018, indicated to continue the Nuedexta 20-20 twice a day,

A review of a physician progress note dated September 10, 2018, failed to reflect a diagnosis of PBA and behaviors exhibited by the resident related to this diagnosis requiring the use of Nuedexta.

Resident 43 had a diagnosis of Alzheimers disease and unspecified right bundle-branch block (Bundle branch block is a condition in which there's a delay or obstruction along the pathway that electrical impulses travel to make your heart beat).

A review of the clinical record review revealed that on July 16, 2018, Resident 43 was prescribed the medication Nuedexta 20-10 mg at hour of sleep for one week then twice a day for 90 days for PBA. The resident continued on the same dose at the time of the survey ending May 10, 2019.

A review of a physician progress note dated July 16, 2018, failed to identify a diagnosis of PBA and behaviors exhibited by the resident that would warrant the use of Nuedexta.

Resident 26 was admitted to the facility on May 21, 2016, and had diagnoses, which included heart failure, dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) without behavioral disturbance, anxiety and Alzheimer's disease (decline in brain function which causes memory loss and causes brain tissue to breakdown).

A review of the clinical record revealed a correspondence to the physician from Employee 5 an LPN (licensed practical nurse) dated September 25, 2018 which read "Resident is still having behaviors where she is crying and yelling one minute then laughing and having a good time the next. When this happens she is usually in the hall. She looks just like the commercial on T.V. for PBA, please advise." The physician responded on September 26, 2018, and ordered Nuedexta 20/10 mg one tablet by mouth at bedtime for one week then twice a day.

The resident was also receiving Depakote 125 mg (mood stabilizer) by mouth three times a day and Celexa 30 mg (antidepressant) one time a day. The resident currently remained on Nuedexta 20/10 mg by mouth twice daily at the time of the survey ending May 10, 2019.

The physician's progress note dated September 27, 2018, indicated that the resident "appears to have PBA and is quite labile." The physician also indicated that the resident had high blood pressure, chronic kidney disease with elevated blood levels and severe aortic stenosis. No diagnostic studies such as an EKG or laboratory values were completed prior to the initiation of Nuedexta according to manufacturer's directions.

Interview with the director of nursing on May 9, 2019, at 1:12 PM, confirmed that Residents 54, 89 and 26 were prescribed Nuedexta for PBA. The DON was unable to provide documented clinical justification for the use of the Nuedexta or that diagnostic testing was conducted prior to the use of the medication and then 3 to 4 hours after the first dose of the medication was administered according to manufacturer's directions.

A review of the clinical record revealed that Resident 54 was admitted to the facility on November 30, 2018, with diagnoses to include dementia.

Nursing documentation dated April 3, 2019, at 1:13 PM revealed a physician order for a urinalysis and culture and sensitivity (a test to find germs (such as bacteria) in the urine that can cause an infection and the right medicine for treating the infection) and to begin Ceftin (an antibiotic medication) 500 mg by mouth, twice a day for 10 days.

Nursing documentation dated April 5, 2019, at 8:22 PM, revealed that a urinalysis and culture and sensitivity report was received. The results were reported to the physician and a new physician order was noted to discontinue the Ceftin 500 mg by mouth twice daily for 10 days.

A review of the lab results report dated April 5, 2019, revealed 10,000 to 40,000 col/ml , mixed bacterial growth, consistent with urogenital and/or skin flora (indicative of no bacterial infection in the urine).

A review of the resident's medication administration record dated April 2019 revealed that Resident 54 received four doses of the Ceftin 500 mg, from April 4 and 5, 2019.

During an interview May 10, 2019 at approximately 12 pm, the Director of Nursing confirmed that the antibiotic drug was started prior to receiving the laboratory results reports and Resident 54 received four doses of unnecessary antibiotic medication.



Cross refer F881

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services
Previously cited 1/18/19, 5/2/19

28 Pa. Code 211.9 (k) Pharmacy services
Previously cited 1/18/19, 5/2/19

28 Pa. Code 211.2(a) Physician services
Previously cited 1/18/19

28 Pa. Code 211.5(f)(g)(h) Clinical records
Previously cited 1/18/19










 Plan of Correction - To be completed: 05/27/2019

1. R 19, R 43, R 26 will have a drug regimen review completed by the physician. R 54 was evaluated and has no ill outcome from the antibiotic usage.
2. New admissions and current residents receiving neudexta or receiving antibiotics have the potential to be affected. Utilizing the "unnecessary medication" QAPI tool the DON/designee will audit residents on Neudexta and antibiotics for clinical need and appropriate monitoring.
3. The Quality Assurance Consultant will educate the licensed nurses on ATB Stewardship on or before the date of compliance.
The Quality Assurance Consultant will educate the nursing management on Focus on F tag 757 on or before the date of compliance.
The DON will review with the medical director and prescribing physicians the manufacturer's product information for Neudexta, as well as antibiotic stewardship on or before the date of compliance.
4. Utilizing the "unnecessary medication" audit the DON will audit 5 residents weekly x 4 weeks who are on Neudexta or antibiotics. The QAA committee will validate corrections.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on review of clinical records, employee health records and staff interview, it was determined the facility failed to provide nursing services consistent with professional standards of quality according to Title 49, Professional and Vocational Standards during the tuberculin skin testing for four of five employees reviewed (Employees 13, 14, 15 and 16) and two of 28 residents sampled (Resident 81 and CR1)

Findings include:

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: 21.145(e) "The LPN may administer immunizing agents and do skin testing only if the following conditions are met: (3) Written policies and procedures under which the LPN may administer immunizing agents do skin testing have been established by a committee representing the nurses, the physicians and the administration of the agency or institution employing or having jurisdiction over the LPN. A current copy of the policies and procedures shall be provided to the LPN at least once every 12 months. The policies and procedures shall provide for: (i) Identification of the immunizing and skin testing agents which the LPN may administer; (ii) Determination of contradictions for the administration of specific immunizing and skin testing agents; (iii) The listing, identification, description, and explanation of principles, including technical and clinical indications, necessary for the identification and treatment of possible adverse reactions; (iv) Instruction and supervised practice required to insure competency in administering immunizing and skin testing agents."

A review of the facility's current guidelines entitled "Tuberculosis Screening" indicated that a two step Mantoux ( tuberculosis screening by a injection under the skin) test is administered, per physicians orders, to patients within 24 hours of admission in order to establish a reliable baseline and read within 48-72 hours of administration and step 2 is administered 1-3 weeks after reading the first step.

The guideline failed to identify if a licensed practical nurse or registered nurse was to administer and read the tuberculin skin tests.

Further review of the facility's TB policy, failed to reflect the requirements of the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) that the policies and procedures shall provide for: (i) Identification of the immunizing and skin testing agents which the LPN may administer; (ii) Determination of contradictions for the administration of specific immunizing and skin testing agents; (iii) The listing, identification, description, and explanation of principles, including technical and clinical indications, necessary for the identification and treatment of possible adverse reactions.

A review of Employee 13's health record revealed that she received step one, of the two step PPD skin test (PPD -Purified Protein Derivative - a solution used to test for Tuberculosis, a potentially serious infectious bacterial disease that mainly affects the lungs) on April 11, 2019. The test was administered by Employee 4 (LPN- Licensed Practical Nurse). Employee 5 (LPN) administered a second step PPD to Employee 13 on April 20, 2019.

A review of Employee 14's health record revealed that she received step one, of the two step PPD skin test (PPD -Purified Protein Derivative - a solution used to test for Tuberculosis, a potentially serious infectious bacterial disease that mainly affects the lungs) on April 9, 2019. The test was administered by Employee 6 (LPN- Licensed Practical Nurse). Employee 7 (LPN) administered a second step PPD to Employee 14 on April 20, 2019.

A review of Employee 15's health record revealed that she received step one, of the two step PPD skin test (PPD -Purified Protein Derivative - a solution used to test for Tuberculosis, a potentially serious infectious bacterial disease that mainly affects the lungs) on March 12, 2019. The test was administered by Employee 5 (LPN- Licensed Practical Nurse). Employee 8 (LPN) administered a second step PPD to Employee 15 on March 21, 2019.

A review of Employee 16's health record revealed that she received step one, of the two step PPD skin test (PPD -Purified Protein Derivative - a solution used to test for Tuberculosis, a potentially serious infectious bacterial disease that mainly affects the lungs) on April 18, 2019. The test was administered by Employee 9 (LPN- Licensed Practical Nurse). Employee 8 (LPN) administered a second step PPD to Employee 15 on April 24, 2019. The second step TB test was administered only 6 days after the first test was given, not 7 days from the first step reading.

An interview with the Director of Nursing (DON) on May 10, 2019, at 11:30 AM verified that LPNs administer PPD skin testing to both staff and residents. The DON was unable to provide any documented evidence of LPN competencies regarding immunizations.

Facility LPNs administered and read TB skin tests for residents and staff, but the facility failed to provide documentation to demonstrate that staff LPNs were provided with the current policies and procedures related to skin testing, which included the above professional requirements (contradictions and adverse reactions). The facility was unable to provide policies and procedures regarding TB skin testing competency testing of the facility LPNs or other information required by the State Board of Nursing.

A review of the clinical record revealed that Resident CR1 was admitted to the facility on February 23, 2019.

Further documentation indicated that Employee 11 (LPN) administered a TB skin test. On March 2, 2019 Employee 12 (LPN) administered the residents step 2 TB test.

A review of the clinical record revealed that Resident 81 was admitted to the facility on February 14, 2019. Further documentation indicated that Employee 11 (LPN) administered a TB skin test. On February 23, 2019, Employee 11 (LPN) administered the resident's second step TB test.

The facility's nursing staff failed to demonstrate the provision of care as set forth under Title 49, Professional and Vocational Standards, Department of State, Chapter 21.11(a)(4) Responsibilities of the Registered Nurse indicated the Registered Nurse implements and evaluated nursing care for individuals for whom responsible and carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b), The registered nurse is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered.

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: 21.145(a) the LPN is prepared to function as a member of the health care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place.




28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 201.20(a) Staff development

28 Pa. Code 201.22(a) Prevention, control, and surveillance of tuberculosis (TB)

28 Pa. Code 211.10 (a)(d) Resident care policies
Previously cited 1/18/19, 5/2/19

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
Previously cited 1/18/19, 5/2/19































 Plan of Correction - To be completed: 05/27/2019

1. Employee 13, 14, 15 and 26 will have a TB signs and symptoms screening completed on or before the date of compliance.
R 81 will have a TB signs and symptoms screening completed on or before the date of compliance
2. An Employee File review will be completed by the HR director to identify those employees hired since 4.8.2019 - current who had their skin test completed by an LPN on or before the date of compliance. Those affected with have a "TB signs and symptoms" completed by an RN.
3. The Quality Assurance Consultant will educate the licensed nurses on the Injection Policy- intra-dermal on or before the date of compliance.
In addition, each licensed practical nurse will be observed by the Quality Assurance Consultant RN for validation of successful completion of an intra-dermal injection on or before the date of compliance.
4. The HR Director will complete an employee file review weekly x 4 weeks on new hires to ensure a trained license nurse completed the skin test. Results will be reviewed with QA&A.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on review of clinical records and select facility policy, observation, staff and family interview it was determined that the facility failed to ensure that physical restraint use was limited to the treatment of medical symptoms for one of 28 sampled residents (Resident 10).

Findings include:

A review of the facility's corporation "Restraint Guidelines" last updated November 2016, revealed that the attending physician is responsible for the identification of the medical symptom requiring the use of the restraint. Prior to the utilization of the restraint, the Interdicsiplinary team completes an evaluation of the patient, interviews the resident and family, identifies previous interventions utilized and any medical evaluation of the presenting medical symptom necessitating the use of the restraint. The decision to utilize a restraint requires an organized approach for the management of the restraint and planned reduction or elimination of the restraint as soon as possible. A physicians order for a restraint includes the type of least restrictive restraint to applied, the medical symptom for which the restraint is being used, circumstances in which the restraint is applied, time specifications for the application of the restraint, release frequency for the restraint and care provided during release. The Physical Restraint Care Area Assessment form is completed to document the Interdicsiplinary team evaluation of the restraint. The individualized comprehensive care plan addresses the medical symptom, the goal for the use of the restraint , individualized interventions and the plan for reduction or elimination of the restraint. The Interdicsiplinary team evaluates continued use of and need for the restraint with scheduled assessments and whenever there is a significant change in patient condition.

A review of Resident 10's clinical record revealed that the resident had diagnoses, which included dementia, psychosis, and anxiety. The resident's cognition was severely impaired.

A review of current monthly physician orders signed May 2019, revealed no order for the use of seat belt on Resident 10's wheelchair.

A review of physical restraint evaluations for Resident 10's dated February 26, 2019 revealed that the restraint identified was a clipped seat belt. It was noted that a physician order was obtained for the use of the device, a release plan was in place and the care plan was initiated. The evaluation noted that the resident had poor safety awareness and the restraint was utilized for positioning in the chair.

A review of an additional physical restraint evaluation dated April 11, 2019, revealed that the resident did not have a medical symptom, which required the use of a restraint. The evaluation noted that the seat belt was to be used when the resident was seated out of bed in the wheelchair. A device release plan was in place and a care plan initiated. It was noted that the resident had poor safety awareness.

A review of the resident's care plan initiated December 11, 2014, and last updated May 3, 2019, indicated that Resident 10 utilized the wheelchair clip belt as a restraint per the physicians order and to release the belt every shift and, as needed, for care.

There was no documented evidence at the time of the survey of a current physician order for restraint use. There was no documented evidence that staff were releasing and repositioning the resident when restrained in wheelchair and/or the frequency. There was no evidence of monthly restraint evaluations for the continued necessity and appropriateness of the restraint in Resident 10's care.

Interview with the Director of Nursing (DON) on May 10, 2019, at 2:00 p.m., confirmed that there was no documented evidence of attempts to reduce the resident's restraint use, a current physician order to restrain the resident and that the restraint was released at regular intervals throughout the day according to the resident's care plan and state regulatory requirements.


28 Pa. Code 201.29 (a) Resident rights
Previously cited 1/18/19, 5/2/19

28 Pa. Code 211.10 (a) Resident care policies
Previously cited 1/1/19, 5/2/19

28 Pa. Code 211.8 (c) Use of restraints

28 Pa. Code 211.12 (a)(d)(5) Nursing services
Previously cited 1/18/19, 5/2/19

28 Pa. Code 211.2(a) Physician services













 Plan of Correction - To be completed: 05/27/2019

1. R10 is currently being evaluated for a personalized wheelchair that will not require the use of a restraint. R 10 current use of restraint will be reviewed by the ICP team to determine specific restraint usage is limited to the treatment of the residents identified medical symptoms, and if continued use is necessary, appropriate orders will be obtained, assessment completed and care plan updated.
2. New admissions and current residents with physical restraints have the potential to be affected by the deficient practice. Utilizing the "Physical Restraints" QAPI tool the DON/designee will audit residents who currently have seat belts for the least restrictive device to ensure the use of the restraint is limited to the treatment of the identified medical symptom and if continued use is necessary, appropriate orders will be obtained, assessment completed and care plan updated.
3. To ensure the deficient practice does not recur, licensed staff will be educated on restraint guideline by the DON/designee on or before the date of compliance.
4. Utilizing the "Physical Restraints" audit tool the DON/designee will audit restraints weekly x4 to ensure appropriate orders and documentation are in place. Results will be reviewed with QA&A.

483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:

Based on a review of select facility investigative reports and the facility's "Prevent Practice Guide" and staff interviews, it was determined that the facility failed to implement established procedures for conducting thorough investigations of an injuries of unknown origin sustained by three residents (Residents 19, 3 and 52) out of 28 residents and failed to develop an abuse prohibition policy that included procedures to fulfill the required components for abuse prevention.


Findings include:

A review of a resident incident report dated February 22, 2019, at 10:00 AM, revealed while providing care to Resident 19, a nurse aide noticed an ecchymotic area to the resident's posterior thigh. The measurement of the ecchymotic area was documented to be 8.5 cm x 5 cm.

Further review of the incident report revealed no witness statements from staff or those who had contact with the resident on prior shifts to demonstrate that thorough investigation was completed to rule out abuse, neglect or mistreatment of the resident as a potential cause of the resident's injuries.

The facility's administrative staff signed the investigation into the resident's injury as completed February 27, 2019.

A review of resident incident report dated April 2, 2019, at 5:15 PM, revealed that while showering Resident 3, a nurse aide noticed a purple bruise on the resident's right elbow, measuring 2.5 cm x 1.5 cm.

Further review of the incident report failed to indicate witness statements were provided from staff who had contact with the resident on prior shifts to demonstrate that thorough investigation was completed to rule out abuse, neglect or mistreatment of the resident as a potential cause of the resident's injuries.

Administrative staff signed the report, as completed, on April 8 and April 9, 2019.

A review of an incident report dated April 17, 2019, at 4:14 PM, revealed that while showering Resident 52, a nurse aide noticed a bruise on the resident's right buttocks, measuring 1 cm x 1cm.

The incident report failed to provide evidence of witness statements were provided from staff who had contact with the resident on prior shifts to demonstrate that thorough investigation was completed to rule out abuse, neglect or mistreatment of the resident as a potential cause of the resident's injuries.

The facility's administrative staff signed the report as completed April 22, 2019, and April 24, 2019.

During an interview on May 10, 2019, at 11:10 AM the Nursing Home Administrator (NHA) confirmed that the facility's procedure for investigation injuries of origin include obtaining statements from staff on the previous shifts from 24 to 48 hours prior to finding an injury of unknown origin. The NHA confirmed that procedures were not followed for thoroughly investigating these injuries of unknown origin.

In response to surveyor inquiry regarding the facility's abuse prohibition policy and procedures, during the survey ending May 10, 2019, the facility provided a document entitled "Prevent Practice Guide," which is a corporation wide document. This practice guide did not include specific requirements for state of Pennsylvania (Act 13/Act 169) or the facility-specific details (i.e., local entities for reporting requirements).

Further review of the provided document indicated that the purpose of the guide is to reduce resident risk, mitigate harm, identify root cause and associated factors and minimize opportunity of recurrence.

The practice guide failed to include procedures, which entailed how the facility will protect the health, welfare and rights of each resident residing in the facility.

Federal guidelines indicate a facility abuse policy must include but are not limited to the following components:

Screening;
Training;
Prevention;
Identification;
Investigation;
Protection; and
Reporting/response.

The facility must have written policies to address the above components, but this information was not provided to the survey team after multiple requests during the survey ending May 10, 2019.

This provided guide failed to define the types of abuse. The facility did not develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property which includes the screening of prospective employees and residents the guide did not indicate written policies and procedures for the investigation of allegations of abuse, neglect and exploitation of residents and misappropriation of resident property and includes the staff identification of abuse, neglect, exploitation, and misappropriation of resident property, protection of residents during investigations, and the reporting of allegations and investigative findings and taking corrective actions nor were polices developed and implemented that includes training.

Interview with the NHA (nursing home administrator) on May 10, 2019 at 2:00 PM stated that the provided guidelines served as the facility's abuse prohibition policy and procedures. The NHA was unable to provide policies and procedures which included the regulatory required abuse prohibition components.



28 Pa. Code 201.14(a)(c) Responsibility of Licensee

28 Pa. Code 201.18(e)(1) Management
Previously cited 1/18/19, 5/2/19

28 Pa. Code 201.29(a)(c) Resident Rights
Previously cited 1/18/19, 5/2/19

28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services
Previously cited 1/18/19, 5/2/19























 Plan of Correction - To be completed: 05/27/2019

1. R 19 was evaluated by the nursing department and currently has no injuries. R 3 was evaluated by the nursing and has no injuries. R 52 was evaluated by the nursing department and currently has no injuries.
Through the centers QAPI committee HCR- Manorcare identified policies, procedures, guidelines, manuals and practice guides have been reviewed and adopted by the Medical Director and the QAPI committee as the centers accepted standards of practice for the overall care of residents. As new HCR-Manorcare policies, procedures, guidelines, manuals and the practice guides are released/updated the centers QAPI committee will review with the Medical Director and QAPI committee and adopt as the standards of practice for the overall care of the residents.
2. New admissions and current residents with injuries of unknown origin have the potential to be affected by the deficient practice. The DON/designee will review investigations for injuries of unknown origin from 5.10.2019 current to validate that thorough/complete investigations were completed.
3. To ensure the deficient practice does not recur, facility staff will be educated on the "QAPI practice guide Investigative process, patient protection practice guide, abuse, neglect and misappropriation patient property prevention policy statement, and the specific requirement for the state of Pennsylvania (Act 13/Act 169) reporting requirements" on or before the date of compliance.
4. Utilizing the "Investigation tool" the NHA/designee will review 5 investigations / week to ensure a complete and thorough investigation was completed.

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 clinical record review and staff interview, it was determined the facility failed to develop a comprehensive person-centered care plan to address one resident's inappropriate sexual behavior (Resident 41) and a resident requiring protection from another resident's behavioral symptoms (Resident 26) for two of 28 sampled residents.

Findings include:

A review of the clinical record revealed that Resident 26 was admitted to the facility on May 21, 2016, with diagnoses which include heart failure, dementia (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) without behavioral disturbance, anxiety and Alzheimer's disease (decline in brain function which causes memory loss and causes brain tissue to breakdown).

A quarterly MDS Assessment (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 16, 2019, indicated that the resident was moderately cognitively impaired with a BIMS score of 10 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 8-12 equates to being moderately cognitively impaired).

Clinical record review revealed that Resident 41 was admitted to the facility on July 25, 2018 with diagnoses, which included encephalopathy (a disease in which some functioning of the brain is affected by some agent or condition) and bipolar disease (a serious mental illness characterized by extreme mood swings, a mood disorder that causes radical emotional changes and mood swings and personal history of other mental and behavioral issues). A quarterly MDS Assessment dated February 1, 2019, indicated that the resident was moderately cognitively impaired with a BIMS score of 11.

Nursing documentation dated May 3, 2019, at 4:38 PM revealed that Resident 41 "pecked" Resident 26 on the lips. The facility implemented direct observation of Resident 41.

Nursing documentation dated May 5, 2019 at 6:15 PM revealed that Resident 41 was walking in the hallway when he stopped to talk to Resident 26 and as he was talking, Resident 41 bent down to try to kiss Resident 26 again. Staff intervened and no contact was made.

Resident 41 was then placed on a 1 to 1 constant supervision.

Resident 26's care plan updated May 3, 2019, indicated that the facility will discuss coping strategies with her after being kissed by another resident and providing her the ability to discuss her feelings.

Resident 41's care plan updated May 3, 2019, indicated that he would be on 1 to 1 supervision, be distracted if possible and have supervision when in a social gathering.

A review of the care plans of Resident 26 and Resident 41 revealed no documented evidence that the facility had identified the specific need to prevent inappropriate physical contact between Resident 41 and Resident 26 (i.e., keeping the residents separated).




28 Pa. Code 211.11(d) Resident care plan

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





 Plan of Correction - To be completed: 05/27/2019

1. R26 and R 41 had their behavioral care plans updated.
2. New admissions and current residents with documented inappropriate sexual behaviors have the potential to be affected by the deficient practice. Utilizing the "Behavior" QAPI tool the DON/designee will audit any residents with documented inappropriate sexual behaviors from 5.10.2019 current to ensure appropriate interventions are in place.
3. To ensure the deficient practice does not recur, the DON/designee will educate the licensed staff on the "Behavior Practice Guide comprehensive care plans" on or before the date of compliance.
4. Utilizing the "Behavior" QAPI tool the DON/designee will audit 5 residents/week who display inappropriate sexual behavior to ensure that care plans are updated with appropriate interventions. Results will be reviewed with QA&A.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based upon clinical record review, observation and staff interview, it was determined that the facility failed revise a resident's comprehensive care plan to reflect the resident's current preferences for one of two sampled residents (Resident 24).

Findings include:

Review of Resident 24's clinical record revealed diagnoses that included traumatic subdural hemorrhage (collection of blood in the brain) without loss of consciousness, traumatic subarachnoid hemorrhage (collection of blood between the brain and the tissue covering the brain) without loss of consciousness, seizures (neurologic disorders that cause brief episodes of spasms, unresponsiveness) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

Review of Resident 24's care plan, which was revised by the facility on February 28, 2019, revealed that the resident preferred not to be kept busy. It was noted that the resident wanted to spend his time relaxing, enjoying independent leisure activities of own choosing. The resident was not interested in group activities, although enjoyed watching TV and listening to most music.

Observations of Resident 24 throughout the days of the survey from May 7, 2019, through May 10, 2019, revealed that the resident was observed lying in bed, staring at the walls or the ceiling. There was no television, music or other forms of preferred sensory stimulation provided as identified on the resident's care plan.

During these observations on May 7, 2019, at 11:08 a.m., May 8, 2019, at 9:50 a.m., 10:50 a.m., and 12:55 p.m., and on May 10, 2019, at 11:40 a.m. the resident was observed wearing a hospital gown.

Interview with Employee 3 (Registered Nurse) on May 10, 2019 at approximately 11:45 a.m. confirmed that Resident 24 was wearing a hospital gown and often remained in bed.

Employee 3 further stated that it was the resident's preference to be in bed and wear a hospital gown. Employee 3 stated the resident's care plan did not reflect the resident's current preferences for wearing a hospital gown and remaining in bed.




28 Pa. Code 211.11 (c)(d) Resident Care Plan
Previously cited 1/18/19, 5/2/19

28 Pa. Code 211.12 (d)(1)(5)Nursing services
Previously cited 1/18/19, 5/2/19




 Plan of Correction - To be completed: 05/27/2019

1. R 24's ADL care plan was updated to include his preferences.
2. New admissions and current residents who prefer to wear a hospital gown and lay in bed have the potential to be affected by the deficient practice. Current residents who prefer to wear a hospital gown and to be in bed throughout the day will be audited and care plans will be updated accordingly by the DON/designee.
3. To ensure the deficient practice does not recur, the licensed staff will be educated by the Quality Assurance Consultant/designee on "Focus on F-tag 657" on or before the date of compliance.
4. Utilizing the "Patient Preference" QAPI tool the DON/designee will audit 5 residents/ week to ensure their preferences are care planned as such. Results will be reviewed with QA&A.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:

Based on a review of clinical records and staff interview it was determined that the facility failed to include a recapitulation of the residents' stay in the discharge summary of one of three closed records reviewed (Resident 115).

Findings include:

A review of the closed clinical record revealed that Resident 115 was admitted to the facility on September 1, 2017, with diagnoses to include Parkinsons disease (a progressive, neurological disease) hypertension and muscle weakness. The resident was discharged to another skilled facility on March 21, 2019.

The resident's closed clinical record contained a facility form entitled "My Transition Home", a summary of of the resident's course of treatment while in the facility, the final prognosis and the reason for discharge.

A review of the summary form revealed that multiple sections of the form were not completed to include, nursing discharge instructions, a review of therapy services received while a resident at the facility, and a discharge summary, dietary discharge instructions, social services summery while a resident at the facility and corresponding discharge instructions, any upcoming physicians appointments and a summary of activities noted during the stay at the facility.

The form was signed as completed on March 21, 2019 by the Social Services Director.

An interview with the Director of Nursing on May 10, 2017 at approximately 2 p.m., confirmed that a recapitulation of Resident 115's stay had not been completed.


28 Pa. Code 211.5 (f) Clinical records.
Previously cited 1/18/19, 5/2/19















 Plan of Correction - To be completed: 05/27/2019

1. R 115 had no ill effect from the deficient practice.
2. New admissions and current residents who are discharged have the potential to be affected by the deficient practice. Current residents with established discharge dates from 5.10.2019 will be audited by the Social Service Director to ensure appropriate recapitulation of stay is ready for discharge.
3. To ensure the deficient practice does not recur licensed staff will be educated by the DON/designee on the "My Transition Home" booklet and the Focus on F-tag 661 on or before the date of compliance.
4. Utilizing the "Discharge Planning" QAPI tool residents with planned discharges will be audited by the Social Service Director weekly x4 to ensure completion. Results will be reviewed with QA&A.


483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to accurately monitor a fluid restriction prescribed to address a resident's clinical condition and maintain adequate fluid balance for one of 28 sampled residents (Resident 98).

Findings include:

A review of the clinical record revealed that Resident 98 was admitted to the facility on January 14, 2019, with diagnoses that included diabetes (condition that occurs when the body can't use glucose (a type of sugar) normally), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and end stage kidney failure treated with dialysis (the process of removing excess water, solutes and toxins from the blood in those whose kidneys have lost the ability to perform these functions in a natural way) three times a week.

A physician order dated January 31, 2019, was noted for 960 cc fluid restriction daily.

The resident's current plan of care indicated that the daily fluid breakdown was: Nursing staff 24-hour allotment 160 cc on the 7 AM to 3 PM shift, 160 ccs per shift 3 PM to 11 PM shift and 40 cc on the 11 PM to 7 AM shift; dietary's 24-hour fluid allotment - meals totaled 600 ccs per day: 240 ccs on the breakfast tray, 240 ccs on the lunch tray and 120 ccs on the dinner tray.

A review of the documentation dated May 2019, in the resident's clinical record revealed that the resident was non-compliant with the fluid restriction.

Further review of the resident's clinical record revealed no documented evidence of an accurate accounting of the amount of fluids the resident consumed each day to assess compliance with physician orders for fluid restriction.

An interview with the Director of Nursing (DON) on May 10, 2019, at 2:50 PM confirmed that the that facility did not have documented evidence of the resident's daily fluid intake. The DON was unable to state the amount of fluid consumed by the resident on a daily basis and if that amount of fluid consumed exceeded the physician prescribed fluid restriction or was sufficient to maintain adequate hydration. The facility was unable to provide documented evidence that this fluid restriction was maintained in accordance with physician orders.



28 Pa. Code: 211.10(a)(c) Resident care policies
Previously cited 5/2/19

28 Pa. Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited 1/18/19, 5/2/19

28 Pa. Code 211.6 (c)(d) Dietary services
Previously cited 1/18/19, 5/2/19

28 Pa. Code 211.5(f)(g)(h) Clinical records
Previously cited 1/18/19, 5/2/19





 Plan of Correction - To be completed: 05/27/2019

1. R 98 fluid restriction was evaluated by the registered dietician.
2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the "fluid restriction" QAPI tool the Dietitian/designee will audit residents requiring fluid restrictions ensure appropriate fluids are administered.
3. To ensure the deficient practice does not recur licensed nurses will be educated on the "alert charting log, Fluid Restriction Worksheet," F-692 and the hydration practice guide. The dietitian completes a fluid restriction worksheet in collaboration with the licensed nurse to determine the amount of fluid to be administered by the nursing every shift. The licensed nurse will document in the clinical record the amount of fluid consumed per shift by the resident. In addition, fluids consumed will be noted on the 24 hour "Daily Interdisciplinary Eagle Room Report" to aide in communication to oncoming licensed nurse of remaining amount of fluid permitted. Residents will be placed on "Alert Charting" as reminders to the licensed nurse to document fluid intake.
4. Utilizing the "Fluid restriction" QAPI tool the registered dietitian/designee will monitor residents on a fluid restriction weekly x4 weeks. Results will be reviewed with QA&A.
483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records, observations, interviews with staff and residents it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one resident out of one sampled receiving hemodialysis through a central line catheter (Resident 213).

Findings include:

A review of the clinical record revealed that Resident 213 was readmitted to the facility on April 26, 2019, with a end stage renal disease and receiving dialysis ( the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). The resident had a double lumen (two tubes) central line catheter for dialysis access on Tuesdays, Thursdays and Saturdays.

Clinical record documentation indicated that Resident 213 previously had a right arm fistula site (The dialysis fistula is often referred to as an AV fistula. This stands for arteriovenous fistula, as it requires joining an artery to a vein. This is the preferred type of access for dialysis because this method has a low risk for blood clots or infection) that was not in use.

The resident had a Tesio catheter (a pair of catheters that are inserted into a central vein for the purpose of accessing blood for dialysis treatments. The catheter is designed to remain in place for an extended period of time, allowing vascular access for dialysis). A nurses note dated March 25, 2019, at 9:37 PM indicated that the Tesio catheter had been inserted at the local hospital.

According to the resident's current care plan, nursing staff were to check the access site for a lack of thrill/bruit (physical indicators that an Afistula is in working order - audible vascular sound associated with turbulent blood flow. Although usually heard with the stethoscope, such sounds may occasionally also be palpated as a thrill). These physical indicators are not used when a resident has a Tessio, implantable catheter, as the dialysis treatment site. The resident's care plan noted to check for evidence of infection, swelling or excessive bleeding per facility guidelines. Report abnormalities to the physician.

There was no reference to the resident's Tesio catheter or its emergency care on the resident's care plan.

During an interview May 8, 2019, at approximately 9 AM, Employee 2, Licensed Practical Nurse (LPN) stated that she would apply pressure to the resident's Tesio catheter if it became dislodged or started to bleed. She confirmed that there were no emergency supplies in the resident's room.

A review of current patient information guide for the Tesio catheter for dialysis, the facility supplied to the survey team during the survey, indicated that if bleeding (leaking) from the catheter occurs, stop the bleeding by pinching, clamping or tying off the end of the catheter and call the physician immediately.

The absence of readily accessible emergency supplies for Resident 213 was confirmed by the resident and also confirmed by the DON (director of nursing) on May 9, 2019 at 1 PM.




28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 1/18/19, 5/2/19





















 Plan of Correction - To be completed: 05/27/2019

1. R 213 renal insufficiency care plan was updated and emergency supplies were placed at bedside.
2. New admissions and current residents receiving hemodialysis have the potential to be affected. The DON will complete a Hemodialysis audit on like residents to ensure emergency supplies are placed at the bedside on or before the date of compliance.
3. To ensure the deficient practice does not recur, the Quality Assurance Consultant will educate the licensed nurses on the Dialysis guidelines on or before the date of compliance.
4. To monitor compliance, the DON will complete a Hemodialysis audit weekly x 4 weeks. Results will be reviewed with QA&A.

209.3(a) LICENSURE Smoking.:State only Deficiency.
(a) Policies regarding smoking shall be adopted. The policies shall include provisions for the protection of the rights of the nonsmoking residents. The smoking policies shall be posted in a conspicuous place and in a legible format so that they may be easily read by residents, visitors and staff.
Observations:

Based on observation and staff interviews, it was determined that the facility failed to post the smoking policy in a conspicuous place and in a legible format that could be easily read by residents, visitors and staff.

Findings include:

During an observation on May 7, 2019, at 11:00 a.m., the facility's smoking policy, including provisions for the protection of the rights of non-smoking residents, was not posted in the facility and was not accessible to residents, staff and visitors.

During an interview with the Nursing Home Administrator (NHA) on May 8, 2019, at 1:30 p.m., the NHA confirmed that the facility failed to post the smoking policy.







 Plan of Correction - To be completed: 05/27/2019

1. No residents were affected by the deficient practice.
2. The center QAA committee and medical director adopted the HCR-Manorcare smoking guidelines last revised 7.2017 as the facility policy for smoking. Smoking policy will be posted at wheelchair height on every nurse station.
3. The facility staff was educated by the NHA/designee on the "smoking guideline" on or before the date of compliance.
4. Utilizing the "smoking" QAPI tool the NHA/designee will observe smoking times at the facility 3x weekly x4 weeks to ensure compliance. Results will be reviewed with QA&A.

211.8(f) LICENSURE Use of restraints.:State only Deficiency.
(f) Every 30 days, or sooner if necessary, the interdisciplinary team shall review and reevaluate the use of all restraints ordered by physicians.
Observations:

Based on a review of clinical records, observation and interview with staff, it was determined that the facility failed to re-evaluate the use of a physical restraint at least every thirty days, for one of two sampled residents (Resident 45).

Findings include:

A review of Resident 45's clinical record revealed that the resident had diagnoses that included traumatic subdural hemorrhage (bleeding in the brain) and dementia (a disorder of the mental processes marked by memory disorders, personality changes, and impaired reasoning.). A Quarterly MDS (Minimum Data Set Assessment - a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 28, 2019, revealed that the resident was severely cognitively impaired and was totally dependent on staff activities for assistance with daily living.

A physician order dated October 3, 2018, indicated the resident's bed was to be kept against the wall at all times.

A review of the physical restraint assessment dated October 3, 2018, revealed that the resident favors the left side of the bed. The resident will move to the left side and falls out of bed.

Physical restraint assessments were completed on November 19, 2018, February 25, 2019, and April 11, 2019. There was no evidence of monthly reviews for the resident's use of this physical restraint.

Interview with the DON (Director of Nursing) on May 10, 2019, at 12:10 PM confirmed that the facility had failed to re-evaluate the resident's use of this restraint monthly.






 Plan of Correction - To be completed: 05/27/2019

1. R 45 has a current restraint assessment.
2. New admissions and current residents with physical restraints have the potential to be affected by the deficient practice. Utilizing the "Physical Restraint" QAPI tool the DON/designee will audit residents who currently have beds against the wall to ensure appropriate documentation.
3. To ensure the deficient practice does not recur, licensed staff will be educated on the restraint guideline and timeliness of restraint assessments every 30 days by the DON/designee on or before the date of compliance.
4. Utilizing the "Physical Restraints" audit the DON/designee will audit restraints weekly x4 to ensure appropriate orders and documentation are completed timely in place. Results will be reviewed with QA&A.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port