Nursing Investigation Results -

Pennsylvania Department of Health
MEADOWOOD
Patient Care Inspection Results

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MEADOWOOD
Inspection Results For:

There are  39 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.
MEADOWOOD - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare Recertification, Civil Rights Compliance Survey and State Licensure Survey, completed on June 10, 2019, it was determined that Meadowood, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.


 Plan of Correction:


483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on individual interviews and a group meeting with residents, observations, review of facility documentation and staff interviews, it was determined that call bells were not being answered in a timely fashion for a majority of the residents of the facility.

Findings include:

A resident interview with Resident R13, during the initial tour of the facility, on June 6, 2019, at 10:30 a.m. indicated, "Often fall asleep before my call bell is answered". Resident R13, further indicated, "Call bell response time is delayed during all three shifts".

An additional resident interview with Resdient R50, on June 6, 2019, at 11:20 a.m. also indicated "Call bell response time overall is not very good". Upon the conclusion of the interview with R50, surveyor asked R50, to press call bell, to observe call bell response time. Resident R50, pressed call bell indicator on at approximaately, 11:55 a.m. which was responded to by Employee E4, CNA, at approximinatley, 12:10 p.m. fifteen minutes from when it was initially turned on by Resident R50.

During the group meeting with five alert and oriented residents, identified by the facility, on June 7, 2019, at 10:30 a.m. it was indicated by each of the five residents, (Residents R7, R13, R15, R27 and R35), "Takes a long time to get assistance after turning on call bell at all times". Resident R35, further indicated, "Staff will come into room, see what you want" and than say, "I will be right back". Resident R7, followed up to what R35, was saying, by indicating, "They never come right back".

Resident R35, shared during the group meeting her call bell experience from earlier in the morning, to get ready to attend the resident meeting. Resident R35, indicated she needs assistance with getting dressed, she turned on her call bell, shortly before 10:00 a.m. for the 10:30 a.m. meeting, to get help with getting dressed, her call bell was responded to by a Certified Nurse Aide, (CNA - nursing assistant), who told, R35, "I will be right back". Resident R35, further indicated, "She never came back", "I'm not suppose to get dressed on my own, but I had to not to be late for the meeting".

An interview with Employee E5, CNA, assigned to Resident R35, for June 7, 2019, at 1:20 p.m. the day of the group meeting with Residents, confirmed that Resident R35, did get dressed indepently, earlier in the day and does require assistance with all activities of daily living.

Review of the call bell indicator log on June 10, 2019, at 2:00 p.m. revealed that Resident R35, did turn call bell on, June 7, 2019 at 9:56 a.m. as she had indicated.

Continued observations on all days of the survey at various times, in different locations of the facility, revealed that call bell response times were delayed in being responded to.

Further review of the call bell indicator response log, in the presence of the Nursing Home Adminstrator and Director of Nursing on June 10, 2019, at 2:00 p.m. revealed in some occassions it took up to 20 minutes and/or longer for a staff person to respond to a residents call bell. During the same interview the Nursing Home Adminstrator and Director of Nursing, indicated, that call bell response time should be with in five to eight minutes, no more than 10 minutes.

An interview with the Nursing Home Adminstrator and Director of Nursing, on June 10, 2019, at 2:15 p.m. confirmed that call bell response time is not accommodating the individual needs of the residents.

Facility has not insured that call bell response time is accommodating the individual needs of the Residents.

Pa. Code: 201.19(b)(1) Management

Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 07/20/18, 03/08/18







 Plan of Correction - To be completed: 07/15/2019

Resident R13, R50, R7, R15, R27, and R35 were provided individual support and review of care plan to further promote individual needs of residents.

Call bell audits are ongoing and will be reviewed to monitor timely response.

Call bell policy and nursing assignment schedule for care review completed with nursing and interdisciplinary team members to further develop support for timely response of call bells and resident needs.

Education for interdisciplinary team members regarding call bell response plan and timely provision of care and services.

A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for timeliness of care and services being provided to the residents. Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or monitoring.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and 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.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

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

Based on a resident group meeting, review of facility policy and procedure and interview with facility staff, it was determined that the facility failed to provide the opportunity for residents to vote in the most recent primary election for three of five residents that attended the group meeting (Residents R7, R27 and R35).

Findings include:

Review of facility policy and procedure, titled, "Voting Policy", dated, June 7, 2019, indicated, "Every resident with cognitive ability and desire shall vote in every and all elections they choose".

During a group meeting with five residents identified by the facility as being cognitively intact, held on June 7, 2019, at 10:30 a.m. three of the residents, R7, R23 and R35, stated that they had not been offered the opportunity to vote during the most recent primary election on Tuesday, May 21, 2019 and they would have liked to vote.

An interview with Employee E3, Social Worker, on June 7, 2019, at 2:00 p.m. indicated that the designated polling location for the facility was at a nearby church and further indicated that the facility offers transporation. Employee E3, confirmed Residents R7, R23 and R35, were not offered the opportunity to vote during the recent primary election held on May 21, 2019 and each of them are cognitively able to exercise there right to vote.

The facility failed to ensure residents were given the opportunity to vote during the recent primary election.

28 Pa. Code: 201.29(i) Resident Rights
Previously cited 07/20/18 06/10/16







 Plan of Correction - To be completed: 07/15/2019

Residents R7, R23, and R35 were provided a copy of the voting policy.

Residents were provided education and review of the voting policy by social service team.

Social service team will document according to protocol support provided for the voting procedure.

A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for support residents voting rights. Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or monitoring.

483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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.
483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that showers were provided in accordance with residents' preferences for one of 18 residents reviewed (Resident R15).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident R15, dated March 29, 2019, revealed that the resident had intact cognition, required one person physical assist for bathing.

The facility's current shower schedule for Resident R15 revealed that the resident was scheduled to receive a shower during the night shift on Thursdays and Mondays.

During the intitial tour of the facility on Thursday, June 6, 2019, Resident R15 stated that he did not receive a shower, because the staff who was assigned to the resident told him there was a staff meeting and there was no time to assist the resident in the shower.

Review of Resident R15's clinical record revealed no documented evidence on June 6, 7, 8, or 9, 2019, regarding the status of the resident's missed shower. Further review of the facility's shower log revealed no documented evidence Resident R15 received a shower on June 6, 7, 8, or 9, 2019.

Interview on June 10, 2019, at 11:50 a.m. with the DON where she stated that the facility's protocol would be if a shower was missed on the resident's shower day, then the resident would be added to the next day for a shower. Further, the DON confirmed that there was no documentation that the resident received a shower or refused a shower on Thursday, June 6, 2019, and the DON confirmed there was no documentation that the resident received a shower on June 7, 8, or 9, 2019.

The facility failed to ensure that showers were provided in accordance with residents' preferences


28 Pa. Code 201.29(i) Resident rights.

28 Pa. Code 201.29(j) Resident rights.





 Plan of Correction - To be completed: 07/15/2019

Resident R 15 was offered a shower

Shower protocol reviewed

Audit completed to review residents offer showers according to protocol.

Education for nursing team members regarding shower protocol

A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for proper support of shower protocol and resident preferences. Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or monitoring.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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.
483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that the resident's wishes for Advance Directives (one's wishes on life-sustaining medical or surgical treatment) were reflected accurately in the clinical record, for one of 18 residents' records reviewed (Resident R11).

Findings include:

Review of the facility policy "Advance Directives and Self Determination," dated last revised January 15, 2009 and last reviewed March 16, 2018, stated that it was the policy of the facility to respect a person's right "as defined by the U.S. Constitution and Commonwealth of Pennsylvania Law" to make decisions about his/her medical care. The purpose of the policy, as stated, " was to ensure that the rights of the resident - including dignity, privacy, autonomy - are protected whether exercised by the resident or the healthcare agent or healthcare representative; to prevent confusion at the time of decision making by identifying the resident's choices or the person responsible for expressing the resident's decision by their knowledge of the residents wishes; and to ensure the health care providers (physician, nurses, social workers and the facility) meet appropriate legal guidelines for treatment limitations/Advance Directives." The same policy continued that upon admission to the facility the Admissions Coordinator and/or social Worker " will provide information regarding the preparation of an Advance Directive and will ascertain whether the resident has completed an Advance Directive." The policy also noted that the resident would be given the "information and the opportunity to complete one (Advance Directive) or to acknowledge in writing that he/she has been given the information and the opportunity to complete an Advance directive and does not wish to do so."

Review of the clinical record for Resident R11 revealed that the resident was readmitted to the facility on February 21, 2019 from an acute care hospital with diagnoses including Parkinsons's Disease (disorder of the central nervous system that affects movement, often including tremors), hypertension (elevated blood pressure), and acute appendicitis ( severe inflammation of the appendix - finger-shaped pouch located on the lower right side of the bowel), post surgery. Review of the physician's orders for Resident R11, dated February 21, 2019, and monthly thereafter, indicated in the Advance Directives section ""No data to display," indicating that there was no physician's order for an Advance Directive (code status- level of emergency medical interventions one wishes to have started if their breathing or heart stops ) for Resident R11. Further review of the resident's electronic record under the clinical tab revealed at the top left side of the display screen in bold letters "DNR (Do Not Resuscitate - do not perform chest compressions to keep the heart beating)." Further review of the record revealed under the Advance Directive tab that Resident R11 was "DNR (Do Not Resuscitate" and was dated February 22, 2019.

During an interview with the Director of Nursing on June 7, 2019,at approximately 12:30 p.m., it was confirmed that the physcian's order for Resident R11 did not accurately reflect the wishes of the resident for DNR (Do Not Resuscitate)..

The facility failed to ensure accurate documentation was maintained regarding residents' wishes for resuscitation upon life-threatening medical conditions.

28 Pa. Code 201.18(b)(1)Management
Previously cited 07/20/18

28 Pa. Code 201.29(i) Resident rights

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

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
Previously cited 07/20/18









 Plan of Correction - To be completed: 07/15/2019

Resident R 11 physician order was obtained to support the desire and advance directives as reflected by resident.

Audit will be completed of residents advance directives to support resident preferences.

Advance directive policy reviewed.

Education for team regarding advance directive policy.

A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for proper support to honor resident advance directives. Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or monitoring.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

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

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

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

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

Based on clinical record review and interview with facility staff, it was determined that the facility failed to provide documentation that the required notification to the office of the State Long-Term Care, (LTC) Ombudsman had been performed after a facility - initiated transfer to an acute care hospital had occurred for six of 18 residents reviewed that were transferred to the hospital (Resident R203, R204, R13, R11, R35, and R78).

Findings include:

Review of Resident R203's clinical record revealed the resident was admitted to the facility on April 3, 2019, with a diagnosis to include coronary artery disease (damage or disease in the heart's major blood vessels).

Further, review of Resident R203's, clinical record revealed that the resident was transferred to the hospital on April 7, 2019, for congestive heart failure (the heart doesn't pump blood as well as it should) and cellulitis (bacterial infection the deep layers of skin and tissue beneath the skin).

Review of Resident R204's clinical record revealed the resident was admitted to the facility on April 10, 2019, with a diagnosis to include ovarian cancer (A disease in which abnormal cells divide uncontrollably and destroy body tissue). Further, review of Resident R204's, clinical record revealed that the resident was transferred to the hospital on April 19, 2019, related to the ovarian cancer.

Clinical record review for Resident R13, on June 7, 2019, revealed on January 12, 2019, R13, was transferred via 911 ambulance to the local hospital for evaluation and treatment related to an infection.

Review of the clinical record for Resident R11 revealed that the resident was readmitted to the facility on February 21, 2019 from an acute care hospital with diagnoses including Parkinson's Disease (disorder of the central nervous system that affects movement, often including tremors), hypertension (elevated blood pressure), and acute appendicitis (severe inflammation of the appendix - finger-shaped pouch located on the lower right side of the bowel), post surgery. Further review of the clinical record revealed that the resident was transferred to the hospital on February 11, 2019 with shortness of breath.

Review of the clinical record for Resident R35 revealed that the resident was readmitted to the facility on March 17, 2019 from an acute care hospital with diagnosis including anxiety (intense, excessive, and persistent worry and fear about everyday situations), hypothyroidism (condition in which the thyroid gland in the neck doesn't produce enough thyroid hormone), and fracture (break in the bone) of the left femur (hip bone). Further review of the clinical record revealed that Resident R35 was transferred to the hospital March 11, 2019 with pain in left hip area following a fall in the bathroom.

Review of the clinical record for Resident R78 revealed that the resident was readmitted to the facility on December 10, 2018 from an acute care hospital with diagnoses including hypertension (elevated blood pressure) and fracture (break in the bone) of the right femur (hip bone). Further review of the clinical record revealed that Resident R78 was transferred to the hospital on December 5, 2018 with pain in right hip area following a fall in her room.

An interview with the administrator on June 10, 2019, at 11:15 a.m., where she confirmed that the State Long- Care, (LTC) Ombudsman was not notified of Residents R13, R203 and R204, R11, R78, and R35's transfer to the hospital.

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

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 07/20/18, 03/08/18; 06/10/16







 Plan of Correction - To be completed: 07/15/2019

Notice sent to ombudsman for residents R 203, R204, R13, R11, R35, and R78 that were transferred to acute care hospital.

Audit completed to review resident transfer /discharge within last three months to review proper notification to the Office of the State Long-Term Care Ombudsman office.

Process and policy for notification to the State Long-Term Care Ombudsman regarding facility initiated transfer reviewed.
Education for social service team.

A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for required notifications upon transfer or discharge. Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or

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

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

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

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

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

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

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

Based on observations, facility policy and clinical record review, and staff interviews, it was determined that the facility failed to maintain appropriate infection prevention and control practices during wound treatment for one resident (Resident R6).

Findings include:

Review of facility policy "Infection Control - Hand Hygiene," dated June 2018, revealed that the purpose of the policy is to provide guidelines to employees for proper and appropriate hand hygiene techniques that will aid in the prevention of the transmission of infections.

Review of Resident R49's clinical record revealed the resident was admitted to the facility on December 3, 2015, with a diagnosis to include dementia (a group of thinking and social symptoms that interferes with daily functioning).

Review of Resident R49's active physician orders revealed an order to assess right rear ankle blister, clean with normal saline and cover with Allevyn dressing one time a day.

Observation of Resident R49's wound care on June 7, 2019, at 1:40 p.m. revealed Employee E5, RN, removed Resident R49's old soiled wound dressing with her gloved hands, then with the same gloves she cleaned the resident's wound with normal saline, and then with the same gloved hands she put on a new clean dressing on Resident R49's rear ankle.

Interview on June 7, 2019, at 1:45 p.m. with Employee E5, RN, where she confirmed that she did not remove her used gloves after removing Resident R49's soiled wound dressing and perform hand hygiene.

The facility failed to maintain infection prevention and control practices during wound treatment.

28 Pa. Code: 211.12(d)(1)(5) Nursing services.
Previously cited 03/08/18, 07/20/18






 Plan of Correction - To be completed: 07/15/2019

Orders and treatment for Resident R49 were reviewed. Education provided to nurse regarding proper technique and handwashing protocol.

Protocol for handwashing reviewed.

Education provided for licensed staff.

A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for proper infection control protocols to support residents care and services. Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or monitoring


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