Nursing Investigation Results -

Pennsylvania Department of Health
SOUTHWESTERN NURSING CARE CENTER
Patient Care Inspection Results

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SOUTHWESTERN NURSING CARE CENTER
Inspection Results For:

There are  146 surveys for this facility. Please select a date to view the survey results.

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SOUTHWESTERN NURSING CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and an Abbreviated survey in response to four complaints completed on May 31, 2019, it was determined that Southwestern Nursing Center was not in compliance with the following 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.


 Plan of Correction:


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

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

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:
Based on a review of facility policies, observations and staff interviews it was determined that the facility failed to properly label and date food products, store scoops utilized to retrieve ice, provide paper towels at the hand washing sink, perform handwashing, utilize clean sanitary equipment to serve food, and properly sanitize equipment during ware washing in the Main Kitchen (Main Kitchen).

Findings include:

A review of facility policy "Food Storage" dated 2/21/19, indicated that food products are dated as to the date they are received. Leftover food is clearly labeled and dated before being stored.

A review of facility policy "Hand Washing" dated 2/21/19, indicated the hand washing facilities are readily accessible and equipped with paper towels and soap. Handwashing is performed after handling soiled equipment, during food preparation to remove soil and contamination, and after engaging in activities that contaminate the hands.

A review of facility policy "Ice Handling/Cleaning of Ice Scoops" dated 2/21/19, indicated that ice scoops are maintained in sanitary conditions to prevent the spread of infections.

A review of facility policy "Employee Sanitary Practices" dated 2/21/19, indicated that employees practice standard sanitary procedures.

A review of facility policy "Bare Hand Contact with Food" dated 2/21/19, indicated that gloves are just like hands. They become soiled and when in contact with a contaminated surface they must be changed.

A review of facility policy "Maintenance of Dish Machine" dated 2/21/19, indicated that the dish machine is maintained to assure proper functioning.

A review of facility policy "Dish Machine Temperature Log" dated 2/21/19, indicated that the staff monitors and records temperatures to assure proper sanitizing of dishes.

During an observation on 5/28/19, at 9:39 a.m. the following was observed:
- in the storeroom were 3 boxes of undated cornbread mix
- in the walk in refrigerator was an opened, undated carton of nectar thick milk
- in the freezer were three packages undated bagels
- stored under the serving line was an opened, undated container of instant mashed potatoes
- the top of the convection oven contained a build up of dust and debris
- the hand washing facility did not contain a supply of paper towels
- the ice scoop was stored in pooling water

During an interview on 5/28/19, at 10:02 a. m the Food Service Director Employee E4 confirmed that the facility failed to date food products, maintain clean equipment, paper towels at the hand washing facility, and properly store the ice scoop which created the potential for cross contamination.

During an observation of the tray line procedures on 5/29/19, at 12:12 p.m. it was revealed that Dietary aide Employee E5 with gloved hands touched the outside of a dinner roll package, retrieved dinner rolls from the package, placed it on the resident's plate and failed to perform handwashing. Dietary Aide Employee E6 utilized a suction cup stored on the counter top to retrieve the pallet base (a heated base used to maintain the temperature of hot food) placed the pallet base on a thermal base, then used the suction cup to retrieve china plates placing the suction cup onto the eating surface of the plate and placed the plate on top of the pallet base, then placed the suction cup onto the counter top. Dietary Aide Employee E6 repeated this procedure through out the meal service and failed to properly sanitize the suction cup.

During an interview on 5/29/19, at 12:45 p.m. Food Service Director Employee E4 confirmed that the facility failed to perform handwashing and maintain equipment in a sanitary condition during meal service which created the potential for cross contamination.

During an observation of the dish room operations on 5/30/19, at 1:46 p.m. it was revealed that the final rinse temperature gauge indicated a final rinse temperature of 142 F (Fahrenheit) which was below the required temperature of at least 180 F.

During an interview on 5/30/19, at 1:57 p.m. Food Service Director Employee E4 confirmed that the facility failed to properly sanitize equipment which created the potential for cross contamination.


28 Pa. Code: 211.6(c)(d)(f) Dietary services.



 Plan of Correction - To be completed: 07/09/2019


Food Service Staff will be re-educated as to the correct manner in which food is to be received and/or stored in the department. Foods will be labeled and dated upon arrival into the department, and 'leftover' food is to be labeled and dated prior to storage.
Employee Sanitary Practices will be reviewed, and dietary employees will be in serviced and re-educated on proper glove use, and the need and frequency with which to change gloves.
Hand Washing signs have be reposted at each hand washing sink, and soap and paper towel dispensers will be placed on a routine check list for a food service supervisor to monitor.
Dietary staff will be re-in serviced as to the proper hand washing techniques, and the performance thereof. Dietary staff members will be re-in serviced as to the proper manner to handle an ice scoop, and the proper cleaning technique and frequency of the scoop holder. The cleaning of the Ice Scoop and Holder will be placed on a daily supervisory check list. Food Service Staff will be re-educated as to the correct technique when using a suction cup to pick up heated plates, and replacing it on the plate stack. Food Service Staff will be re-educated as to the correct temperature range for the dish machine, monitor correct temperatures to ensure sanitary dish ware.
Check lists will be utilized to ensure all food storage areas are monitored for proper use of labels and dating. Check lists will be utilized to ensure food storage areas are monitored for proper use of labels and dating.

Daily temperature sheets, to include wash and rinse temperatures will be utilized and to be initialed by team members taking temperatures and reviewed daily by supervisor. Results of the audits will be presented to Quality Assurance Performance Improvement Committee by the Culinary Director or designee to determine resolution or need for further 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 affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:
Based on review of facility policies, observation and staff interview, it was determined that the facility failed to provide a dignified dining experience for six of six residents (Residents R11, R25, R41, R50, R71, and R90).

Findings include:

The facility policy entitled "Dining and Food Service Experience" dated 2/21/19, indicated that individuals at the same table will be served and assisted at the same time.

The facility policy entitled "Dining Room Service" dated 2/21/19, indicated that staff will notify the food service department of those who wish to receive room service. Food will be delivered promptly to assure quality.

During an observation on 5/28/19, at 12:22 p.m. the meal cart was delivered for those residents dining in the dining room. At 12:24 p.m. the first resident was served their meal tray. At 12:49 Speech Pathologist Employee E7 confirmed that she was calling to the kitchen due to Resident R71 had not received her meal tray.

During an interview on 5/28/19, at 12:57 p.m. Speech Pathologist Employee E7 confirmed that she had obtained Resident R71's meal tray and was delivering it to her (33 minutes after the first resident was served). Upon receiving her meal tray Resident R71's response was "Oh Thank You, Thank You."

During an observation on 5/28/19, at 12:05 p.m. two residents were eating at a table while Resident R25 waited an additional 10 minutes to be served.

During an observation on 5/28/19, at 12:10 p.m. one residents was eating at a table while Resident R41 waited an additional 10 minutes to be served.

During an observation on 5/28/19, at 12:15 p.m. three residents were eating at a table while Resident R11 waited an additional 15 minutes to be served.

Review of the dietary meal service schedule located on the Second Floor nursing unit bulletin board indicated that the first dietary cart was to be delivered at 11:40 a.m. and the second cart at 11:50 a.m.

During an observation on 5/28/19, at 12:02 p.m., the first dietary cart with meal trays was delivered to the Second Floor nursing unit.

During an observation on 5/28/19, revealed Resident R50 awaiting meal service while Resident R90 was finishing her meal in the same room.

During an interview on 5/28/19, at 12:30 p.m., Resident R90 stated that she "used to eat in the dining room but preferred to eat in her room now, they always send my tray earlier the hers (Resident R50).

28 Pa. Code 201.29(j) Resident rights
Previously cited 5/25/18.


 Plan of Correction - To be completed: 07/09/2019

The facility will maintain a dignified dining experience.
Resident R 11, R25, R41, R50, R71, & R90 and like residents will have a dignified dining experience and receive meal trays when all other trays in the area are delivered.
The Director of Staff Development or Designee will re-educate the nursing staff on accurate tray distribution at meal times, including all residents seated in the same area will receive their trays prior to serving residents in another area.
The Director of Nursing or Designee will complete compliance audits of tray distribution on 6 residents at random meal times 5 times a week for 1 week, then 3 times a week for 3 weeks, then weekly for 1 month, then monthly for 2 months. Results of the audits by the Director of Nursing will be presented to Quality Assurance Performance Improvement Committee to determine resolution or need for further monitoring.


483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(f) Frequency of Meals
483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:
Based on a review of facility policies, observations and resident interviews, it was determined that the facility failed to provide meals at a consistent time frame for nine of nine residents (Resident R20 R46, R500, R501, R502, R503, R504, R505, R506, and R507).

Findings include:

A review of the facility policy "Frequency of Meals" dated 2/21/19, indicated that meals are served at regular hours. It is the responsibility of the Food Service Director to make certain that meals are served at the designated times.

A review of the "Meal Service Times" revealed the following for the lunch meal:
Cart Number 1 for the Second Floor Dining Room is delivered at 11:40 a.m.
Cart Number 2 for the Second Floor Dining Room is delivered at 11:00 a.m.
Cart Number 3 for the Firt floor Dining Room is delivered at 12:00 p.m.
Cart Number 4 for the Second Floor Short Hall delivered at 12:10 p.m.
Cart Number 5 for the First Floor Short Hall is delivered at 12:20 p.m.
Cart Number 6 for the Second Floor Long Hall is delivered at 12:25 p.m.
Cart Number 7 for the First Floor Long hall is delivered at 12:30 p.m.
Cart Number 8 for the First Floor Long Hall is delivered at 12:35 p.m.

During a Dining room Observation on 5/28/19, it was observed;
Cart Number 1 for the Second floor Dining room was delivered at 12:02 p.m. 22 minutes late
Cart Number 3 for the First Floor Dining Room was delivered at 12:22 p.m. 22 minutes late
Cart Number 7 for the First Floor Long Hall was delivered at 12:53 p.m. 23 minutes late
Cart Number 8 for the First floor Long Hall was delivered at 12:55 p.m. 20 minutes late.
The last tray served to residents on the First Floor Long Hall was to Resident R20 and Resident R46 at 1:24 p.m. 49 minutes after the scheduled time for delivery and 29 minutes after the tray delivery cart accurately was delivered to the unit.

During a Group interview on 5/29/19, at 1:30 p.m. Resident R500, R501, R502, R503, R504, R505, R506, and R507 expressed concerns that their meals trays are always late.

During an interview on 5/31/19, at 1:00 p.m. Resident R20 and R46 confirmed that their meal trays are always late.

28 Pa Code 211.6(c) Dietary services.


 Plan of Correction - To be completed: 07/09/2019

All Food Service employees will be re-educated on the
appropriate delivery and meal times for residents.
Both Food Service and Nursing staff members will be
re-educated to document the tray delivery times and the
time resident meal trays are passed out to the resident.
Information regarding meal cart delivery times will be
disseminated through in-services. Meal cart delivery times
will be posted at multiple locations on the tray line.

Meal Cart delivery logs will be modified to include
information necessary to gage compliance: time each
meal cart arrives on each unit will be recorded, and the
time the last resident tray was delivered to that resident.


Delivery Logs will be completed indicating the times each meal cart was delivered to each resident
unit, and Nursing will document the actual delivery time to the last resident. The delivery time will be audited 5 times a week for 1 week, 3 times a week for 3 weeks and weekly times 4 weeks to endure time accuracy. Results of the audits will be presented to Quality Assurance Performance Improvement Committee by the Food Service Director or designee to determine resolution or need for further monitoring.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:
Based on a review of facility policies, observations and resident interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for seven of seven residents (Resident R20, R34, R46, R47, R48, R508, and R509).

Findings include:

A review of the facility policy "Food Preferences" dated 2/21/19, indicated resident food preferences will be obtained in order to ensure resident meal satisfaction, optimal nutrition support and quality of life.

A observation of meal services revealed the following:
- Resident R20 on 5/31/19, for the breakfast meal was not served orange juice as requested.
- Resident R34 on 5/30/19, for the lunch meal was served regular french fries instead of baked sweet potato fries as requested.
-Resident R46 on 5/31/19, for the breakfast meal was not served raisin bran cereal as requested.
-Resident R47 on 5/28/19 for the lunch meal was served a sugar cookie instead of vanilla wafers as requested, and on 5/30/19, for the lunch meal was not served apple juice as requested .
-Resident R48 on 5/29/19, for the lunch meal was served Bar-B-Que pulled pork instead of grilled pork chop, and was served cranberry juice instead of two apple juices as requested.
-Resident R508 on 5/28/19, for the lunch meal was not served a dinner roll and on 5/30/19, for the lunch meal was served regular french fries instead baked sweet potato fries and cranberry juice instead of apple juice as requested.
- Resident R509 on 5/28/19, for the lunch meal was served mashed potatoes instead of parslied noodle, yellow squash instead of sliced carrots, a sugar cookie instead of vanilla wafer and failed to receive a dinner roll, on 5/29/19, for the breakfast meal was served scrambled eggs although Resident R509 dislikes scrambled eggs, for the lunch meal was served mixed vegetables instead of cut green beans, on 5/30/19, for the lunch meal was served two pieces of lemon cake instead one piece of lemon cake as requested.

During an interview on 5/29/19, at 1:10 p.m. Food Service Director Employee E4 confirmed that the facility was aware of resident concerns regarding the facility to accurately provide meals according to the resident's pretences.


28 Pa. Code: 211.6(c) Dietary service.


 Plan of Correction - To be completed: 07/09/2019

Food Service staff members will be re-educated on the
matter of tray accuracy to ensure resident preferences,
clinical/menu extensions are followed.

Residents will be provided the menu items that they selected unless a substitution is necessary. Menu items will be served as indicated on the menu,
without modification, unless otherwise indicated by

the approved Substitution List, signed off on by the dietitian.
Tray accuracy audits will be performed 5 times a week for 1 week, 3 times a week for 3 weeks and weekly for 4 weeks. A substitution list will be approved by the dietitian with substitute menu item posted in resident dining rooms. Substitutions will be discussed at each Food Committee Meeting. Results of the audits will be presented to Quality Assurance Performance Improvement Committee by the Food Service Director or designee to determine resolution or need for further monitoring.


483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:
Based on review of facility policies, observations, and resident and staff interviews it was determined that the facility failed to provide a palatable meal to 10 of 10 residents (Resident R47, R50, R90, R500, R501, R502, R503, R504, R505, R506, and R507).

Finding include:

A review of the facility policy "Dining and Food Service Experience" dated 2/21/19, indicated that residents are provided with nourishing, palatable, attractive meals.

During an interview on 5/28/19, at 11:20 a.m. Resident R47 stated that "the food is horrible".

During an interview on 5/28/19, at 12:30 p.m. Resident R50 and Resident R90 stated that the food quality is bad and the meat is tough.

During a group interview on 5/29/19, at 1:30 p.m. Residents R500, R501, R502, R503, R504, R505, R506, and R507 voiced concerns that the quality of the food was poor.

During observation of the lunch meal on 5/29/19, at 12:56 p.m. the planned facility menu consisted of Chicken Kiev (a stuffed chicken breast with butter), Bourbon Marinated Pork, Scandinavian Blend Vegetables, and Rice Pilaf. These food products were tasted for palatability with the following determination:
- the Chicken Kiev consisted of a breaded chicken breast with a garlic butter sauce, it was presented as a stuffed chicken breast
- the Bourbon Marinated Pork consisted of a slice of pork with a chicken flavored gravy it lacked a bourbon flavor and was tough and dry.
- the Rice Pilaf consisted of overcooked, mushy white rice.

During an interview on 5/29/19, at 1:10 p.m. Food Service Director Employee E4 confirmed that the Chicken Kiev was not a butter stuffed chicken breast product, the pork lacked a bourbon flavor and the rice pilaf was overcooked and mushy.


28 Pa. Code: 211.6(c) Dietary services.


 Plan of Correction - To be completed: 07/09/2019

Production staff will be re-educated as to the proper food production method to preserve nutritive value, flavor, and appearance.
Test Trays will be performed with taste tasting. Menu items will be served as indicated on the menu, without modification, unless otherwise indicated by the approved Substitution List, signed off on by the dietitian.
Test tray results will be audited 5 times a week for 1 week, 3 times a week for 3 weeks and weekly for 4 weeks. Any outstanding non-compliant issues will be addressed and brought into compliance.
A substitution list will be approved by the dietitian with substitute menu items posted in resident dining rooms. Substitutions will be discussed at each Food Committee Meeting. Results of the audits will be presented to Quality Assurance Performance Improvement Committee by the Culinary Director or designee to determine resolution or need for further monitoring.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on review of facility policies and pharmacy documentation, and staff interviews, it was determined that the facility failed to accurately document reconciliation of controlled medications (medications that have the potential for abuse) on two of two nursing units (First and Second Floor nursing units).

Findings include:

The facility policy " Receiving Controlled Substances" dated 11/28/19, indicated that a nurse signs for the medications, including controlled substances, on the pharmacy delivery ticket and inspects the medications. A nurse reconciles controlled substance orders and refill requests against what has been received from the pharmacy. The receiving nurse transfers medications and accompanying inventory sheets to an authorized nurse on the unit. Two nurses witness the placement of the controlled substances in the secured compartment of the medication cart.

The facility policy "Controlled substance Storage" dated 11/28/19, indicated that at shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses and is documented.

During a review of the Second Floor nursing unit May 2019, Narcotic Count Sheets revealed 24 of 162 signature blocks were empty on the short hallway medication cart count sheet and 39 of 166 signature blocks were empty on the long hallway medication cart count sheet.

During an interview on 5/28/19, at 10:40 a. m. the Director of Nursing confirmed that the facility failed to accurately document reconciliation of controlled medications on the Second Floor nursing unit.

During a review of the First Floor nursing unit May 2019, Narcotic Count Sheets revealed 44 of 170 signature blocks were empty on the short hallway medication cart count sheet.

During a review of the First Floor nursing unit May 21 - 27, 2019, Master Narcotic Log there were three missing signatures for the nurse receiving the narcotic from the pharmacy, and six missing signatures for the nurse accepting the narcotic to the medication cart.

During an interview on 5/29/19, at 10:00 a. m. Registered Nurse Employee E11 confirmed that the facility failed to accurately document reconciliation of controlled medications on the First Floor nursing unit.

28 Pa. Code: 201.14 (a) Responsibility of licensee.
Previously cited 5/25/18.

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

28 Pa. Code: 211.10 (c) Resident care policies.
Previously cited 5/25/18.

28 Pa. Code: 211.12 (d) (1) (2) (3) (5) Nursing services.


 Plan of Correction - To be completed: 07/09/2019

The Director of Staff Development or Designee will re-educate Licensed staff (RN and LPN) of the proper procedure of signing the narcotic accountability log at the beginning and end of each shift to ensure the narcotic count is correct When Narcotics are delivered from the pharmacy the RN and Cart Nurse is accounting for narcotics in the Master Narcotic Log and signing the log book.

The Narcotic Accountability form will be signed at the end of each shift or when medication cart keys are turned over by the off going to the on-coming licensed nurse.


The Director of Nursing or Designee will complete audits of the Narcotic Accountability Sheets 5 times a week times 1 week, 3 times a week for 3 weeks, weekly for 4 weeks, and monthly for 2 months.


Audit results will be presented by Director of Nursing to the Quality Assurance Performance Improvement Committee to determine resolution or need for continued monitoring.



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 review of facility policies and clinical records and staff interviews, it was determined that the facility failed to develop comprehensive plans of care for three of 24 residents (Residents R13, R69 and R87).

A review of the facility policy "Comprehensive Care Plans" dated 11/28/19, indicated that a comprehensive plan of care will be developed for each resident and will describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

A review of the facility policy "Smoking Policy" dated 11/28/19, indicated that the Interdisciplinary Team will develop an individualized plan of care for each resident who smokes. It will include interventions specific to the needs of the resident based upon the assessment to include the level of supervision needed.

A review of the Admission Record indicated Resident R13 was admitted to the facility on 1/30/19, and the Minimum Data Set (MDS-periodic assessment of care needs) dated 3/7/19, revealed diagnoses that included high blood pressure, irregular heart rhythm, and a history of falls. An order dated 2/23/19, indicated hospice services for end of life care.

A review of Resident R13's plan of care revealed there was no care plan to address end of life care.

A review of the Admission Record indicated Resident R69 was admitted to the facility on 4/26/19, with diagnoses that included pneumonia, an irregular heart rhythm and anxiety disorder.

During an interview on 5/28/19, at 10:15 a.m. Resident R69 became tearful regarding her current health condition that has included "several set-backs."

A review of the progress notes from 4/26/19 through 5/29/19, revealed several entries referencing Resident R69's emotional state exhibited by tearfulness. Social Service note dated 5/2/19, indicated that Resident R69 was recommended to be seen by Med Options for psychiatric services and she declined.

A review of the plan of care revealed that there was no care plan to address Resident R69's emotional state exhibited by tearfulness and unwillingness to be seen by the psychiatrist.

A review of the Admission Record indicated Resident R87 was admitted to the facility on 1/25/19, and MDS dated 5/7/19, indicated diagnoses that included chronic breathing/lung problems with oxygen dependence, an infection in her urine, depression and insomnia.

A review of the smoking assessment dated 5/28/19, indicated that she smokes 5-10 cigarettes a day, that she can light her own cigarette and that she is safe while smoking.

A review of the plan of care revealed that there was no care plan to address Resident R87's smoking needs.

During an interview on 5/31/19, at 12:45 p. m. Assistant Director of Nursing Employee E10 confirmed that the facility failed to develop comprehensive plans of care for Resident R13, R69 and R87.

28 Pa. Code: 211.11 (a) (b) (c) (d) (e) Resident care plan.


 Plan of Correction - To be completed: 07/09/2019

Residents R13, R69, R87 care plans were updated on 5-31-19 to reflect smoking, tearfulness with unwillingness to be seen by a Therapist, and election of Hospice services.
For residents with like situations, conditions, or election of adjunct services, social services or designee will be notified by hospice providers when a resident elects hospice. Upon notification from hospice provider of resident officially on hospice, social services or designee will notify nursing to initiate a hospice care plan.
For residents in similar emotional situations, residents will be evaluated initially by social service assessment and throughout stay through clinical orders review and behavior meetings. Social services will initiate a care plan once identified.
For like residents who smoke, upon admission, the admitting nurse will ask resident if the resident smokes. A smoking evaluation will be completed by admitting nurse upon admission if the resident smokes. A smoking care plan will be implemented by the admitting nurse.
Compliance for hospice care plan and emotion care plan will be monitored by social services daily for 5 days, weekly for 3 weeks, monthly for 2 months and quarterly for two quarters.
Compliance for the smoking care plan will be monitored Nursing supervisor or designee to monitor each shift daily for 5 days, three times a week for three weeks, weekly for 4 weeks, monthly for 2 months, quarterly for 2 quarters.
Audit results will be presented by Director of Nursing and Social Service Director to Quality Assurance Performance Improvement Committee to determine resolution or need for continued monitoring.


483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:
Based on review of facility policy and Resident Council Meeting minutes and resident and staff interviews, it was determined that the facility failed to demonstrate timely and adequate efforts to resolve resident grievances for seven of seven months of Resident Council meetings (November 2018, through May 2019) and eight of eight months of Food Committee meetings (September 2018 through April 2019).

Findings include:

A review of the facility policy "Grievance/Complaints" dated 11/29/18, indicated that grievances and/or complaints may be submitted orally or in writing to any facility staff member, if the issues cannot be immediately resolved the resident or concerned person will be assisted in completing a Grievances/ Complaint form which will be submitted to a designated person within 24 hours. A written report of an investigation and/or resolution will be submitted to the Administrator within five working days, the resident or concerned person will be informed of the findings of the investigation and the actions that will be taken to resolve the issue by the Social Worker orally with five working days and will document the issue, resolution and oral notice to the resident/ resident representative.

Review of the minutes from the monthly Resident Council meetings conducted from November 2018, through May 2019, revealed that residents in attendance had expressed concerns regarding the lack of available towels and washcloths, agency nursing staff not passing medication or doing treatments, missing laundry and food complaints. The Resident Council meeting minutes from November 2018, thru May 2019, indicated that the minutes from the prior meeting were read but did not include any information on resolution of previously raised concerns.

Review of the monthly Food Committee meeting minutes dated September 2018, through April 2019, indicated that numerous food concerns had been raised involving quality, temperature and menu accuracy, however the none of the monthly meeting minutes included any information or resolution efforts in response to the concerns.

During an group resident interview on 5/28/19, at 1:15 p.m., eight residents indicated that they had raised concerns involving agency staff, untimely call bell response by staff, unavailable towels and washcloths, missing laundry and food quality repeatedly during the Resident Council meetings but the facility had made no efforts to resolve the issues or inform the residents of proposed resolutions.

During an interview on 5/30/19, at 12:00 p.m. the Nursing Home Administrator confirmed that the Grievance/Complaints procedures for resolution of grievances were not being followed by staff.

During an interview on 5/30/19, at 12:40 p.m. the Social Worker Employee E8 confirmed that staff are not responding timely to residents concerns brought up during the monthly Resident Council and Food Committee meetings and that there was no documentation of resolution efforts for identified issues.


28 Pa. Code 201.18 (e)(1)(4) Management.

28 Pa. Code 201.29 (i)(j) Resident Rights.


 Plan of Correction - To be completed: 07/09/2019

Upon receipt of grievance form, Grievance Officer or designee will copy the grievance form, attach an investigation form for each concern noted, and submit to manager of department responsible to resolve the grievance.
Upon investigation and resolution of the grievance(s), Administrator/designee will review and initial the grievance resolution to assure compliance. Grievance resolution supportive documentation will be included with the completed grievance.
Department Managers and Grievance Officer to receive education from Administrator/designee regarding grievance initiation, investigation, and resolution.
Compliance audit will be conducted by Social Services or designee daily for 100% of grievances the first 5 days, 75% of grievances weekly for 3 weeks, 50 % grievances monthly for two months, 25% of grievances quarterly for 2 quarters.
Results of audit presented by Administrator to Quality Assurance Performance Improvement Committee to determine resolution or need for further monitoring.


483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:
Based on review of Notice of Rights of Nursing Facility Residents and clinical record, observation and resident and staff interview, it was determined that the facility failed to accommodate the needs of one of 24 residents (Resident R19).

Findings include:

A review of the "Notice of Rights of Nursing Facility Residents" provided to every resident upon admission and displayed in the facility indicated that a resident has the right to have their personal needs and preferences provided for to the extent that they do not interfere with the rights of other residents in the nursing facility.

A review of the clinical record indicated that Resident R19 was admitted to the facility on 9/27/18, and the Minimum Data Set (MDS- periodic assessment of care needs) dated 3/20/19, revealed diagnoses that included below the knee amputations of both legs, diabetes, MRSA bacteremia (an antibiotic resistant infection) and septic infection of the skin and underlying tissue of the right wrist (multiple drug resistant infection that has progressed into the bloodstream) and generalized muscle weakness. MDS Section C0200-C0500 Brief Interview for Mental Status revealed a score of 15 of 15 which indicated that she is cognitively intact

A review of the clinical record revealed an order dated 2/28/19, that stated to discontinue and remove bilateral enabler bars.

During an interview on 5/30/19, at 1:03 p.m. the Occupational Therapist (OT) Employee E3 revealed that the facility went side rail free beginning in January and concluded in February as part of a change in corporate policy. OT Employee E3 revealed that there is no documentation and/or evaluation of Resident R19's bed mobility needs for an alternate device prior to the removal of the enabler bars.

During an interview on 5/28/19, at 11:15 a.m. Resident R19 revealed a concern regarding the trapeze that is over her bed. She indicated that she was not involved in the decision for the trapeze, it "was just put on my bed." She indicated that due to the recent infection of her right hand, she is unable to grip and/or grasp anything with that hand. She reports that she has poor upper body control and leans to the left. The trapeze when in the down and accessible position is in front of her face, requiring it to be stored on top of the bar it is anchored to and out of her reach. In order to utilize the trapeze, she must ring her call bell for staff assistance to lower the trapeze and due to the inability to use her right hand, she must grasp the trapeze with her left hand which only enables her to move to the middle of the bed by an inch or two, which is not midline and/or helpful to her. She stated that since they removed her enabler bars and installed the trapeze, she has lost her independent bed mobility.

A review of a Progress Notes dated 5/25/19, revealed that Resident R19 hit her head on the over-bed trapeze bar and sustained a four centimeter by four centimeter lump to the top of her head.

A review of the Summary of Care Plan meeting dated 5/30/19, revealed that Resident R19 had asked for the trapeze to be removed from her bed.

A review of the physician orders from 2/28/19, through 5/30/19, did not reveal an order for the trapeze mobility device for her bed.

During an interview on 5/30/19, at 1:15 p.m. OT Employee E3 confirmed that the facility failed to involve and accommodate the bed mobility needs for Resident R19.

28 Pa. Code: 201.29 (j) Resident rights.
Previously cited 5/25/18.


 Plan of Correction - To be completed: 07/09/2019

Resident R-19 was evaluated by OT on 5/28/2019 for right shoulder pain and limited ROM, both AROM and PROM. A Bed trapeze was installed, however not documented or addressed in OT POC. OT proceeded to complete a recertification, adding goals to address use of trapeze/repositioning in bed on 6/3/2019. Resident requested to have trapeze removed on 6/5/2019 two days after recertification. Trapeze removed. OT continues to see resident, working on right UE AROM, PROM, and decreasing pain in right shoulder to maximize resident's independence with bed mobility without assistive device and other functional tasks.
DOR will review all residents with trapeze orders and insure they have had therapy intervention to insure compliance with proper training in use of trapeze. Resident identified without formal therapy intervention for trapeze use, will be evaluated immediately and resident needs addressed. MD orders for assistive devices will include therapy orders for formal training, if not ordered by therapy.
RN and LPN staff will be re-educated on need for therapy intervention when new equipment is issued/ordered if not ordered by therapy.
The DOR will complete compliance audits for rehab services intervention with trapeze use daily for 5 days, then weekly for 3 weeks, then monthly for 2 months followed by quarterly for 2 quarters.
Results of audit presented by the administrator to Quality Assurance Performance Insurance Committee to determine resolution or need for further monitoring.

483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect and to investigate any such allegations for injuries of unknown origin for one of one residents. (Resident R15).

Findings include:

A review of the facility policy "Resident Abuse and Neglect Prevention Program" dated 11/28/18, indicated injuries of unknown origin would be investigated.

A review of the clinical record revealed that Resident R15 was admitted to the facility on 12/10/15. A review of the minimum data set (MDS) comprehensive assessment dated 3/4/19, indicated diagnoses of multiple sclerosis and contractures.

A review of a nurse progress note dated 5/14/19, indicated Resident R15 had an abrasion to the right calf.

A review of the open lesion report dated 5/15/19, indicated Resident R15 had a right calf skin tear measuring 3.0 x 0.5 x 0.1 cm (centimeters)

A review of the incident and accident tracking log dated May 2019, did not include Resident R15's right calf skin tear.

A review of facility documents incident reports and investigation reports for May 2019, did not include Resident R15's right calf skin tear.

During an interview on 5/30/19, at 2:00 p.m., the Director of Nursing confirmed the above findings and that the facility failed to investigate injuries of unknown origin for Resident R15 as required to rule out abuse and/or neglect.

28 Pa. Code: 201.14(a) Responsibility of Licensee.
Previously cited 5/25/18.

28 Pa. Code: 201.18(e)(1) Management.

28 Pa. Code: 201.20(a)(b) Staff development.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 07/09/2019

Resident 15 injury was investigated, root cause identified, and interventions placed on 5-14-19. An Incident Report of Resident 15 was completed on 5-30-2019 by the wound care nurse.

Skin assessments of in-house residents were initiated on 5/31/19. Areas identified were investigated to determine if an existing incident report was in place with investigation to rule out abuse and neglect, root cause analysis, and placement of interventions for treatment were in place.


Nursing staff (RN, LPN, Nurse Aide) will be re-educated by the Director of Nursing/designee regarding reporting of noted incidents or injuries as well as those of unknown origin for investigation, completion of a facility incident report if applicable, root cause analysis, rule out abuse and neglect, and placement of an appropriate intervention to prevent recurrence.

Compliance audit will be conducted by the Director of Nursing or designee.
Resident progress notes will be reviewed daily with the morning Interdisciplinary Team meeting process to determine areas identified with the need for incident investigation process as well as review of incident reports generated by staff for appropriate completion, investigation, root cause analysis, and initiation of effective interventions. The Interdisciplinary Team will determine if abuse and neglect should be ruled out with each review.

Incident reports will be audited daily for 5 days, weekly for 3 weeks, monthly for two months, quarterly for 2 quarters.

Results of the audits will be presented to Quality Assurance Performance Improvement Committee by the Director of Nursing or designee to determine resolution or continuation of monitoring.


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(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, facility policy and manufacture instruction, observation, and staff interview, it was determined that the facility failed to make certain the services provided or arranged by the facility, as outlined by the comprehensive care plan meet professional standards of quality for one of one residents (Resident R55).

Findings include:

A review of the facility policy "Administration of Medications" dated 11/28/18, indicated medications will be administered in a safe manner and in accordance to standards of practice.

A review of the manufacture instructions for the use of Basaglar Kwik Pen (insulin injection pen) indicated to use a Kwik Pen compatible needle.

A review of the clinical record revealed that Resident R55 was admitted to the facility on 3/19/19, with diagnoses that include diabetes.

A review of the comprehensive care plan initiated 3/19/19, indicated Resident R55 will have no complications related to diabetes.

A review of a physician order dated 5/7/19, indicated to give Resident R55 Basaglar Kwik Pen 25 units SQ (under the skin) one time a day.

During an observation of a medication administration on 5/30/19, at 8:50 a.m. Licensed Practical Nurse (LPN) Employee E1 was observed drawing insulin out of a Kwik Pen without using a Kwik Pen compatible needle for Resident R55.

During a telephone interview on 5/30/19, at 9:55 a.m. Pharmaceutical Representative (PR) Employee E2 revealed only use the recommended Kwik Pen compatible needle with the Basaglar Kwik Pen.

During an interview on 5/30/19, at 10:45 the Nursing Home Administrator confirmed the above findings and that the facility failed to make certain the services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality for Resident R55.

28 Pa. Code 201.29(d) Resident rights.

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


 Plan of Correction - To be completed: 07/09/2019

Resident 55 demonstrated no ill effects from Kwik Pen administration. No like residents were identified.

Licensed staff (RN and LPN) will be re-educated by the Director of Staff Development or Designee regarding the proper use of insulin pens according to manufactures guidelines to ensure appropriate administration methods.

The Director of Nursing or Designee will conduct medication observations to ensure license staff are following manufactures guideline when using the insulin pen 5 times a week time 1 week, 3 times a week for 3 weeks, weekly for 4 weeks, and monthly for 2 months.

Audit results will be reviewed at the Quality Assurance Performance Improvement meeting to determine resolution or need for further monitoring.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(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 facility policy and clinical record review and staff interview, it was determined that the facility failed to provide a drug regimen free from unnecessary drugs by administering a medication without adequate indication for use for one of 24 residents (Resident R27).

Findings include:

The facility policy "Medication Administration-General Guidelines" dated 11/28/18, indicated that medications are administered as prescribed in accordance with good nursing principals and practices.

A review of the clinical record indicated that Resident R27 was admitted to the facility on 11/28/15, and Minimum Data Set (MDS-periodic assessment of care needs) dated 5/15/19, revealed diagnoses that included a stroke, depression and dementia with behavioral disturbance.

A review of a physician order dated 3/15/19, indicated to increase Medroxyprogesterone Acetate (a hormonal medication given to males for abnormal sexuality) to 75 mg intramuscularly (an injection given into a muscle) every fourteen days at bedtime.

A review of the physician progress notes dated 1/11/19, 2/18/19, 3/29/19, and 4/30/19 did not reveal any noted increase in Resident R27's sexual behaviors (inappropriate touching).

A review of the most recent Med Options Medication Management Assessment dated 4/19/18, did not indicate any sexually inappropriate touching behaviors.

A review of the facility Behavior Intervention Monthly Flow Record dated February 2019, indicated the behaviors to be monitored as depression and anxiety. There were no monthly behavior flow records for January, March, April and May 2019 and none that included sexually inappropriate touching behaviors.

A review of the facility progress notes dated 1/1/19, through 5/30/19, did not reveal documentation of any sexually inappropriate touching behavior.

During an interview on 5/3019, at 1:33 p. m. Registered Nurse Employee E9 confirmed that there are no documented sexually inappropriate behaviors and that the facility failed to provide a drug regimen free from unnecessary medications by administering a medication without adequate indication for use to Resident R27.


28 Pa. Code: 201.14 (a) Responsibility of licensee.
Previously cited 5/25/18.

28 Pa. Code: 211.2 (a) (c) (d) (2) Physician services.

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

28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services.
Previously cited 5/25/18.


 Plan of Correction - To be completed: 07/09/2019

Resident 27 was reviewed in the behavior Monitoring Meeting for appropriate use of the medication, the physician was notified and an order to dc the medication was obtained, like residents will have behavior monitoring sheets placed for staff documentation with notation of specific behaviors related to the reason and need for the ordered psychoactive medication(s).

Nursing staff (RN and LPN) will be re-educated by Director of Staff Development/designee to complete the Behavior Monitoring Intervention Flow Record each shift to monitor behaviors as well as the effectiveness of ordered psychoactive medication.

The Behavior Monitoring Intervention Flow Records will be reviewed by the behavior management team to track the effect of ordered psychoactive medications on noted resident behaviors. The team will also make requests for gradual dose reductions as needed with review.

The Director of Nursing or Designee will complete audits of the Behavior Monitoring Sheets:
5 times a week for 1 week, 3 times a week for 3 weeks, weekly for 4 weeks, then monthly for 2 months.

Audit results will be presented by Director of Nursing to the Quality Assurance Performance Improvement Committee to determine resolution or need for continued monitoring.



205.6(a) LICENSURE Function of building.:State only Deficiency.
(a) No part of a building may be used for a purpose which interferes with or jeopardizes the health and safety of residents. Special authorization shall be given by the Department's Division of Nursing Care Facilities if a part of the building is to be used for a purpose other than health care.
Observations:
Based on a review of facility documents, observation and staff interview it was determined that the facility failed to make certain that the facility's dietary services were only shared with the assisted care residence (Main Kitchen).

Findings include:

A review of facility documents revealed that on 7/31/06, a permanent exception was granted to share dietary service with the assisted care residence.

During an observation on 5/29/19, at 12:12 p.m. it was revealed that facility dietary services operates a retail counter dining service for the public.

During an interview on 5/29/19, at 12:12 p.m. Food Service Director Employee E4 confirmed that the Dietary Service Department offers a retail counter dining service to the public from the Main Kitchen.


 Plan of Correction - To be completed: 07/09/2019

The retail counter dining service for the public has been discontinued. The administrator will request a waiver to share dietary services with the retail counter. The retail counter will remain out of service until a waiver is approved.

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