Nursing Investigation Results -

Pennsylvania Department of Health
SOUTH MOUNTAIN RESTORATION CTR
Patient Care Inspection Results

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SOUTH MOUNTAIN RESTORATION CTR
Inspection Results For:

There are  57 surveys for this facility. Please select a date to view the survey results.

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SOUTH MOUNTAIN RESTORATION CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a Incident survey completed on February 7, 2019, it was determined that South Mountain Restoration 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:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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


Based on review of policies, clinical records and investigation documents, as well as observations and staff interviews, it was determined that the facility failed to complete a thorough investigation and assessment of falls to determine the possible cause(s) and/or if care-planned interventions were in place at the time of the falls for one of 62 residents reviewed (Resident 39); failed to ensure that call bells were within reach for one of 62 residents reviewed (Residents 39) who had limited mobility and was at risk for falls; failed to ensure that fall prevention interventions were in place as care planned for two of 62 residents reviewed (Residents 112, 115); failed to ensure that safe wheelchair transport techniques were used for one of 61 residents reviewed (Resident 19); and failed to ensure that a safe environment was provided for one of 62 residents reviewed (Resident 64).

Findings include:

The facility's policy regarding fall assessment, treatment, and prevention, dated January 14, 2019, revealed that all post-fall evaluations and management would be clearly documented in the resident's clinical record, on the care plan, and on the incident report completed by the staff member observing or discovering that the resident fell. This was to include what the resident was attempting to do at the time of fall, what footwear was in place, the resident's position and condition after the fall, the condition of the floor, the last time the resident was toileted, any comments from the resident, any other pertinent information in the resident's clinical record, if the call bell was within reach, and appliances that were in use, as well as to note whether the resident was compliant with and using appropriately assigned appliances/devices, such as helmets, hip protectors, braces, and walkers.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 39, dated April 1, 2018, revealed that the resident was usually understood and could usually understand; requires extensive assistance from staff for bed mobility, transfers, dressing, and toilet use; was totally dependent on staff for locomotion on and off the unit; was always incontinent of bowel and bladder; and had a fall in the last two to six months prior to admission/entry or reentry. The residents' care plan, dated January 22, 2018, indicated that the resident was at risk for falls related to left side hemiplegia (paralysis on one side of the body) and was to use "One Way Slide" cushion (a cushion the prevents sliding forward while sitting) on his Broda chair (an adaptive wheelchair). A physical therapy assessment note for Resident 39, dated May 9, 2018, revealed that the resident used a Broda chair with mag wheels, anti-tippers, a gel pad, and a "One Way Slide" cushion, and he was able to self-propel. Therapy services recommended the continued use of these devices for mobility.

Nursing notes for Resident 39, dated May 15, 2018, at 2:35 p.m. and 3:06 p.m. revealed that the resident had a fall when he stood up out of his Broda chair and fell against the door of his room and onto the floor. The resident complained about right hip pain. A nurse who was across the hall in another resident's room witnessed the fall. A physician's progress note for Resident 39, dated May 15, 2018, at 2:59 p.m. revealed that the resident had a fall and complained of pain in the right hip.

The facility investigation documents, dated May 15, 2018, and completed by Licensed Practical Nurse 5, revealed that Resident 39's fall was witnessed, that the floor was dry, that the resident was wearing non-skid socks at the time, that the gel pad was stopped, staff were educated about ensuring that the Broda chair was properly reclined, and new interventions were initiated. However, there was no evidence that the investigation determined if the resident's "One Way Slide" cushion was in place as care planned at the time of the fall.

Interview with the Quality Assurance Performance Improvement Director on February 7, 2019, at 9:15 a.m. confirmed that the investigation of Resident 39's fall did not include a determination if the "One Way Slide" cushion was in place at the time of the fall.


The facility's policy regarding nursing personnel, dated December 17, 2018, indicated that staff were to position the call bell as indicated by the resident's care plan.

A quarterly MDS assessment for Resident 39, dated December 3, 2018, revealed that the resident was usually understood and could usually understand, required extensive assistance from staff for daily care, had medical diagnoses that included dementia (brain disorder that causes declines in memory and other thinking skills), Alzheimer's disease (a type of dementia), and hemiplegia. The resident's care plan, dated March 27, 2018, revealed that he had a communication problem related to a head injury and stroke, that he used the call bell but used it inappropriately at times, and staff were to ensure/provide a safe environment and were to keep the call bell in reach and encourage the resident to use it to call for assistance. The care plan revealed that the resident had falls on April 13 and July 4, 2018; the resident remained at risk for falls; and staff were to respond promptly to all requests for assistance.

Observations of Resident 39 on February 4, 2019, at 4:21 p.m. revealed that the resident was in bed and his call bell was clipped to the call bell cord where it plugs into the wall, which was to the resident's left and was out of the resident's reach. Interview with Nurse Aide 4 on February 4, 2019, at 4:35 p.m. confirmed that Resident 39 was able to use his call bell and that the call bell was currently placed out of the resident's reach.

Interview with the Nursing Home Administrator on February 6, 2019, at 8:25 a.m. confirmed that Resident 39's call bell should be within his reach.

Observations of Resident 39 on February 6, 2019, at 2:10 p.m. revealed that the resident was in bed and his call bell was lying across the bedside stand. The bedside stand was approximately 18 inches away from the side of the bed, and the call bell was out of the resident's reach. Interview with Licensed Practical Nurse 5 on February 6, 2019, at 2:15 p.m. confirmed that the resident's call bell should have been placed where he could reach it.


A quarterly MDS assessment for Resident 112, dated January 8, 2019, revealed that the resident was independent with transfers and walking, was totally dependent upon staff for dressing, and had a history of two or more falls without any injury and two or more falls with minor injuries since the last quarterly MDS assessment. The resident's care plan for falls, revised January 18, 2018, indicated that the resident was at risk for falls due to wandering and pacing, and he was to wear knee pads.

Observations on February 7, 2019, at 10:00 a.m. revealed that Resident 112 was walking up and down the hallways of the unit, fully dressed, with his knee pads positioned down around his ankles and resting on top of his shoes. Interview with Registered Nurse 8 on February 7, 2019, at 10:04 a.m., confirmed that Resident 112 was to have knee pads on at all times when up walking, that his current knee pads were stretched out and would not stay in place, and that a new pair should have been obtained for the resident.


A quarterly MDS assessment for Resident 115, dated January 8, 2019, revealed that the resident was understood and could understand; was dependent on staff for bed mobility, transfers, and other daily care tasks; had impaired range of motion to the upper and lower extremities on both sides (impaired movement of the joints); and had diagnoses that included non-Alzheimer's dementia, hemiplegia (paralysis to one side of the body), depression, obesity and abnormalities of gait and mobility. The resident's care plan for falls, dated April 26, 2018, indicated that the resident was at risk for falls due to paralysis as a result of a stroke, and safety measures included that she was to have a bed in the low position with a defined perimeter mattress (built-up edges) and a floor mat beside her bed on the door side. A revision to the care plan, dated August 8, 2018, included that the resident's call bell should be within reach and she should be encouraged to use it.

Observations on February 5, 2019, revealed that Resident 115 was asleep in bed and there was no fall mat on the floor on the door side of the bed, and the resident's call bell was on the floor on the right side of the bed. Her fall mat was folded up and leaning against the wall.

An interview with Licensed Practical Nurse 13 on February 5, 2019, at 2:20 p.m. confirmed that Resident 115's fall mat should have been on the floor beside the bed to prevent injury from a fall, and her call bell should have been within her reach.


A diagnosis list for Resident 19, dated February 4, 2019, indicated that the resident had diagnoses that included drug induced subacute dyskinesia (a movement disorder characterized by involuntary muscle movements) and dementia (brain disorder that causes declines in memory and other thinking skills). A quarterly Minimum Data Set (MDS) assessment for Resident 19, dated November 13, 2018, revealed that the resident had unclear speech and was rarely understood and able to understand others; required extensive assistance for bed mobility, dressing, and hygiene; was totally dependent on staff for transfers and toilet use; was independent for locomotion on the unit after he was placed in a specialized wheelchair; and he had impaired range of motion on both sides of his upper and lower extremities. The resident's care plan, dated June 10, 2018, revealed that he had a history of unpredictable behavior, and staff were to be aware that he may become aggressive quickly and with no warning. The resident's care plan, dated June 24, 2016, revealed the resident used a Broda chair, and a revision dated February 7, 2019, revealed that leg rest were to be used if staff needed to push the resident in the chair and the resident was not lifting his feet.

Observations on February 7, 2019, at 12:24 p.m. revealed that Resident 19 was sitting in his Broda chair just outside the common dining area of the secured unit when Licensed Practical Nurse 1 approached him and proceeded to push him down the hallway toward the solarium (a distance of approximately 75 feet). The Broda chair did not have foot rests attached and the resident's feet glided across the floor the entire distance. The nurse administered the resident's tube feeding while in the solarium with the doors closed, and after this was done, Registered Nurse 8 transported Resident 19 back to his room. Registered Nurse 8 stated that if Resident 19 would be resistive to her pushing his Broda chair, she would have to stop and apply leg rests. Registered Nurse 8 then pushed Resident 19 in his Broda chair down the hallway from the solarium with no leg rests in place, and the resident was very lethargic and his feet were gliding along the floor with his toes pointed downward. After pushing the resident approximately 110 feet, Resident 19 spontaneously lifted his left leg and crossed it over the right leg. Registered Nurse 8 continued to push the resident another 20 feet, made a right turn at the corner where the halls intersected, and continued to push Resident 13 in his Broda chair another 80 feet with his left leg crossed over his right leg, while his right leg continued to glide across the floor, until she reached the resident's room.

Interview with Licensed Practical Nurse 1 on February 7, 2019, at 12:30 p.m., confirmed that she should have used leg rests to transport Resident 19 as he was lethargic (sluggish) and not able to hold his feet up for the distance that she had to move him.

Interview with Registered Nurse 8 on February 7, 2019, at 12:37 p.m. confirmed that she should have used leg rests while transporting Resident 19 an extended distance in his Broda chair.


A quarterly MDS assessment for Resident 64, dated December 11, 2018, revealed that the resident could understand and be understood, had moderately impaired vision, had memory problems and inattention and disorganized thinking that comes and goes, was independent with her own care, and had diagnoses that included dementia, schizophrenia (a mental disorder characterized by abnormal behavior and a decreased ability to understand reality), osteoarthritis (disease of the joints) and extrapyramidal movement disorder (uncontrollable muscle movements usually caused by the side effects of certain medications).

Resident 64's care plan regarding falls, dated March 1, 2017, indicated that she was at risk for falls due to impaired vision and that she had a fall on February 19, 2018. Her care plan for impaired cognitive function and impaired thought due to chronic schizophrenia, revised October 4, 2017, included that she cleaned her room and washed her clothes.

Observations of Resident 64 on February 5, 2019, at 10:31 a.m. revealed that she was bent over at the waist, and then was on her hands and knees, scrubbing her bedroom floor with soap and water, and with disposable gloves on that were stained and appeared well used. At 10:34 a.m. Licensed Practical Nurse 12 also observed that Resident 64's floor was wet and soapy. At that time, the resident was walking in the hallway outside of her room and then she reentered her room when the doorway area was still wet.

Interview with Licensed Practical Nurse 12 on February 5, 2019, at 10:34 a.m. confirmed that Resident 64 has been constantly cleaning her floor for some time and is resistive to encouragement not to clean. Staff try not to give her new gloves because she will wear them all day, causing her hands to become irritated.

There was no documented evidence that Resident 64's care plan included the specific behavior of scrubbing her floor and any measures needed to address the resident's safety and the safety of others related to the resident's floor being wet often.

Interview with the Director of Nursing on February 7, 2019, at 11:01 a.m. confirmed that Resident 64's care plan did not address her specific behavior of scrubbing her floor and any safety measures needed to protect her and other residents from accidents and/or injury.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.




 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that nursing staff did not follow policy for ensuring the care plan for Resident 64 cleaning of her room was inclusive of washing the floor and relevant safety measures. R64's care plan has been updated to note cleaning of the floor and safety measures. Following investigation, it was determined that Licensed Practical Nurse 5 could not identify retroactively if one-way slide cushion was in place per plan of care and that it was not detailed in the fall report. Investigation into findings that R39 call bell was not within reach determined that shift staff during that particular day failed to place call bell for R39 within his reach per resident's care plan. The call bell was placed correctly upon being identified. Investigation for R112 determined that resident was to have knee pads pulled up at all times per the care plan and staff on shift failed to address that resident R112's knee pads had fallen and were inappropriately placed. Further, Registered Nurse 8 stated that knee pads were stretched out and a new pair should be in place. R112 knee pads were replaced. Investigation determined that R115 was to have fall mat at bedside per plan of care intervention and staff on shift failed to put intervention in place. Investigation determined that Licensed Practical Nurse 1 should have used leg rests per plan of care during transport. Licensed Practical Nurse 5 identified as witnessing R39 fall will be addressed by her supervisor to ensure all interventions are in place as outlined in the plan of care. Licensed staff for floors identified in issues will be addressed about deficient practices and this will be documented. Licensed Practical Nurse 1 deficient practice will be addressed by her supervisor

B. The facility cannot correct any other safety or supervisory deficits, which previously occurred.

C. Nursing staff will receive education on requirements to ensure all resident safety devices are in place as ordered or care planned for documenting and investigating resident incidents and their responsibility. Nursing staff will continue to maintain and complete the Assistive Technology sheet that lists assistive devices and seating and positioning devices for all residents. Nursing staff will be re-educated on the Assistive Technology sheets. Quality Assurance will monitor monthly for completion of sheet.

D. The Nurse Managers or designee will complete monitoring on living areas via rounds 10 times per week for 4 weeks to ensure resident safety devices are in place per care plan or facility procedure. Periodic rounds and monitoring will then be continued on an ongoing basis. The Quality Assurance Performance Improvement staff will monitor all incident reports for 4 weeks then 10 per week for 4 weeks to ensure documentation of safety measures and thorough investigation of incidents. Follow-up with the unit supervisors if safety devices were not present or noted. Audits will then occur periodically on an ongoing basis. Quality Assurance will monitor monthly for completion of Assistive Technology sheets for 3 months and periodic thereafter.

E. Beginning March 26, 2019 and monthly thereafter, reports related to monitors of freedom of accidents and adequate supervision will be reviewed by the Quality Assurance and Performance Improvement Committee.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 review of policies and CDC guidelines (Centers for Disease Control and Prevention), as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during an influenza (flu) outbreak for two of 62 residents reviewed (Residents 36, 69).

Findings include:

The facility's policy regarding influenza, dated June 30, 2018, indicated that during a flu outbreak, staff were to follow standard and droplet precautions.

CDC's current guidance for the 2018-2019 flu season, titled "Prevention Strategies for Seasonal Influenza in Healthcare Settings" contained details on flu prevention strategies for all health care settings that included:

Standard Precautions - A set of infection control procedures applied to the care of all patients in all health care settings, regardless of the suspected or confirmed presence of an infectious agent.

Droplet Precautions - Additional infection control procedures intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for seven days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a health care facility.

CDC's guidance indicated that these precautions were a part of the overall infection control strategy to protect against influenza in health care settings and should be used along with other infection control measures, such as isolation or cohorting of ill residents, screening employees and visitors for illness, furloughing ill health care personnel, and discouraging ill visitors from entering the facility. Because residents with influenza may continue to shed influenza viruses while on antiviral treatment, infection control measures to reduce transmission, including following Standard and Droplet Precautions, and should continue while the resident is taking antiviral therapy. This will also reduce transmission of viruses that may have become resistant to antiviral drugs during therapy.

A list of residents testing positive for the flu, provided by the facility on February 4, 2019, revealed that there was one resident who tested positive for the flu. A list of residents testing positive for the flu, provided by the facility on February 7, 2019, revealed that there were seven residents who tested positive for the flu. Resident 36 and Resident 69 were on the list of residents with the flu.

Observations on February 6, 2019, at 4:42 p.m. revealed that there was no evidence of any personal protective equipment visible in the hallways and Resident 36 was observed walking down the hall from the shower to her room without a mask while other residents were in the hallway.

Observations on February 6, 2019, at 4:44 p.m. revealed that Licensed Practical Nurse 15 entered Resident 36's room without a mask, obtained the resident's blood sugar, and administered insulin to her.

Observations on February 6, 2019, at 5:03 p.m. revealed that Resident 69 was observed walking down the hallway without a mask on.

Interviews with the Medical Director on February 6, 2019, at 5:23 p.m. and February 7, 2019, at 10:09 a.m. revealed that he did not feel that droplet precautions or infection control signs "to see the nurse before entering residents' rooms" were indicated for the flu. He thought that the facility's policy did not include droplet precautions for the flu, and he indicated that he had not reviewed the most recent CDC guidelines regarding the flu.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 3/15/18.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.




 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that it failed to ensure that proper infection control practices were followed and did not require Residents 36 and 69 to wear a mask in order to leave their room or require staff to wear a mask in their room.

B. The facility cannot correct any impact of this practice on other Residents; however, no additional residents tested positive for contracting the flu.

C. The Medical director, physicians, Infection Preventionist and Nursing staff will be re-educated on the facilities flu policy and procedures to be followed.

D. The Infection Preventionist will monitor adherence to flu related infection control practices in future cases over the next 6 weeks.

E. Beginning March 26, 2019 and monthly thereafter, reports related to monitoring of infection control practices during flu outbreaks will be reviewed by the Quality Assurance and Performance Improvement Committee.


483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending May 15, 2018, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 7, 2019, identified repeated deficiencies related to failures to maintain a safe, comfortable and homelike environment, to complete timely quarterly Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), to review and to revise residents' care plans, to label and store food under sanitary conditions, and to ensure that residents' clinical records were accurately documented.

The facility's plan of correction for a deficiency regarding a failure to maintain a safe, comfortable and homelike environment, cited during the survey ending March 15, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F584, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding maintaining a safe, comfortable and homelike environment.

The facility's plan of correction for a deficiency regarding a failure to complete quarterly MDS assessments timely, cited during the survey ending March 15, 2018, revealed that the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for completing MDS assessments) or designee was to monitor and report all concerns/findings to the QAPI committee. The results of the current survey, cited under F638, revealed that the QAPI was ineffective in correcting deficient practices related to the completing quarterly MDS assessments timely.

The facility's plan of correction for a deficiency regarding a failure to review and revise residents' care plans, cited during the survey ending March 15, 2018, revealed that the facility developed a plan that included monitoring by the QAPI committee. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure that residents' care plans were reviewed and revised.

The facility's plan of correction for a deficiency regarding labeling and storing food under sanitary conditions, cited during the survey ending March 15, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in correcting deficient practices related to labeling and storing food under sanitary conditions.

The facility's plan of correction for a deficiency regarding a failure to accurately document residents' clinical records, cited during the survey ending March 15, 2018, revealed that the facility developed a plan that included monitoring by the QAPI committee to ensure that residents' clinical records were accurately documented. The results of the current survey, cited under F842, revealed that the QAPI committee was ineffective in correcting deficient practices related to ensuring that the resident's clinical records were accurately documented.

Refer to F584, F638, F657, F812, F842.

28 Pa. Code 201.18(e)(3) Management.



 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that Quality Assurance Performance Improvement process and its Performance Improvement Projects failed to prevent staff from performing deficient practices in areas cited within this report.

B. The facility cannot correct that Quality Assurance Performance Improvement process and its Performance Improvement Projects failed to prevent staff from performing deficient practices in areas other than those cited within this report.

C. The Quality Assurance Performance Improvement Committee, including the Nursing Home Administrator and Director of Nursing will review and ensure member understanding of the committee's responsibility to ensure resident safety and compliance with state and federal regulations


D. Monitors will be developed based on the findings of the current survey and assigned to each responsible department. These monitors will be sent directly to the Quality Assurance Performance Improvement (QAPI) Department for monthly review for compliance and ensure that departments are following through with correctives. All other materials related to completion of plan of correction tasks are sent directly to the QAPI department for review and follow-up with applicable staff.

E. The Quality Assurance Department conducts at least two QAPI Rounds per month with compliance items identified to include findings of this and prior health surveys and follow-up with correctives implemented from each responsible department. Based on findings of these rounds, additional assignments may be issued to staff or departments to increase monitoring or enact additional interventions.

F. A Performance Improvement Project will be chartered and enacted to review QAPI Committee Performance Rounds and Monitoring are effective and ongoing until all revisions have been completed.

G. Each deficient practice will be considered for length of monitoring by the committee before any of the planned reporting periods lapse.

H. Beginning March 26, 2019 and monthly thereafter, reports related to the corrective actions taken for all other deficiencies will be reviewed by the Quality Assurance Performance Improvement Committee.

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

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

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


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to discard food items that were past their "use by" date, and failed to ensure that staff wore proper hair restraints while preparing residents' meals.

Findings include:

The facility's undated policy regarding refrigerator monitoring and food storage indicated that all open food/beverages must be labeled with the date they were opened, beverages were to be discarded seven days after the open date, and all expired items were to be discarded.

Observations in the sixth floor meal service kitchen on February 4, 2019, at 11:41 a.m. revealed one 46 ounce (oz) container of thickened cranberry juice that was labeled as opened on January 13, 2019. Interview with the Dietary Manager at that time confirmed that the container of thickened cranberry juice should have been discarded on January 21, 2019.

Observations in the fifth floor meal service kitchen on February 4, 2019, at 12:55 p.m. revealed a one liter bottle of ginger ale that was labeled as opened on January 14, 2019, and one 46 oz container of thickened cranberry juice labeled as opened on January 25, 2019. Interview with the Dietary Manager at that time confirmed that the ginger ale should have been discarded on January 22, 2019, and the container of thickened cranberry juice should have been discarded on February 2, 2019.

Observations in the 3B meal service kitchen on February 4, 2019, at 1:19 p.m. revealed a 64 oz bottle of light cranberry juice, a container of flavored thickened water, and a pint-sized container of a red, thick, salsa-like substance that were opened but not labeled with the dates they were opened. There was also a medium-sized metal pan containing a brown pudding-like substance that was covered in plastic wrap and labeled to discard it by February 3, 2019, and two bags of shredded lettuce stamped from the manufacturer as "Best if Used By January 23, 2019." Both bags of lettuce were vacuum sealed (unopened), but the lettuce in one of the bags was beginning to turn brown.

Interview with the Dietary Manager on February 4, 2019, at 1:30 p.m. confirmed that the cranberry juice and thickened water should have been labeled with the dates they were opened, and the container of salsa-like substance was a zero calorie salad dressing and should have been labeled and dated. She also indicated that the pan of pudding-like substance covered in plastic wrap was peanut butter and jelly spread and it should have been discarded by February 3, 2019, and the two bags of shredded lettuce should have been discarded by January 24, 2019.

Observations in the 3A meal service kitchen on February 4, 2019, at 12:30 p.m. revealed that Dining Supervisor 14, who had a short beard, was standing at the tray preparation area and was not wearing a hairnet or a beard cover. Upon interview with Dining Supervisor 14 at that time, he indicated that he was not wearing a hair net or beard cover because he was not touching any of the food. Interview with the Dietary Manager on February 4, 2019, at 1:25 p.m. confirmed that Dietary Supervisor should be wearing hair nets and beard covers when they are in or around food preparation areas.

42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve - Sanitary.
Previously cited 3/15/18.

28 Pa. Code 211.6(f) Dietary services.
Previously cited 3/15/18.





 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that nursing and/or dietary staff failed to follow proper procedure to ensure that opened food items are thrown out timely when usable life is exhausted. Facility Quality assurance performance improvement (QAPI) rounds have noted past compliance issues and had implemented several items to improve the process (posted signs on refrigerators, markers and labels kept on refrigerator doors) which had shown to be effective. The facility cannot correct that the dietary supervisor failed to follow procedure and apply hair restraints prior to entering serving area. The supervisor was called to assist last minute and in haste to fill in were needed he forgot to obtain a hairnet. The dietary manager did address the deficient practice with the employee.

B. The facility cannot correct other past instances however none others noted during the survey.

C. Nursing and dietary staff will receive education regarding requirements for use of hair restraints and labeling and discarding of open food items. The temperature log sheets which are placed on each refrigerator have been updated to include instructions to check food labeling and discarding items when due. These checks will be completed on a daily basis with each person completing it being accountable for future issues.

D. The Food Service Manager or designee will monitor use of hair restraints in food preparation and serving areas for 10 meals per week for four weeks and labeling and discarding of outdated items in food service areas seven times per week for four weeks. These items will be monitored during ongoing rounds. The Nurse Managers or designee will complete monitoring on living areas (resident nourishment refrigerators) five times per week for eight weeks to ensure that open food items are labeled and discarded within appropriate timeframes. These items will be monitored during ongoing rounds by nursing personnel and in regular QAPI rounds.

E. Beginning March 26, 2019 and monthly thereafter, reports for monitors related to Food storage and Cleanliness via use of hairnets will be reviewed by the Quality Assurance and Performance Improvement Committee


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 review of clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to maintain resident dignity during toileting for one of 62 residents reviewed (Resident 61).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated December 10, 2018, revealed that the resident had moderately impaired cognition, could usually understand and make herself understood, required the extensive assistance of two staff for toileting, and was frequently incontinent of bowel and bladder.

Facility investigation documents, dated December 15, 2018, revealed that after breakfast, Resident 95 was in the hallway and had his penis out of his pants. Witness statements from Nurse Aide 9, Registered Nurse 10 and Nurse Aide 11 revealed that Registered Nurse 10 attempted to place the resident's penis into his brief, the resident was by the bathroom and waiting to receive care, and she told the staff that the resident needed care and they needed to get his penis in his pants because he was attempting to masturbate. Nurse Aide 9 took Resident 95 into the women's restroom, and Resident 61, a female, was in the last stall by the window with the stall door closed.

Interview with the Quality Assurance Performance Improvement Director on February 6, 2019, at 2:10 p.m. confirmed that staff took a male resident, Resident 95, into the women's restroom when Resident 61, a female, was using the bathroom and they should not have. He indicated that staff were unaware that Resident 61 was in the bathroom until she walked out of the bathroom stall.

The facility failed to maintain Resident 61's dignity while using the bathroom.

42 CFR 483.10(a)(1)(2)(b)(1)(2) Resident Rights/Exercise of Rights.
Previously cited 3/15/18.

28 Pa. Code 201.29(j) Resident rights.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.





 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that female Resident 61's rights were violated when nursing staff moved male Resident 95 from the hallway and into the ladies restroom which was the closest room. R95 is mobile in a wheelchair and was observed by staff to be in the hallway with his genitals exposed. Staff indicated that they wanted to remove him from the view of peers and chose the closest room, but failed to check the room for any females at the time. Staff acknowledged that they knew males should not use female restrooms. R95's care plan addresses behaviors with interventions in place. Interventions includes monitor closely when in or around 6B center TV room and presence of peers, assist R95 to develop more appropriate methods of coping and interacting, caregivers to provide positive interaction frequently, distract by offering snack, assisting to restroom, provide incontinence care, and offer tv as R95 enjoys watching tv. Also included is escort to resident room if exposing self, monitor behavior episodes to determine underlying cause, considering location, time of day, persons involved, or situations, and to utilize 15-minute checks or Direct Observation as needed.

B. The facility also cannot identify or correct any prior occurrences; however, no other situations were observed during the remainder of the survey.

C. Nursing staff will be re-educated on Dignity and Respect, including emphasis on privacy for residents while using the bathroom.

D. Nurse Managers or designee will complete monitoring on living areas during high traffic times to ensure compliance with bathroom expectations and dignity and respect to bathroom privacy. This will be completed 10 times per week for 4 weeks. They will continue to monitor the use of gender specific restrooms during routine rounds and this will also be monitored through routine quality assurance performance improvement rounds.

E. Beginning March 26, 2019 and monthly thereafter, reports related to monitors of resident rights and privacy with bathroom use will be reviewed by the Quality Assurance and Performance Improvement Committee.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration.

Findings include:

The facility's policy regarding medication preparation and administration, dated September 25, 2018, revealed that to ensure proper resident confidentiality, the computer was to be locked or the screen display minimized to prevent information from being viewed.

Observations during medication administration on February 4, 2019, at 12:27 p.m. revealed that Licensed Practical Nurse 1 placed her medication cart in the hallway outside the 6A dining room, prepared a resident's medication, locked the medication cart, but left the computer screen up as she entered a resident's room to administer the medication, which exposed the resident's personal and medication information to any residents and staff who were walking by the medication cart. Observations at 12:30 p.m., 12:39 p.m., and 12:47 p.m. revealed that Licensed Practical Nurse 1 repeated this procedure as she administered medications to additonal residents, repeatedly exposing residents' personal and medication information to residents and staff who were walking by the medication cart.

Interview with Licensed Practical Nurse 1 on February 4, 2019, at 1:04 p.m. confirmed that she should have closed the computer screen so that residents' information was not visible when she left the medication cart unattended.

Interviews with the Medical Director, Nursing Home Administrator, and Director of Nursing on February 5, 2019, at 4:35 p.m. confirmed that if staff leave the area of the medication cart, the computer screen should be locked or minimized to prevent the residents' information from being viewed.

28 Pa. Code 211.5(b) Clinical records.





 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that Licensed Practical Nurse (LPN) 1 did not follow normal practice and
nursing procedure for Medication Administration and left the computer screen unattended and information exposed. Upon discussion with the surveyor, the LPN recognized her error. In addition the LPN's supervisor reviewed the procedure and addressed the deficient practice with her.

B. The facility cannot correct any prior occurrences of laptops being left open and unattended contrary to usual nursing procedure. However, no repeat occurrences were observed for the remainder of the survey and are not normally noted.

C. Licensed Nursing staff will be re-educated on nursing procedure for Medication Administration procedures, including emphasis on personal privacy and confidentiality of records.

D. Nurse Managers or designee will complete monitoring of Medication Administration procedures and
Privacy measures. This will be completed 10 times per week for 4 weeks. They will continue to monitor the privacy of residents during medication administration during routine rounds and this will also be monitored through routine quality assurance performance improvement rounds.

E. Beginning March 26, 2019 and monthly thereafter, reports related to monitoring of resident privacy
during medication administration will be reviewed by the Quality Assurance and Performance Improvement Committee.

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

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

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

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

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

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

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

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


Based on observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was maintained in a homelike manner in one of two resident lounge/activity areas on the 6A nursing unit.

Findings include:

Observations in the 6A resident lounge/activity area located across from resident room 655 on February 4, 2019, at 1:02 p.m. revealed that there were eight wheelchairs stored in front of the windows. At 2:30 p.m. there were nine wheelchairs and a mechanical lift (a device used to move residents who cannot bear weight) stored in front of the windows. At 3:57 p.m. there were eight wheelchairs and a mechanical lift stored in front of the windows, and there were three residents seated in the room watching television. Observations on February 5, 2019, at 9:41 a.m. revealed that there were eight wheelchairs stored in front of the windows, on February 6, 2019, at 2:10 p.m. there were seven wheelchairs stored in front of the windows, and on February 7, 2019, at 1:56 p.m. there were eight wheelchairs stored in front of the windows.

Interview with the Director of Nursing on February 7, 2019, at 5:40 p.m. revealed that she was not aware that the wheelchairs were being stored in the 6A resident lounge. She indicated that she was told that the room was being used to keep residents' wheelchairs in when they were not in use and she felt the room was large enough to have a clear pathway for the residents to get by the wheelchairs.

42 CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment.
Previously cited 3/15/18.

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

28 Pa. Code 207.2(a) Administrator's responsibility.




 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct its deficient practice of parking resident chairs in the rear of the TV room when residents were in bed and did not need them nor that a lift was there to charge as well. Wheelchairs were relocated to each resident's room or a non-resident use area and the mechanical lift to a non-resident use area on 2/8/2019. The Director of Nursing was aware that these items were kept in this location; however, did not recognize it as a deficient practice as it has been done for many years.

B. The facility also cannot correct prior occurrences of chair or lift storage in resident use areas due to facility practice now identified as deficient.

C. Nursing staff will be educated regarding what have now been designated as proper storage locations for resident chairs and lifts on each living area including whirlpool and shower rooms not in use and charting rooms.

D. Nurse Managers or designee will complete monitoring of resident equipment storage and homelike environment. This will be completed 10 times per week for 4 weeks. They will continue to monitor the storage of equipment and homelike environment during routine rounds and this will also be monitored through routine quality assurance performance improvement rounds.

E. Beginning March 26, 2019 and monthly thereafter, reports related to resident equipment storage will be reviewed by the Quality Assurance and Performance Improvement Committee.


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from non-consensual sexual contact for one of 62 residents reviewed (Resident 92), and free from abuse for one of 62 residents reviewed (Resident 95).

Findings include:

The facility's abuse policy, dated September 10, 2018, revealed that sexual abuse included non-consensual contact of any type, especially of the breasts and perineum, and any act of abuse towards a resident was absolutely prohibited.

An annual Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 92, dated March 6, 2018, revealed that the resident had diagnoses that included schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), ambulated independently about the facility, and required minimum assistance from staff for his care. The resident's care plan, dated August 13, 2017, revealed that he had a history of displaying public affection and inappropriate touching of female peers.

A nursing note for Resident 92, dated March 11, 2018, at 12:00 p.m. revealed that at approximately 9:30 a.m. the resident was exiting the elevator in the south hallway outside the center television room where a female resident was standing in the hallway, and he reached out at the resident and inappropriately touched her right breast. The female resident told him to stop and he went into the television room. Resident 92 was redirected away from female residents without further incident and was educated on inappropriate contact with female peers.

A nursing note for Resident 92, dated March 11, 2018, at 2:36 p.m. revealed that the care plan for the potential to publicly display affection/touching was updated and a new interventions were added to redirect and educate the resident on inappropriate contact with female peers, and staff were to monitor the resident for signs of inappropriate tendencies.

A physician's note for Resident 92, dated March 12, 2018, at 1:58 p.m. revealed that the resident touched a female resident's breasts yesterday, she said no and then he walked away. The resident was educated today and was told to ask any female for her permission to touch her prior to touching her and that he was not to touch any female without her permission. He indicated that he understood and would not touch any female without permission.

A psychology consultation for Resident 92, dated March 13, 2018, revealed that he was having some behavior problems, was having sexual advances toward female peers that was getting worse. He was acting out toward different female peers with unpleasant gestures, for example touching them. He was educated in the team meeting about his behavior and staff wanted to get a psychologist to talk to him about the issue. His team was concerned that he was observed on numerous occasions staring at female peers in their rooms or touching female peers. Team staff also reported over the past few weeks or longer that he was "having sexually aggressive behaviors and has tried to touch female residents in the living area, succeeding at inappropriately touching one peer's breast." The resident was educated by the team members and was also on 15-minute checks to monitor for his behavior since the first incident was noted. Team staff were also concerned that many of his peers were not able to provide consent regarding these issues. Recommendations were that the team staff and himself affirmed increased sexual thoughts and boundary violations with female peers. The intensity of these issues are moderate but he also reported worsening. He denied any specific target at this time, but he may be non-truthful. He was acting out toward different female peers. The psychologist discussed individual therapy to begin to address these issues and provide him more education regarding appropriate boundaries. He was in agreement with this plan, pending the psychologist's evaluation with another resident next week.

A psychology consultation for Resident 92, dated April 25, 2018, revealed that the resident had some problems with being sexually aggressive toward female residents and he needed ongoing psychotherapy for this problem.

A psychology consultation for Resident 92, dated May 15, 2018, revealed that the resident reported mild to moderate levels of thoughts regarding sex abuse of others over the past week. They continued to review and practice coping skills designed to help him reduce the frequency, intensity and duration of these issues, including a relaxation exercise. The psychologist provided these interventions with good benefit.

An incident report for Resident 92, dated May 17, 2018, revealed that the resident was seen in Resident 43's room with his hand in her brief. Resident 43 was sleeping in her recliner. Resident 92 was asked to leave the room immediately. He was educated regarding his behavior and was told that he has to get verbal consent prior to touching any female resident. He was told that his behavior was inappropriate and unacceptable. He understood and he said that he would not do anything like this again to any female resident. Resident 92 was placed on direct observation (line of sight), his physician reviewed his medications and ruled out a side effect of increased sexual urge, and a prior dose reduction of Effexor (antidepressant) was resumed. A urinalysis was completed and was negative for urinary tract infection, psychology services were to address impulses and controls and alternative outlets. Observation was reduced to 15-minute checks on May 24, 2018, due to no repeat attempts or other factors which would indicate concern for a repeat offense.

A physician's note for Resident 92, dated May 18, 2018, at 10:07 a.m. revealed that the resident was seen on May 17, 2018, at 2:15 p.m. due to an incident where he was seen in Resident 43's room with his hand in her slacks and brief. Resident 43 was sleeping in her recliner. Resident 92 was educated regarding his behavior and was told that he has to get verbal consent prior to touching any female resident. He was told that his behavior was inappropriate and unacceptable. He understood and said he would not do anything like this again to any female resident.

An interdisciplinary care plan meeting for Resident 92, dated May 18, 2018, at 11:51 a.m. revealed that a special team meeting was held to discuss the event that happened with another female peer. Resident 92 was observed with his hand down her pants, was educated about touching other peers without their permission/consent, and was asked if he would be willing to move to another floor, but he did not want to move. He was educated that the Pennsylvania State Police would be coming to talk to him about the event and that his behavior was inappropriate.

An incident report for Resident 92, dated May 28, 2018, at approximately 11:05 a.m. revealed that staff responded to Resident 131 yelling out that Resident 92 (who was on 15-minute observations) had touched her breasts. Staff immediately redirected Resident 92 away from Resident 131 and placed him on arms-length direct observation with a staff member assigned.

There was no documented evidence of adequate interventions, including supervision at the level and frequency required, to prevent the resident from touching female residents inappropriately.

Interviews with the Quality Assurance Coordinator and the Director of Nursing on February 7, 2019, at 3:25 p.m. confirmed that Resident 92 did not receive adequate interventions to prevent him from inappropriately touching female residents.


A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 95, dated October 15, 2018, indicated that the resident was confused, could usually understand and be understood, and required extensive assistance to total dependence for care.

Facility investigation documents, dated December 15, 2018, revealed that after breakfast, Resident 95 was in the hallway and had his penis out of his pants. Witness statements from Nurse Aide 9, Registered Nurse 10 and Nurse Aide 11 revealed that Registered Nurse 10 attempted to place the resident's penis into his brief, the resident was by the bathroom and waiting to receive care, and she told the staff that the resident needed care and they needed to get his penis in his pants because he was attempting to masturbate. Nurse Aide 9 and Nurse Aide 16 took Resident 95 into the women's restroom to do morning care and Nurse Aide 11 walked in and said, "I can't f*****g stand you, all you do is play with your penis." She then took a wet washcloth out of the sink and slapped the resident in the eye with it. The resident then said, "She hit me, she hit me," and pointed to Nurse Aide 11.

A written statement from Nurse Aide 11, dated December 15, 2018, revealed that she was bringing dirty washclothes back into the bathroom and as she turned, a wash cloth hit Resident 95 in his face.

Interview with the Quality Assurance Performance Improvement Director on February 6, 2019, at 2:10 p.m. revealed that the facility's investigation substantiated that Resident 95 was abused by Nurse Aide 11.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 3/15/18.

 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct the failure to protect R43, R131, and one unnamed victim from R92. Further, the facility cannot correct physical abuse to R95 by staff. Immediately upon learning of the occurrence or allegations, the facility initiated investigations and followed all Resident Abuse policies and investigation procedures pertaining to Freedom from Abuse. For each event noted in this report, the facility submitted their abuse investigation to the department of health and all reports have been accepted. Appropriate interventions implemented for Nurse Aide 11. Resident 92 continues to receive interventions in place prior to and following the March 2018 event and has been monitored by staff via Direct Observation and/or every 15 minute checks since May 2018 for safety. Direct Observation is defined in Policy #2860 Behavior Management as the continuous presence of staff member within six feet to ensure safety of resident or peer. The assigned staff will ensure the safety of the resident, redirect them from negative behaviors, observe for medical change, and/or intervene with risk of falls. The need for and level of observation is reviewed on a routine basis by R92's treatment team. There is no procedure for toileting for independent residents. Staff supervise bathroom entries and re-direct residents of the wrong gender when attempting to enter the wrong bathroom. All bathrooms are clearly marked with gender. In this situation, Licensed Practical Nurse 1 made a conscious and incorrect decision to transport resident into incorrect bathroom. All staff have been informed of availability to receive assistance for stress related or emotional issues from programs such as the Pennsylvania State Employees Assistance Program. All nursing staff receive training on self-regulation through the facility's crisis intervention training. Employees were offered a stress management training in January 2019 and the topic will continue to be discussed in the Staff Development Committee. Nursing staff will be informed about stress management and burnout indicators and prevention. Staff also have access to multiple areas away from living areas to spend break time for a quiet area without stressful influences.


B. The facility also cannot identify or correct any prior occurrences; however, the facility is not aware of any other situations at this time.

C. Registered Nurse Supervisor will evaluate R95 Plan of Care to address behaviors as well as further analysis of behavior for any yet unidentified patterns or interventions. R95 Plan of Care currently addresses exposing genitalia and masturbating to include staff interactions and re-direction, involve in activities, listen to music, and/or involve in 1:1 interaction with staff as well as ensuring privacy. Director of Nursing and Registered Nurse Managers will evaluate Direct Observation Procedure for any necessary changes. Nursing staff will be re-educated on F600 Freedom from Abuse and South Mountain Restoration Center Resident Abuse policy, emphasizing on abuse prevention, intervention methods, staff responsibilities, and timely reporting.

D. Registered Nurse Managers or designee will monitor nursing staff through performance observation rounds, focusing on abuse prevention and staff interactions/behaviors, 10 times per week for 4 weeks. Monitoring will continue periodically on an ongoing basis.


E. Beginning March 26, 2019 and monthly thereafter, reports related to abuse allegations will be reviewed by the Quality Assurance and Performance Improvement Committee.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to report an allegation of physical abuse for one of 62 residents reviewed (Resident 52).

Findings include:

The facility's policy regarding abuse, dated September 10, 2018, indicated that all alleged resident abuse was to be directly reported to any supervisor on duty, the Chief Executive Officer or designee, or the Human Resources Director. All staff and volunteers were expected to report abuse immediately, and the Performance Improvement Director was to submit the abuse allegation and investigation to the Department of Health. The policy included that a report to the Department of Health would be within two hours if there was sexual abuse or serious bodily injury, and within twenty-four hours for all other cases of alleged resident abuse.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated December 3, 2018, revealed that the resident was alert and oriented and was dependent on staff for care.

A nursing note for Resident 52, dated January 28, 2019, at 8:24 p.m. revealed that the resident reported that, "Someone is trying to kill me!" He reported that a nurse aide on the nightshift with long, dark hair and black-framed glasses worked last night, flung him around all night, twisted his arm behind his back while doing range of motion, and he was scared for his life.

There was no documented evidence that the Department of Health was notified about the allegation of physical abuse of Resident 52.

Interview with the Quality Assurance Performance Improvement Director on February 7, 2019, at 4:35 p.m. confirmed that the Department of Health was not notified about Resident 52's allegation of physical abuse.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.




 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct the failure for timely reporting of allegation of suspected abuse of R52 due to inaccurate reporting of the staff aware of the allegation. Upon identification of alleged incident, the facility began appropriate measures to conduct formal investigation to rule out abuse.

B. The facility cannot correct any prior incidents of failure to report abuse that was not identified, although no prior situation were identified at this time.

C. Nursing staff will be re-educated on F600 Freedom from Abuse tag and South Mountain Restoration Center Resident Abuse policy, emphasizing on timely reporting and documentation of events as they occur. Training for staff will include accuracy of reporting and documentation to include exactly what was witnessed and heard at the event, what interventions were implemented, and who was involved and reported to. The Director of Nursing, Nurse Managers, and Nurse Supervisors will be educated regarding their responsibility to routinely monitor resident incident reports and records for items which could require investigation to rule out resident abuse.

D. The Quality and Assurance Department will review and monitor all Incident Reports per week for 4 weeks then 10 per week for 4 weeks and elevate any situation of suspected abuse to review per policy with the Executive staff and Administrator

E. Beginning March 26, 2019 and monthly thereafter, suspected cases, documentation, and investigation processes will be reviewed by the Quality Assurance and Performance Improvement Committee.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to thoroughly investigate potential abuse for one of 62 residents reviewed (Resident 52).

Findings include:

The facility's policy regarding abuse, dated September 10, 2018, indicated that all alleged resident abuse was to be directly reported to any supervisor on duty, the Chief Executive Officer or designee, or the Human Resources Director. All staff and volunteers were expected to report abuse immediately, and the Performance Improvement Director was to submit the abuse allegation and investigation to the Department of Health. The policy included that a report to the Department of Health would be within two hours if there was sexual abuse or serious bodily injury, and within twenty-four hours for all other cases of alleged resident abuse.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated December 3, 2018, revealed that the resident was alert and oriented and was dependent on staff for all care.

A nursing note for Resident 52, dated January 28, 2019, at 8:24 p.m. revealed that the resident reported that, "Someone is trying to kill me!" He reported that a nurse aide on the nightshift with long, dark hair and black-framed glasses worked last night, flung him around all night, twisted his arm behind his back while doing range of motion, and he was scared for his life.

There was no documented evidence that an investigation was completed for Resident 52's allegation of physical abuse on January 28, 2019.

Interview with the Quality Assurance Performance Improvement Director on February 7, 2019, at 4:35 p.m. confirmed that the facility did not conduct an investigation to rule out that abuse occurred for Resident 52's allegation on January 28, 2019.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.




 Plan of Correction - To be completed: 04/01/2019

A. Upon hearing the resident make an allegation of abuse, the Registered Nurse (RN) 1 made report to the charge nurse which did not include the specific concerns and generalized that the resident was delusional and accusatory, which was not abnormal for the resident. Registered Nurse 1 should have immediately documented, communicated, and reported that Resident 52 made specifc statements of being harmed, who was accused of doing so, and who she reported this allegation of abuse. Upon receiving this report the charge RN and RN supervisor addressed the generalized concern they received and spoke with the resident to ensure he felt safe and he voiced no concerns. Had these individuals received a proper detailed account of what was said, they would have ensured the resident was safe and initiated contacts per the abuse investigation process. RN1 subsequently entered a progress note 28 hours later with an effective time of when she heard the allegation. In doing so, the facility mechanisms of reviewing the 24 hour report as well as all progress notes for the prior 24 hours failed to identify this note. The facility cannot correct the delayed investigation of the allegation of abuse of R52. Upon identification of allegation, the facility began formal investigation to rule out abuse per policy. Formal investigation was completed by trained investigators appointed by the Administrator in accordance with the facility policy on Resident Abuse. All investigators will have received the Commonwealth of Pennsylvania 21 Incident Investigation and Reporting training. Investigation determined that the reason why the incident was not properly investigated was Registered Nurse 1 failure to accurately and timely report incident of abuse. Investigation determined that the allegation was unsubstantiated, the report was accepted in the Event Reportable System and root/cause was determined to be R52 increased delusional statements and behaviors as a result of recent hospitalization. The facility will continue review and update R52 Plan of Care to address behaviors and put interventions in place for staff to deal with recent behaviors.

B. The facility cannot correct any prior incidents of failure to investigate alleged abuse, as the facility is not aware of any other instances where suspected abuse occurred that were not appropriately investigated.

C. Nursing staff and trained Abuse Investigators for the facility will be re-educated on F600 Freedom from Abuse tag and facility Resident Abuse policy, emphasizing on timely reporting and documentation of events as they occur. The Director of Nursing, Nurse Managers, and Nurse Supervisors will be educated regarding their responsibility to routinely monitor resident incident reports and records for items, which could require investigation to rule out resident abuse.

D. Registered Nurse Manger will monitor progress notes and performance of Registered Nurse 1 for 4 weeks to ensure compliance with performance standards and accurate reporting. Periodic auditing of all records will continue on an ongoing basis. The Quality and Assurance Department will review and monitor all Incident Reports per week for 4 weeks then 10 per week for 4 weeks and elevate any situation of suspected abuse to review per policy with the Executive staff and Administrator

E. Beginning March 26, 2019 and monthly thereafter, suspected cases, documentation, and investigation processes will be reviewed by the Quality Assurance and Performance Improvement Committee.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

483.20(b) Comprehensive Assessments
483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

483.20(b)(2) When required. Subject to the timeframes prescribed in 413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in 413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:


Based on review of the Resident Assessment Instrument (RAI) User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required time frame for three of 62 residents reviewed (Residents 39, 40, 54).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2017 and October 2018, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admission date + 13 calendar days), and that an annual comprehensive MDS assessment reference date (ARD - the last day of the assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment.

An admission MDS assessment for Resident 39 revealed that the resident was admitted to the facility on March 26, 2018, and the resident's admission MDS assessment was dated as completed on April 10, 2018, which was 16 days after admission.

An admission MDS assessment for Resident 40 revealed that the resident was admitted to the facility on August 28, 2018, and the resident's admission MDS assessment was dated as completed on September 11, 2018, which was 15 days after admission.

An annual MDS assessment for Resident 54 revealed that the ARD was November 28, 2017, and the ARD of the subsequent annual MDS assessment was December 4, 2018 (369 days).

An interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on February 7, 2019, at 8:09 a.m. confirmed that Residents 39's and 40's admission MDS assessments were completed late, and Resident 54's annual MDS assessment was completed late.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 3/15/18.





 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that Registered Nurse Assessment Coordinator (RNAC) failed to monitor the completion status of the assessment for R40 causing it to be submitted a day late. The assessment for R39 was shown as being submitted late overall due to the resident being started on Medicare Part A days after admission retroactive to day 1 and a new assessment was initiated at that time. R54's assessment was submitted at day 366 due to the annual being late the prior year (per survey) and was not possible to move the dates up any further. The deficient practice of the RNAC was addressed by her supervisor.

B. The facility did not identify any other occurrences of late and missing admission or annual assessments in 2018.

C. The RNAC will be re-educated on time structure necessary for assessment completion and the use of the facility tracking tool to ensure timely completion of all assessments.

D. The RNAC will monitor the timely scheduling and completion of all Admission and Annual assessments on an ongoing basis. For 8 weeks she will provide documentation of assessment initiation and schedules to the Director of Nursing as documentation of adherence to process.

E. Beginning March 26, 2019 and monthly thereafter, reports related to timely assessment completion will be reviewed by the Quality Assurance and Performance Improvement Committee.




483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for five of 62 residents reviewed (Residents 43, 54, 56, 82, 86).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (federally-mandated assessments of a resident's abilities and care needs), dated October 2017 and October 2018, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days.

An admission MDS assessment for Resident 43 revealed an ARD of August 7, 2018, requiring the ARD of the next quarterly MDS assessment to be on or before November 7, 2018. However, the ARD of the next quarterly MDS assessment was November 27, 2018 (112 days).

An admission MDS assessment for Resident 54 revealed an ARD of August 7, 2018, requiring the ARD of the next quarterly MDS assessment to be on or before November 7, 2018. However, the ARD of the next quarterly MDS assessment was December 4, 2018 (119 days).

An admission MDS assessment for Resident 56 revealed an ARD of August 22, 2018, requiring the ARD of the next quarterly MDS assessment to be on or before November 12, 2018. However, the ARD of the next quarterly MDS assessment was December 4, 2018 (104 days).

An admission MDS assessment for Resident 82 revealed an ARD of September 11, 2018, requiring the ARD of the next quarterly MDS assessment to be on or before December 12, 2018. However, the ARD of the next quarterly MDS assessment was December 18, 2018 (98 days).

An admission MDS assessment for Resident 86 revealed an ARD of September 17, 2018, requiring the ARD of the next quarterly MDS assessment to be on or before December 17, 2018. However, the ARD of the next quarterly MDS assessment was December 24, 2018 (96 days).

An interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on February 7, 2019, at 8:09 a.m. confirmed that the quarterly assessments were late.

42 CFR 483.20(c) Quarterly Assessment at Least Every 3 Months.
Previously cited 3/15/18.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 3/15/18.




 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that Registered Nurse Assessment Coordinator (RNAC) failed to utilize scheduling and tracking tools(scheduling assistant in electronic health record and tracking spreadsheet developed in house) to monitor the timely scheduling and submission of quarterly assessments for R43, 54, 56, 82, 86). The deficient practice of the RNAC was addressed by her supervisor.

B. The facility did not identify any other occurrences of late and missing quarterly assessments in 2018.

C. The RNAC will be re-educated on time structure necessary for assessment completion and the use of the facility tracking tool(scheduling assistant in electronic health record and tracking spreadsheet developed in house) to ensure timely completion of all assessments.

D. The RNAC will monitor the timely scheduling and completion of quarterly assessments on an ongoing basis. For 8 weeks she will provide documentation of assessment initiation and schedules (using scheduling assistant in electronic health record and tracking spreadsheet developed in house) to the Director of Nursing as documentation of adherence to process.

E. Beginning March 26, 2019 and monthly thereafter, reports related to timely quarterly assessment completion will be reviewed by the Quality Assurance and Performance Improvement Committee.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set (MDS) assessments for two of 62 residents reviewed (Residents 66, 106).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2017 and October 2018, revealed that Section J1900 was to be coded with the number of falls that occurred since admission/entry or reentry or the prior assessment, and the level of fall-related injury for each fall was to be coded in Sections J1900A, J1900B and J1900C. Section J1900C was to capture the number of falls that resulted in a major injury, and major injury includes bone fractures.

An incident report for Resident 66, dated November 3, 2018, at 6:18 a.m. revealed that she was found kneeling on the floor in front of her bed, and she had a 9.0 x 4.0 centimeter (cm) abrasion to the right back below the shoulder blade. A nursing note dated November 3, 2018, at 8:08 a.m. revealed that the nurse was called to the unit to assess the resident's right hand, which was bruised and swollen with a misalignment of right fifth finger. The resident complained of discomfort to the area and was unable to bend the fifth finger. The physician was made aware and an x-ray of the right hand was ordered to rule out a fracture. A nursing note dated November 3, 2018, at 7:21 p.m. revealed that the physician was notified of the x-ray results which showed a fracture of the fifth middle phalanx (finger bone).

A quarterly MDS for Resident 66, dated December 11, 2018, revealed that Section J1900B (number of falls with minor injury) was coded (1) and J1900C (number of falls with major injury) was coded (0), indicating that there were no falls that resulted in major injury.

Interview with the Resident Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for completing MDS assessments) on February 6, 2019, at 9:58 a.m. confirmed that Section J1900 of Resident 66's quarterly MDS dated December 11, 2018, was inaccurately coded and did not reflect the resident's fall with fracture.


The RAI User's Manual, dated October 2017 and October 2018, revealed that if the assessment was the first assessment since the most recent admission/entry or reentry, then Section A0310E was to be coded (1) Yes, and Section J1700, the resident's fall history on admission/entry or re-entry, was to be completed if Section A0310E was coded (1) Yes. If the resident had a fall any time in the last month prior to admission/entry or reentry, then Section J1700A was to be coded (1) Yes. If the resident had a fracture related to a fall in the six months prior to admission/entry or re-entry, then Section J1700C was to be coded (1) Yes.

A nursing note for Resident 106, dated June 28, 2018, at 7:30 a.m. revealed that the resident was found on his back on the south hallway. Nursing notes, dated June 30, 2018, revealed that the resident complained of pain to the right thigh and was unable to bear weight. An x-ray of the right hip and femur (large bone of the upper leg) were obtained and revealed a fractured right femur.

A 5-day scheduled Prospective Payment System (PPS- method of reimbursement in which Medicare payment is made) MDS assessment for Resident 106, dated July 16, 2018, revealed that Section A0310E was incorrectly coded (0) No, indicating that this was not the resident's first MDS assessment since being readmitted (from the hospital). By coding Section A0310E as (0) No, the computerized MDS software did not allow Sections J1700A and J1700C to be completed to reflect that the resident had a fall and fracture in the past 30 days and six months, respectively.

Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on February 7, 2019, at 1:24 p.m. confirmed that Section A0310E of Resident 106's MDS assessment of July 16, 2018, was not accurate, and Sections J1700A and J1700C should have captured the resident's fall and fracture on June 30, 2018.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 3/15/18.



 Plan of Correction - To be completed: 04/01/2019

A. Upon identification of inaccuracy of assessment and reporting for Residents 66 and 106 with their Minimum Data Set(MDS) assessment, corrections were made and MDSs were re-submitted. Discussion with staff noted that both entries were typing/selection errors and were able to express why the codes selected were incorrect. Nursing staff completing these sections receive ongoing training in the MDS completion and any updates or changes. Involved staff responsible for these errors were re-educated on their responsibility for accurate coding of entries.

B. A complete audit of all other injuries using the Event Reportable Submissions and incidents with major injury in 2018 will be completed by the Registered Nurse Assessment Coordinator to identify any other incorrect entries and assessments corrected as needed.

C. Licensed Nursing staff will be re-educated on appropriate coding of injuries as well as careful review of all final entries to assist with ensuring required accuracy of MDS assessments.

D. The Registered Nurse Assessment Coordinator will monitor all reports of fall with injury for 12 weeks to ensure accuracy of injury reporting as well as routine random audits of entries on an ongoing basis.

E. Beginning March 26, 2019 and monthly thereafter, the Quality Assurance and Performance Improvement Committee will review accuracy of MDS assessment completion with the Registered Nurse Assessment Coordinator through report to the committee.


483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans related to the care and services required for the use of anticoagulant (blood thinning) medication for one of 62 residents reviewed (Resident 52).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated December 3, 2018, revealed that the resident was alert and oriented and used a blood thinning medication.

Physician's orders for Resident 52, dated August 1, 2018, included an order for the resident to receive 2.5 milligrams (mg) of Coumadin daily. However, the resident's clinical record did not include a care plan regarding Resident 52's use of a blood thinning medication.

Interview with the Director of Nursing on February 7, 2019, at 5:40 p.m. confirmed that Resident 52 did not have a care plan in place regarding the use of Coumadin.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 3/15/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 3/15/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.




 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that the treatment team for Resident 52 failed to ensure all appropriate diagnoses, medications and needs were addressed in his care plan. The treatment team has the responsibility of ensuring that the care plan is complete and current and note the changes to be made when it is reviewed at the resident's team meetings. Each discipline is tasked with ensuring the plan is correct for their respective areas on an ongoing basis with updates made when needs present. The Care Plan for Resident 52 was updated to include Coumadin Care Plan upon identification of missing interventions.

B. The care plans for all other residents on anti-coagulants were audited to ensure appropriate interventions were in place. All audited had proper care plans for this item.

C. The treatment team for Resident 52 will be re-educated on their responsibility as relative to resident care plans. Licensed Nursing Staff who were responsible for the missing item will be re-educated on creating and timely updating of Care Plans, specifically requirements for interventions related to medical diagnoses, medications including anti-coagulant use, and changes in resident needs.

D. Nurse Managers or designee will complete audits of 5 Care Plans per week for minimum of 8 weeks. An audit tool has been developed, which provides a basis for audits as well as a guide for creating a care plan to provide reference to common areas and topics including high risk medications. Beyond the audit period noted above, all care plans will be audited on an ongoing basis.

E. Beginning March 26, 2019 and monthly thereafter, reports related to audits of resident care plans will be reviewed by the Quality Assurance and Performance Improvement Committee.


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


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident's behavior care plan was updated for one of 61 residents reviewed (Resident 64).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 64, dated December 11, 2018, revealed that the resident could understand and be understood, had moderately impaired vision, had memory problems and inattention and disorganized thinking that comes and goes, was independent with her own care, and had diagnoses that included dementia, schizophrenia (a mental disorder characterized by abnormal behavior and a decreased ability to understand reality), osteoarthritis (disease of the joints), and extrapyramidal movement disorder (uncontrollable muscle movements usually caused by the side effects of certain medications).

Resident 64's care plan for impaired cognitive function and impaired thought due to chronic schizophrenia, revised October 4, 2017, included that she cleaned her room and washed her clothes.

Observations of Resident 64 on February 5, 2019, at 10:31 a.m. revealed that she was bent over at the waist, and then was on her hands and knees, scrubbing her bedroom floor with soap and water, and with disposable gloves on that were stained and appeared well used. At 10:34 a.m. Licensed Practical Nurse 12 also observed that Resident 64's floor was wet and soapy. At that time, the resident was walking in the hallway outside of her room and then she reentered her room when the doorway area was still wet.

Interview with Licensed Practical Nurse 12 on February 5, 2019, at 10:34 a.m. confirmed that Resident 64 has been constantly cleaning her floor for some time.

There was no documented evidence that Resident 64's care plan was updated to address the specific behavior of scrubbing her floor and any measures needed to allow the resident to do so safely for herself and others.

Interview with the Director of Nursing on February 7, 2019, at 11:01 a.m. confirmed that Resident 64's care plan did not address her specific behavior of scrubbing her floor and any safety measures needed.

42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision.
Previously cited 3/15/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 3/15/18.







 Plan of Correction - To be completed: 04/01/2019

A. Resident 64's care plan related to cleaning of her room was updated to list specifically that resident cleans her floor. Safety measures were integrated into the care plan to promote the safety of this and other residents. The facility cannot correct that the nursing staff on Resident 64's floor failed to document in the care plan all relevant safety measures, which they employ in this situation. During each assessment period licensed nursing staff assess each resident and review documentation, current needs and the existing plan, making updates as indicated. This is done prior to the team meeting in which the full plan is reviewed and discussed. The need for safety interventions should have been identified at this time.

B. The care plans of ten other residents were reviewed to ensure completeness of interventions related to safety measures.

C. Licensed Nursing Staff will be re-educated on effective Plan of Care writing and ensuring that all resident behaviors and needs, including safety measures relative to resident behavior, are included.

D Nurse Managers or designee will complete audits of 5 Care Plans per week for minimum of 8 weeks. An audit tool has been developed, which provides a basis for audits as well as a guide for creating a care plan to provide reference to common areas and topics, including high risk medications. Beyond the audit period noted above, all care plans will be audited on an ongoing basis.

E Beginning March 26, 2019 and monthly thereafter, reports related to audits of care plans will be reviewed by the Quality Assurance and Performance Improvement Committee.



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 Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for two of 62 residents reviewed (Residents 19, 45).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.

The facility's policy regarding assessment and treatment of falls, dated November 11, 2018, indicated that after each fall, residents would be assessed for injury by a registered nurse before moving them, and the assessment would be documented in the resident's clinical record. The facility's incident report form, revised February 11, 2002, indicated that the "Medical/Nursing Intervention" section of the form was to be completed by the registered nurse and was to include a specific, measurable description of the injury and the interventions.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated November 13, 2018, revealed that the resident had unclear speech, was rarely understood and rarely able to understand others, required extensive assistance for bed mobility, dressing and hygiene, was totally dependent on staff for transfers and toilet use, and was independent for locomotion on and off the unit, after being placed in a specialized wheelchair. The resident's care plan, dated June 10, 2018, revealed that the resident was able to move himself independently in his specialized wheelchair, yet needed reminders to move his chair slowly and safely in the hallway, so as not to bump his knees or arms into the wall, and staff were to monitor and document the location, size and treatment of skin injuries.

An incident report, dated August 4, 2018, revealed that Resident 19 was observed by staff coming out of a room on the south hallway in his specialized wheelchair. A nurse aide assisted Resident 19 out of the room and noted a superficial scratch to the resident's left upper back area. The "Medical/Nursing Intervention" section of the incident report (that was to be completed by a registered nurse) was completed, signed, and dated August 4, 2018, by Licensed Practical Nurse 6, who documented that the resident had five scratches on his right upper back, without any documentation of the length or width of the five scratches. The incident report was dated and co-signed by Registered Nurse Supervisor 7 on August 6, 2018, two days after the incident. There was no documented evidence that a registered nurse assessed the resident's injuries on the right upper back.

An incident report, dated September 10, 2018, revealed that when assisting Resident 19 to bed, staff discovered an abraded area that was approximately 4.0 x 0.25 inches on the inner aspect of the right lower leg toward the back. The "Medical/Nursing Intervention" section of the incident report (that was to be completed by a registered nurse) was completed by a licensed practical nurse. There was no documented evidence that a registered nurse assessed the resident's injury on the right lower leg.

An incident report dated November 8, 2018, revealed that Resident 19 was found in the North Hall television room sitting on his buttocks. The "Medical/Nursing Intervention" section of the incident report (that was to be completed by a registered nurse) was completed by a licensed practical nurse. There was no documented evidence that a registered nurse assessed the resident for injury following the fall.

Interview with the Director of Nursing on February 7, 2019, at 4:00 p.m. confirmed that there was no documented evidence of a registered nurse assessment of Resident 19's injuries on August 4 and September 10, 2018, or following the fall on November 8, 2018, and there should have been.


An annual MDS assessment for Resident 45, dated November 26, 2018, revealed that the resident was understood and could understand, required extensive assistance for his bed mobility, dressing and hygiene, was totally dependent on staff for transfers and toilet use, and was independent for his locomotion on and off the unit. The resident's care plan, dated December 26, 2017, revealed that he had limited mobility and limited range of motion, was able able to self-propel his wheelchair and manage the wheelchair brakes, he requires total assistance by two staff to dress, and staff were to observe his skin for redness, open areas, scratches, cuts and bruises, and report any changes to the nurse.

Observations of and an interview with Resident 45 on February 5, 2019, at 9:28 a.m. revealed that he had a small, superficial, circular-shaped abrasion to his left lower leg, just below his knee. The resident indicated that he was downstairs, went to sit at a table, went in the wrong way, and struck his leg on a brace under the table.

Interview with Resident 45 on February 7, 2019, 1:35 p.m. revealed that he injured his left leg within the past week or so when he was down at the auditorium. He indicated that he had advised someone at the time of injury and that they were putting something on the injured site.

Nurse aide documentation for Resident 45 revealed that on February 3, 2019, Nurse Aide 3 indicated that the resident had a reddened area. However, there was no documented evidence that a registered nurse was contacted and/or completed an assessment of this change in the resident's skin condition.

Interview with Registered Nurse 2 on February 7, 2019, at 2:10 p.m. confirmed that she could not find any documentation about the injury in Resident 45's clinical record, and she was unaware that the resident had an injury.

A incident investigation provided by the facility, dated February 7, 2019, at 6:05 p.m. included a statement completed by Nurse Aide 3 which indicated that on February 3, 2019, at approximately 7:30 p.m., she and another nurse aide were assisting Resident 45 to bed when they noticed an abrasion on the resident's left knee area. The resident stated that he hit it on a table at church. The injury was reported to the registered nurse. Interview with the Director of Nursing at the time the incident investigation was provided confirmed that there was no documented evidence that a registered nurse was contacted and/or completed an assessment of the resident's injury.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 3/15/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.





 Plan of Correction - To be completed: 04/01/2019

A. For the August 4, 2018 incident for R19 the Licensed Practical Nurse (LPN) did the assessment and informed the Registered Nurse (RN) Supervisor of the matter as evidenced by note on same evening regarding incident. The incident was cosigned during the review by the RN supervisor
which is completed for all incidents. The facility cannot correct the deficient procedure that injuries of this nature were not required to be assessed by an RN. The aide for R45 did report the abrasion to the RN on duty however the RN did not follow procedure to document an assessment or apply interventions if within her scope. The Manager for this RN addressed the deficient practice with her and outlined clear expectations.

B. The facility cannot correct that the facility failed to ensure that a Registered Nurse assessed residents for a change of condition for any other residents not identified

C. Licensed Nursing staff will be re-educated on the requirement for assessments of a resident's change of condition to be performed by a Registered Nurse as well as situations which meet criteria for change in condition. Relevant nursing procedures will be revised to address proper assessments.

D. The Quality Assurance Performance Improvement staff will monitor all incident reports for 4 weeks then 10 per week for 4 weeks to ensure assessments are performed and documented by a Registered Nurse. Periodic audits will occur on an ongoing basis.

E. Beginning March 26, 2019 and monthly thereafter, reports related to monitors of completion of Resident assessments will be reviewed by the Quality Assurance and Performance Improvement Committee

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to obtain physican orders for the use of an indwelling urinary catheter, and failed to remove an indwelling urinary catheter as recommended by the physician for one of 62 residents reviewed (Resident 98).

Findings include:

An interdisciplinary team meeting note for Resident 98, dated November 16, 2018, at 10:49 a.m. revealed that the resident was sent to the hospital on November 13, 2018, for evaluation of a mental status change and was diagnosed with a urinary tract infection. He was treated with an antibiotic and returned to the facility with a indwelling urinary catheter (tube inserted and held in the bladder to drain urine). A physician's order was received on November 15, 2018, for routine catheter care; however, there was no order for the size of catheter to be used or a diagnosis to justify the use of the catheter. The note indicated that the catheter would be kept in until the resident was seen by the urologist (physician that specializes in the male and female urinary tract system).

A urology consultation for Resident 98, dated November 29, 2018, indicated that the resident may benefit from a long-term indwelling urinary catheter and that it should be changed every four weeks.

Hospital records, dated December 5, 2018, revealed that Resident 98 was sent to the hospital and catheter care was provided; however, there was no documented evidence that the catheter was changed while in the hospital.

A hospital transfer sheet for Resident 98, dated January 14, 2019, revealed that the catheter was inserted on November 13, 2018.

There was no documented evidence in Resident 98's clinical that the indwelling urinary catheter was changed until January 15, 2019. Hospital records, dated January 15, 2019, revealed that the resident's indwelling urinary catheter was removed and re-inserted on that date.

Interview with the Director of Nursing on February 7, 2019, at 11:59 a.m. confirmed that there was no physician's order on November 15, 2018, for the size of the indwelling urinary catheter to be used, and the physician's recommendation of November 29, 2018, to change the urinary catheter every four weeks was not followed for Resident 98.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.





 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct the manner in which the catheter related orders for R98 were entered by the physician. The orders relative to this were entered in the manner in which similar orders were written for other residents; however, it was determined to be deficient and lacking a treating diagnosis. Staff physicians enter orders directly into the electronic health record and licensed nursing staff confirm the orders. The nurses did not observe order as deficient due to as noted above, this order was written as was the norm for similar orders. The medication and treatment administration records are a part of the electronic health record software and orders populate on the selected record (treatment or medication) when confirmed. Orders are maintained on list of active orders until discontinued. Catheter changes are documented in the treatment administration record for permanent record and reference of dates of prior changes. The catheter orders for R98 have been corrected and also note the diagnosis for its use. R98's catheter was changed within 4 weeks during hospital admissions, information was relayed to the facility; however, this was not reflected in the written hospital materials available during the survey. The facility cannot correct that the physician ordered a catheter change for a date which was 28 days from the prior change which was not in keeping with a prior recommendation. Subsequent changes occurred within 4 weeks.

B. The records for all other residents with urinary catheters were audited to ensure complete order sets; however, we cannot correct any past catheter changes outside the 28 days timeframe though none noted for current residents.

C. The facility's Physicians will be re-educated on required components for urinary catheter orders and use of newly developed order sets to ensure orders are complete and consistent. The recommended timeframe for catheter changes will also be addressed.

D. The Medical Director will monitor orders for newly ordered catheters and routine changes for 6 weeks and periodically thereafter.

E. Beginning March 26, 2019 and monthly thereafter, reports for monitors related to urinary catheter orders and changes will be reviewed by the Quality Assurance and Performance Improvement Committee.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that appropriate positioning was provided during the administration of a tube feeding formula through a gastrostomy tube for one of 62 residents reviewed (Resident 19), failed to ensure that a resident's gastrostomy tube feeding was administered as ordered by the physician for one of 62 residents reviewed (Resident 19), and failed to ensure that gastrostomy tube care was provided in accordance with the physician's orders for one of 62 residents reviewed (Resident 59).

Findings include:

Tha facility policy regarding gastrostomy tube feedings (the delivery of a nutritional formula through a tube that has been surgically inserted through the abdomen into the stomach), dated January 22, 2019, indicated that the resident was to be kept at a 30 to 45 degree (head up) position for 30 minutes following completion of the feeding, and that licensed staff were to document the administration of the tube feeding in the clinical record, including the amount (volume) of feeding given and the times it was administered.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated November 13, 2018, revealed that the resident had unclear speech, was rarely/never able to make himself understood, rarely/never able to understand others, and had a medical history that included a gastrostomy tube (a tube surgically placed through the abdomen into the stomach). Physician's orders, dated September 19, 2018, included orders for the resident to receive one container of Jevity 1.5 (a specific tube feeding formula) via the gastrostomy tube five times a day (5:00 a.m., 10:00 a.m., 1:00 p.m., 6:00 p.m., and 11:00 p.m.). The resident's care plan, dated March 1, 2018, included that the head of the resident's bed was to be elevated at 45 degrees during his tube feeding and for 30 minutes after.

Observations on February 7, 2019, at 12:35 p.m. revealed that Licensed Practical Nurse 1 administered Resident 19's tube feeding in the solarium of the nursing unit, and after it was administered Registered Nurse 8 pushed the resident to his room, where she and a nurse aide used a mechanical lift to place Resident 19 into his bed. Resident 19 was laid flat in his bed at 12:40 p.m., and was rolled from side-to-side in order to get the lift sling out from underneath him. He was then placed on his side with a supporting wedge behind his back and the head of his bed was elevated to 45 degrees. The approximate time that Resident 19 remained flat was 94 seconds.

Interview with Registered Nurse 8 on February 7, 2019, at 12:45 p.m. confirmed that Resident 19 was to remain upright for 30 minutes after the administration of a tube feeding and they could have waited another 20 minutes prior to putting the resident back to bed.

Resident 19's clinical record, including the Medication Administration Records (MAR's) and nursing notes, revealed no documented evidence that staff administered the tube feeding formula on January 31 and February 1, 2019, at 11:00 p.m.

Interview with Registered Nurse 8 and the Director of Nursing on February 6, 2019, at 3:00 p.m. and 4:35 p.m., respectively, confirmed that there was no documented evidence that staff administered Resident 19's tube feeding formula at 11:00 p.m. on January 31 and February 1, 2019.


An annual MDS assessment for Resident 59, dated December 3, 2018, revealed that the resident was usually understood and could usually understand, had a medical history that included a gastrostomy tube. Physician's orders, dated September 16, 2018, included an order for the gastrostomy tube to be changed every 90 days.

Resident 59's Treatment Administration Record (TAR) for September 2018 revealed that the gastrostomy tube was changed on September 17, 2018. The resident's TAR for December 2018 indicated to see a nursing note dated December 16, 2018. The nursing note, dated December 16, 2018, revealed that there was no doctor in house that day, so the gastrostomy tube change that was scheduled for that day was postponed until the next day.

Resident 59's clinical record, including the TAR for December 2018, revealed no documented evidence that the gastrostomy tube was changed in December 2018.

A nursing note for Resident 59, dated January 4, 2019, indicated that the resident's gastrostomy tube was changed on January 4, 2019, which was 109 days after it was changed on September 17, 2018.

Interview with Registered Nurse 2 on February 6, 2019, at 1:50 p.m. revealed that she was not aware of why Resident 59's gastrostomy tube was not changed until January 4, 2019.

Interview with the Director of Nursing on February 6, 2019, at 4:40 p.m. confirmed that Resident 59 should have had his gastrostomy tube changed on December 16, 2018, and for some reason staff did not feel comfortable changing the gastrostomy tube without the physician being present in the facility. She confirmed that Resident 59's gastrostomy tube was not changed every 90 days as ordered by the physician.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.





 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that the nursing staff failed to follow procedure and record completion of R 19's feedings at 11pm on January 31st and February 1st 2019. Staff have been provided with guidance on how to search administration records for incomplete entries, particularly those at times which may fall to either shift to ensure timely documentation of all care. The facility cannot correct that Licensed Practical Nurse 1 and Registered Nurse 8 did not follow the residents care plan and laid him flat for 94 seconds while removing a lift sling. The facility cannot correct that the nursing staff failed to follow procedure for the tube change for Resident 59. The procedure indicates that feeding tubes are changed on weekdays when a physician is on site in case issues arise. The change was due on a Sunday and communication with the physician to request an order to move change to Monday should have occurred, which also would have prompted staff to address the change more timely. Applicable staff noted above had their deficient practices addressed by their supervisor and/or manager.

B. The facility cannot correct any past deficient practices related to resident positioning after feedings, documentation or timeliness of feeding tube changes, however no other occurrences were observed during the survey.

C. Nursing staff will receive education regarding adherence to care plan for resident positioning during and following meals or feedings. Licensed Nursing staff will receive education on procedures for documenting feedings and ensuring any missed entries are documented promptly. Licensed nursing staff will also receive education regarding timeframes for tube changes. The facility will review the procedure for tube changes and determine if changes may be made to process including orders to prevent reoccurrences.

D. The Nurse Managers or designee will complete monitoring on living areas ten times per week for four weeks to ensure residents who receive tube feedings are positioned per care and periodically on an ongoing basis. They will monitor treatment administration records for residents receiving tube feedings to ensure timely documentation and tube changes. Monitors will cover three residents per week for 12 weeks and will continue periodically on an ongoing basis.

E. Beginning March 26, 2019 and monthly thereafter, reports for monitors related Tube feeding management will be reviewed by the Quality Assurance and Performance Improvement Committee.

483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide effective pain management for one of 62 residents reviewed (Resident 111).

Findings include:

The facility's policy regarding pain management, dated May 25, 2018, revealed that a resident's pain was to be addressed and treated in a way that maximized the resident's ability to reach his/her fullest potential. A pain assessment was to be performed with each newly diagnosed condition known to cause pain or discomfort of a chronic nature, and staff were to ask the resident how they would score their pain on a scale from 1 to 10, with one being very little pain and ten being excruciating pain.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 111, dated October 15, 2018, revealed that the resident was understood, could understand, was independent her bed mobility, ambulation (walking), and toilet use, and was not steady, but was able to stabilize without staff assistance. The resident's care plan, dated December 3, 2017, indicated that she had a potential for pain, and staff were to anticipate her need for pain relief and respond immediately to any complaint of pain.

A incident report for Resident 111, dated December 22, 2018, revealed that the resident fell on December 22, 2018, at 6:30 a.m. A nursing note, dated December 22, 2018, at 7:03 a.m. revealed that the resident fell in the bathroom. She complained of pain in the left wrist; however, there was no documented evidence that a nurse assessed the resident's pain and asked her how she would score her pain on a scale of 1 to 10. A nursing note dated December 22, 2018, at 8:10 a.m. revealed that the resident complained of left wrist pain and the supervisor was made aware.

A neurological assessment for Resident 111, dated December 22, 2018, at 8:10 a.m. indicated that the resident was was experiencing pain in her left wrist that she rated as a 7 out of 10. The physician was made aware and an x-ray ordered.

Resident 111's Medication Administration Records (MAR's) for November and December 2018 revealed that she had no medications ordered for pain until an order was received on December 22, 2018, at 8:43 a.m. for the resident to receive 650 milligrams (mg) of Tylenol (an over-the-counter pain medication) every four hours as needed for pain.

An x-ray report for Resident 111, dated December 22, 2018, revealed there appeared to be an impacted fracture (occurs when the broken ends of the bone are jammed together by the force of the injury) of the distal left radial metaphysis (wrist area).

Resident 111's MAR revealed that staff administered 650 mg of Tylenol to the resident for a pain rating of 5 out of 10 on December 22, 2018, at 9:24 a.m., which was 2 hours and 54 minutes after the resident first complained of pain.

Interview with the Director of Nursing on February 7, 2019, at 12:50 p.m. confirmed that there was no documented evidence that Resident 111's pain rating was assessed at the time of the fall, and that the resident did not receive medication for her pain until 9:24 a.m. on December 22, 2018.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.





 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that the nurse who initially heard Resident 111's complaint of pain did not follow proper nursing procedures to complete and document a Pain Assessment. When Resident 111 stated she had pain to a second nurse 90 minutes later, a Pain Assessment was completed, pain was reported as 7/10, and orders for pain medication were received and medication administered. The deficient actions of the nurse who did not complete the Pain Assessment has been addressed by the supervisor and manager.

B. The facility cannot correct the impact on other residents due to the deficient practices related to pain management.

C. Licensed Nursing Staff will receive education related to pain management particularly documenting Pain Assessment and acting on reports of pain in a timely fashion.

D. The Quality Assurance Performance Improvement Staff will monitor all incident reports for 4 weeks, then 10 per week for 4 weeks, to ensure documentation of Pain Assessment and that reported pain is addressed in a timely fashion. Random audits will be continued on an ongoing basis.

E. Beginning March 26, 2019 and monthly thereafter, reports for monitors related to Pain assessment and management will be reviewed by the Quality Assurance and Performance Improvement Committee.
483.25(n)(1)-(4) REQUIREMENT Bedrails:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that individualized safety assessments were completed for side rail use for one of 62 residents reviewed (Resident 34).

Findings include:

A quarterly Minimum Data Set (MDS) assessment for Resident 34, dated November 20, 2018, indicated that the resident was alert and oriented; was independent with bed mobility, transfers, and walking; and had a history of prior falls.

Observations on February 4, 2019, at 4:30 p.m. and February 7, 2019, at 1:00 p.m. revealed that Resident 34 was in his bed, which was equipped with a single bed bar (small side rail that the resident can use to assist with repositioning) on one side of his bed.

Resident 34's care plan, dated August 30, 2018, indicated that the resident had a history of falls with minor injuries at the facility and used a bed bar to assist with bed mobility and getting in and out of bed. There was no documented evidence that the use of the bed bar was assessed for potential safety hazards prior to being applied to Resident 34's bed.

Interview with the Nursing Home Administrator on February 7, 2019, at 6:51 p.m. confirmed that there was no documented evidence that a side rail safety assessment was completed for Resident 34, and one should have been done.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/15/18.


 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that the Physical Therapy Staff documentation regarding adding a bed bar as an intervention relative to a fall did not include documentation of safety assessment. The missing documentation assessment of safety for Resident 34 has been completed by Physical Therapy.

B. Physical Therapy Staff will audit records of ten other residents using assist bars to ensure assessments are documented and correct as needed.

C. Physical Therapy Staff will receive education regarding required assessment and documentation of resident safety and entrapment risk prior to use of assist bars and other bed bars. An assessment form was created in the electronic health record, which will be used to ensure all required items are assessed and documented when considering use of bed bars.

D. The Chief Physical Therapist will monitor safety assessments for all newly applied bed bars for the next 6 weeks and periodically thereafter.

E. Beginning March 26, 2019 and monthly thereafter, reports for monitors related to bed rail assessments will be reviewed by the Quality Assurance and Performance Improvement Committee
483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

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

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

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that monthly pharmacy medication reviews were completed for one of 62 residents reviewed (Resident 133).

Findings include:

The facility's policy regarding drug reviews, dated November 20, 2018, revealed that each resident's clinical record was to be reviewed, dated and signed by the contractor's pharmacist every calendar month. The pharmacist's drug reviews were to be completed with the report entered into the electronic health record at the time of the review as a progress note.

Pharmacy Medication Regimen Review notes for Resident 133 revealed that the pharmacist reviewed the resident's medication regimen on September 28, October 28 and November 28, 2018.

There was no documented evidence that a monthly pharmacy review was completed for Resident 133 for the month of December 2018.

Interview with the Director of Nursing on February 7, 2019, at 11:15 a.m. confirmed that there was no documented pharmacy medication regimen review in the clinical record for Resident 133 for December 2018, and that medication reviews were to be completed and entered into the resident's electronic health record at the time of the monthly review.

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

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



 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct that the Consultant Pharmacist did not follow facility policy for pharmaceutical services and failed to enter documentation of the monthly Drug Regimen Review for one resident. Per the consolidated report, which is provided, the review was completed within the monthly timeframe; however, a corresponding note was not entered. The Consultant Pharmacist entered a late progress note for Resident 133 to address the Drug Regimen Review, which had been completed on December 21, 2018. The Medical Director, Director of Nursing, and Administrator receive and review a copy of the final consolidated report, which notes how many reviews are done and lists all recommendations. However, the Consultant Pharmacist is responsible to ensure all documentation is present.

B. All records were audited for documentation of Drug Regimen Reviews in December and January and documentation updated as necessary.

C. The Consultant Pharmacist received re-education on the requirements for review and subsequent documentation in the clinical record on a monthly basis.

D. Medical Records Department Staff will monitor all residents' records for Drug Regimen Reviews for February and March 2019. Periodic random audits will also be completed on an ongoing basis.

E. Beginning March 26, 2019 and monthly thereafter, reports for monitors related to Drug Regimen Reviews will be reviewed by the Quality Assurance and Performance Improvement Committee.
483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents' medical records were complete and accurately documented for one of 61 residents reviewed (Resident 19).

Findings include:

The facility's policy regarding gastrostomy tube feedings (the delivery of a nutritional formula through a tube that has been surgically inserted through the abdomen into the stomach), revised January 22, 2019, indicated that staff were to document the method of feeding (continuous or bolus), the name of the formula, the amount/volume in milliliters, and the time of day the formula was administered in the resident's clinical record.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated November 13, 2018, revealed that the resident had a gastrostomy tube. Physician's orders, dated September 19, 2018, included orders for the resident to receive one container (237 milliliters) of Jevity 1.5 (a specific tube feeding formula) via the gastrostomy tube five times a day (5:00 a.m., 10:00 a.m., 1:00 p.m., 6:00 p.m. and 11:00 p.m.).

Tube feeding documentation records for Resident 19, dated January 23 through February 4, 2019, revealed that staff documented that Resident 19 received continuous tube feedings, as opposed to bolus tube feedings, on January 23, 24, 25, 29 and 30, and February 2, 3 and 4, 2019. The amount of tube feeding formula administered was documented as 474 milliliters (ml) on February 1, 2019, at 2:05 p.m. and February 5, 2019, at 2:22 p.m.

Interview with Registered Nurse 8 on February 6, 2019, at 1:37 p.m. confirmed that Resident 19 did not receive continuous tube feedings and the clinical record entries that indicated the tube feeding was continuous were not accurate. She also confirmed that one container of Jevity 1.5 tube feeding formula contained 237 ml and the clinical record entries that indicated that 474 ml was administered were not accurate.

Interview with the Director of Nursing on February 6, 2019, at 4:40 p.m. revealed that in January 2019, it was identified that there were issues with how tube feedings were documented and all staff were re-educated on proper documentation between January 14 through 31, 2019. However, she had not yet completed any audits to determine if the education was effective. She confirmed that errors were made regarding the documentation of Resident 19's tube feedings.

42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable Information.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 3/15/18.





 Plan of Correction - To be completed: 04/01/2019

A. The facility cannot correct the deficient practice related to inaccurate documentation by nursing staff of the bolus feedings for Resident 19. Assessment of the errors and documentation process indicated that the staff were creating errors due to their incorrect use of the documentation tool in the point of care portion of the record and entering incorrect quantities when carrying info to this tool after being viewed in the treatment administration record.

B. The facility cannot correct the deficient practice of prior incorrect documentation of administered tube feedings for any other residents. The dietitian in conjunction with the Medical Director will review records of residents receiving tube feedings to ensure documentation reflects proper nutrition and fluids were administered and residents did not suffer negative consequences of the documentation errors.

C. The Nurse Managers will develop and train staff on a simplified process for documentation and recording quantities to ensure correct documentation of all resident tube feedings. Currently, documentation occurs in the Medication Administration Record (MAR) and a point of care tasks form causing discrepancies in recording the correct information on the tasks as appears in the MAR. New process will entail all documentation being made to MAR without need for duplicate entries of volumes administered. Licensed Nursing staff will receive education on the facility procedures for proper administration and documentation protocols for tube feedings.

D. The Nurse Managers or designee will monitor treatment administration records for residents receiving tube feedings to ensure timely and complete documentation of all administered feedings. Monitors will cover 3 residents per week for 12 weeks and periodic audits on an ongoing basis. The Dietitian will monitor residents on an ongoing basis to review feedings and fluids administered to ensure optimal services to the resident.

E. Beginning March 26, 2019 and monthly thereafter, reports for monitors related to documentation of tube feeding administration will be reviewed by the Quality Assurance and Performance Improvement Committee

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