Nursing Investigation Results -

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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANORCARE HEALTH SERVICES-KINGSTON
Inspection Results For:

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MANORCARE HEALTH SERVICES-KINGSTON - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated complaint survey completed on February 8, 2019, it was determined that Manorcare Health Services Kingston was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 observation, review of clinical records, facility documentation and the facility's abuse prohibition policy and procedure and interviews with staff and residents, it was determined the facility failed to protect one resident (CR1) from physical abuse, which resulted in significant bruising, fractured ribs and transfer to emergency room for one out of nine clinical records reviewed.

Findings include:

A review of the facility's practice guide entitled "Patient Protection Abuse, Neglect, Exploitation, Mistreatment and Misappropriation Prevention" dated October 2018 indicated the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment (causing physical pain), involuntary seclusion and any physical or chemical restraint not required to treat a medical condition. As per this practice guide, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Physical abuse includes hitting, slapping, punching and kicking. It also an injury involving: extreme physical pain, substantial risk of death; protracted loss or impairment of the function of a body member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.

A review of the clinical record of Resident CR1 revealed that the resident was admitted to the facility on January 26, 2019, from the hospital. The resident's hospital stay was from January 23, 2019, as the result of a fall to her knees at home on Janaury 22, 2019, until the resident's admission to the facility on January 26, 2019. The resident's diagnoses included atrial fibrillation (irregular heartbeat), muscle weakness and cutaneous abscess (localized collection of pus in the skin) of the right foot with difficulty walking.

A Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 2, 2019, indicated that the resident required extensive assistance with two persons for toileting such as using the bedpan. An admission nursing assessment dated January 26, 2019, indicated that the resident had clear speech was understood by others and able to communicate her needs. Nursing noted that the resident had several tiny scabs on her abdomen, a fading bruise on her right front knee and a wound on her plantar (bottom) area of her right foot and no complaints of pain.

Documentation provided by the facility indicated that in the early morning of January 30, 2019, at approximately 1:00 AM, Employees 1 and 2 were placing the resident on the bedpan. Employee 2 had been sent from another unit to assist Employee 1 who was assigned to the resident's care during that shift. Employee 1 was on the resident's right side and Employee 2 was on the resident's left side, when Employee 1 went to roll the resident towards Employee 2, Employee 2 grabbed the resident's hip and right arm and "yanked her over." Employee 1 placed the bedpan under the resident. When both nurse aides went to take the resident off the bedpan Employee 2 "pushed the resident on her hip so hard she \ almost fell off the bed." Employee 1 stated that she had to put all her weight against the resident so she would not fall out of the bed. Employee 1 reported Employee 2's "rough care" of Resident CR1 to Employee 3, the LPN (licensed practical nurse). Employee 1 reported that Employee 3 replied that Employee 2 was "acting like that because she actually had to work and not sleep."

A review of a statement from Employee 1 dated February 4, 2019, revealed that she stated she had asked Employee 2 to help her with Resident CR1 [on January 30, 2019, 11 PM to 7 AM shift]. Employee 1 stated that Employee 2 was rough with all the residents she helped her with that night, and in particular Resident CR1. Employee 1 stated Employee 2 pulled Resident CR1 by her arm and pulled her towards her; she then rolled Resident CR1 "so hard that she had to put her knees on the side of the bed and her arms behind the resident so she wouldn't roll off the bed." Employee 1 stated that Resident CR1 sustained a bruise at the location where Employee 2 had pushed the resident.

Employee 2's statement dated February 5, 2019, revealed that Employee 2 stated that "this was not her hall." Employee 2 stated that she went to help another aide for a few people only. Employee 2 stated that she went with Employee 1 into "every single room." She stated "I do not remember. If I see them (the residents) then maybe I remember. I don't remember."

A review of Employee 3's statement confirmed that Employee 1 told her that Employee 2 was "rushed" with care. Employee 3 stated she that was busy and was unaware it was specifically regarding Resident CR1. Employee 3 stated that she "just thought it was a general statement."

A statement was obtained from Resident CR1's roommate, Resident 1. Resident 1 stated that she was in the room while Employees 1 and 2 were providing care to Resident CR1 on that night. Resident 1 stated she didn't actually see anything (the privacy curtain was between them), but she heard Resident CR1 calling out because she was in fear of falling.

Resident 1 was interviewed on February 9, 2019, at 9:40 AM and she confirmed she didn't actually see anything the night in question, but she heard the resident moaning and yelling. Resident 1 also stated she heard Employee 1, with whom she is very familiar, saying to Employee 2 "you have to be careful you are turning her too hard!" Resident 1 also stated Employee 4, an RN (registered nurse), told her "to keep her mouth shut" regarding her account of the incident.

On January 31, 2019, at 12:37 PM nursing documentation indicated that Resident CR1 presented with an ecchymotic (bruised) area in her left axilla (armpit). The resident stated it was "sore," but did not confirm how it happened. The resident had been receiving the blood thinning medication, Coumadin, due to her diagnosis of atrial-fibrillation, according to physician orders. However, the Coumadin had been on hold since January 28, 2019, due to abnormal blood levels.

The facility began an investigation into the resident's bruising on January 31, 2019. As of the date of the survey, February 9, 2019, the facility indicated that the resident had bruising because she was on the blood thinner Coumadin.

The facility's investigation indicated that the resident's daughter called Employee 5, an LPN, to her mother's room on February 3, 2019, to inform the Employee 5 that her mother had bruising to her left armpit region and "she is bruised badly." Employee 6, RN, assessed the resident on February 4, 2019, at 11:35 AM, which revealed that the resident's bruise under her left armpit now encompassed the resident's left breast and was painful with movement of the arm or repositioning the left breast. The resident also had bruising on her left hip. The resident was admitted to the hospital with superficial bruising to the chest wall on February 4, 2019.

A review of the hospital records dated February 4, 2019, indicated that resident was admitted to the hospital with "suspected nursing home staff abuse" and complaints of left arm pain and left hip pain. The hospital records indicated that the injury was caused by a "direct blow." X-ray results revealed a fracture of the left ninth and tenth ribs. This X-ray was compared to the January 23, 2019, hospital evaluation and no rib fractures were identified during that stay. The resident's family requested that the resident not be readmitted to the facility.

Interview with the Nursing Home Administrator (NHA) on February 9, 2019, at 3:00 PM revealed that the facility concluded that the cause of the resident's bruising was from the resident receiving the blood thinner, Coumadin. The NHA stated that the facility could not substantiate abuse, but did suspend Employee 2 and were awaiting her return to work.

The facility failed to ensure residents were free from injury as the result of nursing staff mistreating the resident while assisting the resident on a bedpan, resulting in physical harm to Resident CR1, which included extensive bruising, fractured ribs and transfer to the hospital.


483.12(a)(1) Free from Abuse
Previously cited 7/9/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 11/19/18, 10/16/18, 7/9/18, 4/17/18

28 Pa. Code 201.29(a)(c) Resident rights
Previously cited 11/19/18, 7/9/18

28 Pa. Code 211.12 (a) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 2/21/18, 12/22/17

28 Pa. Code 211.12(c) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17

28 Pa. Code 211.12 (d)(1) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 2/21/18, 12/22/17

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17












 Plan of Correction - To be completed: 03/26/2019

1. Resident CR1 is no longer at the facility. Employees #1 & 2 have received Abuse education, and education on Bed Positioning
2. A Comprehensive audit will be completed of incident reports on bruises utilizing the QAPI Investigative tool to ensure a thorough timely investigation was completed
3. Staff will be educated on resident protection from abuse utilizing "Focus on FTag 600". The nursing staff will receive education on Bed Positioning by date of compliance 3/26/2019
4. Random audits will be completed weekly x 8 weeks by the NHA/Designee to monitor proper reporting and investigation techniques are followed utilizing the QAPI Investigation tool. Results will be reported to the QAPI Committee for any necessary follow up.

483.60(d)(6) REQUIREMENT Drinks Avail to Meet Needs/Prefs/Hydration:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(6) Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration.
Observations:

Based on a review of clinical records, observations, interview with residents and review of the facility Hydration Practice Guide, revealed the facility failed to provide sufficient fluids consistent with resident needs and preferences including those of eight residents observed and/or interviewed (Residents 10, 14, 15, 16, 17, 21, 22 and 23).

Findings include:

According to review of the facility Hydration Practice Guide, interventions to assist residents with adequate fluid consumption included passing fresh water on each shift. When interviewed on February 9, 2019, at 3:10 p.m. the Nursing Home Administrator confirmed that this practice guide was the protocol the facility utilized to meet residents' fluid needs.

Observations completed at 8:05 a.m. on February 9, 2019, revealed a styrofoam cup Resident 22's bedside stand labeled "2/8/18." The cup was one third filled with water and warm to touch. There was no ice in the cup. Subsequent observations were completed at 10:15 AM, 11:35 AM, 1:45 AM and 2:50 PM on February 9, 2019, revealed no evidence that fresh ice/water had been provided to the resident.

Observations completed at 8:07 AM on February 9, 2019, revealed that Resident 23 had a styrofoam cup on the resident's bedside stand. The cup was half filled with water and was warm to touch. There was no ice or ice water in the cup. Subsequent observations were completed at 10:17 AM, 11:37 AM, 1:47 AM and 2:52 PM revealed no evidence that fresh ice water had been provided to the resident.

Residents 10 and 21, residing in the same room were observed at 7:55 AM on February 9, 2019. Observation revealed that neither of the residents had been provided with had fresh ice/water. Resident 20, who also resided in the room, had a styrofoam cup labeled February 8, 2018. The cup was one half filled with water and was warm to the touch. Observations were completed again at 10:05 AM and 11:40 AM on February 9, 2019, and the residents had not received fresh ice water. At 2:30 PM the residents were observed again revealing that Residents' 20 and 21's styrofoam cups remained without fresh ice water. Resident 10, who was observed with a visitor, had a full cup of ice water.


A review of Resident 15's quarterly MDS Assessment (minimum data set - a federally mandated standardized assessment completed at specific intervals to plan resident care) dated December 2, 2018, revealed that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status - a tool to assess resident cognition) score of 15 out of 15 According to review of Resident 14's most recent MDS dated December 26, 2018, Resident 14 was moderately cognitively impaired with a BIMS score of 10 out of 15.

Residents 14 and 15 were observed at 8:11 a.m. on February 9, 2019. Styrofoam cups were observed in their room, which were half full with water and warm to touch. When interviewed at 11:00 AM Resident 15 stated that the staff usually passed fresh water only once a day, but she preferred it more often. Resident 15 stated that she obtained ice water herself for both herself and Resident 14 on a daily basis.

A review of Resident 16's admission MDS Assessment dated January 7, 2019, revealed that the resident was cognitively intact with a BIMS score of 15. According to a review of Resident 17's admission MDS Assessment dated January 25, 2019, revealed that the resident was cognitively intact with a BIMS score of 15.

When interviewed on February 9, 2019, at approximately 11:15 AM Residents 16 and 17 stated that the staff does not consistently pass fresh water on their nursing unit. The residents stated that often times they ring call bell) to ask staff to bring water and the staff does not respond. Resident 16 stated that it is not uncommon for the staff to forget to pass water. As a result, she goes out onto the nursing unit to get ice ware for herself and Resident 17 which was confirmed by Resident 17.

28 Pa. Code 201.29(j) Resident Rights
Previously cited 11/19/18, 10/16/18

28 Pa. Code 211.12 (a) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 2/21/18, 12/22/17

28 Pa. Code 211.12(c) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17














 Plan of Correction - To be completed: 03/26/2019

1. Residents 10, 14, 15, 16, 17, 21, 22, and 23 will be reviewed for their fluid needs and preferences by the dietician and their plans of care will be updated
2. A comprehensive audit of residents fluid needs and preferences utilizing the Hydration QAPI tool will be completed by date of compliance 3/26/2019 and their plans of care will be updated
3. The nursing staff will be educated on fluid needs and preferences including providing fresh water each shift utilizing FTag 807 by date of compliance 3/26/2019
4. Random audits using the Fresh Water Pass QAPI tool will be completed by Unit Managers/Supervisors to monitor compliance of fresh water provided each shift 3x a week for 8 weeks with results presented to the QAPI Committee for any necessary follow up


483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on review of clinical records and grievances lodged with the facility and staff and resident interviews it was revealed that the facility failed to demonstrate sufficient efforts to fully investigate, address and resolve grievances expressed by residents for two residents out of nine sampled (Resident 16 and Resident 5).

Findings include:

A review of a facility Concern Form dated January 13, 2019, completed by Resident 16, revealed that the resident was upset because she had to wait to have her "ice bucket" filled by staff. The resident also questioned the adequacy of staffing on all three shifts (7 AM to 3 PM, PM to 11 PM and 11 PM to 7 AM). The "Documentation of Facility Follow-up" section of the Concern Form was blank at the time of the review during the survey ending February 9, 2019. Documentation in the "Resolution of Concern," section of the form dated January 29, 2019, noted that the resident was "happy" with her care at the facility and noting that the resident had stated "things are just fine." The Registered Nurse completing this documentation noted that "the resident was pleasant that morning during the treatment she was administering and denied any complaints."

There was no documented evidence of the facility's efforts to resolve the specific the concerns, which the resident had expressed regarding refilling her "ice bucket" and the resident's impression that there was not enough staff on all three tours of nursing duty.
A review of the resident's most recent MDS Assessment (minimum data set assessment - a federally mandated standardized assessment process completed at specific intervals to plan resident care) completed upon admission, January 7, 2019, revealed that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status - a tool to assess cognitive function) score of 15 out of 15.

Interview with Resident 16 on February 9, 2019, at 1:10 PM revealed that the resident clarified that when she referred to her ice bucket in her grievance she meant ice that was to be placed in a cooling device (machine) that was to be placed on her knee. The resident stated that she has to continually ring her call bell, to request that staff provide ice for the cooling device and many times the staff does not respond. The resident stated that the issue had resolved itself because she no decided to longer utilize the cooling device. Observation of the resident at the time of the interview revealed that she was not utilizing the device nor was it observed in the vicinity of her bed.

During the interview, Resident 16 further stated the facility the is not adequately staff and staff does not answer call bells, pass fresh ice water and are not attentive to resident needs. She confirmed these were among the issues she originally intended to voice in her grievance of Janaury 13, 2019. The resident confirmed that no facility staff had discussed her grievance with her so that she may be able to voice detailed complaints.

A review of the resident's clinical record confirmed that she was admitted to the facility for care following surgery for an infected right knee. A review of physician's orders initiated on January 3, 2019, which remained current at the time of survey ending February 9, 2019, revealed the resident was to have a cooling device applied to her right knee every two hours for 30 minutes.

According to review of the resident's treatment administration records for January 2019 and February 2019, the order remained active and the licensed nurses continued to document the application of the device through the time of the survey. The last documented application was February 9, 2019 at 1:00 PM for 15 minutes, which was during the surveyor's interview with the resident.

During a second interview with the resident 2:15 PM on February 9, 2019, the resident stated that about two weeks ago, she stopped using the device because the pain in her leg had lessened and the staff was still not bringing the ice. Resident 16 stated that she picked up the machine herself and placed it in her closet. Observation of the resident's closet confirmed that the machine was on the shelf in the resident's closet at the time of the interview.

At 2:40 PM on February 9, 2019, the Director of Nursing (DON) stated that she had interviewed Resident 16 regarding her concern dated January 16, 2019, "just a few minutes ago" (on February 9, 2019). The resident informed the DON that the ice she spoke of in the grievance was for the cooling device and the problem was resolved because she was no longer using the machine. However, the Director of Nursing was unaware that the device had not been discontinued by the resident's attending physician, but rather by the resident because nursing staff failed to provide the ice. The DON was also unaware that nursing staff continued to document the application of the device for the resident's use.

A review of a facility Concern Form dated January 28, 2019, completed by Resident 5, revealed that the resident stated that when Employee 7, a nurse aide, went to get her washed she would not take her to the bathroom and she was very rough with the resident. The resident stated that the aide "slammed her into her chair." Employee 7, was suspended related to the resident's allegation of rough care, but facility indicated that the aide was then trained on proper transfer techniques and returned to work. There was no documented evidence that the facility had addressed Employee 7's failure to assist the resident to the bathroom as the resident had requested.

Interview with Resident 5 on February 9, 2019, at 2:30 PM confirmed that she has to ask another staff member to help her to the bathroom on that day (of the grievance) because Employee 7 would not help her on that date.

Interview with the Director of Nursing on February 9, 2019, at 3 PM confirmed that the facility had not addressed Employee 7's failure to assist Resident 5 to the bathroom when requested.

483.10(j)(1)-(4) Grievances
Previously cited 11/19/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 11/19/18, 10/16/18, 7/9/18, 4/17/18

28 Pa. Code 201.18(e)(4) Management
Previously cited 11/19/18

28 Pa. Code 201.29(i) Resident Rights.
Previously cited 11/19/18

28 Pa. Code 201.29(j) Resident Rights.
Previously cited 11/19/18, 10/16/18




.









 Plan of Correction - To be completed: 03/26/2019

1. Residents #5, #16 are no longer at facility. A compliance investigation was initiated for Resident 16's grievance. Employees were suspended pending the investigation.
2. A comprehensive audit of resident grievances expressed within the last 30 days will be will be completed utilizing the QAPI Investigative tool to determine if they sufficiently demonstrate full investigation was completed and address and resolve concerns
3. The interdisciplinary team will be educated by the NHA/Designee on the Grievance Process by date of compliance 3/26/2019. The concern forms have been updated to allow NHA to sign off on resolution and completeness of investigation.
4. Random Audits will be completed by NHA/Designee utilizing the QAPI Investigation tool to monitor resolution of the concern weekly x8 weeks. Results will be reported to the QAPI committee for any necessary follow up.

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 review of clinical records, observations and staff interviews it was revealed that the facility failed to devise resident centered care plans, which were reflective of the resident's specific problems/needs for one (Resident 12) out of nine residents reviewed.

Findings include:

A review of Resident 12's clinical record revealed that the resident had a diagnosis of dementia, did not speak/communicate in English and displayed socially inappropriate behaviors, including being resistive and combative with care, wandering, hoarding and rummaging.

Interdisciplinary progress notes dated January 26, 2019, revealed that the resident was wandering and exit seeking. The resident attempted to leave the facility at 1:14 PM and was stopped by a housekeeping employee before exiting the door located by the beauty shop.

On January 30, 2019, staff was ambulating the resident out of dining room and the resident slapped another resident in the forehead.

A review of the resident's comprehensive plan of care, last updated by the facility December 19, 2018, revealed no evidence that the facility had addressed the resident's exit seeking behaviors. The facility also failed to identify the resident's peer directed physically abusive behavior. There was no evidence that the facility had developed and implemented interventions, including methods to communicate with the resident whose ability to understand English was limited, to ensure all staff are able to interact and communicate with the resident.

When interviewed on February 9, 2019, the Nursing Home Administrator (NHA) confirmed that the resident's ability to communicate in English was limited. The NHA stated that the facility relies on the resident's family, one of whom was an employee of the facility and a translator service to communicate with the resident.

483.21(b) Comprehensive Care Plans
Previously cited 11/19/18, 1/25/18

28 Pa. Code 211.15(f)(g) Clinical Records.
Previously cited 11/19/18, 10/16/18, 4/17/18, 3/9/18

28 Pa. Code 211.11(d)(e) Resident care plan
Previously cited 1/25/18

28 Pa. Code 211.12(c) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17







 Plan of Correction - To be completed: 03/26/2019

1. Resident 11 Care plan has been updated to address resident's behaviors and communication methods.
2. A comprehensive audit will be completed on current residents and the plan of care utilizing the QAPI Care Plan tool to validate it reflects the resident's current status.
3. Licensed staff will be educated on creating and maintaining care plans utilizing Focus on Ftag 656 by date of compliance 3/26/2019
4. Audits of care plans will be completed utilizing the QAPI Care Plan tool weekly x 8 weeks. Results will be reported to the QAPI Committee for any necessary follow up.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of clinical records and grievances lodged with the facility, observation and staff and resident interviews it was determined that the facility failed to carry out physician orders for the use of a therapeutic device and adhere to professional standards for documentation the provision of care to one resident out nine sampled (Resident 16).

Findings include:

A review of a facility Concern Form dated January 13, 2019, completed by Resident 16, revealed that the resident was upset because she had to wait to have her "ice bucket" filled by staff. The resident also questioned the adequacy of staffing on all three shifts (7 AM to 3 PM, PM to 11 PM and 11 PM to 7 AM).

A review of the resident's most recent MDS Assessment (minimum data set assessment - a federally mandated standardized assessment process completed at specific intervals to plan resident care) completed upon admission, January 7, 2019, revealed that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status - a tool to assess cognitive function) score of 15 out of 15.

Interview with Resident 16 on February 9, 2019, at 1:10 PM revealed that the resident clarified that when she referred to her ice bucket in her grievance she meant ice that was to be placed in a cooling device (machine) that was to be placed on her knee. The resident stated that she has to continually ring her call bell, to request that staff provide ice for the cooling device and many times the staff does not respond. The resident stated that the issue had resolved itself because she no decided to longer utilize the cooling device. Observation of the resident at the time of the interview revealed that she was not utilizing the device nor was it observed in the vicinity of her bed.

A review of the resident's clinical record confirmed that she was admitted to the facility for care following surgery for an infected right knee. A review of physician's orders initiated on January 3, 2019, which remained current at the time of survey ending February 9, 2019, revealed the resident was to have a cooling device applied to her right knee every two hours for 30 minutes.

According to review of the resident's treatment administration records for January 2019 and February 2019, the order remained active and the licensed nurses continued to document the application of the device through the time of the survey. The last documented application was February 9, 2019, at 1:00 PM for 15 minutes, which was during the surveyor's interview with the resident.

During a second interview with the resident 2:15 PM on February 9, 2019, the resident stated that about two weeks ago, she stopped using the device because the pain in her leg had lessened and the staff was still not bringing the ice. Resident 16 stated that she picked up the machine herself and placed it in her closet. Observation of the resident's closet confirmed that the machine was on the shelf in the resident's closet at the time of the interview.

At 2:40 PM on February 9, 2019, the Director of Nursing (DON) stated that she had interviewed Resident 16 regarding her concern dated January 16, 2019, "just a few minutes ago" (on February 9, 2019). The resident informed the DON that the ice she spoke of in the grievance was for the cooling device and the problem was only resolved because she was no longer using the machine because staff failed to provide the ice. The Director of Nursing however, was not aware that the device had not been discontinued by the resident's attending physician, but rather by the resident and that nursing staff continued to document its use.

A review of the resident's clinical record confirmed that she was admitted to the facility for after surgery care of an infected right knee. A review of physician's orders initiated on January 3, 2019, revealed the resident was to have a cooling device applied to her right knee every two hours for 30 minutes. According to review of the resident's treatment administration records, the order remained active and the licensed nurses continued to document the application of the device. The last documented application was January 9, 2019 at 1:00 PM for 15 minutes(during the surveyor resident interview.)

An interview with Employee 8, LPN, assigned to the resident's care on February 9, 2019, at 2:30 PM revealed that this employee stated that nursing staff continue to provide the cooling device for the resident and it is stored at the resident's bedside.

At 2:40 PM, the Director of Nursing stated that she had just interviewed Resident 16 regarding her concern of January 16, 2019. The resident had confirmed that the ice she spoke of in the complaint, was for the cooling device and the problem was resolved because she stopped using the machine. The Director of Nursing, however, was unaware that the physician did not discontinue the order for device, but rather the resident stopped using it due to staff's failure to provide the ice for the machine. The DON was also unaware that nursing staff continued to document the application of the device at times that the device was not actually in use by the resident.

28 Pa. Code 211.5(f)(g)(h) Clinical records
Previously cited 11/19/18, 10/16/18, 4/17/18, 3/9/18

28 Pa. Code 211.12 (a) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 2/21/18, 12/22/17

28 Pa. Code 211.12(c) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17

28 Pa. Code 211.12 (d)(1) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 2/21/18, 12/22/17

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 11/19/18, 7/9/18, 4/17/18, 3/9/18, 1/25/18, 2/21/18, 12/22/17












 Plan of Correction - To be completed: 03/26/2019

1. Resident #16 is no longer at the facility. A compliance investigation was initiated for Resident 16's grievance. Employees were suspended pending the investigation.
2. A comprehensive audit will be completed of resident treatment administration records to ensure appropriate orders are in place and care are rendered and/or monitored as ordered
3. Licensed nurses will receive Corporate Compliance education and Principles of Documentation education. The nursing staff will receive education on Quality of Care utilizing Focus on F-tag 684 by date of compliance 3/26/2019
4. Random Audits using the treatment QAPI tool will be completed 3x week for 8 weeks by the DON/Designee to ensure treatments ordered by the physician are provided and/or monitored according to order. Results will be reported to the QAPI Committee for any necessary follow up.


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