Nursing Investigation Results -

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

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MANORCARE HEALTH SERVICES-DALLASTOWN
Inspection Results For:

There are  100 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MANORCARE HEALTH SERVICES-DALLASTOWN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an abbreviated survey completed on February 24, 2019, in response to a complaint, it was determined that ManorCare Health Services - Dallastown 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:


483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
Observations:


Based on observation and review of facility policies, it was determined that the facility failed to provide dignity to one of 176 residents reviewed. (Resident 1).

Findings include:

Review of the facility's policy titled, "Catheter Care: Indwelling Catheter," last reviewed February 2019, revealed that after catheter care the staff member should " place the bag in catheter bag holder if appropriate."

Review of Resident 1's clinical record revealed that she has diagnoses which include hypertension (high blood pressure), and retention of urine (the inability to completely or partially empty the bladder).

Review of Resident 1's current and active physician orders for February 2019, revealed an order to maintain indwelling catheter with 16 French 10 cc balloon for urinary retention.

Observation of Resident 1's room from the doorway on February 24, 2019, at 8:20AM revealed an uncovered catheter collection bag on the floor on the right (hallway side) of Resident 1's bed. It was exposed to anyone who passed down the hallway and urine was visible. Licensed Practical Nurse (LPN) 2 observed this catheter collection bag and when asked replied it needed to be "better covered". LPN 2 then went to get a cover for the collection bag and then covered and hung the bag so it was not touching the floor.

During an interview with the Nursing Home Administrator on February 24, 2019, at approximately 1:30 PM revealed that her expectation is the bag should be covered in a way that you cannot see the urine.

28 Pa. Code: 201.18(b)(2) Management.

28 Pa. Code: 201.29(j) Resident's rights.

28 Pa. Code: 211.10(d) Resident care policies.

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





 Plan of Correction - To be completed: 03/15/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.


1. The LPN Charge Nurse covered the catheter bag at the time of the survey for Resident 1. The RN Unit Manager completed an Indwelling Catheter assessment for Resident 1 to ensure we were meeting her needs.

2. All resident's in house that have a catheter will be audited by the RN Unit Managers or designee to ensure the catheter bags are covered to promote dignity.

3. The Administrator or designee will in-service the nursing staff on treating residents with dignity including the catheter care policy.

4. The Unit Manager or designee will audit each unit weekly for 4 weeks and monthly for 2 months to ensure that catheter bags are covered. The results of the audits will be submitted to the Quality Assurance Committee monthly for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 3/15/19



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

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

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

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

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

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

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


Based on observation, staff interviews, clinical record review and facility policy and procedure review it was determined that the facility failed to implement infection control measures to prevent the potential spread of infection on one of 176 residents reviewed. (Resident 1).

Findings include:

Review of the facility's policy titled, "Catheter Care: Indwelling Catheter," last reviewed February 2019, revealed that after catheter care the staff member should " Check that tubing is not looped, kinked, clamped or positioned above the bladder and off the floor-place bag in catheter bag holder if appropriate."

Review of Resident 1's clinical record revealed that she has diagnoses which include hypertension (high blood pressure), and retention of urine. (the inability to completely or partially empty the bladder).

Review of Resident 1's current and active physician orders for February 2019, revealed an order to maintain indwelling catheter with 16 French 10 cc balloon for urinary retention.

Observation of Resident 1's room from the doorway on February 24, 2019, at 8:20 AM revealed an uncovered catheter collection bag on the floor on the right (hallway side) of Resident 1's bed. LPN 2 noted it shouldn't be on the floor, when asked. She went to get a cover for the collection bag and then covered and hung the bag, so it was not touching the floor.

During an interview with the Nursing Home Administrator on February 24, 2019, at approximately 1:30 PM revealed that her expectation is the bag should not be touching the floor.

28 Pa. Code: 211.10(d) Resident care policies.

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









 Plan of Correction - To be completed: 03/15/2019

1. The RN Unit Manager completed an Indwelling Catheter assessment for Resident 1 and the catheter was discontinued.

2. All resident's in house that have a catheter will be audited by the RN Unit Managers to ensure the catheter is placed correctly per policy to prevent the spread of infection.

3. The Administrator or designee will in-service the nursing staff on infection control as it pertains to the catheter care policy.

4. The Unit Manager or designee will audit each unit weekly for 4 weeks and monthly for 2 months to ensure that catheter bags are not touching the floor. The results of the audits will be submitted to the Quality Assurance Committee for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 3/15/19


483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:


Based on clinical record review, surveyor observation and staff interview, it was determined that the facility failed to ensure that resident needs were accommodated regarding accessibility of call bells for one of 176 residents observed (Resident 2).

Findings Include:

Review of the facility's policy titled, "Call Light" last reviewed February 2019, revealed "Always position call light conveniently for use and within reach."

Review of the clinical record for Resident 2 revealed she was admitted to the facility on April 13, 2015. Further review of Resident 2's clinical record revealed diagnoses including Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and Diabetes Mellitus (DM- failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of Resident 2's quarterly Minimum Data Set (MDS- periodic assessment of resident care and service needs) dated February 10, 2019, revealed under section "G" Functional Status, section A: Bed Mobility, Resident 2 was coded as a 3(Extensive Assist) for Self-Performance. Resident 2 was also coded as a 3(two plus persons physical assist) in Section A- for Support in bed mobility.

Review of Resident 2's, Interdisciplinary Plan of Care, which was current at the time of review, revealed an intervention under the Focus heading: "At risk for falls due to history of falls, potential medication side effects, cognitive loss, poor safety awareness. One of the interventions to prevent falls was "Double soft touch call lights." (a pad type of call button that is easier to manipulate).

Observation of Resident 2 on February 24, 2019, at 8:30 AM revealed the call light button was attached to the right side of the resident's pillow, beside and slightly above her head. When asked Resident 2 stated she was unable to reach the call bell pad. When asked to "try" by the surveyor, Resident 2 was unable to reach the call bell pad. The location of the call bell button was observed by Licensed Practical Nurse (LPN) 2. LPN 2 then asked Resident 2 if she could reach the call bell, again the resident replied, "no". LPN 2 also asked the resident to try, and Resident 2 was unable to reach the call bell pad. LPN 2 then repositioned the pad and asked the resident to demonstrate the ability to use the call bell pad, which Resident 2 was able to complete.


An interview with the Nursing Home Administrator on February 24, 2019, at 1:30 PM, revealed an expectation the call bell would be within the resident's reach.

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







 Plan of Correction - To be completed: 03/15/2019

1. Resident 2 was assessed by the RN Unit Manager to ensure all needs are being met.

2. The RN Unit Managers or designee will do a whole house audit to ensure that call lights are within resident reach.

3. The Administrator or designee will in-service nursing staff on reasonable accommodation of needs as it relates to having the call bell within reach when the resident is in their room.

4. The RN Unit Manager or designee will randomly audit 10% of their unit's call lights weekly X 4 weeks and monthly X 2 months to ensure they are in reach and being answered timely. The results of the audits will be submitted to the Quality Assurance Committee for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 3/15/19

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.35(g) Nurse Staffing Information.
483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:


Based on observations and interviews with staff, it was determined that the facility failed to post the required daily staffing in a prominent place for review by the residents and public.

Findings include:

An observation on February 24, 2019, at 8:03 AM, revealed the staffing posting which is required to include the date, facility name, census, nursing staff and hours worked was dated February 23, 2019, the day before the observation.

During an interview with the Nursing Home Administrator, on February 24, 2019, at 1:20 PM, it was revealed the correct staffing document had not been displayed, and her expectation was that it should have been.

The staffing documentation was not correctly posted and readily accessible for residents and the public.

42 CFR 483.30(e)(2)(ii). Nursing Staff Information.

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



 Plan of Correction - To be completed: 03/15/2019

1. No residents were affected by this deficiency.

2. No residents were affected by this deficiency.

3. The scheduler or designee will post the nurse staffing information daily for the following day before the end of the shift. On the weekend the receptionist will post the staffing sheets for the following day. The night shift RN Supervisor will check to ensure the staffing sheet is posted at midnight daily.

4. The Administrator or designee will audit the posting weekly x 4 weeks and monthyly x 2 months to ensure that it is posted. The results of the audits will be submitted to the Quality Assurance Committee for review and determination of need for further action as needed.

5. Facility alleges substantial compliance on 3/15/19


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