Nursing Investigation Results -

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

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MANORCARE HEALTH SERVICES-LAURELDALE
Inspection Results For:

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MANORCARE HEALTH SERVICES-LAURELDALE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey and Civil Rights Compliance survey completed on March 13, 2019, it was determined that Manor Care Health Services-Laureldale was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirments for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



































 Plan of Correction:


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 facility policy, observation, and staff interview, it was determined that the facility failed to 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 on two of four nursing units. (Heritage nursing unit, West nursing unit)

Findings include:

Review of the facility's policy entitled "Support Services, Laundry Services and Linen Handling Practices", dated January 1, 2019, revealed that clean linen was to be covered for protection during transport and clean linen was to be stored in a protected area until distributed for use.

Observation of the Heritage nursing unit on March 10, 2019, between 9:06 a.m. and 11:00 a.m., revealed two uncovered linen carts, one on the low hall and one on the high hall.

Observation of the Heritage nursing unit on March 11, 2019, at 10:25 a.m., revealed an unattended, uncovered linen cart on the low hall.

Observation during the medication pass on the Heritage nursing unit low hall, on March 10, 2019, between 9:06 a.m., and 10:00 a.m., revealed an opened, uncovered container of applesauce on top of the medication cart.

Observation of Resident 92's room on March 10, 2019, at 9:30 a.m., 11:00 a.m., and 1:00 p.m., revealed an oxygen concentrator with tubing and canula draped over the concentrator that was not bagged, labeled, or dated.

Observation of West nursing unit dining room on March 11, 2019, at 9:35 a.m., revealed an unattended, blue-colored ice cooler containing partially melted ice and large styro-foam cup stored inside.

Observation of the West nursing unit dining room on March 11, 2019, at 11:14 a.m., revealed an unattended red-colored ice cooler with a scoop stored inside and a used resident meal tray stored below the ice cooler. A second observation on the same day at 2:01 p.m., revealed the same used meal tray had not been removed from the ice cart.

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

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

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









 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. No residents were directly impacted by this deficient practice.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Nursing Services QAPI audit tool, a comprehensive audit was
completed for compliance

3. To ensure the deficient practice does not recur, the nursing staff will be educated by the NHA/ designee on Focus on F Tag 880, Infection Prevention & Control on or before the date of compliance

4. Utilizing the Nursing Service QAPI audit tool the Administrator / designee will audit 4 observations weekly for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019

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 clinical record review, observation and staff interview, it was determined that the facility failed to ensure that a call bell was answered timely for one of 39 sampled residents. (Resident 92)

Findings include:

Clinical record review revealed that Resident 92 had diagnoses that included heart disease, heart failure and a need for assistance with personal care. Review of the Minimum Data Set assessment dated January 25, 2019, revealed that the resident was alert and oriented and required extensive assistance from staff for activities of daily living (ADL)'s including transfers, dressing and personal hygiene. Review of the current plan of care revealed an intervention for staff to assist the resident with daily hygiene, grooming and dressing as needed.

Observation on March 11, 2019, from 9:50 a.m., through 10:10 a.m., revealed that the resident had activated her call light and was in need of assistance to finish her personal hygiene and to get out of bed and transfer into her wheelchair. The call light was answered by a staff member at 10:10 a.m., 20 minutes after the resident had activated the call light. In an interview with Resident 92 at this time she stated that she often had to wait a long time before her call light was answered. In an interview on March 12, 2019, at 2:00 p.m., the Administrator stated that the expectation was for staff to answer a resident's call bell within at least 15 minutes after the call light had been activated by the resident.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/6/18

28 Pa. Code 211.12(5) Nursing services.





 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. A grievance form was completed for R92. R92 was not negatively impacted by this deficient practice

2. New admissions and current residents have the potential to be affected by the deficient practice. In order to establish call light response timeliness, an ad hoc resident council will be held.

3. To ensure the deficient practice does not recur, facility nursing staff will be educated on Focus on F Tag 550, Resident Rights, by the NHA/DON/designee on or before the date of compliance.

4. Utilizing the nursing services QAPI audit tool, the Administrator / designee will audit each nurses' station 3 times a week for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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.
483.60(f) Frequency of Meals
483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

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

483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on a review of the facility's meal cart delivery time sheet, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs for two of 39 sampled residents. (Resident 10, 92)

Findings include:

Review of the facility's meal cart delivery time sheet revealed that the regularly scheduled time for the last cart with lunch trays for the Heritage Nursing Unit was to be served to the residents at 12:38 p.m..

Clinical record review revealed that Resident 10 had a diagnosis of metastatic breast cancer. Review of the Minimum Data Set assessment dated February 22, 2019, indicated that the resident was alert and oriented and required set up help only for eating. Observation of the lunch being served on the Heritage Nursing Unit on March 10, 2019, revealed that Resident 10 received her lunch late at 1:45 p.m. (over an hour past the regularly scheduled lunch serving time). Resident 10 eats in her room and at this time she stated that "the lunch was very late today".

Clinical record review revealed that Resident 92 had diagnoses that included heart disease and diabetes. Review of the Minimum Data Set assessment dated January 25, 2019, revealed that the resident was alert and oriented. Observation of the lunch being served on the Heritage Nursing Unit on March 10, 2019, revealed that Resident 92 received her lunch at 1:30 p.m. (52 minutes past the regularly scheduled lunch serving time). Resident 92 was eating in her room that day and she stated that "the lunch was really late today".

In an interview on March 13, 2019, at 12:00 p.m., the Administrator stated that the lunch was served unacceptably late on March 10, 2019, and past the regular scheduled meal time in accordance with the resident's needs.






 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. A grievance form was completed for R10 & R92. Neither resident was negatively impacted by this deficient practice.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Tray Accuracy QAPI audit tool, a comprehensive audit was completed for frequency of meals.

3. To ensure the deficient practice does not recur, dietary staff will be educated by the NHA/Food Service GM/designee on Focus on F Tag F809, Frequency of Meals on or before the date of compliance

4. Utilizing the Tray Accuracy QAPI audit tool, the Administrator Food Service General Manager/ designee will audit 10 resident food trays weekly for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

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

483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:

Based on clinical record review and observation, it was determined that the facility failed to ensure that a resident was served preferred food items on their meal trays for one of 39 sampled residents. (Resident 10)

Findings include:

Clinical record review revealed that Resident 10 had diagnoses that included metastatic breast cancer with bone, liver and upper abdominal metastasis. Review of the Minimum Data Set assessment dated February 22, 2019, revealed that the resident was alert and oriented and required only set up help for eating. Review of the current care plan revealed the resident was at nutrition risk due to metastatic breast cancer and there was an intervention since April 9, 2018, for staff to honor the resident's food preferences. Review of the menu for lunch on March 10, 2019, revealed that the lunch meal for the day was salisbury steak with gravy, mashed potatoes, brussel sprouts, and pound cake with strawberry topping. Observation on March 10, 2019, at 1:45 p.m., revealed that Resident 10 had received her lunch; however, all that was on the tray was one piece of the salisbury steak. Review of the meal ticket tindicated that the resident had preferred to receive the salisbury steak with gravy, mashed potatoes, brussel sprouts and the pound cake. The resident had selected these items for lunch and did not receive the items that she had selected on her tray.







 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. A grievance form was completed for R10. R10 was not negatively impacted by this deficient practice.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Tray Accuracy QAPI audit tool, a comprehensive audit was completed for resident food preferences.

3. To ensure the deficient practice does not recur, dietary staff will be educated by the NHA/Food Service GM/designee on Focus on F Tag F806, Resident Allergies / Preferences on or before the date of compliance

4. Utilizing the Tray Accuracy QAPI audit tool, the Administrator Food Service General Manager/ designee will audit 10 resident food trays weekly for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/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.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician ordered medication was available from the pharmacy for one of 39 sampled residents. (Resident 10)

Findings include:

Clinical record review revealed that Resident R10 had diagnoses that included metastatic breast cancer with bone, liver, and upper abdominal metastasis. Review of the Minimum Data Set assessment dated February 22, 2019, indicated that the resident was alert and oriented and that she had an active diagnosis of cancer. Review of the current care plan revealed an intervention since April 2018 for staff to administer medications and treatments as ordered. On March 1, 2019, a physician had ordered a chemotherapy medication (Verenzio) to be administered by staff to the resident two times a day. Review of the Medication Administration Record for March 2019 revealed that the chemotherapy medication (Verenzio) had not been administered to the resident as ordered from March 2, 2019 to March 12, 2019. Review of a nursing note dated March 7, 2019, revealed that the chemotherapy medication Verenzio had not been administered because it was unavailable from the pharmacy. In an interview on March 13, 2019, at 10:03 a.m., the Director of Nursing stated that the chemotherapy medication had not been administered to the resident as ordered by the physician between March 2 and 12, 2019, because it had been unavailable from the pharmacy.

28 Pa. Code 211.9(j) Pharmacy services

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/6/18





 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. R10's medications were delivered. R10's physician and responsible party were both made aware.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Medication Error QAPI audit tool, a comprehensive audit was completed for medications that were unavailable from the pharmacy

3. To ensure the deficient practice does not recur, licensed nurses will be educated by the DON/designee on Focus on F Tag F755, Pharmacy Services on or before the date of compliance

4. Utilizing the Medication Error QAPI audit tool the Administrator / designee will audit 5 (or less if less are unavailable) weekly for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019

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 and observation, it was determined that the facility failed to ensure that a call bell was accessible for two of 39 sampled residents. (Resident 47, 60)

Findings include:

Clinical record review revealed that Resident 47 had diagnoses that included a fractured left hip surgical repair and peripheral neuropathy (nerve related pain in her extremities. According to the Minimum Data Set (MDS) assessment, dated December 13, 2018, the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as bathing, grooming, and hygiene. On March 10, 2019, at 9:37 a.m., the resident was observed in bed with the call bell out of reach on the floor on the opposite side of the bed.

Clinical record review revealed that Resident 60 had diagnoses that included hypertension and dementia. According to the MDS assessment, dated December 27, 2018, the resident was able to communicate needs to staff and required extensive assistance from staff for mobility and activities of daily living such as bathing, grooming, and hygiene. On March 10, 2019, at 9:37 a.m., the resident was observed in bed with the call bell out of reach on the floor.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/6/18

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



 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. A grievance form was completed for both R47 & R60. Neither were negatively impacted by this deficient practice.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Nursing Services QAPI audit tool, a comprehensive audit was completed for call bells to be in reach.

3. To ensure the deficient practice does not recur, facility nursing staff will be educated on Focus on F Tag 558, Accommodation of Needs by the NHA/DON/designee on or before the date of compliance.

4. Utilizing the Nursing Service QAPI audit tool the Administrator / designee will audit each 10 residents 3 times a week for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019

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 observation, it was determined that the facility failed to maintain confidentiality in regards to residents' health information on one of four nursing units. (Heritage Nursing Unit)

Findings include:

Observation during a medication pass on March 13, 2019, from 9:10 a.m., through 9:40 a.m., on the Heritage Nursing Unit, revealed that RN1 had left a resident roster that included the names of residents and their vital signs on top of the medication cart. The resident roster was uncovered and was visible to anyone in the hallway during that time frame.

28 Pa. Code 201.29(j) Resident rights.







 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. No residents were negatively impacted by this deficient practice.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Medication Management Skills Evaluation QAPI audit tool, a comprehensive audit was completed for maintaining resident privacy as it relates to private information on medication/treatment cards.

3. To ensure the deficient practice does not recur, facility nursing staff will be educated on Focus on F Tag 583, Personal Privacy by the NHA/DON/designee on or before the date of compliance.

4. Utilizing the Medication Management QAPI audit tool the Administrator / designee will audit 3 licensed nurses each week for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019.

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 review, and staff interview it was determined that the facility failed to develop a comprehensive care plan to meet the resident's current needs for one of 39 sampled residents. (Resident 22)

Findings include:

Clinical record review revealed that Resident 22 had a diagnosis of end-stage lung cancer. Review of the Minimum Data set assessment dated December 3, 2018, indicated that the resident was alert and oriented and required extensive assistance from staff to complete her activities of daily living including bathing, dressing and transfers. Review of nursing documentation dated March 6, 2019, revealed that the resident had a urinalysis that identified that she had ESBL (Escherichia coli) an infection in her urine and she was placed on an antibiotic for ten days. The nursing note further indicated that the infection control nurse was aware of the infection and that the resident had been placed on isolation. A nursing note dated March 8, 2019, revealed that the resident was on contact precautions for the ESBL. A nursing note dated March 11, 2019, revealed that the resident continued to be on an antibiotic for the infection in her urine. In an interview on March 10, 2019, at 9:20 a.m., RN1 confirmed that Resident 22 was on contact precautions for ESBL in her urine. There was no documented evidence that a care plan had been developed with interventions to address the infection or the contact precautions. In an interview on March 14, 2019, at 11:00 a.m., the Administrator confirmed that there had not been a care plan developed to address the infection and contact precautions for this resident.

28 Pa. Code 211.11(d) Resident care plan








 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. R22's care plan was immediately updated to reflect her current infection at that time.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Change of Condition Eagle Room tool, a comprehensive audit was completed for those residents with current infections.

3. To ensure the deficient practice does not recur, Licensed nurses, Social Services, Activity Director, Dietitian, & Nursing Management will be educated by the DON/designee on Focus on F Tag 656, Creating And Maintaining Care Plans QRG, ROP Interdisciplinary Care Planning on or before the date of compliance

4. Utilizing the Change of Condition Eagle Room QAPI audit tool the Administrator / designee will audit five changes of condition weekly for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019

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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that Professional standards of quality were maintained and that care and services were provided according to acceptable standards of clinical practice for one of 39 sampled residents and two licensed nursing staff. (Resident 10, RN1, LPN2)

Findings include:

Review of facility policy entitled "Medication Administration: Medication Pass", dated January 1, 2019, revealed that the purpose was to safely and accurately prepare and administer medication according to physician order and patient needs.

Clinical record review revealed that Resident 10 had diagnoses that included metastatic breast cancer with bone, liver and upper abdominal metastasis. Review of the Minimum Data Set assessment dated February 22, 2019, revealed that the resident was alert and oriented, required minimal assistance with activities of daily living, had an active diagnosis of cancer and had been administered an opioid medication over the last seven days. Review of the care plan revealed an intervention since April 2018 to administer medications and treatments as ordered. There was also a care planned area that addressed that Resident 10 was on pain medication therapy related to cancer. Review of the physician's orders revealed that on March 1, 2019, a physician ordered for staff to administer a chemotherapy medication (Verenzio) twice daily.

Review of the Medication Administration Record (MAR) for March 2019, revealed that the medication (Verenzio) had not been given to the resident on several days between March 2 and March 12, 2019, because the medication was unavailable from the pharmacy. Further review of the MAR revealed that the medication was signed out as administered by RN1 on March 3, 2019, both doses, and again on March 4, 6, and 11, 2019, for the 9:00 a.m., dose. In addition, LPN2 signed out that the medication was administered on March 9, 2019, for the 9:00 a.m., dose. In an interview on March 13, 2019, at 10:03 a.m., the Director of Nursing stated that the Verenzio medication was not available from the pharmacy between March 2 and March 12, 2019, and that the licensed nurses had inaccurately signed out on the MAR that they had administered the medication to the resident as ordered by the physician.

Further clinical record review revealed that Resident 10 had a current physician's order for staff to administer an opioid medication for pain (Oxycodone) every 12 hours. Observation during the medication pass on March 10. 2019, at 9:30 a.m., revealed that RN1 was preparing to administer Residnet10's medications. RN1 had pre-poured the Oxycodone into a souffle cup and had kept the medication in the top drawer of the medication cart that was not double locked. RN1 stated at this time that she had "pre-poured" the Oxycodone for Resident 10 earlier that morning. Observation of the controlled substance log revealed that RN1 had not signed out that she had pre-poured the Oxycodone. In an interview on March 12, 2019, at 2:00 p.m., the Director of Nursing stated that that the pain medication was not to be pre-poured and that the narcotic should have been kept double locked in the medication cart prior to being poured and accounted for by the nurse. The facility failed to ensure that Professional standards of quality was maintained in regards to accountability by licensed nursing staff for medications and failed to follow facility policy for medication administration in accordance with the Pennsylvania Code, Title 49 Professional and Vocational Standards, 21.11 (a)(4) Responsibilities of the Registered Nurse and 21.145(a), Functions of the LPN.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/6/18

28 Pa. Code 211.12(5) Nursing services.








 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. LPN1 received education for placing a narcotic in a single-locked drawer (vs. double). LPN1 & LPN2 received a discipline for their documentation. Neither residents were negatively impacted by this deficient practice.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Medication Management Skills evaluation audit tool, a comprehensive audit was completed for observing proper professional standards.

3. To ensure the deficient practice does not recur, Licensed nurses will be educated by the DON/designee on Focus on F Tag 658, Services Provided meet Professional Standards on or before the date of compliance.

4. Utilizing the Medication Management QAPI audit tool the Administrator / designee will audit 3 licensed nurses each week for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019

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 clinical record review and resident interview, it was determined that the facility failed to administer pain medication in accordance with physician's orders for one of six sampled residents with pain. (Resident 47)

Findings include:

Clinical record review revealed that Resident 47 was admitted to the facility on September 5, 2018 and had diagnoses that included a fractured left hip surgical repair and peripheral neuropathy (nerve related pain in her extremities). According to the Minimum Data Set assessment, dated December 13, 2018, the resident was able to communicate needs to staff and had pain that required routine medication. Since admission, the physician orderd that staff aminister a pain medication (Tylenol) up to every six hours if needed for additional pain. On March 10, 2019, at 9:37 a.m., the resident stated to the nurse administering her routine medications (LPN1) that she had "aching" in her legs that she rated a "six" on a scale of one to ten. The following day there was no documented evidence in the clinical record that the nurse documented the presense of resident's leg pain, and there was no evidence that the nursing staff treated the resident's pain in accordance with the physician's order.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 4/6/18

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



 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. A pain assessment was immediately completed on R47.

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the Pain Eagle Room QAPI audit tool, a comprehensive audit was completed for pain management.

3. To ensure the deficient practice does not recur, Licensed nurses will be educated by the DON/designee on Focus on F Tag 697, Pain Management on or before the date of compliance

4. Utilizing the Pain Eagle Room QAPI audit tool the Administrator / designee will audit 5 residents weekly for 4 weeks for compliance.

5. The building will allege compliance on May 7, 2019

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 observation it was determined that the facility failed to post accurate and current nurse staffing.

Findings include:

During a tour of the facility conducted on March 10, 2019, at 9:00 a.m., the staffing information that was posted in the lobby was dated March 7, 2019.



 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. No residents were negatively impacted by this deficient practice.

2. No residents were negatively impacted by this deficient practice.

3. To ensure the deficient practice does not recur, the scheduler, Unit Managers, & Managers on Duty will be educated by the NHA/DON/designee on Focus on F Tag 732, Posting Staffing Information on or before the date of compliance.

4. Utilizing the Nursing Staffing QAPI audit tool the Administrator / designee will audit weekly x4 for compliance.

5. The building will allege compliance on May 7, 2019

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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.
483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observation, it was determined that the facility failed to properly dispose of garbage and refuse properly.Findings include:Observation of the dumpster area during the intial dietary tour conducted on March 10, 2019, at 9:15 a.m., revealed the dumpster area was littered with garbarge including paper, plastic and one bag of soiled personal care items. 28 Pa. Code 201.14(a) Responsibility of licensee.











 Plan of Correction - To be completed: 05/07/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

1. No residents were negatively impacted by this deficient practice.

2. No residents were negatively impacted by this deficient practice.

3. To ensure the deficient practice does not recur, the Dietary department, Housekeeping department, and Maintenance Department will be educated by the NHA/ designee on Focus on F Tag 814, Dispose of Garbage Properly on or before the date of compliance,

4. Utilizing the Kitchen/Food Service QAPI audit tool the Administrator / designee will audit weekly x4 for compliance.

5. The building will allege compliance on May 7, 2019


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