Nursing Investigation Results -

Pennsylvania Department of Health
LUTHERAN HOME AT HOLLIDAYSBURG, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LUTHERAN HOME AT HOLLIDAYSBURG, THE
Inspection Results For:

There are  86 surveys for this facility. Please select a date to view the survey results.

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LUTHERAN HOME AT HOLLIDAYSBURG, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on February 6, 2020, it was determined that The Lutheran Home at Hollidaysburg was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.21(b)(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 Pennsylvania's nursing practice act, clinical record reviews, and staff interviews, it was determined that the facility failed to clarify a physician's order for an indwelling urinary catheter for one of 36 residents reviewed (Resident 32).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, and was responsible for assessing human responses and plans, implementing nursing care, and analyzing/comparing data with the norm in determining care needs.

Diagnosis information for Resident 32, dated September 30, 2019, revealed that the resident had diagnoses that included benign prostatic hypertrophy (BPH - an enlarged prostate). A comprehensive significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated November 30, 2019, revealed that the resident had an indwelling urinary catheter (a tube held in the bladder to drain urine).

Physician's orders for Resident 32, dated November 19, 2019, included an order to maintain the urinary catheter, for catheter care every shift, and to empty the urine collection bag before it was half full every shift. However, there was no documented evidence that the order included the size of the catheter and balloon (filled with sterile water to hold the catheter in place) to be used, and no documented evidence that nurses attempted to clarify the incomplete order with the physician.

An interview with the Director of Nursing on February 6, 2020, at 11:16 a.m. confirmed that the order for Resident 32's catheter was not complete and that it should have included the size of the catheter and balloon.

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

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

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



 Plan of Correction - To be completed: 03/30/2020

Physician notification was made immediately on February 6, 2020 to clarify physician's order that was implemented immediately. Residents care plan was also updated to reflect Foley order and interventions as resident specific to Foley order and care.
re-education will be provided to all current licensed nurses, new nursing staff and agency staff on the importance of clarifying a physicians order for indwelling urinary catheters. An audit will be created to monitor all physician orders related to all new orders related to Foley's and the proper clarification of orders related to the maintenance of such.
The Director of Nursing or Designee will be responsible to monitor entries on the audit tool. The audit will be completed weekly times four weeks and monthly times two months. All findings will be reported through the Quality Assurance Performance Improvement meetings.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.75(g) Quality assessment and assurance.

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


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

Findings include:

The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the surveys ending March 14, August 7 and September 24, 2019, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 6, 2020, identified repeated deficiencies related to failures to complete accurate Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), to develop and implement a comprehensive, individualized care plans for each resident, to review and revise care plans for each resident, to ensure that professional nursing standards were followed, to ensure that physician's orders were followed, to ensure that the resident environment remained free from accident hazards, to ensure that residents received pain management programs, to ensure the accountability of controlled medications, to maintain complete and accurate medical records, and to ensure that infection control practices were followed.

The facility's plans of correction for deficiencies regarding accurate MDS assessments, the development of comprehensive, individualized care plans, care plan review and revision, meeting professional standards of quality, the resident environment being free from accident hazards, pain management, the accountability of controlled medications, complete and accurate medical records, and infection control practices, cited during the survey ending March 14, 2019, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, F656, F657, F658, F684, F689, F697, F755, F842 and F880 revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations.

The facility's plan of correction for a deficiency regarding reviewing and revising care plans for each resident, cited during the survey ending August 7, 2019, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to maintain ongoing compliance with this regulation.

The facility's plan of correction for deficiencies regarding quality of care and following physician's orders, and infection control practices, cited during the survey ending September 24, 2019, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684 and F880 revealed that the facility's QAPI committee failed to maintain ongoing compliance with these regulations.

Refer to F641, F656, F657, F658, F684, F689, F697, F755, F842 and F880.

28 Pa. Code 201.14(a) Responsibility of licensee.

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







 Plan of Correction - To be completed: 03/30/2020

The current Quality Assurance Performance Improvement program has been reviewed by the Director of Quality Improvement. The repeat deficiencies have been reviewed and audits have been developed to provide accurate data collection and process improvement. Director of Quality Improvement will review monthly Quality Assurance and Performance Improvement Minutes. Education has been provided to the Interdisciplinary Team Regarding the repeat deficiencies. Audits for repeat deficiencies will be completed per their individual plan of corrections. All Audits will be reviewed at Quality Assurance and Performance Improvement monthly meeting where a Root Cause Approach will Evaluate new and recurrent Deficiencies. Revision or extension of audits will be discussed with the Interdisciplinary Team. Any audits that need to be revised will be done at that time.
483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and 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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 38 residents reviewed (Resident 31).

Findings include:

The facility's policy regarding documentation of medications and treatments, dated January 14, 2020, indicated that the individual who administered the treatment was to record the administration on the Treatment Administration Record (TAR) directly after it was administered, and at the end of each shift the person administering the treatments was to review TAR's to ensure the necessary treatments were administered and documented.

Physician's orders for Resident 31, dated January 3, 2020, included an order to cleanse the left top foot wound with normal saline solution (sterile salt and water), pat dry, apply Medihoney (a wound healing ointment) to the wound bed, apply gauze moistened with saline and cut to fit the size of the wound, cover with dry gauze, and secure with conform (a disposable stretchy gauze wrap) and tape daily.

Review of Resident 31's Treatment Administration Records (TAR's) for January 3 through February 4, 2020, indicated that staff signed that they completed a daily treatment of irrigating the left top foot wound with normal saline solution, wiping it dry with gauze, applying Medihoney to the wound bed, applying moistened gauze cut to fit the size of the wound, covering with dry gauze, and securing with conform.

Observations on February 4, 2020, at 10:09 a.m. revealed that Licensed Practical Nurse 2 completed a treatment of cleansing the two open wounds on Resident 31's left foot with normal saline solution, dabbing the areas dry with gauze, applying Medihoney to each wound base, cutting out two pieces of Systagenix Adaptic gauze (a specialized wound dressing that is impregnated with Vaseline to keep the gauze from sticking to the wound) in shapes to fit the wound beds and placing them into the wound beds, covering the wounds with a Telfa pad (a non-adherent gauze pad), and wrapping the left foot and leg with conform gauze.

Interview with Licensed Practical Nurse 2 on February 4, 2020, revealed that the Wound Clinic changed Resident 31's wound dressing orders recently to replace the moistened gauze with Systagenix Adaptic gauze to make the dressing changes less painful for the resident. She indicated that the wound clinic sent a sheet of Systagenix Adaptic gauze back with the resident after her last appointment.

A wound care treatment consult sheet, dated January 24, 2020, revealed that the resident was seen in the clinic that day and orders were given for the wound care as above, including the use of Adaptic gauze cut to fit and to be placed in each wound bed.

There was no documented evidence that Resident 31's TAR's were updated to reflect the wound dressing that was actually being completed since January 24, 2020.

Interview with the Director of Nursing on February 6, 2020, at 4:00 p.m. confirmed that Resident 31's wound care orders were changed on January 24, 2020; however, the TAR's were not updated with the current order and should have been. She confirmed that staff continued to document that they completed the daily dressing change that was ordered on January 3, 2020, even though that was not the treatment that they provided as of January 24, 2020.

28 Pa. Code 211.5(f) Clinical Records.




 Plan of Correction - To be completed: 03/30/2020

Resident 31's orders were immediately fixed by the director of nursing to indicate the proper orders according to the Wound clinic and the treatment in place. Was administered to resident for pain of 7 twice, pain of 9 and pain of 5 on four separate occasions. In order to protect residents in similar situations re-education will be provided to all current licensed nurses, new nursing staff and agency staff on the correct administration of treatments according to physician orders and the importance of transcribing new orders upon return from outside consults.
An audit will be created to monitor random outside consults and new orders to include the new order and if it is in place and being followed. Folder placed in Supervisor Office where copies of the Consults will be placed and taken to Morning Meeting for review and to ensure orders are processed properly.
The Director of Nursing or Designee will be responsible to monitor entries on the audit tool. The audit will be completed weekly times four weeks and monthly times two months. All findings will be reported through the Quality Assurance Performance Improvement meetings.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45 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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) stored in the emergency medication storage unit.

Findings include:

The facility's undated policy/manual for the emergency medication storage unit indicated that medications included in the Drug Enforcement Administration's (DEA) classification as "controlled substances" were subject to special handling, storage, disposal and record keeping in the facility, in accordance with federal, state and other applicable laws and regulations. At each shift change, a physical inventory of all controlled medications (including the emergency supply) was to be conducted by two licensed nurses and was to be documented on the shift change controlled medication accountability record.

Interviews with the Director of Nursing and with Registered Nurses 3 and 4 on February 5, 2020, at 10:16 a.m. revealed that there was no sign-out log in the emergency medication system, and there was no accountability, as no one was counting the medications at the end of any specific shift or day, and there was no one person who was responsible for the accountability within the system. Registered Nurse 3 stated that the pharmacy may keep records of what medications were in the drawers, but the facility does not, and once a nurse accesses the machine he/she can pull whatever they want from the machine at any time.

Observations during a count of all controlled substances in the facility's emergency medication storage unit that was conducted by the Director of Nursing on February 5, 2020, at 10:16 a.m. revealed that there were twenty-six 5/325 milligram (mg) tablets of Percocet (a controlled narcotic pain medication) when there should have been twenty-eight, seven 10 mg tablets of Oxycontin (a controlled narcotic pain medication) when there should have been six, and two unopened 30 milliliter (ml) vials of morphine sulfate (a controlled narcotic pain medication) that should not have been there.

Interview with the Director of Nursing on February 5, 2020, at 10:21 a.m. confirmed that there was no documented evidence to account for the narcotic medication discrepancies in the facility's emergency medication supply. She indicated that she has never run a discrepancy report and the pharmacy should run reports and notify the facility if there was a discrepancy, but she was not sure how often they do that.

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

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



 Plan of Correction - To be completed: 03/30/2020

Director of nursing immediately put in to place a system of two licensed staff to count the narcotics every shift in the emergency medication storage unit. The system includes a narcotic count sheet for each narcotic in the system and the amount of medications in the unit. The binder also holds a signing count sheet for each shift to sign with two licensed nurses ensuring the count in the machine is correct. The Director of nursing is also completing a weekly audit of the machine for any discrepancies.
Education was provided to all licensed staff, current, new, agency on the new process of signing the medications out of the book and counting between shifts. Education also included that you must take a copy of the order to the med dispense with attaining any medication form the machine and always have another nurse present for a second verifier of the correct medications. The discipline action to be followed for not following accurate accounting. The emergency medication storage unit was also programmed to now require two licensed nursing staff signatures to remove any narcotic from the machine.

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


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as observations and staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 36 residents reviewed (Residents 51, 52).

Findings include:

The Long-Term Care Resident Assessment Instrument (RAI) manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section M1040D (Other Ulcers, Wounds and Skin Problems) was to be checked if the resident had any open lesion(s), other than ulcers, rashes or cuts (e.g., cancer lesion).

A nursing note for Resident 51, dated December 11, 2019, at 12:02 p.m. and authored by the facility's wound nurse, indicated that Resident 51 had a 1.5 x 1.5 x 1.0 (depth) centimeter (cm) scalp wound with minimal serosanguinous drainage (yellow tinged with blood), the wound's size and drainage had decreased, and new orders were obtained to change the dressing on Mondays, Wednesdays and Fridays, and in between if soiled.

An annual MDS assessment for Resident 51, dated December 14, 2019, revealed that Section M1040D was blank and not coded to capture the presence of the scalp wound. Instead, Section M1040Z (none of the above) was checked, indicating that the resident had no lesions, surgical wounds, burns or moisture-associated skin damage.

Interview with Registered Nurse 3 (the facility's infection control/wound nurse) on February 5, 2020, at 4:45 p.m. confirmed that he authored the December 11, 2019, note concerning Resident 51's open and draining scalp wound and indicated that the resident's wound was present and open at the time of the MDS assessment dated December 14, 2019, and was still open and draining at the current time.

Interview with Registered Nurse Assessment Coordinator 4 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on February 6, 2020, at 10:10 a.m. confirmed that Section M1040D should have been checked on Resident 51's annual MDS assessment to reflect the presence of the open and draining scalp wound.


The RAI User's Manual, dated October 2019, revealed that if the resident received hospice (end-of-life) services during the assessment period, then Section O0100K2 was to be checked.

Physician's orders for Resident 52, dated March 15, 2019, included orders for the resident to receive hospice services. However, a quarterly MDS assessment dated December 16, 2019, revealed that Section O0100K2 was not checked, indicating that the resident did not receive hospice services.

Interview with Registered Nurse Assessment Coordinator 4 on February 6, 2020, at 11:04 a.m. confirmed that Section O0100K2 of Resident 52's MDS assessment of December 16, 2019, was not accurate and should have been checked to indicate that the resident received hospice services.

28 Pa. Code 211.5(f) Clinical records.





 Plan of Correction - To be completed: 03/30/2020

The Long Term Care Resident Assessment Instrument manual was reviewed by the Registered Nurse Assessment Coordinator to make the necessary changes. Resident 51's Minimum Data Set Assessments were corrected to include the wound. Resident 52's Minimum Data Set Assessments were corrected to include the hospice order. Resident 12's Minimum Data Set Assessments were corrected to include the fall. In order to protect residents in similar situations an audit of random residents will be created to monitor accurate completion of Minimum Data Set assessments. Registered Nursing Assessment Coordinator was reeducated on accurate completion of minimum data set assessment.
The audit created will include the resident name and if sections J, M and O are completed correctly. The Nursing Home Administrator or Designee will be responsible to monitor entries on the audit tool. The audit will be completed weekly times four weeks and monthly times two months. All findings will be reported through the Quality Assurance Performance Improvement meetings.

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


Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions that accurately reflected the services to be furnished for four of 36 residents reviewed (Residents 4, 25, 32, 43).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated October 25, 2019, revealed that the resident was cognitively impaired, required extensive assistance with daily care tasks, and was incontinent of bowel and bladder.

As of February 6, 2020, there was no documented evidence that Resident 4's care plan included specific and individualized interventions related to the his incontinence.

Interview with the Quality Assurance Nurse on February 6, 2020, at 6:46 p.m. confirmed that a care plan regarding incontinence was not developed for Resident 4.


Physician's orders for Resident 25, dated November 19, 2019, included an order for 5,000 units of Heparin (an injectable blood thinner) to be administered subcutaneously (injected just under the skin) three times a day. The resident's Medication Administration Records (MAR's) for November and December 2019, and January and February 2020, revealed that staff administered the Heparin injections as ordered by the physician.

As of February 6, 2020, there was no documented evidence that Resident 25's care plan included specific and individualized interventions related to the administration of Heparin injections.

An interview with the Director of Nursing on February 6, 2020, at 5:39 p.m. confirmed that a care plan regarding the administration of Heparin injections was not developed for Resident 25.


A significant change MDS for Resident 32, dated November 30, 2019, revealed diagnoses that included benign prostatic hyperplasia (BPH - a condition in which the flow of urine is blocked due to the enlargement of prostate gland) requiring the use of an indwelling urinary catheter (a flexible tube that is held in the bladder to drain urine). Physician's orders for Resident 32, dated November 19, 2019, included an order to maintain the urinary catheter.

As of February 6, 2020, there was no documented evidence that Resident 32's care plan included specific and individualized interventions related to the use and care of the resident's indwelling urinary catheter.

An interview with the Director of Nursing on February 6, 2020, at 11:16 a.m. confirmed that a care plan regarding the use and care of an indwelling urinary catheter had not been developed for Resident 32.


A quarterly MDS assessment for Resident 43, dated December 12, 2019, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, and had diagnoses that included diabetes (interferes with blood sugar control, which increases risk for poor wound healing) and dementia (causes declines in the abilities to think and remember). Physician's orders, dated January 31, 2020, included an order for the resident to receive 500 milligrams (mg) Cipro (an antibiotic) every 12 hours for his left foot, second toe amputation site.

A nursing note for Resident 43, dated February 3, 2020, at 1:35 p.m. revealed that the culture results of his left foot second toe amputation site showed pseudomonas aeruginosa (a multi drug resistant pathogen) and coagulase negative staphylococcus (a type of bacteria that commonly live on a person's skin, but can cause infections when present in large amounts, or when present in the bloodstream). The note indicated that the resident was receiving Cipro two times daily until February 11, 2020, and it was susceptible to this infection. The physician was aware, and the resident was to continue the antibiotic as ordered.

Review of Resident 43's care plan revealed no documented evidence that it included specific and individualized interventions related to the infection.

An interview with the Director of Nursing on February 6, 2020, at 5:22 p.m. confirmed that Resident 43 did not have a care plan in place for the infection of his amputation site.

28 Pa. Code 211.11(d) Resident care plan.

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



 Plan of Correction - To be completed: 03/30/2020

Resident 4's care plan was updated to include the incontinence care plan and adequate interventions as indicated. Resident 25's care plan was updated to include anticoagulant therapy and interventions as indicated. Resident 32's care plan was updated to include Foley catheter and interventions as indicated. Resident 43's care plan was updated to include infection of amputated toe and interventions as indicated. In order to protect residents in similar situations re-education will be provided to all current Registered nurses, new nursing staff and agency staff on the importance of proper care planning. Department Heads will be going over new orders in morning meeting and determining the responsible party for each new order to care plan each order.
An audit will be created to monitor random care plans to include that specific and individualized interventions are in place in a timely manner. The Director of Nursing or Designee will be responsible to monitor entries on the audit tool. The audit will be completed weekly times four weeks and monthly times two months. The Interdisciplinary care plan team reviews resident care plans during their quarterly reviews, Grand Rounds (Facility quarterly meeting prior to Care Plan Date) and as needed. All findings will be reported through the Quality Assurance Performance Improvement meetings.

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' care plans were updated/revised to reflect current care needs and/or new interventions for one of 36 residents reviewed (Resident 59).

Findings include:

The facility's policy regarding admission care plan procedures, dated January 14, 2020, indicated that after an initial assessment, care plans were developed upon admission. The interdisciplinary team would evaluate and develop goals, approaches, interventions, as well as assign the disciplinary area to assist with the problem or need for the resident to meet their goal. The facility's policy regarding the care plan procedure, dated January 14, 2020, indicated that residents' care plans were to be individualized based on assessments and other related information and would be reviewed at least quarterly.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated June 21, 2019, revealed that the resident's activity preferences of importance included being around animals, keeping up with the news, doing things with groups of people, religious services, and attending favorite activities. The resident's care plan, dated June 13 and 24, 2019, revealed that she was a risk for falls and elopement, and staff were to provide emotional support, meaningful and familiar activities, and ample physical activities. On September 23, 2019, an intervention was added to involve the resident in activities to encourage new relationships with other residents.

A psychological services note, dated September 30, 2019, suggested that all caregivers and family use consistent, concreted statements to convey that Resident 59's placement in the facility was permanent, and follow-up statements should be empathic and supportive to encourage socialization with peers. A psychological services note, dated October 22, 2019, suggested that the resident be reminded that she played bingo, attended other activities, and liked to hear she was a positive influence with other residents and to encourage activities and socialization. A psychological services note, dated December 3, 2019, suggested to continue previous recommendations and encourage socialization as tolerated. A psychological services note, dated January 7, 2020, suggested that the resident be encouraged to have activity outside of her room as tolerated.

Observations on February 4, 2020, at 10:40 a.m. revealed that Resident 59 was sitting in the hallway next to her room. There was a religious activity scheduled at 10:15 a.m..

As of February 6, 2020, there was no documented evidence that Residents 59's care plan was updated to address the need for activities.

Upon interview with Activity Staff 1 on February 6, 2020, at 2:15 p.m., she indicated that an activity care plan was not necessary for Resident 59 because this was not a current issue as her attendance had increased.

Interviews with the Director of Nursing and the Nursing Home Administrator on February 6, 2020, at 4:35 p.m. confirmed that Resident 59's care plan should have been updated to include a specific plan related to activities.

A incident report for Resident 59, dated December 21, 2019, at 7:00 p.m. revealed that the resident was found in her room on her knees wiping debris from the floor. A note by the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is often involved in assessing a resident's needs and developing and/or revising care plans), dated December 23, 2019, at 9:40 a.m. indicated that the resident was re-educated not to get out of her wheelchair and to alert staff if something needed cleaning.

There was no documented evidence that the resident's care plan was updated following this fall.

Interview with the Nursing Home Administrator on February 6, 2020, at 4:22 p.m. confirmed that Resident 59's care plan should have been updated following the fall on December 21, 2019.

28 Pa. Code 211.11(d) Resident care plans.




 Plan of Correction - To be completed: 03/30/2020

Resident 59 care plan was updated to include an activity care plan with adequate interventions as indicated. No other Residents were identified to be lacking activities care plans upon immediate audit. In order to protect residents in similar situations re-education will be provided to the Activities Director on the importance of individualized care plans for each resident of the facility.
Care plans will be reviewed at least quarterly with care plan meetings and as needed on an individualized basis. All new admissions will have an activities care plan created to be individualized to residents' specifics. All findings will be reported through the Quality Assurance Performance Improvement meetings.

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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to follow physician's orders for one of 36 residents reviewed (Resident 44).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 44, dated September 12, 2019, indicated that the resident was cognitively impaired, required extensive assistance to perform daily care tasks, and had diagnoses that included heart failure and high blood pressure.

Physician's orders for Resident 44, dated October 24, 2019, included an order to weigh the resident daily for seven days and to call the physician if there was a greater than two pound weight gain in 24 hours.

A nursing note for Resident 44, dated October 29, 2019, at 11:58 p.m. indicated that the resident was weighed twice that day, once during the day shift and once during the evening shift, which revealed a 3.9 pound discrepancy in less than an eight hour lapse of time. The physician was contacted and new orders were given to weigh the resident daily, during the day shift and at the same time every day, and report (to the physician) if a greater than two pound weight gain or loss was obtained. There was no documented evidence of what the weights were that were obtained on October 29, 2019.

Review of Resident 44's weight tracking report revealed that on October 30, 2019, the resident's weight was recorded as 159.8 pounds at 7:20 a.m., and the previous recorded weight, which was obtained on October 28, 2019, at 9:18 p.m., was 157.0 pounds, an increase of 2.8 pounds. A nursing note dated October 30, 2019, at 10:23 a.m., and authored by a licensed practical nurse, indicated that both of the resident's lower legs were swollen, the resident was short of breath upon exertion, and was observed to have increased fatigue. The note indicated that the weights were reviewed by the registered nurse supervisor; however, there was no documented evidence in the clinical record that the physician was notified about the 2.8 pound weight gain.

Interview with the Director of Nursing on February 6, 2020, at 6:00 p.m. confirmed that there was no documented evidence of exactly what either of the two weights were that were obtained on October 29, 2019, and there was no documented evidence that the physician was notified about the 2.8 pound weight gain between the confirmed weight of 157.0 on October 28, 2019, at 9:18 p.m. and the next documented weight of 159.8 pounds on October 30, 2019. She confirmed that there should have been some communication with the resident's physician on October 30, 2019, regarding the 2.8 pound weight gain, leg swelling, shortness of breath and increased fatigue.

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

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



 Plan of Correction - To be completed: 03/30/2020

For Resident 44 issue unable to be corrected as it was identified from the past. No adverse effects noted. No other residents identified. In order to protect residents in similar situations re-education will be provided to all current licensed nurses, new nursing staff and agency staff on the importance of physician notification with changes in condition as well as following physician's orders as written.
An audit will be created to monitor all physician orders related to obtaining daily weights and following the physician orders for notification. During morning meeting the team will continue to review all daily weights with noted increases/decreases as indicated.
The Director of Nursing or Designee will be responsible to monitor entries on the audit tool. The audit will be completed weekly times four weeks and monthly times two months. All findings will be reported through the Quality Assurance Performance Improvement meetings.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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


Based on review of manufacturer's operation instructions and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that adequate supervision was provided in accordance with a care plan for one of 36 residents reviewed (Resident 51).

Findings include:

The operation instructions for shower chair commode models used by the facility, dated March 14, 2015, indicated that the wheel castors were to be locked when the chair was in the shower being used, the user and the chair were to be dried as completely as possible when the shower was finished, and to use caution as the chair may be slippery. The operation instructions also included a precaution to never leave an at-risk user unattended in the chair.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated August 2, 2018, indicated that the resident was cognitively and visually impaired, required extensive assistance with transfers, had difficulty with balance and stabilizing himself, had a recent history of a falls, and had diagnoses that included dementia (causes deterioration in memory and thinking skills). The resident's care plan, dated December 6, 2018, identified that he was at risk for falls due to weakness, that he did not like to wait on staff to perform care, was non-compliant with asking for assistance with care and transfers, and would attempt to do his own care, which had resulted in injuries.

An incident report for Resident 51, dated September 5, 2019, at 3:30 p.m. revealed that a nurse aide left the resident unattended in a shower chair after the shower was completed to get the licensed practical nurse to look at a mark on the resident's head. Upon returning to the shower room, she found Resident 51 on the floor on one knee, holding the railing. The facility's investigation documents revealed that Resident 51 stated that he leaned forward to dry between his toes better and leaned forward too far. The report indicated that the resident sustained an "L" shaped abrasion to his left buttock measuring 3.0 x 3.0 centimeters (cm) and also a 1.7 x 0.2 cm abrasion to his right knee.

Interview with the Nursing Home Administrator on February 6, 2020, at 5:11 p.m. confirmed that given Resident 51's history and care plan, staff should not have left him unattended in the shower chair.

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



 Plan of Correction - To be completed: 03/30/2020

Resident 51 was assessed at the time of the incident with only an abrasion noted. No other residents identified.
In order to protect residents in similar situations re-education will be provided to all current licensed nurses, new nursing staff and agency staff on the importance of not leaving a resident alone in the shower room on a shower chair per manufactures recommendations.
In order to protect residents in similar situations re-education will be provided on the proper use of shower chairs, transferring on shower chairs and not letting residents alone on shower chairs. An audit will be created for random residents to include residents that require the use of a shower chair and the proper utilization of the chair.
The Director of Nursing or Designee will be responsible to monitor entries on the audit tool. The audit will be completed weekly times four weeks and monthly times two months. All findings will be reported through the Quality Assurance Performance Improvement meetings.

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide pain management that was consistent with professional standards of practice for one of 36 residents reviewed (Resident 56).

Findings include:

The facility's policy regarding pain management, dated January 14, 2020, indicated that a licensed nurse would complete a pain screening upon admission and a pain assessment interview in conjunction with the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) schedule. When a pain medication was administered, the location and level of pain (based on a scale of 1-10 where 10 is the worst possible pain) would be recorded in the electronic health record.

Resident 56's care plan, dated December 17, 2019, indicated that the resident had the potential for pain, and interventions included for nursing staff to complete an assessment of pain, administer pain medication as ordered (by the physician), followed by an assessment of unwanted side effects.

Physician's orders for Resident 56, dated January 3, 2020, included orders for the resident to receive 650 milligrams (mg) of Tylenol (an over-the-counter pain medication) every four hours as need for mild pain rated 1 and 4, and 50 mg of Tramadol (a controlled narcotic pain medication) every eight hours as needed for moderate or severe pain rated 5 and 10.

Resident 56's Medication Administration Records (MAR's) for January and February 2020 revealed that staff failed to administer pain medication as ordered by the physician by administering Tylenol to the resident on January 10 at 5:00 p.m. for a pain rating of 7, January 29 at 2:14 p.m. for a pain rating of 9, February 2 at 3:15 p.m. for a pain rating of 7, and February 3 at 10:51 a.m. for a pain rating of 5.

Interview with the Director of Nursing on February 6, 2020, at 4:22 p.m. confirmed that the nurses should have followed physician's orders for pain medications.

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

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




 Plan of Correction - To be completed: 03/30/2020

Unable to address past situation for Resident 56. No other residents identified. In order to protect residents in similar situations re-education will be provided to all current licensed nurses, new nursing staff and agency staff on the correct administration of medication according to physician orders. An audit will be created to monitor pain medication administration for random residents and will include the correct medication for pain scale.
The Director of Nursing or Designee will be responsible to monitor entries on the audit tool. The audit will be completed weekly times four weeks and monthly times two months. All findings will be reported through the Quality Assurance Performance Improvement meetings.

483.60(d)(6) REQUIREMENT Drinks Avail to Meet Needs/Prefs/Hydration: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)(6) Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration.
Observations:


Based on clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure that drinks were provided in accordance with the resident's preferences for one of 36 residents reviewed (Resident 31).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated November 28, 2019, indicated that the resident was cognitively intact and could understand and make herself understood. Physician's orders, dated December 11, 2019, included an order to add chocolate ice cream daily to the resident's lunch meal to provide additional calories and protein.

Resident 31's care plan, dated December 11, 2019, and January 22, 2020, include to honor the resident's food preferences and provide chocolate ice cream with lunch.

Observations during the lunch meal on February 3, 2020, at 12:35 p.m. revealed that staff delivered a meal tray to Resident 31 in her room, opened a green-colored can of soda, placed a straw in it, and handed the drink to the resident. Resident 31 took a sip of the soda, made a dissatisfied face, and put the soda back down on the tray. When asked what was wrong, Resident 31 stated that the soda was ginger ale and she only liked lemon-lime.

Observations during the lunch meal on February 6, 2020, at 12:45 p.m. revealed that staff delivered a meal tray to Resident 31 in her room and began to set up the items. Resident 31 handed the small can of ginger ale that came on the tray to staff and asked to have lemon-lime instead. She also requested chocolate ice cream, as opposed to the vanilla ice cream that staff opened for her. Observations of the printed tray ticket that accompanied Resident 31's tray indicated that the resident was to receive chocolate ice cream and lemon-lime soda.

Interview with the Dietary Manager on February 6, 2020, at 1:00 p.m. confirmed that Resident 31 should have received lemon-lime soda and chocolate ice cream, as indicated on her tray ticket and in accordance with her preferences.

28 Pa. Code 201.29(j) Resident rights.







 Plan of Correction - To be completed: 03/30/2020

Resident 31 was immediately provided with items of preference. Resident 31 Preferences were updated to state only provide specified drink and dessert unless substitute requested by resident
All Residents that are served via tray line will have their drinks preferences updated by Dietary Manager or designee for accuracy and selection preference by corrective action date.
Education will be provided to all team members that assist with meal time service.
Audits will be completed as follows: 10 resident on tray line drink preferences will be audited weekly for 4 weeks, 5 resident drink preferences audited monthly for 2 months. Audits will be completed by Dietary Manager or Designee. All audits will be reviewed at Quality Assurance and Performance Improvement monthly meeting. Revision or extension of audits will be discussed with the Interdisciplinary Team. Any audits that need to be revised will be done at that time.

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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were used during care for one of 36 residents reviewed (Resident 31).

Findings include:

The facility's policy regarding standard (infection control) precautions (hand washing and glove use to prevent the spread of microorganisms), dated January 14, 2020, revealed that staff were to wear gloves and wash their hands before and after contact with potentially infectious materials, and hands were to be washed immediately after gloves were removed.

The facility's policy regarding open wounds, dated January 14, 2020, indicated that each opening in the skin may become infected, so standard precautions were taken when cleaning and applying lotions or treatments to areas involved.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 31, dated November 28, 2019, indicated that the resident was cognitively intact, required extensive assistance for personal hygiene and bathing, and had a history of vascular ulcers (open sores that are difficult to heal due to poor blood circulation to the affected limb).

Physician's orders for Resident 31, dated January 3, 2020, included an order to cleanse the left top foot wound with normal saline solution, pat dry, apply Medihoney (a wound healing ointment) to the wound bed, apply gauze moistened with saline cut to fit the size of the wound, cover with dry gauze, and secure with conform (a disposable stretchy gauze wrap) and tape daily.

Observations on February 4, 2020, at 10:09 a.m., revealed that with gloves on, Licensed Practical Nurse 2 removed the existing dressing from Resident 31's left foot and discarded the old dressings into a waste bag. She then removed her gloves, and without washing her hands put on a new pair of gloves and rinsed the top open wound with a vial of normal saline and dabbed it dry with a gauze pad. Licensed Practical Nurse 2 then rinsed the lower open wound with saline and used the same gauze pad to dab it dry. Licensed Practical Nurse 2 then removed her gloves and put on a new pair without washing her hands, applied Medihoney to two different cotton swab applicators, and used a different swab applicator for each open wound. Licensed Practical Nurse 2 removed her gloves, brushed her hair back from the right side of her face with her right hand, and put on a new pair of gloves without washing her hands. She then cleaned her scissors with an alcohol wipe, cut out two pieces of Systagenix in shapes to fit the wound beds, placed them into the wound beds, covered the wounds with a Telfa pad (a non-adherent gauze dressing), applied Aquaphor (a hydration lotion) to both the left and right legs, and then wrapped the left foot and leg with conform gauze. Licensed Practical Nurse 2 then cleaned up her wound care supplies, removed her gloves and put them into the bag with the discarded old dressings and new dressing wrappers, and placed all the resident's frequently used items back onto the overbed table within the resident's reach. Licensed Practical Nurse 2 then exited Resident 31's room and discarded the bag of used dressing and supplies in the medication room, took the remaining wound care supplies back to the treatment room and put them away, and came out to the computer at the nursing station and began to chart on the computer. Licensed Practical Nurse 2 did not wash her hands after removing her gloves at the conclusion of the wound care, or prior to leaving the resident's room, or before beginning her charting on the computer.

Interview with Licensed Practical Nurse 2 on February 4, 2020, at 10:18 a.m. confirmed that she should have washed her hands after each time she removed her gloves and prior to putting on new gloves, but she did not. She also confirmed that she did not wash her hands prior to leaving Resident 31's room and before putting away the supplies and sitting down to chart on the computer, and she should have. She confirmed that she used the same piece of gauze to pat both open wounds dry and should have used a different gauze for each wound.

Interview with the Infection Control Nurse on January 5, 2020, at 4:00 p.m. confirmed that Licensed Practical Nurse 2 should have washed her hands after each glove change and prior to leaving the resident's room and touching other objects, he also confirmed that the same piece of gauze should not have been used to dry two separate open wounds.

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

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







 Plan of Correction - To be completed: 03/30/2020

Resident 31 was assess by the Wound Team with no adverse effects noted, No signs/symptoms of infection.
In order to protect residents in similar situations re-education will be provided to all current licensed nurses, new nursing staff and agency staff on the correct administration of treatments according to physician orders the proper time to complete handwashing during wound care. Education will also be provided on the proper steps of wound care and not using the same supplies between more than one wound.
An audit will be created to monitor random residents' wound care to include the proper steps, following physician orders and proper hand hygiene practices and timing.
The Director of Nursing or Designee will be responsible to monitor entries on the audit tool. The audit will be completed weekly times four weeks and monthly times two months. All findings will be reported through the Quality Assurance Performance Improvement meetings.


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