Nursing Investigation Results -

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

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LUTHERAN HOME AT HOLLIDAYSBURG, THE
Inspection Results For:

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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 complaint survey completed on September 26, 2019, 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:


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25 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 follow physician's orders for one of four residents reviewed (Resident 3).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 12, 2019, indicated that the resident was incontinent, required extensive assistance for personal hygiene and bathing, and was at risk for skin breakdown. The resident's care plan, dated April 19, 2019, revealed that she was at risk for altered skin integrity. Physician's orders, dated May 30, 2019, included an order for diaper rash cream to be applied to the anus and buttocks every shift for skin irritation.

Review of Resident 3's Treatment Administration Records for May, June, July, August and September 2019, revealed that diaper rash cream was applied one time each day instead of every shift as ordered by the physician.

Interview with the Director of Nursing on September 24, 2019, at 6:30 p.m. confirmed that the diaper rash cream for Resident 3 was not applied as ordered by the physician and should have been applied each shift.

42 CFR 483.25 Quality of Care.
Previously cited 3/14/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/7/19, 4/25/19, 3/14/19.


 Plan of Correction - To be completed: 11/12/2019

Resident 3 was found to have physician orders not followed for diaper rash cream. Immediate corrective action was to update order as physician prescribed.
In order to protect residents in similar situations re-education will be provided to all current Registered Nurses, new registered and agency Registered nurses, on the importance of transcribing physician orders and placing them in the Medication Administration Record and Treatment Administration Record. In addition to education a system will be created to check all new order entries as well as an audit for tracking.
An audit will be created that new physicians orders will be logged to determine the efficiency of placing in the MAR and TAR. The audit will include the times a day for the medication or treatment to prevent further occurrences.
The Director of Nursing or Designee will be responsible to monitor entries on the physician order audit. This will ensure the transfers are handled according to plan of care. The flow sheet will be monitored daily for one week, twice weekly for 4 weeks and then weekly for 2 months.

483.10(b)(3)-(7)(i)-(iii) REQUIREMENT Rights Exercised by Representative: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(b)(3) In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated.
(i) The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the representative.
(ii) The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law.

483.10(b)(4) The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law.

483.10(b)(5) The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law.

483.10(b)(6) If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns when and in the manner required under State law.

483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident's behalf. The court-appointed resident representative exercises the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law.
(i) In the case of a resident representative whose decision-making authority is limited by State law or court appointment, the resident retains the right to make those decisions outside the representative's authority.
(ii) The resident's wishes and preferences must be considered in the exercise of rights by the representative.
(iii) To the extent practicable, the resident must be provided with opportunities to participate in the care planning process.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident was transferred to the legal representatives' preferred hospital for one of four residents reviewed (Resident 4).

Findings include:

A comprehensive significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated September 11, 2019, revealed that the resident was cognitively impaired, required extensive assistance for daily care tasks, and had diagnoses that included vascular dementia (a brain disease that causes declines in the ability to think and remember).

A general power of attorney for Resident 4, dated March 19, 2015, revealed that Resident Family Members 1 and 2 were given full power and authority to act as true and lawful agents for Resident 4. Admission paperwork for the resident, dated April 18, 2019, indicated that Resident Family Members 1 and 2 wanted the resident sent to their hospital of choice.

A nursing note for Resident 4, dated August 17, 2019, at 9:15 p.m. revealed that a nurse heard a resident call out that she fell and needed help. The resident was found on the floor behind the nursing station, lying on her right side and holding her head. A registered nurse assessed the resident and obtained a physician's order to send the resident to the hospital (not the hospital of choice). There was no documented evidence that the resident's legal representative was notified about the transfer until August 18, 2019, at 2:50 a.m.

A care plan note for Resident 4, dated August 20, 2019, at 10:14 a.m. revealed that the resident's legal representative was present and discussed her transfer to the hospital on August 17, 2019. The representative inquired why the resident was sent to the wrong hospital and stated that she did not wish the resident to be sent to the hospital for any circumstances, unless the legal representative was notified and agreeable.

An interview with the Registered Nurse Assessment Coordinator on September 24, 2019, at 5:10 p.m. confirmed that Resident 4 was sent to the wrong hospital on August 17, 2019.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/7/19, 4/25/19, 3/14/19.





 Plan of Correction - To be completed: 11/12/2019

Resident 4 was found to not be transferred to the legal representatives' preferred hospital. Resident 4 had her face sheet updated immediately to reflect the hospital of choice and to notify the family with any transfer to hospital prior to sending.
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 hospital transfer and family preference. In addition all registered nurses will be provided re-education in regard to family notification with change in condition and hospital transfer.
A hospital flow sheet will be created that Registered Nurses will record hospital transfers with proper notifications and proper place of transfer. The admission process will also be updated to include adding the hospital of choice for any transfers.
The Director of Nursing or Designee will be responsible to monitor entries on the hospital flow sheet. This will ensure the transfers are handled according to plan of care. The flow sheet will be monitored daily for one week, twice weekly for 4 weeks and then weekly for 2 months.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:


Based on review of manufacturer's instructions and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate services to maintain personal hygiene for one of four residents reviewed (Resident 3).

Findings include:

The manufacturer's label for McKesson Shampoo and Body Wash indicated that the product was to be applied to a wet wash cloth, gently massaged onto the skin, then rinsed with clean water.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 12, 2019, indicated that the resident required extensive assistance for personal hygiene and bathing.

Observations on September 24, 2019, at 7:10 p.m. revealed that Nurse Aides 1 and 2 performed evening care for Resident 3 and washed the resident's perineum (the area around the genitals) and buttocks with McKesson Shampoo and Body Wash. After washing the resident, the nurse aides dried him with a towel without rinsing the soap from the resident's skin with clean water.

Interview with Nurse Aide 2 on September 24, 2019, at 7:24 p.m. confirmed that the instructions on the bottle of body wash indicated that it was to be rinsed with clean water after using the product. She confirmed that Resident 3 was not rinsed after they washed him.

Interview with the Director of Nursing on September 24, 2019, at 8:00 p.m. confirmed that the McKesson Body Wash should have been rinsed off Residents 3's skin.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/7/19, 4/25/19, 3/14/19.


 Plan of Correction - To be completed: 11/12/2019

Immediate corrective action was taken for resident 3 to educate the staff with verbal que to repeat incontinence care on September 24, 2019.
In order to protect residents in similar situations re-education will be provided to all nurse aids, new nursing aids and agency aids on the proper use of McKesson Body Wash soap and the importance of rinsing the soap. In addition to education certified nurse aids will be audited randomly and return demonstration will be provided.
An audit will be created that certified nurse's aides will be evaluated on performing proper incontinence care to random residents. The audit will include the proper steps and include the rinsing of the soap properly as indicated.
The Director of Nursing or Designee will be responsible to monitor audits. This will ensure the transfers are handled according to plan of care. The flow sheet will be monitored daily for one week, twice weekly for 4 weeks and then weekly for 2 months.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of four residents reviewed (Resident 3).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated September 11, 2019, revealed that the resident was confused, required extensive assistance for care, and had diagnoses that included dementia (causes declines in the ability to think and remember). Physician's orders, dated August 2, 2019, included an order for the resident to receive 7.5 milligrams of Remeron (a medication used to treat depression or to increase appetite) every evening in an attempt to increase her appetite.

A care plan meeting note for Resident 3, dated August 20, 2019, at 10:14 a.m. revealed that Family Members 1 and 2 were present, discussed the resident's overall status with declines in cognition, frequent falls, communication, improvement in appetite but still poor, increase in behaviors, and hallucinations. The Remeron start date and dosage were discussed, and the family members expressed a concern that the resident may be having an adverse reaction to the medication. The family stated that the resident has some difficulty with medications, has reactions to them, and cannot take a lot of things. Family Members 1 and 2 requested that Remeron be discontinued to see if her behaviors improved.

A nursing note for Resident 3, dated August 20, 2019, at 4:04 p.m. indicated that the physician was aware of the family's request to discontinue Remeron, and physician's orders, dated August 20, 2019, included an order to discontinue Remeron.

However, Resident 3's Medication Administration Record for August 2019, revealed that staff continued to administer Remeron to the resident from August 20 to 30, 2019.

Interview with the Director of Nursing on September 24, 2019, at 6:30 p.m. confirmed that Resident 3's Remeron should have been stopped on August 20, 2019, as ordered by the physician.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/7/19, 3/14/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/7/19, 4/25/19, 3/14/19.




 Plan of Correction - To be completed: 11/12/2019

Resident 3 was noted to have attained unnecessary medications when reviewed. Immediate action was to review residents Medication Administration Record to ensure accuracy.
In order to protect residents in similar situations re-education will be provided to all current Registered Nurses, new registered nursing team members and agency registered nurses on the importance of transcribing physician orders and placing them in the Medication Administration Record and Treatment Administration Record . In addition to education a system will be created to check discontinued order entries as well as an audit for tracking.
An audit will be created that discontinued orders will be logged on to determine the efficiency of removing them from the Medication Administration Record and Treatment Administration Record . The audit will include the mediation or treatment and if it is removed from the Medication Administration Record or Treatment Administration Record to prevent further occurrences. In addition education was provided to identified Registered Nurse with noted transcription discrepancy.
The Director of Nursing or Designee will be responsible to monitor entries on the physician order audit. This will ensure the transfers are handled according to plan of care. The flow sheet will be monitored daily for one week, twice weekly for 4 weeks and then weekly for 2 months.

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 clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were performed during care for one of four residents reviewed (Resident 3).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated July 12, 2019, indicated that the resident was cognitively impaired and required extensive assistance for personal hygiene and bathing.

Observations on September 24, 2019, at 7:10 p.m. revealed that Nurse Aides 1 and 2 performed evening care for Resident 3 and washed the resident's perineum (the area around the genitals) then his buttocks while wearing the same gloves and with the same washcloth.

Interview with Nurse Aide 2 on September 24, 2019, at 7:24 p.m. confirmed that she should have changed her gloves after washing Resident 3's perineum and also confirmed that she should have used a clean washcloth to clean the resident's buttocks.

Interview with the Director of Nursing on September 24, 2019, at 8:00 p.m. confirmed that staff should have changed her gloves after cleaning Resident 3's perineum and should have used a new washcloth to clean his buttocks.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/7/19, 4/25/19, 3/14/19.



 Plan of Correction - To be completed: 11/12/2019

Immediate corrective action was taken for resident 3 to educate the staff with verbal que to repeat incontinence care on September 24, 2019.
In order to protect residents in similar situations re-education will be provided to all current nurse aids, agency nurse aids and new staff team member aids on the proper steps to complete incontinence care and proper supplies needed. In addition to education certified nurse aids will be audited randomly and return demonstration will be provided.
An audit will be created that certified nurse's aides will be evaluated on performing proper incontinence care to random residents. The audit will include the proper steps and when to change gloves and use different wash clothes.
The Director of Nursing or Designee will be responsible to monitor audits. This will ensure the transfers are handled according to plan of care. The flow sheet will be monitored daily for one week, twice weekly for 4 weeks and then weekly for 2 months


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