Nursing Investigation Results -

Pennsylvania Department of Health
GINO J. MERLI VETERANS CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GINO J. MERLI VETERANS CENTER
Inspection Results For:

There are  94 surveys for this facility. Please select a date to view the survey results.

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

Based on a Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on January 31, 2020, it was determined that the Gino J. Merli Veterans Center was not in compliance with the following requirements of 42 Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Licensure Regulations.



 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(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 a review of clinical records, information submitted by the facility and resident incident reports it was determined that the facility failed to provide timely and necessary assistance with activities of daily living as planned to prevent a fall with serious injury, a fractured hip, for one of five residents (Resident 151) sampled for falls.

Findings include:

A review of the clinical record revealed that Resident 151 was admitted to the facility on November 20, 2018. The resident had diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and a history of falling.

A review of the resident's care plan for ADL (activities of daily living) functioning and self-care deficit revealed an intervention dated November 20, 2018, indicating that the resident required the assistance of one staff member when dressing.

A review of a fall risk assessment dated November 17, 2019, revealed that the resident was assessed at a high risk for falling.

A review of an annual Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated November 20, 2019, revealed that the resident was moderately cognitively impaired and required one person staff assistance for activities of daily living, including dressing, personal hygiene and using the bathroom.

A planned intervention dated December 9, 2019, indicated that the resident required the assistance of one staff member when toileting (to include scheduled voiding, personal hygiene, adjusting clothing). Further review of the resident's care plan dated December 9, 2019, revealed that the resident was on a scheduled toileting program and was to be assisted to the bathroom 30 minutes prior to meals and up to an hour after meals, upon rising, during the night and when the resident requests.

A review of progress notes dated December 14, 2019, at 8:09 AM indicated that the resident was observed lying on the floor in her bathroom. The resident at that time stated she was trying to get dressed. Non-skid socks were in place. The resident was encouraged to use the call bell.

A review of a facility incident report dated December 14, 2019, at 8:08 AM revealed that Resident 151 was in the bathroom getting dressed and staff found her lying on the bathroom floor in her bedroom.

A witness statement dated December 14, 2019, revealed Employee 11, RN (registered nurse) entered the resident's room to administer her medications. The employee observed the resident lying on the floor in her bathroom. The call bell was not activated. The resident was assisted off the floor to her recliner.

A falls investigation form dated December 14, 2019, revealed Employee 12, nurse aide, did not witness the resident fall. Employee 12 stated that the nurse had informed Employee 12 that the resident was on the floor in the bathroom and that the resident fell when she was going to the bathroom.

A review of the resident's "Bowel and Bladder Detailed Entry Report" dated December 14, 2019, revealed that the last time the resident was toileted prior to the fall was at 1:45 AM.

A review of the resident's care plan revealed no new interventions were put in place after this fall to prevent falls and similar occurrences of the resident attempting to self-toilet and dress or evidence that the facility staff had toileted the resident upon rising as care planned on December 9, 2019.

A review of a nursing note dated December 15, 2019, at 10:31 AM revealed that a nurse entered Resident 151's room and observed her lying on the floor in her room at the bottom of her bed. The resident's nightgown was partially removed, feces were observed on her non-slip socks and on the bathroom floor.

Further review of nursing notes dated December 15, 2019, at 10:35 AM revealed that the resident was lying on the floor in her room. The resident was complaining of severe pain to the left hip and shoulder. The resident was transferred to the hospital for further evaluation.

A review of the incident report dated December 15, 2019, at 10:18 AM revealed that the nurse entered the resident's room to obtain her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). The resident was observed to be lying on the floor in her room. The resident stated that she slipped when coming back from her bathroom. The resident had fecal matter on her socks and fecal matter was observed on the resident's bathroom floor. The resident was in severe pain and was transferred to the hospital for evaluation.

A review of Employee 11, RN's witness statement dated December 15, 2019, revealed that the employee entered the resident's room and found her lying on her bedroom floor. Feces were observed on her socks and bathroom floor. The resident reported to the employee that she had discomfort in her left side and was transferred to the hospital.

A review of a falls investigation form completed by Employee 12, nurse aide, dated December 15, 2019, revealed that the employee returned to the floor (nursing unit) from her break and was informed that the resident was on the floor in her room and being sent to the hospital. The employee was asked if the resident was toileted within the past two hours. The employee did not answer the question, but stated that the resident was independent with toileting.

A review of a falls investigation form completed by Employee 13, nurse aide, dated December 15, 2019, revealed that the employee was also on break and when she returned to the nursing unit the employee was informed that the resident was on the floor in her room. The employee was asked if the resident was toileted within the past two hours. The employee did not answer the question, but also stated that the resident was independent with toileting.

A review of the resident's "Bowel and Bladder Detailed Entry Report" dated December 15, 2019, again revealed that the last time the resident was toileted prior to the fall was at 1:45 AM.

A review of an X-ray report dated December 15, 2019, at 11:49 AM revealed that Resident 151 had sustained a displaced left femoral neck fracture (one type of hip fracture, which occurs just below the ball of the ball-and-socket hip joint, the region of the thigh bone called the femoral neck) as a result of the fall.

An interview with Employee 11, RN, on January 31, 2020, at 9:00 AM revealed that the employee stated that the resident fell in her room coming back from the bathroom, but could not remember the exact details. The employee further stated the resident was independent with toileting herself.

An interview with Employee 12, nurse aide, on January 31, 2020, at 11:00 AM revealed that the resident stated that she could not remember the exact time, but sometime after breakfast the resident tried to take herself to the bathroom and fell. The employee stated the resident was independent when using the bathroom. The employee stated the Kardex (a medical information system used by nursing staff to communicate important information on their patients) is kept at the nursing station with the resident's plan of care, so staff is aware of the resident's functional status.

A review of the resident's Kardex that was in place at the time of the resident's fall on December 15, 2019, indicated that the resident required the assistance of one staff member when toileting and dressing.

The facility failed to implement the resident's care plan dated December 9, 2019, to assist the resident to the bathroom 30 minutes prior to meals and up to an hour after meals, upon rising, during the night and when the resident requests.

An interview with the director of nursing on January 31, 2019, at approximately 1:00 PM confirmed the facility failed to provide timely and necessary staff assistance to meet this resident's assessed and identified level of assistance with toileting to prevent a fall with serious injury.

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services
Previously cited 5/6/19, 12/7/18

























 Plan of Correction - To be completed: 03/23/2020

0689

1. Resident 151's care plan and orders have been reviewed/revised to assure interventions/orders are in place for timely and necessary assistance with ADLs to prevent falls with injury.
2. Resident care plans and orders will be reviewed/revised to assure interventions/orders are in place for timely and necessary assistance with ADLs to prevent falls with injury.
3. The preventative fall policy/procedure will be reviewed/revised to assure interventions/orders are put in place for timely and necessary assistance with ADLs to prevent falls with injury. The policy will be in-serviced to direct care staff.
4. QA/Designee will audit a random sample of 5 residents per week x 8 weeks to assure interventions/orders are in place for timely and necessary assistance with ADLs to prevent falls with injury. The results of the audit will be reviewed by the QA team.
5. March 23, 2020

483.70(e)(1)-(3) REQUIREMENT Facility Assessment:This is a less serious (but not lowest level) 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 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.
483.70(e) Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. The facility assessment must address or include:

483.70(e)(1) The facility's resident population, including, but not limited to,
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

483.70(e)(2) The facility's resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
Observations:

Based on staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to ensure the facility wide assessment identified the specific resources, which were necessary to care for its current resident population.

Findings include:

At the time of the survey ending January 31, 2020, the facility provided a facility assessment last updated January 28, 2020.

At the time of the survey ending January 31, 2020, the current population of 185 residents at the facility included 97 residents with dementia, 30 residents with behavioral healthcare needs, 30 residents requiring the use of a Wanderguard system, including two displaying intrusive wandering behaviors and two bariatric residents requiring special equipment for transfers, locomotion and showers.

The facility's assessment dated January 28, 2020, did not identify the specific and unique needs of its current resident population and the available and accessible resources to meet these needs on a daily basis and during emergent situations.

The facility assessment presented to the survey team did not include comprehensive data and corresponding resources necessary in order to competently and safely care for the current residents in the facility for bariatric residents and residents with intrusive wandering behaviors.



28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 5/6/19, 12/7/18

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 5/6/19, 12/7/18
























 Plan of Correction - To be completed: 03/20/2020

0838
1. The facility assessment tool has been updated to identify the specific and unique needs of its current resident population (residents on wander guard, residents displaying intrusive wandering behavior and bariatric) and the availability and accessible resources to meet these needs on a daily basis and during emergent situations.
2. Regulation regarding the Facility wide assessment has been reviewed by management to assure the facility assessment tool reflects specific and unique needs of our current resident population and the availability and accessible resources to meet these needs on a daily basis and during emergent situations.
3. QA/designee will review the facility assessment tool weekly X 8 with the management team to assure the facility assessment tool reflects specific and unique needs of our current resident population and the availability and accessible resources to meet these needs on a daily basis and during emergent situations. The assessment tool will then be audited quarterly and PRN.
4. March 23, 2020

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and staff interview, it was determined the facility failed to ensure that a written notice of transfer to the hospital was provided to the resident and the residents' representative, which included the name, address and email address for the entity with whom to file an appeal, the time frame to appeal and necessary documentation to file an appeal and the name of the State Long Term Care Ombudsman for four of five residents reviewed (Residents 159, 130, 86, 151).


Findings include:

A review of the clinical record of Resident 159 revealed that the resident was transferred and admitted to the hospital on November 13, 2019, and was readmitted to the facility on November 22, 2019. The resident was again transferred and admitted to the hospital on November 29, 2019, and was readmitted to the facility on December 10, 2019.

Resident 130 was transferred from the facility to the hospital on December 25, 2019, at 1:58 p.m. after a fall on December 24, 2019. The resident was readmitted to the facility on December 25, 2019, at 8:18 p.m.

Resident 151 was transferred to the hospital on December 15, 2019, after a fall. The resident was readmitted to the facility on December 19, 2019.

Resident 86 was transferred from the facility on November 4, 2019 and admitted to the hospital. The resident was readmitted to the facility on November 12, 2019.

A review of the transfer notices provided to these residents and their representatives revealed that the notices failed to include name, address and email address for the entity with whom to file an appeal, the time frame to appeal and necessary documentation to file an appeal and the correct name of the State Long Term Care Ombudsman




483.15(c)(3)-(6)(8) Notice Requirements Before Transfer/Discharge
Previously cited 12/7/18.

28 Pa. Code 201.29(h) Resident rights
Previously cited 12/7/18, 5/6/19.

28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 12/7/18, 5/6/19.


















 Plan of Correction - To be completed: 03/23/2020

0623

1. A corrected written notice of transfer letter to hospital was provided to residents and representatives which include name, address and email address for the entity with whom to file an appeal, the time frame to appeal and necessary documentation to file an appeal and the name of the state long term care ombudsman for residents 159, 130, 151 and 86.
2. The corrected written notice of transfer letter to the hospital will be sent to residents and resident representatives for those transferred to the hospital. The letter will include the time frame to file an appeal, necessary documentation to file the appeal and the name of the state long term care ombudsman.
3. The letter for transfer of a resident to hospital was reviewed/revised to include the time frame to file the appeal and necessary documentation to file the appeal and the name of the state long term care ombudsman. The social service department will be educated on the new letter and the regulation (483.15(c)(3) regarding the requirements of the letter.
4. QA/Designee will audit the transfer letters to assure they include the time frame to file the appeal, necessary documentation to file the appeal and the name of the state long term care ombudsman. The audit will be conducted weekly x 8 weeks then monthly on a random sample of 3 Residents, the results of the audit will be reviewed by the QA team.
5. March 23, 2020


483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
483.95(g) Required in-service training for nurse aides.
In-service training must-

483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

483.95(g)(2) Include dementia management training and resident abuse prevention training.

483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at 483.70(e) and may address the special needs of residents as determined by the facility staff.

483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:

Based on review of the facility's staff education records and interviews with staff, it was determined the facility failed to conduct at least 12 hours of in-service education for nurse aides based on the outcome of their annual individual performance reviews.

Findings include:

Review of employee education records for Employee's 5, 6, 7, 8, and 9 based on hire date, revealed there was no documented evidence that each nurse aide received 12 hours of in-service education based on their individual performance reviews to address areas of weakness and the facility assessment to address special needs of residents.

An interview with the Assistant Director of Nursing on January 31, 2020, at 10:30 a.m. could not provide any documented evidence of the required 12 hours of inservice education for nurse aides employed by the facility.



28 Pa. Code 201.20(a)(c) Staff development.





 Plan of Correction - To be completed: 03/23/2020

0947
1. The automated tracking system for in-service education will be adjusted to pull records by hire date for staff, including nurse aides.
2. Performance reviews will reflect re-education and counseling received by staff, including nurse aides in the past year since their last employee performance review (EPR).
3. Policy/procedures for annual in-serving will be reviewed/revised to assure nurse aides receive one on one re-education or in-service training based on their annual performance review and clinical observation of their performance.
4. QA/designee will audit 3 random nurse aide personnel records each month to assure they received at least 12 hours of mandatory in-service training from hire date to anniversary date, and that the employee training record includes any re-education or one on one training that was necessary to improve performance.
5. March 23, 2020

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on a review of clinical records, observations and staff interviews it was determined that the facility failed to develop and implement person-centered plans to address dementia-related behavioral symptoms displayed by two residents out of 35 sampled (Residents 139 and 187).

Findings included:

A review of the clinical record revealed that Resident 139 had diagnoses, which included dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning).

An annual Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated, December 16, 2019, indicated that the resident was severely cognitively impaired with a BIMS (brief interview for mental status, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired) score of 3 and required staff assistance for transfers, ambulation and locomotion.

Review of information dated May 25, 2019, at 7:35 PM submitted by the facility revealed that when Resident 163, a severely cognitively impaired resident, attempted to redirect Resident 139 out of his room by pushing Resident 139's wheelchair, his hand slipped and hit Resident 139 in the back of the neck. Resident 139 responded by standing from his wheelchair and punching Resident 163 in the face. Resident 163 could not recall where on his face he was punched, but recalled that he knew he was hit somewhere.

Review of the facility incident report dated May 25, 2019, indicated that Resident 163 was placed on every 30 minute checks. The report noted that Resident 139 frequently goes into other residents' rooms, does not know where he is and other residents become upset. The behavior was noted to occur daily and significantly intrudes on the privacy or activities of others. The intervention was to place Resident 139 on 1:1 observation (staff member present with resident).

Review of a nurses note dated May 29, 2019, at 12:19 PM revealed that Resident 139 was changed from 1:1 observation to every one hour observation/documentation (staff visually checks on and documents the resident was observed).

Review of the resident's current care plan initially dated June 5, 2019, and last revised December 26, 2019, indicated that Resident 139 has behavioral symptoms and can wander into other resident's rooms and engage in verbal arguments with these residents. The goal was that the resident refrain from wandering into other residents' rooms. The approach included providing redirection to a safe location, separate if found confronting peer, and when possible provide gentle redirection before the resident has an opportunity to enter another resident's room.

Observation on January 28, 2020, at approximately 9:30 AM on the 3 South nursing unit revealed mesh stop signs were attached with velcro to the door frames of resident rooms 302, 306, 314, and 316.

Interview with Resident 23, a cognitively intact resident residing in one of those rooms, on January 29, 2020, at 12:40 PM revealed that the stop sign was placed across the door frame to deter residents from entering his room uninvited. Resident 23 stated that Resident 139 frequently wanders into his room (up to three times per week) at different times of the day despite the placement of the stop sign. Resident 23 stated that Resident 139 uses a wheelchair and goes right under the stop sign. Resident 23 stated that staff are aware of Resident 139's intrusive wandering.

Interview with Employee 10 (registered nurse) on January 31, 2020, at 8:45 AM revealed that staff are aware Resident 139 wanders including into other residents' rooms. Employee 10 stated that staff will redirect the resident when the resident is observed attempting to enter other residents' rooms.

Interview with Resident 45, a cognitively intact resident, on January 31, 2020, at 10:00 AM revealed that the a stop sign was placed across the door frame to this resident's room to deter residents from entering his room uninvited. Resident 45 stated that Resident 139 enters his room uninvited. Resident 45 relayed that Resident 139 has at times cursed at him. Resident 45 further stated that he alerts staff of Resident 139's presence in his room by ringing the call bell, but are not always quick to respond, which allows Resident 139 time to use the bathroom located in Resident 45's room.

Review of the Resident 139's Behavior/Intervention Monthly Flow Record revealed episodes of wandering into other residents' rooms were documented as follows: January 4, 2020, (5 episodes), January 5, 2020, (4 episodes), January 14, 2020, (3 episodes), January 18, 2020, (3 episodes), January 19, 2020, (4 episodes), and January 27, 2020, (3 episodes). Interventions included redirection, activity, return to room, toilet, give food, give fluids, change position, and offer back rub. Interventions planned for use in response to the resident's behavior included redirecting the resident, offer food (specific food preferences not specified), and bring the resident back to his room. These interventions attempted in response to the behaviors were noted as ineffective. The additional listed intervention of 1:1 supervision was not attempted according to the flow records.

Observations throughout the days of the survey from January 28, 2020, through January 31, 2020, revealed that Resident 139 independently propels in a wheelchair throughout the 3 South nursing unit.

Interview with the Director of Nursing (DON) on January 31, 2020, at approximately 1:00 PM failed to provide documented evidence the facility had developed and implemented individualized person-center interventions to deter Resident 139's intrusive wandering.

A review of the clinical record revealed that Resident 187 was admitted to the facility on September 30, 2019, had diagnoses, which included dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning) with behavior disturbance.

Nursing documentation dated September 30, 2019, at 9:57 p.m. indicated that the resident was wandering into other resident rooms and became agitated when redirected. He continued to self-ambulate on October 2, 2019, and attempted to enter other resident rooms. The resident was being observed by staff every 30 minutes for safety checks, which were implemented on that date. The resident continued to wander in other resident rooms, taking food off other resident meal trays, then becoming agitated when redirected.

On October 3, 2019, at 9:07 PM progress notes indicated that the resident stood up from his wheelchair, flipped it over, and stated he was working on his bike. He then attempted to throw the wheelchair at the staff.

On October 4, 2019, the resident's dose of the Risperdal (antipsychotic) was increased to 0.5 mg three times a day and the resident was placed on every one hour visual checks by staff.

The resident continued to self-rise from his wheelchair according to documentation dated October 5, 2019, and continued to be resistive with redirection.

On October 6, 2019, it was noted that the resident was physically aggressive towards staff and placed his hands around a nurse aide's neck. He was then placed on 1 to 1 observation, which was reduced to every one hour observation on October 7, 2019.

An admission Minimum Data Set Assessment dated October 7, 2019, indicated that the resident was severely cognitively impaired with a BIMS score of 4 and required staff assistance for transfers. The resident required limited assistance of one person for locomotion on the unit with the assistance of a wheelchair.

On October 7, 2019, the resident was transferred to the hospital and evaluated by psychiatry due to his aggressive behaviors. He returned to the facility on the same day and was placed on every one hour visualization.

This close observation was discontinued on October 8, 2019, and reduced to every shift visualization.

The resident's aggressive behaviors continued on October 9, 2019, when he was noted to be hitting and cursing at staff.

Review of information dated October 11, 2019, submitted by the facility revealed this resident, Resident 187 entered a cognitively impaired resident's room, Resident 71 grabbed her by the right wrist and dragged her out of bed, pushing her up against the bedroom wall.

Nursing documentation dated October 11, 2019, at 8;25 p.m. indicated that Resident 187 grabbed Resident 71 by the right wrist and dragged her out of bed, pushing her up against the bedroom wall. Resident 71 was yelling "help me" and Resident 187 stated "she is crazy." Resident 187 was placed on 1:1 observation and the physician ordered that resident to be transferred out of the facility for evaluation.

The resident was sent to the hospital for evaluation from the facility on October 11, 2019 at 9:16 p.m. after he had pulled Resident 71 out of her bed

The resident returned to the facility on October 14, 2019, and was placed on 1:1 close observation and utilized a Wanderguard.

The resident's behavior record revealed that he had continued aggressive behaviors and remained on 1:1 observation until October 21, 2019, when observation was reduced to every hour observation,

On October 25, 2019, documentation indicated that staff observed the resident enter another resident's room. The resident was redirected and placed back on 1:1 observation, which was subsequently reduced to hourly observation until the resident was transferred to another faciity and admitted to their dementia unit on November 5, 2019.


The facility failed to demonstrate the development and implementation of person-centered, individualized plans designed to address, manage and/or mitigate the residents' dementia-related behavioral symptoms.

The care plans and behavioral interventions developed by the facility in response to the residents; behavioral symptoms, included reactionary and generalized tasks and approaches, without including the residents' specific preferences and individualized diversional activities based on past habits, personal history and/or daily routines.


28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services

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



 Plan of Correction - To be completed: 03/23/2020

0744
1. The interdisciplinary team met and reviewed/revised/implemented person-centered plans to address aggressive and intrusive dementia related behavioral symptoms for Residents 139. Resident 187 has been discharged from GMVC.
2. Residents experiencing aggressive and intrusive dementia related behavioral symptoms will have their care plans reviewed to assure they have a person-centered plan in place for their behaviors.
3. Facility has reviewed/revised the policy/procedure for behavior intervention protocol. Policy/procedure will reflect that the facility provide appropriate care plans/interventions for dementia related behaviors. Policy/procedure for behavior intervention protocol has been in-serviced to facility staff.
4. QA/designee will audit 5 random samples of residents with dementia to assure there are person-centered plans in place to address behavioral symptoms. The audit will take place for 8 weeks then quarterly thereafter. The results will be reviewed by the QA team.
5. March 23, 2020

483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:

Based on a review of employee personnel files and the facility's abuse prohibition policy and procedures and staff interviews, it was determined that the facility failed to implement procedures to fully screen three employees out of five review to ensure that they were eligible for employment in a long term care nursing facility (Employees 2, 3, 4).

Findings include:

A review of the facility's policy "Freedom from Abuse, Neglect, Exploitation, and Misappropriation of Resident Property" last reviewed by the facility on October 15, 2019 revealed that under the area of screening, the facility will:
1. Complete thorough investigations of the histories of individuals they are considering hiring.
2. Inquiry of the state nurse aide registry and /or other licensing authorities.
3. Check information from previous and/or current employers, whether favorable or unfavorable, and make reasonable efforts to uncover information about any past criminal prosecutions.

Review of the personnel files of newly hired employees since the last standard survey December 7, 2018, revealed that Employee 2 (LPN) was hired November 18, 2019. The employee's application for employment indicated that she had four previous employers. There was no indication that the facility contacted any of the previous employers to fully screen the individual to ensure the individual was eligible for employment in a long term care nursing facility.

Employee 3, nurse aide, was hired November 18, 2019 . The employee's application for employment indicated that he had four previous employers. There was no indication that the facility contacted any of the previous employers.

Employee 4, nurse aide, was hired January 13, 2020. The employee's application for employment indicated that she had two previous employers. There was no indication that the facility contacted any of the previous employers.

Interview with the Human Resources Director on January 31, 2020 at 11:15 a.m., confirmed that the employees' previous employers were not contacted according to facility procedures for screening employees.



28 Pa Code 201.18 (e)(1) Management
Previously cited 12/7/18, 5/6/19.

28 Pa. Code 201.29(a)(c) Resident rights
Previously cited 12/7/18, 5/6/19.






 Plan of Correction - To be completed: 03/23/2020

0607
1. GMVC has contacted previous employers for employees 2, 3 and 4 to assure they are fully screened and are eligible for employment in a long-term care facility.
2. Pre-employment screening will include screening for employees that will assure they are eligible for employment in a lon- term care facility
3. Facility policy was revised to include measures to contact previous employers to fully screen the individuals to be eligible for employment in a long-term care facility.
4. QA/Designee will audit new hires to verify previous employers were contacted to assure individuals are eligible for hire in a long-term care facility. The audit will be conducted weekly x 8 weeks and quarterly thereafter, the results of the audit will be reviewed by the QA team.
5. March 23, 2020

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 a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 35 sampled (Resident 82).

Findings include:

According to the RAI User's Manual, Section A 1500 Preadmission Screening and Resident Review (PASRR) is to be completed if the type of assessment is an admission assessment, significant change or annual assessment.

An annual MDS Assessment of Resident 82 dated February 20, 2019, revealed Section A 1500 was coded as "0" indicating that the resident was not considered by the State to require a Level II PASRR process, to have serious mental illness, and/or intellectual disability or mental retardation or a related condition.

However, a review of Resident 82's clinical record revealed a Level I PASRR was completed on February 21, 2017, which indicated that the resident met the criteria for a Level II PASRR, that was completed June 2, 2017.

Interview with the RNAC (registered nurse assessment coordinator) on January 30, 2020, at 11:30 a.m. confirmed that the resident's annual MDS Assessment dated February 20, 2019, was inaccurate, with respect to completion of Section A 1500 related to the PASRR.


28 Pa. Code 211.5(g)(h) Clinical records
Previously cited 5/6/19

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 5/6/19, 12/7/18
















 Plan of Correction - To be completed: 03/23/2020

0641
1. A corrected MDS was submitted that accurately reflects the status of Resident 82s section A with the correct PASRR level.
2. Residents with level 2 PASRR MDSs were checked and if needed corrected to reflect the corrected PASRR level.
3. Section A of the MDS and the corresponding section of the RAI manual was reviewed with the Registered Nurse Assessment Coordinators to assure they understand the coding of the correct PASRR level.
4. QA/Designee will audit 5 random MDS per week x 8 weeks to assure the correct level from the PASRR is coded in section A of the MDS. The results of the audit will be reviewed by the QA team.
5. March 23, 2020

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on a review of clinical records and staff and interviews it was determined that the facility failed to consistently provide care and services, consistent with professional standards of practice, to prevent pressure sore development for one of three residents sampled with pressure sores (Resident 86).

Findings include:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk.

ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of the clinical record revealed that Resident 86 was readmitted to the facility on August 1, 2019, with diagnoses to include Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), Type II diabetes (disease that occurs when your blood sugar is too high) and overactive bladder.

A review of a quarterly Minimum Data Set assessment dated November 18, 2019 (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was severely cognitively impaired, required total dependence with the assistance of two people with bed mobility (how the resident moves about in bed) and transferring (how the resident moves between the bed and the chair), and was at risk for developing pressure areas.

A review of the resident's readmission skin check dated August 1, 2019, revealed that the resident had a reddened area on his coccyx (area at the base of the spinal column) measuring 11 cm (centimeters) x 7 cm.

A review of the resident's readmission Braden scale for predicting pressure sores dated August 1, 2019, revealed that the resident was at moderate risk for developing a pressure sore.

A review of wound management tracking dated August 5, 2019, at 3:04 PM revealed that the area on the resident's bottom was assessed and measured 4 cm x 4 cm. The facility further documented the area as a DTI (deep tissue injury) that was present upon admission.

Preventative measures put in place on admission to promote healing and prevent further pressure sores included the following: Dermagran ointment apply to the sacrum (area on lower back between the 2 hip bones), coccyx, and buttocks every shift for prevention; an air mattress to the resident's bed and check placement every shift; skin prep and Allevyn to the sacrum every 2 days and as needed and a Roho cushion to his scoot chair.

A review of a wound assessment note dated August 22, 2019, at 1:17 PM revealed that the resident was assessed on wound rounds on August 21, 2019. The resident's DTI to the sacrum was fully healed. Recommendations were made to continue house moisturizer cream and repositioning as per facility policy. Dermagran ointment, Skin Prep and Allevyn were discontinued on August 22, 2019.

A review of nursing documentation dated August 29, 2019, at 12:35 PM revealed that the resident was complaining to staff that his bottom hurt. It was noted at 12:59 PM on August 29, 2019, that the resident had a Stage III pressure sore (localized areas of tissue necrosis that typically develop when soft tissue is compressed between a bony prominence and an external surface for a long period of time. Stage 3 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer) measuring 0.5 cm x 0.5 cm x 0.1 cm.

There was no documented evidence at the time of survey ending January 31, 2020, that the recommendations to continue the use of house barrier cream and repositioning were implemented to prevent the resident from redeveloping pressure ulcers.

An interview with the DON on January 31, 2019 at approximately 1:00 PM confirmed that the facility was unable to demonstrate the consistent implementation of measures recommended at the time the resident's sacral DTI healed, August 21, 2019, consistent with professional standards of practice, to prevent the redevelopment of pressure ulcers for a resident at risk for skin breakdown.



28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 12/7/18, 5/6/19

28 Pa. Code 211.5(f) Clinical records.
Previously cited 5/6/19










 Plan of Correction - To be completed: 03/23/2020

0686

1. Resident 86 care plan has been reviewed/revised so a professional standard of practice is in place to prevent pressure sore development.
2. Resident care plans will be reviewed/revised so professional standards of practice are in place to prevent pressure sore development.
3. Wound policy/protocol has been reviewed/revised to assure professional standards of practice are in place to prevent pressure sore development. Direct care staff will be in-serviced on the protocol. RN supervisors and charge nurses will round daily on their unit to see that standards of care are in place for those with wounds.
4. QA/Designee will audit 5 random residents per week x 8 weeks to assure measures are in place and care planned to prevent pressure sores. The results of the audit will be reviewed by the QA team.
5. March 23, 2020

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive 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 clinical records, observations and interviews with staff it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one out of two sampled residents receiving hemodialysis (Resident 167).

Findings include:

A review of the clinical record revealed that Resident 167 was admitted to the facility on June 24, 2019, with a diagnosis of end stage kidney disease and dependence on kidney dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). The resident had a right tunnel chest catheter (surgical connection involving the placement of a thin tube under the skin in a vein in the chest allowing access to the bloodstream) for dialysis access on Tuesdays, Thursdays and Saturdays.

A review of Resident 167's current physician's orders dated June 24, 2019, and care plan initiated on June 25, 2019, revealed an order and safety intervention respectively, for an "Blue clamp with pressure dressing behind head of bed frame and on wheelchair."

According to the National Kidney Foundation patients receiving hemodialysis should keep emergency care supplies on hand.

Observations on January 28, 2020, at 2:50 a.m., January 29, 2020, at 9:27 a.m., January 30, 2020, at 2:05 p.m. and on January 31, 2020, at 8:09 a.m. revealed there was no emergency equipment located in the resident's room or on his wheel chair.

During an interview with Employee 1 (LPN-Licensed Practical Nurse) on January 31, 2019, at approximately 8:25 a.m., Employee 1 confirmed that there was no emergency equipment located either in the resident's room, specifically on the head board of the resident's bed, or on his wheel chair.


28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services.
Previously cited: 5/6/19, 12/7/18























 Plan of Correction - To be completed: 03/23/2020

0698
1. The emergency supply for Resident 167's hemodialysis has been put in place according to physician orders. Care plan has been reviewed and updated.
2. Orders/Care plans for residents receiving hemodialysis have been reviewed to assure that supplies are in place as ordered.
3. Policy/procedure on hemodialysis will be reviewed/ revised to assure proper supplies that are ordered are available and in place. Charge nurses will round on their units to see that emergency equipment is at the bedside for residents requiring such equipment. The policy will be in-serviced to direct care staff.
4. QA/Designee will audit residents on hemodialysis weekly X 8 then quarterly to assure orders/care plans are followed and proper supplies are in place. The audit will be reviewed by the QA team.
5. March 23, 2020


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