Nursing Investigation Results -

Pennsylvania Department of Health
HOMETOWN NSG & REHAB CTR
Patient Care Inspection Results

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HOMETOWN NSG & REHAB CTR
Inspection Results For:

There are  135 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.
HOMETOWN NSG & REHAB CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on October 22, 2021, it was determined that Hometown Nursing & Rehab Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


483.25(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 review of clinical records, information submitted by the facility and select incident reports, observations and resident and staff interviews it was determined that the facility failed to provide necessary staff assistance and supervision at meals, consistently follow physician orders for positioning and utilize the most effective safety device during transfer to prevent accidents, including falls with injuries for two residents, a fractured rib for one resident and a fractured arm for one resident, and burns sustained by one resident out of 20 sampled residents (Resident 49, 5, 140).

Findings include:

A review of resident 49' s clinical record revealed admission to May 7, 2021, with diagnoses to include a left leg amputation (missing limb) above the knee.

A review of a significant change MDS Assessment (Minimum Date Set Assessment is a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated May 19, 2021, indicated the resident required the assistance of two staff for all activities of daily living. The resident required extensive assistance of two staff members for bed mobility, transfers dressing, toilet use, personal hygiene and bathing.

A review of an Occupational Therapy (OT) note dated August 17, 2021, revealed that OT received a screen from nursing regarding the resident's out of bed positioning in her current 22 inch wheelchair. The screen indicating that the resident was sleeping frequently in the chair with head hyperextended and resident sliding from the chair, requiring staff to boost her frequently. OT provided the resident with a tilt-n-space wheelchair with extra thick cushion. The positioning devices to be in upright position for all meals, tilt all other times The note also indicates that OT provided education and training to several NA's LPN's and RN's on first shift. Staff demonstration with verbal understanding.

A physician order dated August 17, 2021, was noted for an out of bed tilt-n-space wheelchair with lateral supports along the leg and right hips, a foot buddy (a cushion that controls flexion contracture of the legs) on elevated legs rests and small pillow behind the resident's head. The chair was to be positioned upright for all meals only and at a tilt at all other times.

An incident/accident report dated October 2, 2021 at 9:15 AM, revealed that the resident had an unwitnessed fall in her room while seated in the tilt-n-space wheelchair. A nickel size ecchymotic (bruised) hematoma (a collection of blood outside of blood vessels. Most commonly, hematomas are caused by an injury) was noted to the left temporal region (the are of the head just behind the temples) with moderate amount of bleeding. The resident was sent to the hospital for evaluation and treatment. X-ray results dated October 2, 2021, revealed a non-displaced fracture to the left posterior lateral third rib.

A review of a written statement provided by Employee 3 (nurse aide) regarding the resident's fall indicated that she heard a loud bang and heard a yell for help. Resident 49 was found on the floor, face down and she appeared to be bleeding from her forehead.

A review of a written statement by Employee 4 (nurse aide) stated that prior to the resident's fall she had transported resident from the dining room back to her room. Employee 4 indicated that she was unaware of the resident's specific care needs and that she was not assigned to the resident that day.

A physician order was noted October 2, 2021, for Norco (combination of acetaminophen and hydrocodone. Hydrocodone is an opioid pain medication) tablet 5-325 mg one every 6 hours as needed for left rib pain. A review of the resident's October 2021, Medication Administration Record (MAR) revealed that the resident was medicated with Norco medication 21 times from October 2, 2021, through October 16, 2021.

The resident also had a physician order current for October 2021, for Ultram (Tramadol, a pain medicine similar to an opioid) 50 mg 1 every 12 hours for pain. A review of the October 2021 MAR revealed that the resident received Ultram eight times from October 2, 2021, through October 16, 2021. Eight doses of those doses of Ultram administered during October 2021 wer administered on the same days that the resident also received Norco for management of left rib pain.

During an interview with the Nursing Home Administrator (NHA) on October 21, 2021, at 10:55 AM, the NHA stated the nurse aide who had returned the resident to her room from the dining room after breakfast, was not aware that the resident's chair needed to be adjusted into a tilt position after meals. The NHA stated that at the time of the survey ending October 22, 2021, only Resident 49 was using a tilt-n-space chair in the facility.

A review of the clinical record revealed that Resident 5 was admitted to the facility on January 4, 2019, with diagnoses to include CVA (stroke) with left hemiplegia (is the paralysis of limbs on the left side of the body), dysphagia (difficulty swallowing), morbid obesity, and muscle weakness with difficulty walking.

A review of a significant change Minimum Data Set Assessment dated October 13, 2021, revealed that Resident 5 was cognitively intact and required extensive assistance of two plus persons physical assist for toileting, dressing, and bed mobility. The resident was totally dependent for transfers with two plus persons assistance and not steady during surface-to-surface transfers.

The resident's plan of care, October 2, 2020, indicated that Resident 5 had ADL (activities of daily living) deficits related to impaired balance related to CVA with hemiparesis and required the use of a mechanical lift with the assistance of two persons for transfers.

A review of information submitted by the facility dated October 2, 2021, at 9:15 AM, revealed that Resident 5 had a fall during transfer with a mechanical lift. According to the nurse aides, while transferring Resident 5 utilizing a split-sling lift pad, the resident slipped out of the sling and fell to the floor. The resident was lying supine (means lying horizontally with the face and torso facing up) next to door side of bed. The nurse aides reported that they "gently broke" the fall and the resident did not hit her head. The facility noted that the mechanical lift was assessed and was working properly and the split-sling lift pad was assessed with no abnormalities noted. However, the facility identified that the lift pad used was observed to be the inappropriate size.

After the fall, the Resident 5 had complaints of breakthrough left shoulder pain and the physician ordered x-rays of the left shoulder, left clavicle (or collarbone), and left scapula (shoulder blade or wing bone).

Review of x-ray results dated October 2, 2021, at 2:31 PM, revealed that Resident 5 sustained an acute displaced fracture of the left humeral neck (the humerus is a long bone in the arm that runs from the shoulder to the elbow and the humeral neck is the ball-like head of the humerus). Resident 5 was sent to the hospital to be evaluated.

Review of hospital records dated October 2, 2021, indicated that Resident 5 sustained a 3-foot fall out of the Hoyer lift and was diagnosed with a comminuted left proximal humeral fracture (is a fracture where the bones are broken in several fragments and are not aligned that can be caused by trauma). Post fall with fracture that occurred October 2, 2021, Resident 5 had complained of severe pain at levels of 10 (on a scale of 1-10, with 10 being the most severe) for 10 days after the fall.

An "Employee Witness Statement" received from the nurse aides providing care to the resident on October 2, 2021, revealed that Employee 1, a nurse aide, stated that on October 2, 2021, they (nurse aides - Employee 1 and Employee 2) were getting Resident 5 out of bed and found a blue trimmed lift pad on the resident's chair and placed it under her. Employee 1's statement indicated that while the resident was sitting in the Hoyer lift [is an assistive medical device that is a portable patient floor lift which typically uses electric, hydraulic, or battery power, and specialized sling-style pads that slide under the user's body to securely and comfortably transfer an individual requiring 90% - 100% assistance to move from a bed to a wheelchair, toilet, or chair] the resident was leaning to the left side, and the resident started to slide out of the sling. Employee 1 indicated that they (nurse aides) tried to stop her from falling and broke her fall.

The "Employee Witness Statement" received from Employee 2, nurse aide, dated October 2, 2021, at 9:15 AM, indicated that she assisted Employee 1 with the getting Resident 5 out of bed with the Hoyer lift. Employee 2 indicated that while transferring the resident, the Resident 5 slipped out of the sling and they gently broke her fall and lowered her to the ground. Employee 2 noted that the Hoyer was set up correctly and all the proper precautions were taken.

Interview with Resident 5 on October 21, 2021, at 9:30 AM, indicated that while she was being lifted in the Hoyer lift, the nurse aides (Employee 1 and Employee 2) were lifting her up and at the same time began to move the lift over to her chair. During the transfer, Resident 5 stated that they (nurse aides) performed the transfer quickly and the resident stated that she told the nurse aides that she was sliding from the pad. Resident 5 stated "the next thing I knew, I was on the floor." The resident stated when the nurse aides realized that she was falling, they attempted to break her fall and protected her head. Resident 5 stated that since the fall she doesn't want to get out of bed (OOB) because she is afraid of the Hoyer lift. The resident also stated that her left arm hurts. She stated that she had limited function to her left side due to a previous stroke, but after her fall has to keep her left arm in a sling to keep the fracture in place.

Interview with Employee 1 on October 21, 2021, at 1:35 PM, revealed that she operated the Hoyer lift and during Resident 5's transfer and fall. Employee 1 stated that she heard the sling clip "snap" and then noticed that the resident was leaning. Employee 1 reported that she heard the resident say that she was "slipping" and that the resident slid from the sling onto the floor. The employee stated that the transfer happened quickly. Employee 1 also stated that if they (nurse aides) kept the resident over her bed until fully elevated, instead of moving the Hoyer while the lift was still elevating he resident, the resident may have landed on her bed instead of on the hard floor when she fell.

Interview with Employee 2 on October 21, 2021 at 1:25 PM, revealed she had never been assigned to Resident 5 prior to that date and was just assisting Employee 1 with the transfer and was not actually operating the lift. Employee 2 stated that the blue sling lift pad was already in place when she arrived to assist, but she was sure that it was the correct lift pad because the trim was blue.

Interview with the director of nursing (DON) on October 21, 2021, at 10:30 AM, during observation of the Hoyer lift pad used in Resident 5's transfer revealed that the DON stated that the blue trimmed Hoyer lift pad used at time of the incident was an older Hoyer lift pad, but was considered the correct pad to use based on the resident's weight. However, the DON stated that the newer blue trimmed lift pads came with a newer lift purchased by the facility. The DON compared the differences between the new blue trimmed Hoyer lift pad and the older blue trimmed Hoyer pad. She stated that both were considered safe for bariatric residents, although the new blue trimmed Hoyer pads are larger and have safety locks on the clips that get attached to the lift. The older blue trimmed Hoyer pad was observed and appeared to be smaller in size and did not have a safety clip to prevent it from slipping out of place when compared with the new lift pads. Additionally, the DON reported that the NAs that were involved in the incident, saw that the Hoyer pad that was on the resident's chair was trimmed in blue and used it because it was the appropriately color coded pad per the manufacturer's recommendations for use.

During interview on October 22, 2021, at 11:45 AM, the DON stated that the old blue trimmed Hoyer lift pad should have been taken out of use when the new lift pads were obtained because the new pads were larger size and had the enhanced safety feature on the sling clip.

The facility failed to ensure that the safest equipment was used, which resulted in Resident 5 fall with fracture and pain.

A review of the clinical record of Resident 140 revealed admission to the facility on September 28, 2021, with diagnoses which include unspecified dementia without behaviors, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) of his non dominant, left side, dysphagia (difficulty swallowing) and diabetes mellitus.

A review of an admission MDS assessment dated October 5, 2021, indicated the resident was severely cognitively impaired with a BIMS of 3 (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 00-07 equates to severe cognitive impairment). The resident required extensive assistance with two persons for bed mobility, transfers, and dressing and extensive assistance of one person for feeding.

A review of facility report dated October 18, 2021 at 11:52 AM indicated that the resident was in the dining room awaiting to be assisted with lunch when he spilled thickened coffee on himself and sustained minor burns to his right forearm (reddened ares measuring 28 cm x 10 cm) and abdomen (15 cm x 10 cm).

A statement written by Employee 6, a nurse aide, indicated that she placed the resident's lunch meal tray in front of the resident and "out of his reach." She stated she then continued to serve other residents their lunch trays.

A statement from Employee 7, a nurse aide, revealed that after finishing passing trays to all residents in the dining room she noticed that Resident 140 was not being assisted with feeding by anyone. She stated when she approached him to assist him with his lunch, she noticed he had thickened coffee spilled on him. She stated she asked him if he got burned and he stated "yes."

Nursing documentation dated October 18, 2021, at 12:14 PM by Employee 8, RN (Registered Nurse) indicated that the Charge Nurse/LPN requested that she come to west wing to the resident's room to assess Resident 140's skin. Employee 8 stated Resident 140's right forearm had areas of reddened skin, 28 cm by 10 cm red area, and the right side of his abdomen had a 15 cm by 10 cm area.

Documentation dated October 19, 2021 at 4:15 PM, indicated the resident's son stated his father did not usually drink coffee or teas and the resident's son would prefer the facility not to serve him hot beverages.

An observation of the resident's burns on October 21, 2021 at 8:45 AM revealed multiple red areas on the resident's right abdomen. The resident's skin was intact with no blisters. Observation of his right anterior forearm revealed a large reddened area with Silvadene cream present over an area which appeared to be a blister that had opened/healing. The resident's right antecubital area also had healing reddened areas without blisters.

Interview with the director of nursing (DON) on October 21, 2021 at 2:00 PM revealed that the facility failed to sufficient supervise the resident and provide the necessary feeding assistance with meals to prevent this resident's burn injuries.


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


















 Plan of Correction - To be completed: 12/14/2021

Staff involved in each situation received counseling per facility policy.

Coffee temperatures were monitored and recorded and within parameter on the date of the event for resident #140.
The blistered area for this resident has resolved.

The rib fracture for resident #49 is in the healing process.

The fracture for resident #5 is in the healing process, although this resident has chosen not to receive therapy.

Residents requiring assistance with feeding will receive their meal trays once all others have been served.
To guide staff involved in transporting residents from the dining room, the posted seating chart will indicate when staff is to contact the licensed nursing staff for further instruction, i.e., placing seat in slightly reclined position following meals.

All existing and new employees (prior to be released from orientation) are required to complete a competency: demonstration/return demonstration regarding use of each mechanical lift used in the facility.

Nursing staff is being educated regarding the following: meal tray service order, seating chart guidance & mechanical lift competency.

The Director of Nursing or designee will complete a Quality Assessment Performance Improvement (QAPI) project to ensure that all incidents and accidents are properly addressed. This study will continue until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the scheduled QAPI/Infection Prevention/Safety & Compliance Meeting and if indicated corrective action will be taken.

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 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(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, observations and staff and resident interviews it was determined that the facility failed to consistently provide timely, planned care, services, and treatment, consistent with professional standards of practice, to prevent and promote healing of pressure sores for two residents out of 20 residents sampled (78 and 5).

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 78 was admitted to the facility on June 4, 2020, with diagnoses to include muscle weakness, diabetes type 2, and end stage renal disease. The resident had a below the knee amputation of the left lower extremity and an above the knee amputation of the right lower extremity

A review of significant change Minimum Data Set assessment dated September 17, 2021, (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident required extensive assistance with activities of daily living and was at risk for developing pressure areas.

A review of a physical therapy (PT) encounter note dated September 30, 2021, revealed that the resident had an open area on his left residual limb. The PT note indicated that the wound nurse was aware and told therapy staff to hold on applying the resident's stump shrinker (Shrinkers are used to reduce, prevent or control swelling \ in the below knee residual limb. They are designed to fit snugly and apply pressure to the soft tissues of the stump).

There was no documented evidence of an evaluation of the resident's open area on his left residual limb at the time it was identified by physical therapy, including the characteristics and size of the wound when found.

A review of the resident's September 2021 treatment administration record revealed no documentation the resident was provided a treatment or wound care to the open area found on the left stump on September 30, 2021.

A review of September 2021 tasks revealed no interventions were in place for skin care for the left stump provided during the month of the September 2021 or wound care initiated on the last day of month, September 30, 2021, when the open area was found in therapy. Turning and repositioning of the resident was not completed on six occassions as planned during the month of September 2021, according to task record. Further it was noted that staff signed the task record indicating that they had performed turning and repositioning of the resident for during shift, on 38 occassions during the month, before the staff had actually completed the task during their shift of duty, according to the timing of their documentation of completion of the tasks.

A review of a physical therapy encounter note dated October 1, 2021, revealed that the resident's stump shrinker continued to be held at the direction of the wound nurse due to the open area the resident's left residual limb.

A review of a facility incident report dated October 3, 2021, at 9:50 PM, three days after the wound was found in therapy, indicated that staff found an open area on the resident's left stump that appeared to be a pressure ulcer. The wound measured 1.5 cm (centimeter) x 1 cm.

A review of a progress note dated October 4, 2021, at 1:17 PM, indicated that the resident had an open area to his left stump measuring 3 cm x 3.5 cm x 0.1 cm, round, red, and warm. Within that wound there is another circle in the center measuring 1.5 cm x 1 cm x 0.2 cm with purulent drainage.

A review of a therapy encounter note dated October 4, 2021, indicated that therapy staff had to apply a pillow under the resident's left thigh to elevate the stump off the resident's bed and reduce pressure. The therapy staff educated the direct care staff and nurse on the unit on positioning the resident while in bed.

A review of a physician consult note dated October 5, 2021, revealed the resident had a superficial pressure ulcer measuring 3 cm x 3 cm.

A review of the resident's October 2021 treatment administration record (TAR) revealed a treatment was not ordered or applied to the pressure ulcer until October 6, 2021, six days after the wound was initially found. According to the TAR, The treatment was not applied to the wound as ordered on October 8, 11,15, and 20, 2021.

A review of October 2021 tasks revealed the intervention for a pillow to be placed under the resident's left leg to float the left residual stump was not initiated by nursing staff until October 7, 2021, 4 days after therapy had educated staff on its use and 7 days after the wound was found. Nursing staff did not complete this task 12 times during the month of October 2021 as of the time of the survey ending October 22, 2021.

Further review of October 2021 tasks revealed the resident was not turned and repositioned eight times. It was also indicated staff signed they completed turning and repositioning for the shift 33 times before completing the task for the shift.

A review of a weekly wound observation dated October 12, 2021, revealed that the facility did not stage the resident's pressure wound. The facility defined the wound as shearing despite the consulting physician classifying it as a pressure wound. (Friction and shear are mechanical forces contributing to pressure ulcer formation. The tissue injury resulting from these forces may look like a superficial skin insult. Shear and friction are 2 separate phenomenons, yet they often work together to create tissue ischemia and ulcer development)

An interview with Employee 8 RN (registered nurse) on October 22, 2021, at 12:24 PM revealed that the employee thought the wound was shearing, but did confirm that the physician classified the wound as a pressure ulcer. Employee 8 stated that since the resident returned from having his right leg amputated the resident was not as mobile anymore and was not using the prosthetic and remained either in his bed or wheelchair.

An observation of the resident on October 22, 2021, at approximately 12:30 PM revealed the resident was seated in his wheelchair. A pillow was attached to the leg rest of the wheelchair. The pillow was not placed under his thigh and the resident's left stump wound was lying directly on the surface of the chair. The resident's stump was not elevated. Measurements of the wound were obtained at that time. The wound was opened and measured 2.5 cm x 2 cm. The wound bed appeared yellow in color with a red circle area in the middle of the wound.

An interview with Resident 78 on October 22, 2021, at the time of the observation revealed that since he had his right leg amputated, he has been in his bed or wheelchair. He has not been able to use his left leg prosthetic since there is a wound to his left stump. He stated that his left stump was not being elevated prior to the development of the pressure wound. He stated that his left stump would lay on the pad of his wheelchair leg rest and he thinks that is how he got the open wound. He further stated that staff do not turn and reposition him all the time.

The facility failed to consistently implement measures necessary for a resident at risk for skin breakdown to prevent the development of a pressure sore.

An interview with the director of nursing on October 22, 2021, at approximately 1:30 PM confirmed that the facility was unable to demonstrate the consistent implementation of measures planned to prevent pressure ulcers for residents at risk for skin breakdown and to promote healing of existing skin issues.

A review of the clinical record revealed that Resident 5 was admitted to the facility on January 4, 2019, with diagnoses to include CVA (stroke) with left hemiplegia (is the paralysis of limbs on the left side of the body), dysphagia (difficulty swallowing), morbid obesity, and muscle weakness with difficulty walking.

A review of a significant change Minimum Data Set Assessment dated October 13, 2021, revealed that Resident 5 was cognitively intact and required extensive assistance of two plus persons physical assist for toileting, dressing, and bed mobility. She was totally dependent for transfers with two plus persons assistance and not steady during surface-to-surface transfers.

Review of facility provided document "Incident Report - Skin Impairment" that was dated October 15, 2021, at 6:33 AM, revealed that Resident 5 was observed to have developed an open area to the right buttock, 2 cm, and no drainage noted. The facility's immediate action taken was to cleanse the right buttocks with normal saline solution, pat dry, apply zinc ointment (skin treatment), and side-to-side repositioning with wedge cushion at all times, except when eating. The facility identified that the open area developed due to the resident's refusal to get out of bed since fall.

Current "Braden Scale for Predicting Pressure Sore Risk" dated October 15, 2021, indicated that the resident was occasionally moist, chair fast, very limited ability to change and control position, and had a potential problem with friction and shearing.

A physician order dated October 16, 2021, revealed an order to cleanse the right buttock with normal saline solution, pat dry, apply zinc ointment (skin treatment), and side-to-side repositioning with wedge cushion at all times, except when eating.

The resident's TAR for October 2021, revealed that the physician order for treatment to the right buttocks was not initiated until 24-hours later.

Review of October 2021 tasks revealed that there was no documented evidence that side-to-side repositioning with wedge cushion at all times, except when eating was implemented until October 19, 2021, four days after identification of area.

Further review of October 2021 tasks revealed that staff signed they completed turning and repositioning prior to completing the task for their shift of duty.

An interview with the director of nursing on October 22, 2021, at approximately 1:35 PM, confirmed that the facility was unable to demonstrate the consistent implementation of measures planned to prevent pressure ulcers for residents at risk for skin breakdown.


28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services.

28 Pa. Code 211.5(f) Clinical records.








 Plan of Correction - To be completed: 12/14/2021

Resident 78 has a history of co-morbid conditions and is being followed by a vascular surgeon for the stump wound. The resident also attends dialysis several days each week.

The open area on the right buttocks of resident 5 is healed.

The Director of nursing will ensure that all residents receive a comprehensive skin assessment, standardized pressure ulcer assessment and care planning and implementation to address areas of risk.

The nursing staff is being re-educated regarding: the three measures above, documentation of tasks once completed, proper documentation when a resident is not in the facility to receive care, i.e., at dialysis, ensuring adaptive equipment is in place, and ensuring timely performance of wound care treatments.

The Director of Nursing or designee will complete a Quality Assessment Performance Improvement (QAPI) project to ensure the implementation of interventions to prevent/treat the development of pressure ulcers. This study will continue until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the scheduled QAPI/Infection Prevention/Safety & Compliance Meeting and if indicated corrective action will be taken.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on a review of the antibiotic stewardship policy and staff interview, it was determined the facility failed to fully develop and implement an antibiotic stewardship program.

Findings include:

Review of the facility policy entitled "Antibiotic Stewardship" last reviewed by the facility on May 18, 2021, revealed that the facility will prescribe and administer antibiotics to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for medication utilization and prescribing. The program will include how inappropriate use of antibiotics affects individual residents and the overall community.

There were no protocols developed to review clinical signs and symptoms and laboratory reports to determine if the antibiotic is indicated or if adjustments to therapy should be made and identify what infection assessment tools or management algorithms are used for one or more infections.

There was no process for periodic review of antibiotic use by prescribing practitioners. No protocols were developed to optimize the treatment of infections by ensuring residents receiving antibiotics are prescribed the appropriate antibiotic.

In an interview on October 22, 2021, at 1:15 PM, Employee 11 (Infection Control Preventionist) stated that the facility had not yet developed specific protocols relating to antibiotic use and was unable to provide evidence of a functioning antibiotic stewardship program in the facility at the time of the survey.

28 Pa. Code 211.12 (c) Nursing services

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








 Plan of Correction - To be completed: 12/14/2021

The facility had an Antibiotic Stewardship policy in place at the time of the survey. The contracted laboratory was unable to provide an antibiogram due to, "not having enough isolates throughout the year." This email from the lab is on file in the facility and available for review.

The Antibiotic Stewardship Policy will be further enhanced to include the following: How inappropriate use of antibiotics (ABTs) affects individual residents and the overall community; review of clinical signs and symptoms and laboratory reports to determine if an ABT is indicated or adjustments to therapy should be made and will identify what infection assessment tools or management algorithms are used for one of more infections; process for periodic review of ABT use by prescribing practitioners; protocols to ensure optimization of treatment of infections by ensuring residents receiving ABTs are prescribed the appropriate ABT.

The Infection Prevention Nurse will be educated regarding the changes to the Antibiotic Stewardship policy and will be responsible for implementation.

The infection prevention nurse will perform ongoing monitoring for all residents to ensure adherence to the Antibiotic Stewardship policy. Results will be shared at the scheduled Quality Assessment Performance Improvement/Infection Prevention/Safety/Compliance Meeting and if indicated, corrective action will be taken.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on observation and staff interview, it was determined the facility failed to ensure adherence to pharmaceutical expiration/use by dates on two of two medication storage rooms .

Findings include:

An observation of the east wing medication storage room on October 21, 2021, at 9:46 AM revealed 13 bottles of 100 ml normal saline solution that expired October 8, 2021, one vial of Novolog insulin 100 units/ml opened September 3, 2021 and was to be discarded October 1, 2021, and 26 urine complete cup kits that expired September 2021.

An interview with Employee 5 RN (registered nurse) on October 21, 2021, at 9:56 AM confirmed the drugs and pharmacy supplies in the medication room were expired.

An interview with the DON (Director of Nursing) on October 21, 2021, at approximately 1:00 PM revealed the expired biologicals should have been removed from the medication room.

An observation of the West wing medication room on October 21, 2021, at 10:15 AM revealed one vial of Calcitonin 200 unit vial (Calcitonin is a man-made form of a hormone that occurs naturally in the thyroid gland. Calcitonin injection is used to treat Paget's disease of bone, or high levels of calcium in the blood (hypercalcemia). Calcitonin injection is also used to treat osteoporosis in postmenopausal women) for Resident 26 stored in the refrigerator. The vial noted an order date of November 30, 2020 and the date the pharmacy sent this vial to the facility was June 29, 2021. There was no date indicating when this vial was opened and available for resident use.

Employee 9, RN, stated that all medications should be dated when opened to ensure potency. Employee 10, LPN, stated she did utilize this vial for administration to Resident 26 on this date, October 21, 2021.

According to documention provided by the Mayo Clinic the Calcitonin is to be stored unopened in the refrigerator. Do not freeze. An opened bottle may be stored in an upright position at room temperature, away from heat and direct light. An opened bottle of can be stored for up to 35 days. Unused medication after 35 days must be thrown away.

An opened vial of Lantus 100 units/ML belonging to Resident 140 was observed in the refrigerator but not dated when initially opened


28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services

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







 Plan of Correction - To be completed: 12/14/2021

When observed, all expired medication was immediately removed.

The 11P-7A Licensed Nursing Staff is responsible to verify that all multi-dose medications are within date and if expired are discarded.

The 11P-7A licensed nursing staff is being re-educated regarding checking for expired medication on a daily basis.

The Director of Nursing or designee will complete a Quality Assessment Performance Improvement (QAPI) project to ensure all multi-dose medications are within date and that the facility policy for medication dating is being followed. This study will continue until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the monthly QAPI/Infection Prevention/Safety & Compliance Meeting and if indicated corrective action will be taken.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to afford residents the right to formulate advance directives (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by three residents out of 20 residents sampled (Residents 2, 28 and 42).

Findings include:


A review of the clinical record revealed Resident 28 was admitted to the facility on February 11, 2020, and had diagnoses that included hypertension, acute kidney failure, and anxiety.

According to the resident's clinical record, Resident 28 elected to be a DNR (do not provide Cardio-pulmonary resuscitation, CPR, in event of the resident's breathing or heart stops) upon a hospitalization as of October 11, 2020.

A review of the clinical record revealed Resident 2 was admitted to the facility on April 17, 2018, and had diagnoses that included coronary artery disease, history of stroke and heart failure.

The clinical record revealed that Resident 2 elected to be a DNR (do not provide Cardio-pulmonary resuscitation, CPR, in event of the resident's breathing or heart stops) upon a hospitalization as of June 29, 2021.

A review of the clinical record revealed Resident 42 was admitted to the facility on October 28, 2019, and had diagnoses that included chronic pain, diabetes mellitus and high blood pressure.

According to the clinical record, Resident 42 elected to be a full code (provide Cardio-pulmonary resuscitation, CPR, in event of the resident's breathing or heart stops) upon hospitalization as of March 31, 2021.

A review of documentation in the aforementioned residents' clinical records failed to indicate whether these residents had an advance directive or that the facility had afforded the residents the right to formulate an advanced directive at the time of the residents' admission or throughout their stay. The residents elected code/DNR options with hospitalizations. The residents' clinical records did not include discussions of the resident's right to formulate an Advance Directive or how to go about formulating an Advanced Directive if the resident wished to do so.

An interview with the director of nursing on October 21, 2021 at 10:30 AM confirmed that the facility was unable to provide evidence that the facility had afforded the above residents the opportunity to formulate an advance directive.


28 Pa. Code 211.5 (f) Clinical records

28 Pa. Code 201.29(a)(l)(2) Resident rights

28 Pa. Code 201.18(b)(1)(2)(3)(e)(1) Management







 Plan of Correction - To be completed: 12/14/2021

At the time of the survey, residents 2, 28 and 42, each had a "Medical Care Desired," Form present on their clinical record, specifying the care they preferred if unable to make medical decisions.

Residents 2, 28, and 42 and all other capable residents and/or resident representative are being afforded the opportunity to formulate an advance directive.

A policy regarding formulating an advance directive is being developed and the Director and Assistant Director of Social Services will be educated by the NHA regarding same.

The Director of Social Services will complete a Quality Assessment Performance Improvement (QAPI) project to ensure that all residents and/or resident representatives are offered the ability to formulate an advance directive at the time of admission, annually and PRN. This study will occur until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the monthly QAPI/Infection Prevention/Safety & Compliance Meeting and if indicated corrective action will be taken.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely consult with the physician regarding a change in condition for one resident out of 20 sampled (Resident 69).

Findings include:

A review of facility policy entitled "Physician Notification Guidelines" last reviewed May 18, 2021, revealed it is the responsibility of the nursing staff to observe the change, make an assessment and notify the physician based upon the assessment.

A review of the clinical record revealed that Resident 69 was admitted into the facility on January 22, 2021, with diagnoses including hemorrhage of the anus and rectum.

A review of a nursing progress note dated October 4, 2021, at 1:53 AM revealed that staff observed that the resident had frank red blood in her stool.

A review of a nursing progress note dated October 4, 2021, at 4:41 AM revealed the resident again had frank red blood in her stool.

Interview with the Director of Nursing on October 21, 2021, at approximately 1:00 PM confirmed the facility failed to notify the physician of the resident's blood in her stool.


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





 Plan of Correction - To be completed: 12/14/2021

Resident 69 did not experience complications related to the physician not being immediately notified of bleeding from the anus/rectal area. Bleeding from this area was a chronic condition.

Resident 69 and all residents will have the physician will have the physician notified for a significant change in condition.

The licensed nursing staff are being re-educated regarding the physician notification policy and procedure for significant change in condition.

The Director of Nursing or designee will complete a Quality Assessment Performance Improvement (QAPI) project to ensure the physician is notified of all significant changes in a resident's condition. This study will continue until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the monthly QAPI/Infection Prevention/Safety & Compliance Meeting and if indicated corrective action will be taken.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on observations, a review of clinical records and a facility investigation report and staff and resident interviews it was determined the facility failed to ensure that nurse aides possessed the skills and competencies necessary to meet residents' needs, as identified through resident assessments and described in the plan of care, to perform safe transfers and prevent accidents and injuries for one resident out of four residents reviewed (Resident 5).

Findings Include:

A review of the clinical record revealed that Resident 5 was admitted to the facility on January 4, 2019, with diagnoses to include CVA (stroke) with left hemiplegia (is the paralysis of limbs on the left side of the body), dysphagia (difficulty swallowing), morbid obesity, and muscle weakness with difficulty walking.

A review of a significant change Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 13, 2021, revealed that Resident 5 was cognitively intact and required extensive assistance of two plus persons physical assist for toileting, dressing, and bed mobility. She was totally dependent for transfers with two plus persons assistance and not steady during surface-to-surface transfers.

Review of her care plan dated October 2, 2020, indicated that Resident 5 had ADL (activities of daily living) deficits related to impaired balance related to CVA with hemiparesis and required the use of a mechanical lift with the assistance of two persons for transfers.

A review of information submitted by the facility dated October 2, 2021, at 9:15 AM, revealed that Resident 5 had a fall during transfer with a mechanical lift. According to the nurse aides, while transferring Resident 5 utilizing a split-sling lift pad, the resident slipped out of the sling and fell to the floor. The resident was lying supine (means lying horizontally with the face and torso facing up) next to door side of bed. The nurse aides reported that they "gently broke" the fall and the resident did not hit her head. The facility noted that the mechanical lift was assessed and was working properly and the split-sling lift pad was assessed with no abnormalities noted. However, the facility identified that the lift pad used was observed to be the inappropriate size.

Review of hospital records dated October 2, 2021, indicated that Resident 5 sustained a 3 feet fall out of the Hoyer lift and diagnosed with a comminuted left proximal humeral fracture (is a fracture where the bones are broken in several fragments and are not aligned that can be caused by trauma).

Interview with Employee 1, nurse aide, on October 21, 2021, at 1:35 PM, indicated that she began working at the facility September 2021, and that she transferred from an affiliated skilled nursing facility. She stated that October 2, 2021, was the first time that she was assigned to Resident 5 and was not familiar with that type of lift required to transfer the resident and assumed that Employee 2 knew how to maneuver that type of lift because she worked at this facility longer. She stated that the facility did not educate or orient her on that specific mechanical lift during her orientation to the facility because it was out of service.

Interview with Employee 2, a nurse aide, on October 21, 2021 at 1:25 PM, she stated that started working in this facility February 2021, and was not trained or familiar with that particular mechanical lift. She stated that she had never been assigned to Resident 5 and was just assisting Employee 1 with the resident's transfer and was not actually operating the lift.

During interview with the DON on October 21, 2021, at 10:30 AM, the DON stated that Employee 1's orientation check list was received/accepted from the sister skilled nursing facility and that another skills list was not performed to orient her to this facility's equipment. Additionally, the DON also stated that the facility was unable to provide documented evidence that Employee 2 completed the facility's required "CNA Skills Inventory" during orientation to ensure that she was trained to safely operate the Hoyer lift used to transfer Resident 5.

Further interview with the DON on October 22, 2021, at 11:45 AM, confirmed that the facility failed to ensure that all nurse aides received training on the facility's CNA (nurse aide) skills inventory check list that was required to be completed prior to being released from orientation to independently perform duties safely to prevent injuries.

Refer F689


28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services

28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 201.20(b) Staff development




 Plan of Correction - To be completed: 12/14/2021

The mechanical lift was immediately removed from service and checked by the maintenance staff for proper function, with no concerns identified.

Prior to returning to work, the two staff members involved were required to meet with the restorative nurse and the nursing home administrator to re-enact the event. All lift pads which, contained, what the facility considered to be a flawed clip mechanism, were immediately removed from service.

A mechanical lift competency was developed for all nursing staff, which includes demonstration/return demonstration of each mechanical lift used in the facility. All staff are required to successfully complete the competency.

Moving forward, all new staff are required to complete the mechanical lift competency prior to release from orientation.

The Director of Nursing or designee will complete a Quality Assessment Performance Improvement (QAPI) project to ensure all staff are properly trained on the use of the mechanical lifts used in the facility. This monitoring will continue until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the scheduled QAPI/Infection Prevention/Safety & Compliance Meeting and if indicated corrective action will be taken.

483.80 (h)(1)-(6) REQUIREMENT COVID-19 Testing-Residents & Staff: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 (h) COVID-19 Testing. The LTC facility must test residents and facility staff, including
individuals providing services under arrangement and volunteers, for COVID-19. At a minimum,
for all residents and facility staff, including individuals providing services under arrangement
and volunteers, the LTC facility must:

§483.80 (h)((1) Conduct testing based on parameters set forth by the Secretary, including but not
limited to:
(i) Testing frequency;
(ii) The identification of any individual specified in this paragraph diagnosed with
COVID-19 in the facility;
(iii) The identification of any individual specified in this paragraph with symptoms
consistent with COVID-19 or with known or suspected exposure to COVID-19;
(iv) The criteria for conducting testing of asymptomatic individuals specified in this
paragraph, such as the positivity rate of COVID-19 in a county;
(v) The response time for test results; and
(vi) Other factors specified by the Secretary that help identify and prevent the
transmission of COVID-19.

§483.80 (h)((2) Conduct testing in a manner that is consistent with current standards of practice for
conducting COVID-19 tests;

§483.80 (h)((3) For each instance of testing:
(i) Document that testing was completed and the results of each staff test; and
(ii) Document in the resident records that testing was offered, completed (as appropriate
to the resident’s testing status), and the results of each test.

§483.80 (h)((4) Upon the identification of an individual specified in this paragraph with symptoms
consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the
transmission of COVID-19.

§483.80 (h)((5) Have procedures for addressing residents and staff, including individuals providing
services under arrangement and volunteers, who refuse testing or are unable to be tested.

§483.80 (h)((6) When necessary, such as in emergencies due to testing supply shortages, contact state
and local health departments to assist in testing efforts, such as obtaining testing supplies or
processing test results.
Observations:

Based on a review of the facility's COVID-19 testing, standards established by the Centers for Medicare & Medicaid Services, and staff interview, it was determined the facility failed to timely conduct testing of three residents exhibiting signs and symptoms of COVID-19 out of 20 sampled residents. (Resident 69, 74, and 54)

Findings include:

According to the Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group QSO-Memo - 20-38-NH initially dated August 26, 2020 and revised on September 10, 2021, residents either vaccinated or unvaccinated who exhibit signs and symptoms of COVID-19 must be tested for COVID-19.

A review of Resident 69's clinical record revealed that on October 5, 2021, at 9:00 PM, the resident had a fever of 101.9 degrees Fahrenheit at 5:20 PM. Tylenol was administered, and temperature rechecked. The resident had a temperature of 103.3 degrees Fahrenheit in right ear and 102.3 degrees Fahrenheit in left ear.

No documentation was noted that the resident was tested for COVID-19 despite exhibiting signs and symptoms.

A review of Resident 74's clinical record revealed on October 18, 2021, at 5:13 PM, the resident noted with to be wheezing, had diminished lung sounds and a chronic cough.

A review of Resident 74's clinical record revealed no documentation the resident was tested for COVID-19 despite exhibiting signs and symptoms.

A review Resident 54's clinical record revealed on June 29, 2021 the resident had a sore throat and a low grade temperature. The facility notified the CRNP (certified registered nurse practitioner) who indicated to monitor the resident and report if no improvement.

There was no documentation in Resident 54's clinical record that the resident was tested for COVID-19 despite exhibiting signs and symptoms.

Interview with Director of Nursing on October 21, 2021, at approximately 1:00 PM conformed there was no documented evidence in the clinical record that the residents exhibiting potential signs and symptoms of COVID-19 were promptly tested.



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

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

28 Pa. Code: 211.12 (c) Nursing services.






 Plan of Correction - To be completed: 12/14/2021

There were no residents in the facility that experienced adverse consequences, as a result of not being tested for COVID-19, when exhibiting potential signs/symptoms of the disease. None were confirmed as having COVID-19.

Moving forward, residents 69, 74, 54 and all residents who exhibit signs and symptoms of COVID-19 will be tested for COVID-19, regardless of the physician's order for monitoring.

The licensed nursing staff is being re-educated regarding the need to test all residents, regardless of vaccine status, who are potentially symptomatic for COVID-19.

The Assistant Director of Nursing/Infection Prevention Nurse or designee will complete a Quality Assessment Performance Improvement (QAPI) project to ensure that all residents who have potential signs/symptoms of COVID-19 are tested. This study will continue until 100% compliance has been achieved for 3 consecutive months. Results will be shared at the monthly QAPI/Infection Prevention/Safety & Compliance Meeting and if indicated corrective action will be taken.


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