Pennsylvania Department of Health
WALNUT CREEK HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WALNUT CREEK HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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WALNUT CREEK HEALTHCARE AND REHABILITATION CENTER - 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 and an Abbreviated Complaint Survey completed on June 28, 2024, it was determined that Walnut Creek Healthcare and Rehabilitation Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

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

§483.10(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to provide resident privacy during medication administration for one of four residents reviewed (Resident R22).

Findings include:

Review of facility policy entitled "Confidentiality of Information and Personal Privacy" dated 1/5/24, indicated "The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records." and "Access to resident personal and medical records will be limited to authorized staff ..."

During observation of medication administration for Resident R22 on 6/26/24, at 8:01 a.m. Registered Nurse (RN) Employee E1 prepared medications for a resident from the Neighborhood 400 medication cart parked sideways in the hallway with the computer open sitting on top of the medication cart. RN Employee E1 then proceeded into the resident room to administer medications to a resident in the room. RN Employee E1 did not cover/protect resident/medication information that was revealed on the computer on top of the medication cart and was visible to those walking in the hallway. During the medication administration, RN Employee E1 was unable to view the computer on top of the medication cart parked sideways in the hallway outside of the resident room.

During an interview on 6/26/24, at 8:15 a.m. RN Employee E1 confirmed that he/she left the medication cart with the computer open and did not cover/protect resident/medication information that was on the computer on top of the medication cart from anyone walking through the hallway. RN Employee E1 also confirmed that resident information is to be covered when not within view.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 07/29/2024

The RN employee E1 received immediate education to ensure that resident information is protected and not visible when they are not at the medication cart.
The clinical administration team audited all medication carts immediately upon notification to ensure that all other residents' privacy had been maintained and protected when the nurse was not present at the medication cart.
The Director of Nursing or designee will provide re-education to the licensed nursing staff on facility policy of "Confidentiality of Information and Personal Privacy".
The Director of Nursing or designee will audit medication administration to ensure that the licensed nurses maintain privacy and confidentiality of medical information. These audits will be conducted 3 times weekly for four weeks on varying shifts and staff. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§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 review of facility policies, manufacturer's guidelines, observations, and staff interviews, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications and to appropriately discard outdated medications for two of two medication carts reviewed (Neighborhood 300 and Neighborhood 400).

Findings include:

Review of facility policy entitled "Medication Storage in the Facility" dated 1/5/24, indicated "Medication rooms, carts and medication supplies are locked or attended by persons with authorized access." and "Outdated, contaminated or deteriorated medications ... are immediately removed from stock, disposed of according to procedures for medication disposal ..."

Review of manufacturer's guidelines revealed that an open Insulin Lantus vial must be used within 28 days after opening or be discarded, even if the vial still contains insulin.

Review of facility policy entitled "Medication Administration - General Guidelines" dated 1/5/24, indicated "During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse ..."

Observation of drug storage on 6/25/24, at 3:22 p.m. of the Neighborhood 400 medication cart revealed an open bottle Insulin Lantus with an open date written on it of 5/20/24. Additional observations of Neighborhood 400 medication cart revealed an open bottle of Iron Gluconate (an over the counter supplement that helps increase red blood cells) with a best-by date of 4/2024, and an open date of 6/10/24, which was beyond the best by date.

During an interview on 6/25/24, at 3:22 p.m. with Licensed Practical Nurse (LPN) Employee E2 he/she confirmed that the open date on the Insulin Lantus was beyond the 28 days and should have been discarded. He/she also confirmed that the open bottle of Iron Gluconate had a manufacturer best-by date of 4/2024, which should have not been opened after the best-by date and should have been discarded.

Observation of drug storage on 6/25/24, at 3:30 p.m. of the Neighborhood 300 medication cart revealed an open bottle of Iron Gluconate with a best-by date of 4/2024, and an open date of 6/1/24, which was beyond the best by date.

During an interview on 6/25/24, at 3:30 p.m. with Registered Nurse (RN) Employee E3, he/she confirmed that the open bottle of Iron Gluconate had a manufacturer best-by date of 4/2024, which should not have been opened after the best-by date and should have been discarded.

During observation of medication administration on 6/26/24, at 8:10 a.m. RN Employee E1 walked away and left the medication cart unattended while it was unlocked with a resident sitting approximately one foot away from the unlocked medication cart. RN Employee E1 then proceeded to walk down the hall and entered a resident room two rooms away from the medication cart, which remained unlocked.

During an interview on 6/26/24, at 8:13 a.m. RN Employee E1 confirmed that he/she left the medication cart unlocked that was out of his/her view when he/she was in a resident room. RN Employee E1 also confirmed that the medication cart was to be locked when out of view.

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

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

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

Plan of Correction - To be completed: 07/29/2024

The Insulin Lantus and Iron Gluconate on Neighborhood 400 medication cart were discarded immediately. The Iron Gluconate on Neighborhood 300 medication cart was discarded immediately. The RN Employee E1 received immediate education on ensuring that medication cart must be locked when not within view to prevent potential unauthorized access.
The clinical administration team audited all medication carts immediately upon notification to ensure that multi-dose medications were within the labeled use by date and within manufacturer guidelines for use by once opened date. Medication carts on all units were audited to ensure that each was locked when not within the sight of a licensed staff member to prevent potential unauthorized access.
The Director of Nursing or designee will provide re-education to the licensed nursing staff on the facility policies "Medication Storage in the Facility" and "Medication Administration- General Guidelines".
The Director of Nursing or designee will audit medication carts to ensure that Insulin Lantus and Iron Gluconates are within their use by dates, within use by date per the manufacturer's guidelines, and are locked when not in sight of a licensed nursing staff member. These audits will be conducted 3 times weekly for four weeks on varying shifts and staff. The results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.

483.20(g) REQUIREMENT Accuracy of Assessments:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on review of clinical records and facility documentation, and staff interview, it was determined that the facility failed to complete the Minimum Data Set (MDS-periodic assessment of resident care needs) to accurately reflect the resident's status at the time of the assessment for one of 22 residents reviewed (Residents R21).

Findings include:

Review of Resident R21's clinical record revealed an admission date of 10/28/17, with diagnoses that included end stage renal disease, anxiety, depression, heart failure and high blood pressure.

During an interview on 6/25/24, at 3:30 p.m. it was identified that Resident R21 was alert and oriented.

Review of the Quarterly MDS dated 6/04/24, entered at 11:14 a.m. under the Cognitive Patterns Section C0500 BIMS (Brief Interview for Mental Status) indicated that Resident R21 was cognitively impaired with a BIMS score of 3 (BIMS score range of 00-15, with a score of 15 being alert and oriented and a 3 being cognitively impaired).

During an interview on 6/27/24, at 11:40 a.m. the Nursing Home Administrator confirmed that Section C0500 of the Quarterly MDS dated 6/04/24, was incorrectly coded for Resident R21 regarding the BIMS score for their cognitive status.

28 Pa. Code 211.5(f)(ix) Medical records

Plan of Correction - To be completed: 07/29/2024

I hereby acknowledge the CMS 2567-A, issued to WALNUT CREEK HEALTHCARE AND REHABILITATION CENTER for the survey ending 06/28/2024, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

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