Pennsylvania Department of Health
BETHLEN HOME OF THE HUNGARIAN REFORMED FEDERATION OF AMERICA
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BETHLEN HOME OF THE HUNGARIAN REFORMED FEDERATION OF AMERICA
Inspection Results For:

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BETHLEN HOME OF THE HUNGARIAN REFORMED FEDERATION OF AMERICA - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a complaint survey completed on May 13, 2024, it was determined that The Bethlen Home of the Hungarian Reformed Federation of America 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:

483.45(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 review of facility policies and manufacturer's guidelines, as well as observations and staff interviews, it was determined that the facility failed to monitor medication refrigerator temperatures on one of two nursing units (300/400/500 unit).

Findings include:

The facility's policy regarding medication storage, dated December 1, 2023, indicated that all medications housed on the premises will be stored in the medication room according to manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. All medications requiring refrigeration will be stored within 36-46 degrees Fahrenheit. Charts are kept on each refrigerator, and temperature levels are recorded daily by the charge nurse or other designee.

Observations of the first refrigerator in the 300/400/500 medication room on May 13, 2024, at 1:39 p.m. revealed three vials of Humalog insulin, three vials of Aplisol (tuberculosis skin testing solution), one vial of Lantus insulin, two Ozempic pens (medication used for diabetes), 1 vial of Prevnar (pneumonia vaccination), one bottle of Protonix (liquid), seven Aspart insulin pens, three Trulicity insulin pens, and two Humira pens (medication used for arthritis). Observations of the second refrigerator revealed two tubes of Latanoprost eye drops, one bottle of Protonix (liquid), one Ozempic pen, six Aspart insulin pens, one glargine insulin vial, two Humulin R insulin pens, one Levemir pen, four Basaglar insulin pens, four Lantus insulin pens, one Prolia pen (medication used for bone loss), and two Daptomycin intravenous bags (antibiotic medication). There was no documented evidence that temperatures were monitored daily to ensure the medications were stored within 36 to 46 degrees Fahrenheit per the manufacturer's recommendations for these two refrigerators from July 2022 to May 13, 2024.

Interview with Registered Nurse 1 on May 13, 2024, at 1:39 p.m. confirmed that there was no evidence to indicate that temperatures were monitored daily for the two refrigerators in the 300/400/500 medication room, per manufacturer's recommendations since July 2022.

Interviews with the Director of Nursing on May 13, 2024, a 2:20 p.m. confirmed there was no documentation that the 300/400/500 medication refrigerators were being monitored daily to maintain temperatures between 36 and 46 degrees Fahrenheit.

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

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

Plan of Correction - To be completed: 06/24/2024

The preparation and/or execution of the plan of correction does not constitute admission of agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

No residents suffered ill effects as a result of inconsistency in completion of the medication refrigerator temperature log.

Licensed nursing staff educated on completion of the temperature log of the medication refrigerator.

Assistant Director of Nursing or designee observing completion of the medication refrigerator temperature logs five times per week for four weeks and then monthly random checks for three months.

Medication refrigerator temperature logs will be discussed at the monthly Quality Assurance Performance Improvement meeting for six months.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary conditions.

Findings include:

The facility's policy regarding personal hygiene, dated December 1, 2023, revealed that all dietary staff must wear hair restraints (e.g., hairnet, hat and /or beard restraint) to prevent hair from contacting food and to prevent contamination of food by food service employees.

Observations in the main kitchen during service for the lunch meal on May 13, 2024, at 11:33 a.m. revealed that Dietary Aide 2 was placing meal tickets and silverware on the trays and Dietary Aide 3 was placing the food on the plates in the tray line. Dietary Aides 2 and 3 had hair nets on but they were not covering all their hair and there were strands of hair touching the backs of their necks.

Interview with the Dietary Manager on May 13, 2024, at 1:24 p.m. confirmed that dietary staff should have their hair covered when working in the kitchen.

28 Pa. Code 211.6(f) Dietary Services.

Plan of Correction - To be completed: 06/24/2024

The preparation and/or execution of the plan of correction does not constitute admission of agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

Residents suffered no ill effects.

1. The dietary manager educated dietary aide 2 and dietary aide 3 on hair net placement policies and procedures and techniques on 5/13/2024.

2. The dietary manager educated the dietary department on proper hair net placement policies and procedures and techniques.

3. The dietary manager or designee will observe meal service routinely to ensure hair net placement is completed per policies and procedures and document findings.

4. The documented observation of meal service regarding hair net placement will be submitted to the Quality Assurance Committee for two months.

483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):

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

§483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.

Observations:

Based on review of the facility's policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's code status was clarified for one of seven residents reviewed (Resident 5).

Findings include:

The facility's policy regarding Physician Orders for Life Sustaining Treatment (POLST), dated December 1, 2023, revealed that residents would be questioned upon admission about their preferences for resuscitation in the event of cardiac or respiratory arrest. The nurse will clarify physician discussions regarding the residents' diagnoses and prognosis with the resident and/or responsible party, as well as resuscitation status, existence of Advance Directives and/or Durable Power of Attorney. A stated desire to not have resuscitation instituted in the presence of a deteriorating, irreversible medical condition will be referred to the physician for discussion of the consequences of a DNR order.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated March 20, 2024, revealed that the resident had severe cognitive impairment. Physician's orders, dated April 23, 2023, included an order for the resident to be a DNR (no attempt to revive in the event of cardiac arrest) and a POLST located in the resident's hard chart at the nurse's station, dated June 28, 2021, for the resident to be a full code (to be provided CPR in the event of cardiac arrest).

Interview with Registered Nurse 1 on May 13, 2024, at 11:30 a.m. revealed that she was not certain which code status Resident 5 was to be, a full code or a DNR, since both were listed on the resident's chart as his code status.

Interview with the Director of Nursing on May 13, 2024, at 1:02 p.m. revealed that Resident 5's code status should have been clarified so that only one code status would remain on his medical chart and staff would know what to do in the case of an emergency.

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

Plan of Correction - To be completed: 06/24/2024

The preparation and/or execution of the plan of correction does not constitute admission of agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

A review of current residents revealed no other failures in transcription of orders.

Registered Nurse 1 received education on ensuring accuracy of order transcription on 5/13/2024. Licensed nursing staff educated on ensuring accuracy of order transcription on 5/13/2024.

A newly developed audit tool will be utilized by the Director of Nursing or designee weekly times four then monthly times three to ensure accuracy of order transcription. The audits will be discussed during the facility's monthly Quality Assurance Performance Improvement meeting for six months.

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a peripherally-inserted central catheter (PICC - a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart) was flushed according to facility policy for one of seven residents reviewed (Resident 6).

Findings include:

The facility's policy regarding Intravenous Administration, dated December 1, 2023, revealed that the PICC line was to be flushed before and after each administration with 10 milliliters of normal saline.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated April 25, 2024, revealed that the resident was cognitively intact, required assistance for daily care needs, and diagnoses that included osteomyelitis of the left foot (an infection in the foot) requiring intravenous medications.

Physician's orders for Resident 6, dated May 7, 2024, included an order for the resident to receive 50 milligrams of Tigecycline solution (intravenous antibiotic medication) for osteomyelitis two times a day.

Review of the May 2024 Medication Administration Record (MAR) for Resident 6 revealed no documented evidence that the resident's PICC line was flushed before and after each administration of intravenous antibiotic medication, per the facility policy.

An interview with the Director of Nursing on May 13, 2024, at 1:27 p.m. confirmed that there was no documented evidence that Resident 6's PICC line was flushed before and after each administration of intravenous antibiotic medication, per the facility policy.

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

Plan of Correction - To be completed: 06/24/2024

The preparation and/or execution of the plan of correction does not constitute admission of agreement by the provider of truth of the facts or conclusions set forth in the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provision of federal and state laws.

Resident 6 suffered no ill effects related to the failure to document that an intravenous line was flushed.

The documentation was reviewed for current residents with intravenous lines.

The licensed nursing staff educated on documenting the completion of intravenous line flushing on 05/13/2024.

Order sets have been updated to reflect the need for flushes before and after medication administration, along with flushes every shift to maintain patency when no medications are to be administered.

Orders are reviewed during the clinical portion of the Interdisciplinary Team meeting and updates are made to the care plan as needed.

Intravenous line flushing documentation will be audited by Nursing Administration weekly times four then monthly times three. For continued compliance intravenous line flushing audits will be discussed during Quality Assurance Performance Improvement meeting for six months.

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