Nursing Investigation Results -

Pennsylvania Department of Health
BROOMALL MANOR
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BROOMALL MANOR
Inspection Results For:

There are  164 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.
BROOMALL MANOR - 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 survey for one complaint, completed on February 13, 2020, it was determined that Broomall Manor 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 for the health care portion of the survey.






 Plan of Correction:


483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:

Based on review of the Resident Assessment Instrument User's Manual, clinical records and staff interviews, it was determined that the facility failed to complete a quarterly Minimum Data Set assessments timely for 15 of 18 residents reviewed (Residents 3, 4, 6, 7, 8, 10, 11, 12, 15, 16, 17, 19, 20, 22, and 51).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions for completing Minimum Data Set (MDS- assessments (mandated assessments of residents' abilities and care needs), dated October 2017, indicated that a quarterly assessment was to be completed within 92 days of the previous assessment's (any type) reference date.

Review of Resident 3's clinical record revealed that the last assessment was completed on August 23, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 4's clinical record revealed that the last assessment was completed on August 30, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 6's clinical record revealed that the last assessment was completed on September 6, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 7's clinical record revealed that the last assessment was completed on September 19, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 8's clinical record revealed that the last assessment was completed on September 19, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 10's clinical record revealed that the last assessment was completed on September 19, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 11's clinical record revealed that the last assessment was completed on September 20, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 12's clinical record revealed that the last assessment was completed on September 20, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 15's clinical record revealed that the last assessment was completed on October 4, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 16's clinical record revealed that the last assessment was completed on October 4, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 17's clinical record revealed that the last assessment was completed on September 27, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 19's clinical record revealed that the last assessment was completed on September 23, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 20's clinical record revealed that the last assessment was completed on August 30, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 22's clinical record revealed that the last assessment was completed on October 11, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Review of Resident 51's clinical record revealed that the last assessment was completed on August 23, 2019. There was no documented evidence that a quarterly assessment was completed within 92 days of the last completed assessment.

Interview with Employee E5 on February 12, 2020, at 10:13 a.m., confirmed that quarterly MDS assessments should have been completed for Residents 3, 4, 6, 7, 8, 10, 11, 12, 15, 16, 17, 19, 20, 22, and 51.

28 Pa Code 211.5(f) Clinical records
Previously cited 3/25/19

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 3/25/19



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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Residents 3, 4, 6, 7, 8, 10, 11, 12, 15, 16, 17, 19, 20, 22, and 51 had quarterly assessments completed.

Audit completed to identify incomplete quarterly assessments.

New full time MDS Coordinator in place as of 2/24/2020 and educated on importance of completing MDS assessments timely.

MDS coordinator/designee will audit weekly x8 weeks for timely completion of MDS assessment.

Audit results will be reviewed at monthly QAPI x3 months.

MDS Coordinator/designee will be responsible. NHA will monitor for compliance.

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 upon review of clinical records, it was determined that the facility failed to ensure the physician was notified of the late administration of an antibiotic medication for one of two residents reviewed (Resident #77).

Findings include:

Review of Resident #77's diagnosis list revealed diagnoses including acute (sudden) osteomyelitis (bone infection) of the right ankle and foot, and diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of Resident #77's February, 2020, physician orders revealed an order for Cefepime (antibiotic medication) 2 grams to be administered intravenously (through a catheter in the vein) over 60 minutes every 8 hours with scheduled administration times of 2:00 a.m., 10:00 a.m., and 6:00 p.m.

Review of Resident #77's nursing progress notes dated February 11, 2020, revealed "Resident currently receiving IV (intravenous) Cefepime (antibiotic medication) via RUE (right upper extremity) D/L PICC (peripherally inserted central catheter) line; This nurse went to resident's room at 2:20 am to hang 2 am scheduled dose of IV Cefepime and administer resident's 2 am PO (by mouth) oxycodone, and perform dressing change to resident's foot; resident was asleep, this nurse woke resident and informed her of time and scheduled meds and treatments that I attempted to administer; Resident watched this nurse prime IV tubing and just as I was about to connect her to her IV ABT (antibiotic), resident stated, 'can I give you money so that you can get me drinks out of the employee break room vending machine' , I explained to resident that staff is not permitted to receive any monies from residents and that she must arrange all money transfers involving purchases through facility social worker, resident then asked who was her assigned CNA and said, I'll just ask her to get her drinks from vending area; this nurse asked resident if she could administered IV resident then stated, 'You don't know what you are doing any damn way oh wait a minute, I have to pee; This nurse left room and returned 5 minutes later, resident was still in bathroom. This nurse made 3 more attempts to perform dressing change to wound and administer IV abt (antibiotic) and resident was still in [resident's] bathroom. Resident remained in bathroom for over 1 hour. While resident was in bathroom I informed [resident] that I needed to perform her dressing change to her foot and she said, "you're and idiot, you could have been done it while I was asleep". At 4:30 am this nurse went to resident's room to remove IV antibiotic that was primed in pump and resident connected IV med on her own without this nurse present and approx. 60cc had infused, this nurse visualized IV ABT to ensure that it was safely connected".

Review of Resident #77's clinical record failed to reveal evidence that the physician was notified that Resident #77 did not receive the antibiotic at the scheduled time of 2:00 a.m.

Interview with the Director of Nursing on February 13, 2020, at approximately 8:30 a.m., confirmed that the physician was not notified of the late antibiotic administration.

28 Pa. Code 211.5(f) Clinical Records
Previously cited 3/25/19

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 3/25/19










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

Resident 77's physician was notified and there were no ill effects to the resident.

A full house review of the medication administration record was conducted to identify any discrepancies and physician notifications as indicated.

Licensed nursing staff re-educated regarding physician notification timely.

DON/designee will review the 24-hour report for any indications of a discrepancy 5 X week for 4 weeks, 3 X week for 4 weeks.

Results will be presented at QAPI meeting x3 months.

DON/designee will be responsible. NHA will monitor for compliance
483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of facility policy, review of information submitted by the facility to the state agency, clinical record review, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 18 residents reviewed (Resident 31).

Findings include:

Review of facility policy tiltled Pennsylvania Resident Abuse, last revised July 2019, defined injuries of unknown origin as an injury where "the source of the injury was not observed by any person, or the source of the injury could not by explained by the resident and the injury is suspicious because of the extent of the injury."

Further review of the policy revealed that the investigation must be completed in five working days from the alleged occurrence and that the investigation should include interviewing witnesses. The policy stated "Witnesses generally include anyone who: witnessed or heard the incident; came in close contact with the resident the day of the incident ...and employees who worked closely with the accused employee(s) and/or the alleged victim the day of the incident."

Further review of the policy revealed "If there are no direct witnesses, then the interviews may be expanded. For example, to cover all employees on the unit, or, as appropriate, the shift. For injuries of unknown source, the investigation will generally involve talking with both the shift on duty when the injury was discovered and the prior shifts as well." The policy went on to say that written statements should be obtained from each witness.

Review of Resident 31's clinical record revealed diagnoses including, but not limited to, muscle weakness, difficulty walking, dementia, and schizophrenia.

Review of Resident 31's last available quarterly MDS (Minimum Data Set - periodic assessment of resident care needs) dated October 22, 2019, revealed the resident had moderate cognitive impairment and was totally dependent on two staff persons for transfers.

Review of Resident 31's progress notes revealed a nurse's note dated January 24, 2020, at 6:21 p.m. which stated "notified this nurse that resident c/o [complained of] R [right] leg pain when attempting to reposition to left side. Upon assessment, slight facial grimacing when turned. (+)ROM [positive range of motion] without c/o pain, no redness, warmth or edema noted. Medicated with PRN [as needed] Tylenol, results pending."

Further review of Resident 31's progress notes revealed a nurse's note dated January 25, 2020 at 8:38 a.m. which stated "resident cont [continues] to c/o severe right hip pain, when care being provided she is crying out in pain, prn Tylenol having minimal effects. call placed to [physician] informing him of situation N.O. [new order] xray 2 view of right hip. doctor request to be called with the results ASAP [as soon as possible] staff to monitor."

Further review of Resident 31's progress notes revealed the resident's x-ray showed a right femoral neck fracture (right hip fracture), and the resident was transferred to the hospital for further evaluation.

Review of information submitted to the state agency revealed that Resident 31 had no recent falls.

Review of witness statement from nursing assistant Employee E6 revealed "On Friday, January 24, 2020, I gave care to [Resident 31] and there were no complaints of pain. She was transferred by hoyer with assist of another [unidentified nursing assistant] and there were no complaints of pain during or after transfer."

Review of all other witness statements obtained failed to reveal any employees stating that they helped Employee E6 transfer Resident 31 in the hoyer lift.

The Director of Nursing was asked if the facility determined who the unidentified nursing assistant was. The Director of Nursing first stated that the second employee was another nursing assistant. The Director of Nursing then stated that the unidentified nursing assistant was actually a licensed nurse (Employee E7).

Review of the information provided by the facility to the state agency failed to reveal a witness statement from Employee E7.

The Director of Nursing provided a witness statement from Employee E7 that was obtained February 12, 2020, 13 working days from when Resident 31 first began complaining of right hip pain.

The facility's failure to timely and thoroughly investigate Resident 31's injury of unknown origin was discussed with the Nursing Home Administrator on February 12, 2020 at 1:55 p.m.

28 Pa. Code 201.18(b)(1)(e)(1)ManagementPreviously cited 3/25/19

28 Pa. Code 201.29(a)(d) Resident Rights

28 Pa. Code 211.5(f) Clinical RecordsPreviously cited 3/25/19

28 Pa. Code: 211.12(d)(1) Nursing servicesPreviously cited 3/25/19




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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Resident 31 had a thorough investigation completed.

Incidents from the past 30 days will be reviewed to ensure a thorough investigation has been completed.

The NHA and DON have been re-educated regarding conducting and maintaining a thorough investigation.

DON/designee will review investigations weekly during Resident Review to validate investigations have been completed.

Results will be presented at monthly QAPI x3 months.

DON/designee will be responsible. NHA will monitor for compliance.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to develop comprehensive care plans for three of 18 residents reviewed (Resident #21, Resident #57 and Resident #67).

Findings include:

Review of Resident #21's diagnosis list revealed diagnoses including Escherichia Coli infection (bacteria), in the urine which required contact isolation precautions.

Review of Resident #21's active care plan failed to reveal a care plan for contact isolation precautions.

Interview with the Director of Nursing on February 13, 2020, at approximately 8:25 a.m. confirmed that no care plan for contact isolation precautions was in place for Resident #21.

Review of Resident #57's clinical records revealed that Resident #57 received a pacemaker (a small device implanted in the chest to help control abnormal heart rates) on November 20, 2019.

Review of Resident #57's clinical record and Medication Administration Record (MAR) revealed that Resident #57 was ordered Eliquis 5mg, two times a day (an anticoagulant medication that reduces blood clotting) on November 22,
2019.

Further review of Resident #57's clinical record on February 12, 2020, that the care plan did not address the pacemaker or the anticoagulant medication Eliquis.

Interview with the Director of Nursing on February 13, 2020, at 8:47 confirmed that the care plan for the anticoagulant Eliquis had not been created until February 12, 2020 and that a care plan for the pacemaker had not been initiated.

Review of Resident #67's physician's orders revealed an order for Xarelto (anticoagulant - blood thinning medication) 15 milligrams (mg), one tablet by mouth daily.

Review of Resident #67's care plan failed to reveal a care plan addressing the resident taking an anticoagulant.

The facility's failure to have a plan of care in place addressing Resident #67 taking an anticoagulant was discussed with the Nursing Home Administrator on February 12, 2020, at 2:00 p.m.


28 Pa. Code 211.11 (b) (d)Resident Care Plan
Previously cited on 3/25/2019

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously Cited on 3/25/2019

28 Pa. Code 211.5(f) Clinical records
Previously cited on 3/25/2019








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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Resident 57 care plan updated to reflect pacemaker and anticoagulant therapy. Resident 21 care plan updated to reflect isolation status.
Resident 67 care plan updated to reflect anticoagulant therapy.

Audit completed to ensure care plans were in place related to anticoagulant therapy, pace maker status, and isolation status and updated if indicated.

Licensed staff re-educated regarding completion of care plans for changes in resident care or medications.

DON/designee will review residents changes 5 X week during clinical meeting to ensure changes have been reflected in the care plan.

Results will be presented during QAPI meeting x3 months.

DON/Designee will be responsible. NHA will monitor for compliance.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based upon review of facility policy and procedures, observation and clinical record review, it was determined that the facility failed to administer medications according to physician orders for two of two residents reviewed (Resident #33 and Resident #77).

Findings include:

Review of facility policy and procedure titled General Dose Preparation and Medication Administration, revised January 1, 2013, revealed "Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident."

Review of Resident #33's diagnosis list revealed diagnoses including diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of Resident #33's February 2020 physician orders revealed an order for Accu check (blood glucose monitoring) four times per day with sliding scale coverage with Admelog (insulin - medication used to treat high blood sugar levels) to be administered at 7:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m.

Further review of Resident #33's February 2020 physician orders revealed an order for Admelog insulin, 10 units, to be injected three times a day at 8:00 a.m., 12:00 p.m. and 4:30 p.m.

Review of Resident #33's February 2020 Medication Administration Record (MAR), revealed an Accu check was completed on February 11, 2020 at 7:30 a.m. with a blood sugar result of 234 milligrams per deciliter (mg/dl) which, according to physician's order required insulin coverage of 4 units of Admelog.

Observation of medication administration on February 11, 2020, at 9:25 a.m., revealed Licensed Employee E4 administer Admelog 10 units combined with the Admelog 4 units that was to be administered at 7:30 a.m. when Resident #33's blood sugar level was obtained.

Interview with the Director of Nursing on February 13, 2020, at 8:25 a.m., confirmed that the medication was administered at 9:30 a.m., two hours after the blood sugar level was obtained, and one and one half hours after the scheduled time of 8:00 a.m.

Review of Resident #77's diagnosis list revealed diagnoses including acute (sudden) osteomyelitis (bone infection) of the right ankle and foot and diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of Resident #77's February 2020 physician orders revealed an order for Cefepime (antibiotic medication) 2 grams to be administered intravenously (through a catheter in the vein) over 60 minutes every 8 hours, with scheduled administration times of 2:00 a.m., 10:00 a.m. and 6:00 p.m.

Review of Resident #77's nursing progress notes dated February 11, 2020, revealed "Resident currently receiving IV (intravenous) cefepime (antibiotic medication) via RUE (right upper extremity) D/L PICC (peripherally inserted central catheter) line; This nurse went to resident's room at 2:20am to hang 2am scheduled dose of IV Cefepime and administer resident's 2am PO (by mouth) oxycodone and perform dressing change to resident's foot; resident was asleep, this nurse woke resident and informed her of time and scheduled meds and treatments that I attempted to administer; Resident watched this nurse prime IV tubing and just as I was about to connect her to her IV ABT (antibiotic), resident stated, 'can I give you money so that you can get me drinks out of the employee break room vending machine', I explained to resident that staff is not permitted to receive any monies from residents and that she must arrange all money transfers involving purchases through facility social worker, resident then asked who was her assigned CNA and said, I'll just ask her to get her drinks from vending area; this nurse asked resident if she could administered IV resident then stated, "You don't know what the f--k you are doing any damn way oh wait a minute, I have to pee; This nurse left room and returned 5 minutes later, resident was still in bathroom. This nurse made 3 more attempts to perform dressing change to wound and administer IV abt (antibiotic) and resident was still in [resident's] bathroom. Resident remained in bathroom for over 1 hour. While resident was in bathroom I informed [resident] that I needed to perform her dressing change to her foot and she said, "you're and idiot, you could have been done it while I was asleep". At 430 am this nurse went to resident's room to remove IV antibiotic that was primed in pump and resident connected IV med on her own without this nurse present and approx. 60cc had infused, this nurse visualized IV ABT to ensure that it was safely connected".

Interview with the Director of Nursing on February 11, 2020, at 8:25 a.m., confirmed that Resident #77 did not receive the antibiotic medication at 2:00 a.m. according to the physician's order.



28 Pa. Code 211.5(f) Clinical Records
Previously cited 3/25/19

28 Pa. Code 211.10(d) Resident Care Policies
Previously cited 3/25/19

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously 3/25/19










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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Resident 33 had no ill effects noted from insulin administration. Resident 77 received IV antibiotic and physician was notified.

Audit of the MARS conducted for any discrepancies and physician notified if indicated.

Licensed staff re-educated regarding signing medications administered at the actual time of administration, and notifying physician if delay in medication administration.

DON/designee will complete 2 medication passes a week x4 weeks, 1 medication pass a week x4 weeks, and randomly thereafter.

Results will be presented at QAPI meeting x3 months.

DON/designee will be responsible. NHA will monitor for compliance.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(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 facility policy, observation, clinical record review, and staff interview it was determined that the facility failed to ensure a smoking assessment was completed for one of two residents.

Findings include:

Review of facility policy "Smoking Policy" revised on May 15, 2018, revealed that "safe smoking evaluations will be completed on admission, readmission, quarterly, and with any significant change in the smoking residents' condition."

Review of smoking assessment for Resident (R11), completed on November 29, 2018, revealed resident must be supervised by staff. On March 1, 2019, a smoking assessment was completed stating resident chose not to smoke. No further smoking assessments/evaluations were completed.

Interview with Resident (R11) on February 11, 2020, at approximately 11:45 p.m., revealed resident is a current smoker.

Observation on February 12, 2020, at approximately 1:38 p.m., revealed resident in smoking area with lit cigarette.

Interview with Director of Nursing on February 13, 2020, at approximately 8:47 a.m., confirmed no evaluation for safe smoking had been completed since November 18, 2018.

Interview on February 13, 2020, at approximately 9:35 a.m. with Employee(E3), revealed staff responsible to supervise residents while in the smoking area are to follow the smoking assessment completed by nursing.

28 Pa. Code 201.18 (b)(1) Management
Previously cited on 3/25/2019

28 Pa. Code 211.10 (d)Resident Care Policy

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited on 3/25/2019





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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Resident 11 smoking assessment completed.

Audit of residents that smoke completed to ensure smoking assessments have been completed.

Licensed staff re-educated on completing the smoking assessment.

DON/designee will audit smoking assessments are completed weekly with the MDS schedule x2 months and randomly thereafter.

Results will be presented at QAPI meeting x3 months.

DON/designee will be responsible. NHA will monitor for compliance.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:


Based on staff interview, it was determined that the facility failed to provide evidence that nurse aides received at least 12 hours of annual in-service education for one of five nurse aides reviewed, and failed to provide evidence that nurse aides received annual performance reviews for three of five nurse aides reviewed.

Findings include:

During the entrance conference on February 10, 2020, at approximately 12:00 p.m., the Nursing Home Administrator and Director of Nursing were asked to provide a list of currently employed nurse aides who had been working at the facility for at least a year and evidence that the nurse aides had received 12 hours of annual in-service education and had received annual performance reviews.

Review of documentation revealed that one of the five nurse aides reviewed had not received 12 hours of annual in-service education and three nurse aides had not received annual performance reviews.

Interview with the Nursing Home Administrator on February 13, 2020, revealed that the facility could not provide documented evidence that nurse aides received at least 12 hours of annual in-service education and that annual performance reviews were completed.



28 Pa. Code 201.20(a)(c) Staff development
Previously cited 3/25/19






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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Identified employee was removed from schedule until education completed. The three identified nurse aides evaluations completed.

An audit completed regarding training and evaluations for nurse aides.

NHA and DON have been educated regarding the requirement that nurse aides have at least 12 hours of annual in service and annual performance reviews are completed.

Payroll Coordinator/designee will audit monthly for evaluations and education completion.

Results will be presented at QAPI meeting x3 months.

Payroll coordinator/designee will be responsible. DON will monitor for compliance.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(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 upon review of facility policy and procedure, review of manufacturer's guidelines, and observation, it was determined the facility failed to ensure that medications were appropriately labeled on one of two medication carts reviewed (North Wing Short Hall medication cart).

Findings include:

Review of facility policy and procedure titled General Dose Preparation and Medication Administration, revised January 1, 2013, revealed "Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g. insulins, irrigation solutions, etc.)".

Review of the manufacturer's guidelines for Novolog Insulin (medication used to treat high blood sugar levels) revealed unopened and unrefrigerated Novolog Insulin should be discarded 28 days after removal from refrigeration.

Review of the manufacturer's guidelines for Humalog Insulin (medication used to treat high blood sugar levels) revealed unopened and unrefrigerated Novolog Insulin should be discarded 28 days after removal from refrigeration.

Review of the manufacturer's guidelines for Levemir Insulin (medication used to treat high blood sugar levels) revealed open, in-use Levemir should be discarded 42 days after opening.

Observation of the North Wing Short Hall medication cart on February 11, 2020, at approximately 9:15 a.m., revealed two unopened and undated Novolog Insulin pens, three opened and undated Levemir Insulin pens, one unopened and undated Humalog Insulin pen, and one open and undated Humalog Insulin vial.

Interview with the Director of Nursing on February 13, 2020 at approximately 8:30 a.m. confirmed that the above medications should have had open dates on the items.


28 Pa. Code 201.18(b)(1) Management
Previously cited 3/25/19

28 Pa. Code 211.9(a)(i)(3) Pharmacy services

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 3/25/19




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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Items were removed from the medication cart and discarded.

House audit conducted to ensure there are no expired or undated medications.
Licensed staff have been re-educated regarding dating of medications when opened and removing expired medication from use.

DON/designee will conduct a weekly audit of the medication carts to ensure no expired or undated medications are available x8 weeks, and randomly thereafter.

Results will be provided at the QAPI meeting x3 months.

DON/designee will be responsible. NHA will monitor or compliance.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based upon review of facility policy and procedures, observation and clinical record review, it was determined that the facility failed to accurately document administered medications according to physician orders for two of two residents reviewed (Resident #33 and Resident #77).

Findings include:

Review of facility policy and procedure titled "General Dose Preparation and Medication Administration", revised January 1, 2013, revealed "Document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given, injection site of a medication, if medications are refused, PRN medications, application sight) on appropriate forms."

Review of Resident #33's diagnosis list revealed diagnoses including diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of Resident #33's February 2020 physician orders revealed an order for Accu check (blood glucose monitoring) four times per day with sliding scale coverage with Admelog (insulin - medication used to treat high blood sugar levels) to be administered at 7:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m.

Further review of Resident #33's February 2020 physician orders revealed an order for Admelog Insulin 10 units to be injected three times a day at 8:00 a.m., 12:00 p.m., and 4:30 p.m.

Review of Resident #33's February 2020 Medication Administration Record (MAR) revealed an Accu check was completed on February 11, 2020, at 7:30 a.m., with a blood sugar result of 234 milligrams per deciliter (mg/dl) which, according to physician's order required insulin coverage of 4 units of Admelog.

Observation of medication administration on February 11, 2020, at 9:25 a.m., revealed Licensed Employee E4 administer Admelog 10 units combined with the Admelog 4 units that was to be administered at 7:30 a.m. when Resident #33's blood sugar level was obtained.

Further review of Resident #33's February 2020 MAR revealed that the Admelog 10 units, which was administered at 9:25 a.m. was signed as administered at 8:00 a.m. on the MAR and the Admelog 4 units, which was administered at 9:25 a.m. was signed as administered at 7:30 a.m.

Interview with the Director of Nursing on February 13, 2020, at 8:25 a.m., confirmed that the MAR should have reflected the actual time the medications were administered.

Review of Resident #77's diagnosis list revealed diagnoses including acute (sudden) osteomyelitis (bone infection) of the right ankle and foot, and diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of Resident #77's February 2020 physician orders revealed an order for Cefepime (antibiotic medication) 2 grams to be administered intravenously (through a catheter in the vein) over 60 minutes every 8 hours with scheduled administration times of 2:00 a.m., 10:00 a.m. and 6:00 p.m.

Review of Resident #77's nursing progress notes dated February 11, 2020 revealed "Resident currently receiving IV (intravenous) Cefepime (antibiotic medication) via RUE (right upper extremity) D/L PICC (peripherally inserted central catheter) line; This nurse went to resident's room at 220am to hang 2am scheduled dose of IV Cefepime and administer resident's 2am PO (by mouth) oxycodone and perform dressing change to resident's foot; resident was asleep, this nurse woke resident and informed her of time and scheduled meds and treatments that I attempted to administer; Resident watched this nurse prime IV tubing and just as I was about to connect her to her IV ABT (antibiotic), resident stated, 'can I give you money so that you can get me drinks out of the employee break room vending machine' , I explained to resident that staff is not permitted to receive any monies from residents and that she must arrange all money transfers involving purchases through facility social worker, resident then asked who was her assigned CNA and said, I'll just ask her to get her drinks from vending area; this nurse asked resident if she could administer IV resident then stated, "You don't know what the f--k you are doing any damn way oh wait a minute, I have to pee; This nurse left room and returned 5 minutes later, resident was still in bathroom. This nurse made 3 more attempts to perform dressing change to wound and administer IV abt (antibiotic) and resident was still in [resident's] bathroom. Resident remained in bathroom for over 1 hour. While resident was in bathroom I informed [resident] that I needed to perform her dressing change to her foot and she said, "you're and idiot, you could have been done it while I was asleep". At 430 am this nurse went to resident's room to remove IV antibiotic that was primed in pump and resident connected IV med on her own without this nurse present and approx. 60cc had infused, this nurse visualized IV ABT to ensure that it was safely connected".

Review of Resident #77's February 2020 MAR revealed that the antibiotic medication was signed as administered at 2:00 a.m. on February 11, 2020.

Interview with the Director of Nursing on February 11, 2020, at 8:25 a.m., confirmed that Resident #77 did not receive the antibiotic medication at 2:00 a.m. according to physician's order, and further confirmed that the February 11, 2020 MAR should have reflected the actual time of medication administration.



28 Pa. Code 211.5(f) Clinical Records
Previously cited 3/25/19

28 Pa. Code 211.10(d) Resident Care Policies
Previously cited 3/25/19

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously 3/25/19



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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Resident 33 had no ill effects noted from insulin administration. Resident 77 received IV antibiotic and physician was notified.

Audit of the MARs conducted for any discrepancies and physician notified, if indicated.

Licensed nursing staff re-educated regarding signing medications were administered at the actual time of administration and notifying physician if delay in medication administration.

DON/designee will complete a 2 medication passes a week x4 weeks, 1 medication pass a week x4 weeks, and randomly thereafter.

Results will be presented at QAPI meeting x3 months.

DON/designee will be responsible. NHA will monitor for compliance.


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