Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-KINGSTON COURT
Patient Care Inspection Results

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MANORCARE HEALTH SERVICES-KINGSTON COURT
Inspection Results For:

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MANORCARE HEALTH SERVICES-KINGSTON COURT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and a complaint survey, completed on January 9, 2020, it was determined that ManorCare Health Services-Kingston Court 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:


483.25 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 on observations, clinical record review, and interviews it was determined that the facility failed to follow physician orders regarding the use of Metoprolol (a medication used to stabilize high blood pressure) with an order date of November 29, 2019, for one of 27 records reviewd (Resident 42).

Review of Resident 42's clinical record revealed diagnoses that included; hypertension (high blood pressure), heart failure (the heart does not pump blood as well as it should), chronic kidney disease (the kidneys don't filter waste and excess fluid from the blood as well as they should) and aphasia (loss of ability to understand or express speech, affects one's ability to communicate).

Review of Resident 42's January 2020 physician orders revealed an order for Metoprolol 25mg (unit of measure) every 12 hours for hypertension, hold for systolic (the top number of the blood pressure reading, refers to the amount of pressure in your arteries during the contraction of your heart muscle) blood pressure less than 110 mm Hg (millimeter of mercury, measurement used to evaluate blood pressure), with a start date of November 29, 2019.

Review of Resident 42's December 2019 Medication Administration Record (MAR, documentation of medications that were administered) revealed that Metoprolol was administered on December 5th when Resident 42's systolic blood pressure was 104 mm Hg, and on December 21st when Resident 42's systolic blood pressure was 104 mmHg.

During an interview with the Nursing Home Administrator on January 9, 2020, at approximately 10:00 AM it was revealed that the blood pressure medication was administered out of parameter per physician order on December 5th and 21st, and should not have been administered.


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

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

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







 Plan of Correction - To be completed: 02/20/2020

- Resident 42 suffered no ill effects from her Metoprolol being administered outside of blood pressure parameters on 12/5/19 or 12/21/19.
- Residents with physician's orders for medications to be given with specific parameters will be reviewed to determine if the medication has been administered within those parameters and appropriate action taken as identified.
- New Admissions and current residents who require medications to be administered within specific parameters have the potential to be affected by the deficient practice. Licensed nurses will be educated on the Medication Administration Medication Pass policy by the Director of Nursing or designee.
- Weekly audits will be conducted weekly x4 weeks by the DON or designee to assess medication administration and blood pressure documentation for Metoprolol. Findings will be provided to the Quality Assurance and Assessment Committee to determine the need for further auditing.

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 on clinical record review and staff interview it was determined that the facility failed to maintain accurately documented and complete resident medical records for one of forty-eight residents reviewed (Resident 101).

Findings Include:

Review of Resident 101's January 2020 physician orders revealed diagnoses including hypertension (elevated blood pressure) and anemia (a condition marked by a deficiency of red blood cells resulting in pallor and weakness).

Review of Resident 101's clinical record revealed the Pennsylvania Orders for Life-Sustaining Treatment (POLST), completed on October 9, 2019, where Resident 101 listed her desire to receive Cardiopulmonary Resuscitation (CPR), in the event she were found without a pulse and not breathing.

Further review of Resident 101's physician orders also revealed Resident 101 to be Full Code Status.

Review of Resident 101's interdisciplinary plan of care revealed a Kardex Report listing her as a Do No Resuscitate (DNR) in the event she were found without a pulse and not breathing.

An interview with the Director of Nursing, on January 9, 2020, at 9:04 AM revealed staff would refer to the Kardex for code status orders and confirmed Resident 101's Kardex and interdisciplinary plan of care should have been updated to reveal her desire for CPR in the event of an emergency.


28 Pa. Code 211.11 (d) Resident care plan
28 Pa. Code 211.12 (d) (5) Nursing services











 Plan of Correction - To be completed: 02/20/2020

- Resident 101's Interdisciplinary Plan of Care and task/kardex list was corrected to reflect her desire to be a Full Code.
- A facility review will be conducted to ensure that residents' POLST, physician's order and Interdisciplinary Plan of Care and task/kardex list are consistent.
- New Admissions and current residents with POLST's have the potential to be affected by the deficient practice. Licensed nursing staff will be educated by the Director of Nursing or designee on accurate documentation requirements for completion of residents' POLST, physician's orders and the Interdisciplinary Plan of Care and task/kardex list completion.
- Weekly audits will be conducted for 4 weeks by the DON or designee to assess consistency of documentation of the resident's POLST, physician's order and Interdisciplinary Plan of Care and task/kardex list. Findings will be provided to the Quality Assurance and Assessment Committee to determine the need for further auditing.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:



Based on observation, facility document review and staff interview it was determined that the facility failed to ensure infection control policies and procedures were implemented to decrease the transmission of infectious disease for two of 7 Halls observed (Halls 2 and 4).

Findings include:

Review of facility document titled, "Clinical Insight," revealed it stated that when a resident is identified as having colonization or active infection of Candida auris (C. auris - "...a drug-resistant fungus") or Carbapenem-resistant Enterobacteriaceae (CRE - bacteria resistant to Carbapenems - a last resort antibiotic which, "..when an individual [bacteria] becomes resistant to Carbapenems there is no other antibiotic to treat them with") According to the document staff are to, "Perform hand hygiene with sanitizer or soap and water; gown and glove prior to entering room. If potential for splashing, wear mask." Review of the facility document revealed that it stated, "...patients diagnosed with active or colonized CRE or C. Auris must remain on contact isolation for their entire stay."

During general observations on January 6, 2020 at approximately 1:23 PM, it was revealed Housekeeper 1 completing housekeeping tasks (mopping floor, removing trash) from a room on the 400 unit. Observation of the room doorway from the hallway revealed a magnetic notice that instructed visitors to speak to the unit nurse prior to entering the room. To the right of the doorway (observed from the hallway) was a small plastic container which contained Personal Protective Equipment (items such as disposable gowns, masks, gloves, etc to be worn to prevent the spread of infection disease). Observations of Housekeeper 1 revealed no PPE (gloves, gown, mask) were worn by Housekeeper 1. An interview with LPN 1, at approximately 1:25 PM, revealed the room was under contact precautions (precautions which include wearing PPE while entering the room to decrease the transmission of an infectious disease).

At approximately 1:30 PM, Housekeeper 1 left the room on the 400 unit. Housekeeper 1 then walked down and entered an occupied room on the 200 unit. Housekeeper 1 did not perform hand hygeine. At approximately 1:32 PM, Housekeeper 1 exited the room with a bag of trash from the room.

During a staff interview on January 9, 2020 at approximately 9:30 AM, the Nursing Home Administrator revealed that Housekeeper 1 should have utilized PPE when in the room under contact precautions. During a staff interview on January 9, 2020 at approximately 11:45 AM, the Director of Nursing revealed that both residents in the room, Housekeeper 1 was cleaning while not wearing PPE, had positive swab tests for C. Auris. The Director of Nursing revealed that staff should be utilizing PPE and guidelines from the aforementioned facility document.


28 Pa code 211.12(d)(3) (5) Nursing services




 Plan of Correction - To be completed: 02/20/2020

- Housekeeper 1 has been re-educated on contact precaution requirements including PPE usage and hand hygiene protocols.
- A facility review will be conducted to ensure residents with isolation precaution requirements have necessary PPE and hand washing supplies available for use, as well as appropriate signage outside of resident room door.
- New Admissions and current residents who require isolation precautions have the potential to be affected by the deficient practice. Housekeeping staff will be educated by the DON or designee on proper isolation precaution procedures including PPE usage and hand hygiene protocols.
- Weekly audits will be conducted for 4 weeks to assess the correct usage of appropriate PPE and hand hygiene for residents on isolation precautions. Findings will be provided to the Quality Assurance and Assessment Committee to determine the need for further auditing.


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