Pennsylvania Department of Health
CATHEDRAL VILLAGE
Patient Care Inspection Results

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CATHEDRAL VILLAGE
Inspection Results For:

There are  87 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.
CATHEDRAL VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on August 4, 2022, it was determined that Cathedral Village 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 related to the health portion of the survey process.



 Plan of Correction:


483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on observation, review of facility policy, and interview with staff and residents, it was determined that the facility did not ensure that residents needs were met related to call bell placement for one of 18 clinical records reviewed (Resident R55 ).

Findings include:

Review of facility policy "Call Bell Response," dated February 16, 2021, revealed that staff is to "keep the call bell within resident reach at all times."

Observations conducted on August 2, 2022, at 12:32 p.m. revealed that Resident R55 was lying in bed and that her call bell was not within her reach; it was hung on the wall several feet from her bed. The resident revealed that she was unable to transfer herself from the bed due to chronic pain and stiffness in her hips.

Interview with Licensed nurse, Employee E15 at 12:35 p.m. confirmed that the call bell was not in reach of the resident, and that this was not facility policy.


28 Pa. Code: 201.29(j) Resident rights

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

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



 Plan of Correction - To be completed: 09/15/2022

A. R55 call bell placed within reach while in her room. No negative outcomes noted.
B. An audit of current residents was performed to ensure that residents had a call bell within their reach while in their room.
C. Licensed staff and Certified Nursing Assistants were reeducated on the importance of keeping resident call bells within a residents reach while in their rooms.
D. The NHA or designee will complete an audit of 5 current residents weekly x 4 and then monthly X 2 to ensure resident call bells are within their reach while in their room. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review recommendations, to include ensuring successful evaluation.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:

Based on observation, review of facility policy and interviews with staff, it was determined that the facility did not ensure that professional standards were maintained during medication administration for three of five residents observed (R19, R52, and R50).

Findings include:

According to Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, section 21.145. Functions of the LPN (Licensed Practical Nurse), subsection (a), "The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency."

Review of facility policy "Preparation and General Guidelines," undated, section IIA2 "Medication Administration-General Guidelines" revealed that "medications are not pre-poured either in advance of med pass or for more than one resident at a time."

Observation of medication administration was conducted on August 4, 2022, at 7:51 a.m. Licensed nurse, Employee E8 was in the process of administering medications to the residents on the unit when the surveyor approached the medication cart. Three unlabeled medication cups were noted to be on the top of the cart, each containing pills. Licensed nurse, Employee E8 also had one cup in his hand which he stated he had just finished preparing for Resident R42. Licensed nurse, Employee E8 was able to identify which cup contained medications for each of the residents they had been prepared for (R19, R52, and R50), as well as which pills were in each cup. This was confirmed with the electronic record by Employee E8 and the surveyor. The cups were then labeled with the resident names.

Licensed nurse, Employee E8 then walked away from the medication cart to administer medication to Resident R42, leaving the other three cups of pills unsecured on the top of the cart. He returned to the cart and then recovered the cup of medicine for Resident R50. Licensed nurse, Employee E8 then walked into Resident R50's room to administer medication again leaving the other two cups unsecured on the top of the cart. Upon return to the cart, Licensed nurse, Employee E8 retrieved one cup, and secured the final cup in the medication cart.

Interview with the Director of Nursing on August 4, 2022, at 10:30 a.m. confirmed that it was against facility policy to pre-pour medications or to leave medication unattended and unsecured during medication administration.

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

28 Pa. Code 211.10(c) Resident care policies

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

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




 Plan of Correction - To be completed: 09/15/2022

A. Residents R19, R52 and R50 received their medication with no ill effects.
B. Employee 8 received immediate re-education on Medication Administration policy which includes not pre pouring medications and leaving medications unsecured.
C. Licensed nursing staff was re-educated on the Medication Administration policy which includes not pre pouring medications and leaving medications unsecured.
D. DON/Designee will perform a random audit of 3 Licensed Nursing staff during medication administrations, weekly x4 and monthly x2 to ensure medications are not being pre poured and medications are not left unattended. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observations, review of clinical records, and interview with staff and residents, it was determined that the facility failed to maintain adequate grooming for a dependent resident for one of 18 residents reviewed (Resident R60).

Findings include:

Review of Resident R60's clinical record revealed the resident had diagnoses of hemiplegia (paralysis of the muscles on one side of the body) affecting right side, muscle weakness, lack of coordination, need for assistance with personal care, and contracture (permanent tightening of the muscles) of right lower leg, right/left hand, and right/left shoulder.

Review of Resident R60's Quarterly Minimum Data Set (MDS - assessment of care needs) dated June 28, 2022, revealed the resident was cognitively intact and required at least 1-person physical assistance with personal hygiene.

Observations on August 1, 2022, at 11:15 a.m. revealed Resident R60 had very long fingernails with dark substance underneath a few nails. Interview with Resident R60 revealed they would like to have their fingernails trimmed and cleaned.

Follow-up observations on August 3, 2022, at 11:45 a.m. revealed Resident R60's nails were still very long and dirty underneath the nail. Interview with Resident R60 again revealed that they would like to have their fingernails trimmed and cleaned.

Review of Resident R60's clinical record and point of care daily charting for May, June, July, and August 2022 revealed no documented evidence that the resident refused assistance with personal hygiene.

Interview with the Nursing Home Administrator, Employee E1, on August 3, 2022, at 12:45 p.m. confirmed that Resident R34 needed their fingernails trimmed and cleaned.

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

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





 Plan of Correction - To be completed: 09/15/2022

A. Resident R60 had their fingernails cleaned and trimmed. Resident R60 had no negative outcomes.
B. An audit of current residents' fingernails who are dependent and require assistance with nail care was completed. No variances were noted.
C. Licensed nursing staff and Certified Nursing assistants were re-educated on the importance of providing nail care to dependent residents, and to ensure appropriate documentation in the resident record is reflective of resident's needs and preference.
D. DON/Designee will conduct a random audit of 3 dependent residents' nails weekly X 4 weeks, then monthly x 2 months to ensure nail care has been provided and documented appropriately in the resident record. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation.


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and 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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to ensure that necessary treatment was provided to promote wound healing for one of one sampled resident reviewed with pressure ulcer (Resident R50).

Findings include:

Review of Resident R50's clinical record revealed the resident was admitted to the facility on April 17, 2020, and had diagnoses of hemiplegia left side dominant (paralysis of one side of the body), dysphagia (swallowing difficulty), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).

Review of Resident R50's care plan revealed the resident had fragile skin and was at risk for pressure ulcers and skin tears.

Review of June 2022 Medication Treatment Administration Report revealed an order to apply barrier cream to buttocks in the morning.

Review of Resident R50's skin-check dated June 19, 2022, revealed a moisture ulcer (MASD- moisture associated skin damage) was identified on the residents left gluteal fold. Review of Resident R50's June 2022 Treatment Administration Record, revealed a physician order on June 19, 2022 to apply protective cream to MASD on left gluteal fold.

Interview with the Director of Nursing, Employee E2, on August 4, 2022, at 2:00 p.m. revealed this documentation was an error and the wound was identified on Resident R50's right gluteal fold not the left gluteal fold.

Review of Resident R50's wound consult dated June 23, 2022, by the Nurse Practitioner Wound Consultant, Employee E4, confirmed the resident was assessed for an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed) of the right gluteal fold, which originated as MASD. New interventions included to apply medical grade honey (medihoney) to wound base daily and as needed.

Review of Resident R50's wound consult dated July 7, 2022, by Employee E4, again included interventions to apply medical grade honey to the wound base daily and as needed.

Review of Resident R50's treatment administration record for June and July 2022 revealed treatment orders were delayed and inaccurately transcribed on July 7, 2022. Review of treatment orders dated July 7, 2022, indicated to apply medihoney to the right gluteus three times a week, instead of daily as recommended.

Interview with the Director of Nursing on August 4, 2022, at 2:00 p.m. confirmed the delay in and inaccurate transcription of treatment orders from wound consult recommendations on June 23, 2022, and July 7, 2022.

Review of Resident R50's wound consult dated July 14, 2022, by Employee E4, revealed recommendations to adjust wound treatment orders and apply Santyl ointment to wound base daily.

Review of Resident R50's treatment administration record revealed physician orders dated July 14, 2022, for application of Santyl ointment daily and discontinuation of medihoney 3x/week.

Observations on August 4, 2022, at 9:45 a.m. revealed Registered Nurse, Employee E3, completed Resident R50's wound treatment. Observations during wound care revealed Employee E3 applied Medihoney instead of the Santyl ointment as ordered.

Interview with Licensed nurse, Employee E3 on August 4, 2022, at 2:00 p.m. confirmed Santyl ointment should have been used for wound treatment.

28 Pa. Code 211.10(c) Resident care policies

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

28 Pa. Code 211.5(f) Clinical records.






 Plan of Correction - To be completed: 09/15/2022

A. Resident R50 had the appropriate wound treatment administered. No ill effects were noted.
B. Employee E4 was reeducated on the 5 Rights to ensure that the appropriate physician/physician extender ordered wound treatment is applied to the appropriate resident.
C. Licensed staff to be reeducated on the 5 Rights to ensure that the appropriate physician/physician extender ordered wound treatment is applied to the appropriate resident.
ADON to conduct a random audit of 2 licensed staff weekly X4 and then monthly X2 to ensure physician /physician extender ordered wound treatments are applied to the appropriate resident. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on observation, review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to assess and implement interventions to ensure acceptable parameters of nutritional status for three of 18 residents reviewed (Resident R37, R47, and R50).

Findings Include:

Based on review of facility policy "Weights" last reviewed July 29, 2019, revealed the objective is to assure all residents are weighed and that action is taken when variances occur. Variances of plus or minus 5 pounds or more for residents over 100 pounds, or plus or minus 3 pounds for residents under 100 pounds require a re-weigh within 24 hours and a report to the physician, dietitian, and responsible party. The dietitian is responsible to assess the resident to determine why the change occurred and initiate approaches to remedy the change in weight.

Review of Resident R37's clinical record revealed the resident had diagnoses of muscle weakness, anxiety disorder (feeling of fear, dread, and uneasiness), and lack of coordination.

Review of Resident R37's care plan dated May 24, 2022, revealed the resident had altered nutritional status related to malnutrition (lack of proper nutrition caused by not eating enough or being unable to use the food that one does eat), recent history of weight loss, underweight status, and limited mobility. Interventions dated May 31, 2022, included 1 ounce (oz.) of ProSource (nutritional supplement) twice per day and 4 oz. of Ensure Plus (nutritional supplement) each shift with medications.

Review of Resident R37's weight history revealed documented weights on April 1, 2022, of 80.5 pounds(lbs.) and a confirmed weight on April 4, 2022, of 80.4 lbs. Continued review of Resident R37's weight history revealed a documented weight on May 10, 2022, of 72 lbs, representing a weight loss of 11.6% and 8.4 pounds (lbs) over the course of 1 month. Review of clinical record revealed no documented evidence that the registered dietitian was made aware of the resident 8 pounds weight loss. Another weight was obtained on May 31, 2022, of 71 lbs. confirming significant weight loss.

Review of Resident R37's clinical record revealed the severe weight loss was not addressed by the Registered Dietitian until May 31, 2022. Review of documentation by Registered Dietitian, Employee E9, dated May 31, 2022, revealed new interventions to add 4 oz. Ensure Plus with each shift and increase frequency of ProSource nutritional supplement to twice per day. Review of Resident R37's medication administration record revealed no documented evidence supplements were implemented.

Review of Resident R37's nutrition assessment by Registered Dietitian, Employee E10, dated June 2, 2022, revealed the resident denied additional supplementation. Employee E10 recommended a new intervention of weekly weights for monitoring. Review of Resident R37's clinical record revealed no documented evidence weekly weights were completed as recommended.

Review of Resident R47's clinical record revealed the resident had diagnoses of muscle wasting, contracture (tightening of the muscles) of right shoulder, and dysphagia (swallowing difficulty). Review of the resident's care plan dated April 4, 2022, revealed the resident had potential risk for altered nutritional status related to dementia, mechanically altered diet, and chewing/swallowing difficulty.

Review of Resident R47's nutrition assessment by Registered Dietitian, Employee E10, dated June 21, 2022, revealed a goal that the resident's weight wound be maintained at 220 lbs. +/-3% over 90 days.

Review of Resident R47's weight history revealed documented weights on June 1, 2022, of 220 lbs. and on July 1, 2022, of 206.4 lbs. Documented weights reflected a weight loss of 6.5% and 13.6 lbs. over the course of 1 month. Review of Resident R47's clinical record revealed no documented evidence staff made the Registered Dietitian aware of the weight loss or obtained a re-weigh after loss on July 1, 2022.

Review of Resident R47's clinical record revealed the Registered Dietitian did not address the resident's weight loss until July 19, 2022. Review of documentation by the Registered Dietitian, Employee E16, dated July 19, 2022, revealed Resident R37 was eating 50-100% of meals and added new interventions to provide Ensure one time per day and weigh weekly for four weeks.

Review of Resident R50's clinical record revealed the resident had diagnoses of dysphagia, irritable bowel syndrome (disorder affecting the large intestine including cramping, abdominal pain, bloating, gas, and diarrhea), hemiplegia left side (paralysis of one side of the body), and major depressive disorder (persistent feeling of sadness and loss of interest). Review of the resident's care plan dated May 4, 2022, revealed the resident was at risk for altered nutrition status related to self-feeding difficulty, anxiety, and recent history of weight loss.

Review of Resident R50's weight history revealed a documented weight on May 3, 2022, of 122 lbs and on June 1, 2022, of 115.3 pounds. Documented weights reflected a significant weight loss of 5.8% and 6.7 lbs over the course of 1 month. A reweigh was not obtained until June 7, 2022, with a documented weight of 114.4 lbs confirming the significant weight loss.

Review of Resident R50's clinical record revealed documentation by the Registered Dietitian, Employee E9, dated June 6, 2022, that new nutrition interventions were implemented and included updated food preferences to promote food intakes. Resident R50's food preferences included banana's and to provide orange juice at each meal.

Observations on August 4, 2022, at 9:30 a.m. revealed Resident R50 did not get a banana and orange juice with breakfast as recommended by the Registered Dietitian and as indicated on the resident's meal ticket. Observations revealed the resident was instead provided with apple juice. Observations were confirmed by Registered Nurse, Employee E5.

Interview with Resident R50 on August 4, 2022, at 9:30 a.m. revealed that the resident did not like the apple juice and requested that staff provide the orange juice and banana.

28 Pa. Code 211.5 (f) Clinical records

28 Pa. Code 211.6 (d) Dietary services

28 Pa. Code 211.12 (c)(5) Nursing Services








 Plan of Correction - To be completed: 09/15/2022

A. Resident R37 and R47 were reweighed and documented, dietitian was made aware of resident R37 and R47 weight loss. Interventions were put into place. Care plans and Medication Administration records were updated. R50 had a reweight completed and documented, dietary was made aware of resident preferences. No additional interventions were put into place for R37, R47, and R50.
B. An audit was completed of current residents to ensure reweights were completed timely, dietitian was notified of any weight loss, and appropriate interventions were put into place in per Weight policy. An additional audit was completed on current residents with weight loss to ensure resident preferences are offered by dietary
C. Licensed nursing staff and registered dietitian will be reeducated on the Weight policy. Dining staff will be reeducated on resident food preference accuracy prior to offering meal.
D. DON/designee will conduct random audits of 3 current residents weekly X4 and then monthly X2, to ensure reweights are completed timely if appropriate, dietitian notification of weight loss is timely and interventions are put into place per weight policy. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation.
Dining Director/designee will conduct a random audit on 3 current residents with weight loss weekly X4 and then monthly X2 to ensure resident preferences are being offered by dietary. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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.
483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:

Based on observations, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure adaptive equipment was available during dining services for one of 18 residents reviewed (Resident R34).

Findings include:

Review of Resident R34's clinical record revealed the resident had diagnoses of contracture (permanent tightening of the muscles) of left hand, generalized muscle weakness, and hemiplegia (paralysis of the muscles on one side of the body) affecting left side.

Continued review of Resident R34's clinical record revealed a care plan dated May 16, 2022, that indicated the resident was at potential risk for dehydration and altered nutritional status related to limited mobility and self-feeding difficulty. Interventions included to provide adaptive equipment as recommended by occupational therapy.

Review of Resident R34's quarterly Minimum Data Set (MDS - assessment of resident care needs) dated May 22, 2022, revealed the resident had range of motion impairments to bilateral upper extremities.

Review of nutrition assessment dated May 31, 2022, by Registered Dietitian, Employee 9, revealed Resident R34 required adaptive equipment with meals including a blue weighted mug for hot drinks and a sippy cup for cold drinks.

Review of adaptive equipment report for all dining locations confirmed Resident R34 was on the list for a sippy cup with lid.

Observations during the lunch time meal service on August 2, 2022, at 12:45 p.m. revealed Resident R34 was not provided a sippy cup for cold beverages as indicated on the meal ticket. Resident R34 reported the sippy cup is rarely provided, but that it would be easier to use for beverages due to her limited mobility. Observations were confirmed by Registered Nurse, Employee E7.

Follow-up observations during the lunch time meal service on August 3, 2022, at 1:15 p.m. revealed Resident R34 was not provided with a sippy cup for cold beverages as indicated on the meal ticket. Resident R34 continued to express that a sippy cup would be easier to use. Observations were confirmed by nursing assistant, Employee E6.

28 Pa. Code 201.18 e (1) Management.

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

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





 Plan of Correction - To be completed: 09/15/2022

A. Resident R34 was given a sippy cup with a lid at the observed lunch meal. Resident R34 did not experience any noted ill effects.
B. Dining Director/designee conducted an audit of current residents who are to be provided a lidded sippy cup during meal times to ensure residents are receiving the appropriate adaptive equipment. No variances were noted.
C. Dining staff will be reeducated on proper distribution of lidded sippy cups during meal times.
D. Dining Director/designee will conduct a random audit of 3 residents during mealtimes weekly x4, then monthly x2 to ensure residents who require a sippy cup with a lid are receiving the appropriate adaptive equipment. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation.

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 observations, review of facility policy, review of clinical records, and staff interview, it was determined that the facility failed to maintain effective infection control prevention practices for hand hygiene during wound treatment to prevent spread of infection for one of one wound treatment observed (Resident R50).

Findings include:

Review of facility policy "Hand Hygiene" revealed hand hygiene is the most important infection control measure to prevent illness in skilled nursing facilities. Hands should be sanitized or washed before and after direct resident contact, before and after each procedure or task, and after contact with excretions (any bodily fluid).

Review of Resident R50's clinical record revealed the resident developed a new area to her right gluteal fold on June 19, 2022.

Observations on August 4, 2022, at 9:45 a.m. revealed Registered Nurse, Employee E3, completed Resident R50's wound treatment. Observations during wound care revealed Registered Nurse, Employee E3 removed a soiled dressing from the gluteal wound and cleaned the barrier cream from the wound. Upon completion of the task, Registered Nurse, Employee E3 put on a pair of new gloves and did not use hand sanitizer or soap and water after handling the soiled dressing and continued to apply a clean dressing to the resident's wound.

Upon completion of wound care, findings were reviewed and confirmed with Registered Nurse, Employee E3.

28 Pa. Code 211.10(c) Resident care policies

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




 Plan of Correction - To be completed: 09/15/2022

A. Resident R50 did not have ill effects from deficient practice.
B. Employee E3 was reeducated on the Hand Hygiene policy and its role in wound care.
C. Licensed staff were reeducated on the "Hand Hygiene" policy with a focus on wound care and dressing changes.
D. ADON will conduct an audit of 5 random staff members weekly X4 and then monthly X2 to ensure hand hygiene is performed appropriately during wound care dressing changes. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation
DON/designee to conduct an audit of the ADON X2 weekly and then X2 monthly to ensure ongoing ADON compliance with hand hygiene during wound care. Audit findings will be forwarded monthly to the Quality Assurance Process Improvement team for review and recommendations, to include ensuring successful evaluation.


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