Nursing Investigation Results -

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

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WEATHERWOOD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  105 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.
WEATHERWOOD HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit and abbreviated complaint survey completed on January 29, 2020, it was determined that Weatherwood Healthcare and Rehabilitation Center corrected the federal deficiencies cited during the surveys ending November 13, 2019, and December 11, 2019, but continued to be out of 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.





 Plan of Correction:


483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
483.80(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:


Based on a review of clinical records and staff interview it was determined that the facility failed to maintain a system to effectively monitor antibiotic usage for five of seven sampled residents (Residents 3,4,5,6,7).

Findings include:

At the time of the survey ending January 30, 2020, there was no facility policy and established procedures for Antibiotic Stewardship available to the survey team.

A review of a facility C-Diff (Clostridioides difficile - bacteria that causes diarrhea) Tracker for Area 2, revealed that on December 26, 2019, Resident 1 developed diarrhea; on December 24, 2019, Resident 2 developed diarrhea and Resident 3 developed diarrhea on December 28, 2019. Stool samples for C-Diff were collected and sent to the lab.

Lab results for Residents 1 and 2, dated December 27, 2019 were noted positive for C-Diff. The physician was notified and both residents were placed on Vancomycin ( an antibiotic medication) 125 mg, by mouth, four times a day for 10 days.

Resident 3 was noted to be positive on December 30, 2019, and the resident was also prescribed Vancomycin 125 mg QID for 10 days.

A review of Resident 1 and 2's Medication Administration Records (MAR) dated December 27, 2019, through January 6, 2020, revealed that the resident received 10 days of the antibiotic medication therapy

A review of Resident 3's Medication Administration Record (MAR) dated December 30, 2019, through January 9, 2020, revealed that the resident received 10 days of the antibiotic therapy.

Further review of the tracking form revealed that on December 28, 2019, Resident 4 developed diarrhea. A stool sample was sent to the lab on that date and Vancomycin 125 mg by mouth QID, for 10 days was initiated.

A review of Resident 4's MAR for December 2019, revealed that Resident 4 received 8 of Vancomycin 125 mgs from December 29, 2019, through December 31, 2019.

A review of a lab report results dated December 30, 2019 revealed that Resident 4 did not have a C-Diff infection and received the Vancomycin unnecessarily.

A review of the tracking form revealed that on December 29, 2019, Resident 5 presented diarrhea and a stool sample was sent to the lab on that date. Vancomycin 125 mg by mouth QID, for 10 days, was initiated at that time.

A review of Resident 5's December 2019 MAR revealed that the resident received 8 doses of the antibiotic medication between December 29, 2019, and December 31, 2019.

A review of a lab report results dated December 30, 2019, revealed that Resident 5 did not have a C-Diff infection and received the Vancomycin unnecessarily.

A review of the tracking form revealed that on December 27, 2019, Resident 6 displayed diarrhea. A stool sample was sent to the lab on that date and the resident was started on Vancomycin 125 mg by mouth QID for 10 days.

A review of the resident's MAR for December 2019, revealed that Resident 6 received 6 doses of the antibiotic medication between December 29, 2019 and December 31, 2019.

The resident's January MAR revealed that Resident 6 received 32 doses of the antibiotic.

A review of a lab report results dated December 30, 2019, revealed that Resident 6 did not have a C-Diff infection and received the Vancomycin unnecessarily.

Further review of the tracking form revealed that on December 28, 2019, Resident 7 had diarrhea and a stool sample was sent to the lab on that date. Vancomycin 125 mg by mouth, QID, for 10 days was also initiated.

Resident 7's MAR for December 2019, revealed that Resident 7 received 8 doses of the antibiotic medication between December 29, 2019 and December 31, 2019.

A review of a lab report results dated December 30, 2019 revealed that Resident 4 did not have a C-Diff infection and received the Vancomycin unnecessarily.

During an interview January 29, 2020 at approximately 2 PM the Director of Nursing confirmed that there was no current antibiotic stewardship program in the facility.

Refer F880


28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
previously cited 12/11/19, 11/13/19, 10/1/19, 6/14/19

28 Pa. Code 211.2(a) Physicians services

28 Pa. Code 211.10(a) Resident care policies















 Plan of Correction - To be completed: 02/19/2020

1. The facility cannot retroactively correct the antibiotic usage for R3, R4, R5, R6 and R7 as those residents are currently not receiving antibiotics for a current infection and had no negative effects.
2. The facility will conduct an audit on current residents receiving antibiotics for C. Difficile to ensure that those antibiotics were prescribed following the guidelines outlined in the facilities antibiotic stewardship program.
3. The facility will re-educate its licensed nursing staff and attending physicians on the antibiotic stewardship program to ensure that residents with infections are prescribed antibiotics that follow its guidelines.
4. The facility will conduct random weekly audits x4 weeks, then monthly x 2 months on residents receiving antibiotics to ensure those antibiotics were prescribed per guidelines outlined in the antibiotic stewardship program. Those results will be brought to the facilities monthly QAPI meeting.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.80 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 review of the facility's infection control log and staff interview, it was determined that the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility.

Findings include:

A review of the facility's infection control data revealed that the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner.

A review of facility infection control logs for September 2019 through January 2020 revealed that the logs contained no documented evidence how the facility tracked infections and of any trends contained in this tracking data. There was also no evidence of the measures the facility had developed and implemented among staff and residents to deter the spread of any of infection.

There was no documentation of the resolution date for many of the infections noted in the facility's monthly infection control tracking logs.

There was no indication that the limited data that was compiled was then evaluated to determine what could be done to prevent the spread or recurrence of infection.

Interview with the Director of Nursing on January 30, 2020, revealed that the DON was unable to provide evidence of the development and implementation of an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible.



Refer F881



28 Pa. Code 211.12 (c) Nursing services
Previously cited 12/11/19, 11/13/19, 10/01/19, 6/14/19

28 Pa. Code 211.10 (a)(d) Resident care policies
previously cited 11/13/19, 6/14/19











































































 Plan of Correction - To be completed: 02/19/2020

1. The facility will implement an infection prevention and control program that monitors as well as prevents infections in the facility.
2. By implementing an infection and prevention control program the facility will have accurate log books documenting that the program is in place which in-turn positively affects current residents that are affected by infections.
3. The facility will re-educate its nursing department on the infection prevention and control program to ensure the program stays in place.
4. The facility will audit on a weekly basis x4 weeks, then monthly x 2 months its infection control logs and surveillance records to ensure that the records are accurate and up to date per program guidelines. Those results will be brought to the facilities monthly QAPI meeting.

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 on clinical record review and staff interview, it was determined that the facility failed to timely notify the physician of a significant weight loss for one of two sampled residents (CR 1).

Findings include:

A review of the clinical record revealed that Resident (CR 1) was admitted to the facility on November 5, 2019, and had diagnoses that included hypertension and cancer of the right lung.

A review of the resident's weight record revealed the following recorded weights:

November 5, 2019 (9:35 PM) - 188.8 lbs
November 5, 2019 (10:59 PM) -188.8 lbs
November 13, 2019 173.0 lbs - a 15.8 lbs weight loss (8.4%) in 8 days.
November 26, 2019 161.1 lbs - a 11.9 lbs weight loss (11.9%) in 13 days.

The resident lost a total of 27.7 lbs or 14.7% loss of body weight in less than one month.

There was no documented evidence that the physician was notified of the resident's significant weight losses recorded on November 13, 2019, and November 26, 2019.

Interview with the Nursing Home Administrator on January 29, 2020, at approx. 3:45 p.m., confirmed that the physician was not notified timely of the resident's significant weight loss.

Refer F692

28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing services
Previously cited 1/14/19, 3/7/19





 Plan of Correction - To be completed: 02/19/2020

Submission of our plan of correction does not constitute an admission or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care for our residents and to comply with all applicable and state and federally regulatory requirements.

1. The facility is not able to retroactively correct the physician notification for CR1 as this resident has passed away.
2. The facility will complete an audit of current residents to identify those who have had a significant weight loss in the last 14 days and validate the physician has been notified of that weight loss.
3. The DON/Designee will re-educate the licensed nursing staff on the policy for notifying the physician when a resident has a significant weight loss.
4. The facility will complete random weekly audits of residents x4 weeks, then monthly x 2 months to verify that residents who have a significant weight loss, also had their physician notified. The results of the audits will be brought to the facilities monthly QAPI meeting.

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 observations, a review of clinical records and resident incident/accident reports and staff and resident interview, it was determined that the facility failed to provide adequate staff supervision to prevent an elopement by one resident (Resident 7) out of 15 residents reviewed.

Findings include:

A review of the clinical record revealed that Resident 7 was admitted to the facility on December 21, 2019, with diagnoses to include dementia with behavioral disturbance.

An admission Minimum Data Set Assessment (MDS -a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 27, 2019, indicated that the resident was severely cognitively impaired according to the resident's BIMS score (The BIMS is an assessment conducted periodically to assess cognition over time) and was able to ambulate with limited supervision, in the hallways of the locked dementia unit on which he resided within the facility.

Nursing admission documentation dated December 21, 2019, at 3:44 PM revealed that Resident 7 was at potential risk for elopement.

A review of the resident's plan of care for elopement risk related to exit seeking behaviors, initiated December 21, 2019, revealed a goal that the resident will not leave the facility unattended. Planned interventions at that time were to ask family members/visitors to notify staff when leaving following a patient visit and when he is exhibiting exit seeking behavior, redirect him to an appropriate area and provide supervision.

A review of nursing documentation dated December 21, 2019, at 10:10 PM revealed that Resident 7 was oriented to his room and the call bell system and was exit seeking. A Wanderguard bracelet (a system to prevent a resident with exit seeking behaviors from exiting an area, the resident wears a monitoring bracelet on the wrist or ankle. When this resident approaches a door with the corresponding sensor, the door will alarm and or lock, preventing the resident from exiting the building) was applied to Resident 7's right wrist.

Nursing documentation dated December 23, 2019, at 1:32 PM revealed that Resident 7 was exit seeking and standing by the exit doors (of the locked unit). Again on December 26, 2019 at 10:24 PM it was noted that Resident 7 was exit seeking on the unit.

This continued exit seeking behavior continued throughout the month of December 2019, according to nursing documentation.

On January 1, 2020, at 2:03 PM nursing documentation indicated that Resident 7 walked out of the lock dementia nursing unit behind a guest exiting the unit doors. A therapy staff member returned Resident 7 to the dementia unit when the staff member discovered the resident in the lobby area of the facility.

Nurses notes dated January 2, 2020, at 1:49 PM revealed that Resident 7 displayed "high anxiety" this shift and multiple attempts to exit the area. Nursing noted that the resident "runs for the door when he hears the code typed in (the exit doors to the unit require a code typed into the keypad to open the doors)." Nursing documentation dated January 3, 2020, through January 8, 2020, indicated that this resident made multiple attempts to exit the nursing unit.

A review of a facility investigation report and information dated January 9, 2020, at 12:55 PM submitted by the facility revealed that at approximately 1:03 PM the Wanderguard panel alarmed for the main entrance of the building. According to the report, Resident 7 was last seen on the secured dementia unit at approximately 12:55 PM. At 1:05 PM a code purple an elopement in the facility) for elopement was sounded. At approximately 1:08 PM staff found the resident outside the front main entrance to the facility walking up the sidewalk. Upon facility investigation, it was revealed that a visitor had let Resident 7 out the front door. The resident was promptly returned to the building and to his room. However, further facility investigation revealed that an activity staff member explained that at approximately 12:55 PM Employee 1 (activity aide) entered the front doors of the locked dementia unit and allowed Resident 7 to exit the door not recognizing him as a resident.

A review of a witness statement (no date or time indicated ), Employee 1 (activity aide) revealed that "at approximately 12:55 PM I was coming into area 2 (locked dementia unit) to do emotional support visits. I saw a gentleman with a plastic bag and clothes in his hand. I thought he was a visitor taking clothes that don't fit a resident anymore. I allowed him to exit through the door. I walked around the unit and realized that it was a bad time (to be on the unit for visits) because the residents were eating. As I was going to exit the doors, there was a nurse aide looking for Resident 7. Then I realized that I may have been the reason why this was happening. So I asked what the resident looked like and if he had a plastic bag with him. The nurse aide said yes. At this point, I went to area 1 and noticed that the wanderguard system was going off at the front door. I told the nursing home administrator what happened and a code purple was called. When I let him out, he didn't seem like he had dementia. He was walking normal."

Employee 1 (activity aide) was suspended at that and terminated from employment on January 20, 2020.

A review of an employee employment record revealed that Employee 1 (activity aide) was hired at the facility on June 7, 2019, as a "helping hands" employee ( assists nursing staff with ancillary, non nursing duties). He attended nurse aide training and was promoted to nurse aide on October 8, 2019, and received his nurse aide certification on November 1, 2019.

A review of Employee 1's nursing assistant orientation (no date or time indicated), however, revealed that Employee 1 received mostly unsatisfactory scores on the evaluation list to include, "needs to be told to check his residents, not completing his facility training, education requirements and was noted to sit behind the nurses station a lot, needs to be told what to do all the time, can not do an assignment independently. He still can not remember resident's name/faces."

Facility human resources documentation dated December 10, 2019, revealed that Employee 1's job was changed from a nurse aide to an activity aide.

Interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on January 29, 2020, at approximately 2 PM revealed that the locked dementia unit has an "elopement risk" book with pictures and descriptions of the residents at risk for elopement from the dementia unit. The NHA stated that Employee 1 (activity aide) was not familiar with the elopement risk book or the need to familiarize himself with the contents prior to working with the residents on the unit. The NHA also confirmed that this employee allowed Resident 7 to exit the locked dementia unit and subsequently a visitor to the facility allowed him to exit the building.


28 Pa. Code 201.20(b) Staff development

28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services
Previously cited 7/27/18, 3/6/18, 11/28/17, 9/20/17, 8/3/17




















































 Plan of Correction - To be completed: 02/19/2020

1. The facility terminated the employment of employee 1 who allowed R7 to exit the dementia unit.
2. The facility will complete an audit of current residents on locked dementia unit to identify those who wear a wanderguard bracelet to ensure their pictures are up to date in the facilities elopement books. The facility will place signs on the locked dementia unit to remind staff and visitors to be aware of residents trying to leave the unit.
3. The facility will educate its employees on the guidelines for the elopement book, identification of residents who are at high risk for elopement, and procedure for entering the locked dementia unit.
4. The facility will conduct random weekly audits x4 weeks then monthly x 2 months of the elopement books to ensure they are up to date with resident pictures. The facility will also conduct random weekly audits x 4 weeks then monthly x 2 monthly of employees to verify they understand the procedure to enter the lock dementia unit and understanding of the elopements books for identifying residents of high elopement risk. The results will be brought to the facilities monthly QAPI meeting.


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 clinical record review, and staff interview, it was determined that the facility failed to timely implement measures to improve nutritional parameters and deter further weight loss for one of two sampled residents (CR1).

Findings include:

A review of the clinical record revealed that Resident (CR 1) was admitted to the facility on November 5, 2019, and had diagnoses that included hypertension and cancer of the right lung.

A review of the resident's weight record revealed the following recorded weights:

November 5, 2019 (9:35 PM) - 188.8 lbs
November 5, 2019 (10:59 PM) -188.8 lbs
November 13, 2019 173.0 lbs - a 15.8 lbs weight loss (8.4%) in 8 days.
November 26, 2019 161.1 lbs - a 11.9 lbs weight loss (11.9%) in 13 days.

The resident lost a total of 27.7 lbs or 14.7% loss of body weight in less than one month.

There was no documented evidence that the facility had recognized the significant weight loss identified with the weights on November 13, 2019, and November 26, 2019. There was no documented evidence of the development of additional interventions to promote weight gain and/or revision of existing nutritional support approaches to deter further progressive weight loss for this resident.

When interviewed on January 29, 2020, at approx. 3:10 PM, the Registered Dietitian confirmed that there was no evidence that the resident had been reweighed to confirm accuracy of the significant weight losses or evidence of the development of additional or revised nutritional support interventions to promote weight gain and/or deter further weight loss for this resident.

Interview with the Nursing Home Administrator on January 29, 2020, at approx. 3:45 PM, confirmed that the facility did not act timely upon the resident's weight losses noted on November 13, 2019, and November 26, 2019.

Refer F580


28 Pa Code 211.6(c)(d) Dietary services.

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

28 Pa Code 211.12 (a)(c)(d)(3)(5)Nursing services.
Previously cited 1/14/19, 3/7/19






 Plan of Correction - To be completed: 02/19/2020

1. The facility cannot retroactively correct the measures to improve nutritional status of CR1 as the resident has since passed away.
2. The facility will complete an audit of current residents with documented significant weight loss in the last 14 days to ensure that timely interventions have been put into place to deter further weight loss.

3. The DON/Designee will re-educate licensed nursing staff and dietitian on the policies for weight loss and measures to ensure that weight loss is identified with interventions put into place timely.

4. The facility will conduct random weekly audits weekly x4 then monthly x 2 months on residents experiencing significant weight loss to verify that timely interventions were put in place to prevent future weight loss.

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