Nursing Investigation Results -

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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  173 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.
MOUNTAIN LAUREL HEALTHCARE AND REHABILITATION CENTER - 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 a complaint completed on December 12, 2019, it was determined that Mountain Laurel Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:


Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent.

Findings include:

Observations during medication administration on December 12, 2019, revealed that three medications errors were made during 26 opportunities for error, resulting in a medication administrator error rate of 11.54 percent.

The card of potassium chloride ER (an extended release mineral supplement) tablets, dated December 2019, indicated that the pills should not be crushed.

Physician's orders for Resident 151, dated June 22, 2019, included an order for the resident to receive one 10 milliequivalent (meq) tablet of potassium chloride ER four times daily.

Observations during medication administration on December 10, 2019, at 4:33 p.m. revealed that Licensed Practical Nurse 4 poured one 10 meq tablet of potassium chloride ER for Resident 151, crushed the pill, then administered it to the resident along with other crushed medications mixed in pudding. Stickers present on the medication card for potassium chloride ER indicated that the medication was not to be crushed.


Manufacturer's instructions for carbidopa and levodopa ER, revised April 2018, indicated that the medication should be administered whole and not crushed.

Physician orders for Resident 151, dated June 22, 2019, included an order for the resident to receive two 25-100 milligram (mg) tablets of carbidopa-levodopa four times daily.

Observations during medication administration on December 10, 2019, at 4:33 p.m. revealed that Licensed Practical Nurse 4 poured two tablets of carbidopa-levodopa ER for Resident 151, crushed the pills, then administered them to the resident along with other crushed medications mixed in pudding. Stickers present on the medication card for the carbidopa-levodopa ER indicated that the medication was not to be crushed.


Physician's orders for Resident 151, dated November 2, 2019, included an order for the resident to receive 200 mg of a 125 mg per milliliter (mg/ml) phenytoin suspension (seizure medication) four times a day.

Observations during medication administration on December 10, 2019, at 4:33 p.m. revealed that Licensed Practical Nurse 4 poured phenytoin suspension into a medicine cup for Resident 151. The label on the medication bottle indicated that the 200 mg dose was equal to 8 milliliters of the suspension. The medication cup used by the nurse to measure the phenytoin suspension was marked at 5 ml, 7.5 ml and 10 ml. Observations revealed that the nurse poured the medication in an amount that was above the 7.5 ml mark; however, there was no way to determine if the dose poured was 8 milliliters. The nurse then administered that phenytoin suspension to the resident.

An interview with Licensed Practical Nurse 4 on December 10, 2019, at 4:33 p.m. confirmed that she crushed all of Resident 151's pills and administered them to the resident in pudding. She indicated that she did not see the labels indicating that the extended release potassium and carbidopa-levodopa were not to be crushed, and it was an error to crush them. She also confirmed that she was not certain if she gave the correct amount of phenytoin to the resident, but she always poured it just a little above the 7.5 ml line on the medicine cup.

An interview with the Director of Nursing on December 11, 2019, at 2:40 p.m. confirmed that the extended release potassium and carbidopa-levodopa should not have been crushed, and that Licensed Practical Nurse 4 should have used a syringe to accurately dispense the ordered amount of phenytoin suspension, instead of guessing the amount in the medicine cup.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 6/13/19.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/30/19, 6/13/19.




 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
Resident 151 is now receiving a potassium sprinkle which can be crushed. The carbidopa and levodopa Extended Release is not being crushed for administration and the phenytoin suspension is measured utilizing a graduated syringe.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All residents receiving medications have the potential to be affected by the finding. Licensed (Registered Nurse and Licensed Practical Nurse) nurses will be re-educated on proper medication pass procedure by 1/24/20. Any agency licensed nurses scheduled to work will be re-educated prior to their next shift to work.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Director of Nursing/designee will conduct 4 random medication pass audits/observations weekly to ensure proper procedure. Random audits/observations will continue until 3 consecutive months of compliance is achieved.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Director of Nursing/designee will present the results of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and compliance.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficient practices.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending June 13 and September 30, 2019, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 12, 2019, identified repeated deficiencies related to accident hazards, medication storage and labeling, food palatability, and kitchen sanitation.

The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free from accident hazards, cited during the surveys ending June 13 and September 30, 2019, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding accident hazards.

The facility's plan of correction for a deficiency regarding proper storage and/or labeling of medications, cited during the survey ending June 13, 2019, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storing and labeling residents properly.

The facility's plan of correction for a deficiency regarding serving palatable food at appropriate temperatures, cited during the survey ending June 13, 2019, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F804, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding palatable food and food temperatures.

The facility's plan of correction for a deficiency regarding sanitary food storage and preparation, cited during the survey ending June 13, 2019, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding kitchen sanitation and food storage.

Refer to F689, F761, F804, F812.

42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities.
Previously cited 6/13/19.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 6/13/19.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 6/13/19.



 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
No resident was identified to be affected by the finding.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All residents have the potential to be affected by the finding. The facility Quality Assurance Performance Improvement Committee will review results of all audits pertaining to this Plan of Correction. Any audit(s) found to be incomplete or out of compliance will be discussed during Quality Assurance Performance Improvement Meeting and a sub-committee will be developed to evaluate the incompletion/noncompliance issue utilizing Root Cause Analysis and establish further oversight directions to monitor the issue.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The facility Regional Director of Operations/designee will review monthly Quality Assurance Performance Improvement Committee Meeting Minutes to ensure compliance with this Plan of Correction.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Regional Director of Operations/designee will review the monthly Quality Assurance Performance Improvement Committee Meeting minutes and indicate approval or needed action until the terms of this Plan of Correction are met.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

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

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


Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to ensure that opened food items were properly labeled and dated, that stored produce was in edible condition, and that food preparation equipment was clean and sanitary.

Findings include:

The facility's food storage policy, dated June 28, 2019, indicated that all food items were to be dated upon receipt with the month, day and year, and all opened and partially used foods were to be be sealed, labeled and dated before being returned to the storage area.

Observations in the kitchen's walk-in cooler on December 9, 2019, at 9:54 a.m. revealed that there was a previously opened 56 ounce container of whipped margarine and a bag of lettuce that were not labeled with the dates they were opened. There were also three inedible heads of cabbage with large, black spots on them. Interview with the Dietary Manager at that time confirmed that the margarine and lettuce should have been dated when they were opened, and the cabbage should have been discarded.


The facility's current dietary cleaning schedules indicated that the a.m. prep cook was to clean the prep area top and bottom daily and the a.m., and the dietary aide was to clean the counters daily.

Observations in the kitchen on December 9, 2019, at 10:05 a.m. and December 10, 2019, at 9:28 a.m. revealed that the mixing bowl of a large stand mixer had shredded yellow cheese particles inside it, the tops of two heating lamps located above the tray line had a thick film of grease on them, and the shelving above the tray line had an accumulation of dust on it. Interview with the Dietary Manager on December 10, 2019, at 10:04 a.m. confirmed that the mixing bowl should have been clean, and the heating lamps and shelving above the tray line needed cleaned.


The facility's housekeeping/cleaning policy, dated June 28, 2019, indicated that cleaning of the A-Wing and B-Wing pantry and equipment was to be completed at 3:30 p.m. by housekeeping staff.

Observations in the B wing pantry on December 10, 2019, at 3:00 p.m. and December 11, 2019, at 9:26 a.m. revealed that there were multiple brown and yellow, removable particles throughout the inside of the microwave. Interview with the Dietary Manager on December 11, 2019, at 9:27 a.m. confirmed that the microwave needed cleaned.

Observations in the A wing pantry on December 10, 2019, at 3:08 p.m. and December 11, 2019, at 9:20 a.m. revealed that there were removable, yellow and white-colored substances on the inside bottom of the microwave, the vent in the back had a brown colored substance on it, and the microwave had a foul odor when the door was opened. Interview with the Dietary Manager on December 11, 2019, at 9:20 a.m. confirmed that the microwave needed cleaned.

42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary.
Previously cited 6/13/19.

28 Pa. Code 211.6(f) Dietary services.
Previously cited 6/13/19.





 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
No resident was identified to be affected by the finding. The identified issues were corrected.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All residents have the potential to be affected by the finding. Dietary Staff will be re-educated on food storage/labeling and cleaning schedules by 1/24/20.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Dietary Manager/designee will complete a Kitchen Sanitation (including food dating and storage as well as sanitation/cleaning) 3 times per week to ensure proper cleaning and food storage/dating.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Dietary Manger/designee will present the findings of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and compliance.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for one of 65 residents reviewed (Resident 16).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated September 22, 2019, revealed that the resident was alert, required minimal assistance from staff for daily care tasks, and had diagnoses that included diabetes (a disease that interferes with the body's blood sugar control) and end-stage renal (kidney) disease requiring hemodialysis (the mechanical process of cleansing the blood, used when the kidneys do not function properly).

Resident 16's care plan, dated August 14, 2018, indicated that the resident's medications would be administered as ordered and that there would be no complications related to dialysis devices or treatment.

Physician's orders for Resident 16, dated August 2, 2019, included orders for the resident to receive 10 milligrams (mg) of midodrine HCl (a medication that is used to treat low blood pressure) one time a day every Monday, Wednesday and Friday, and the medication was to be sent with the resident to dialysis, as he takes this medication two hours into dialysis.

A dialysis treatment note for Resident 16, dated September 3, 2019, revealed that the resident did not receive midodrine as ordered by the physician because the medication was not sent with him.

A dialysis treatment note for Resident 16, dated September 4, 2019, revealed that the resident did not receive midodrine as ordered by the physician because the medication was not sent with him again. A dialysis note dated September 4, 2019, at 10:42 a.m. revealed that the resident arrived 43 kilograms (kg) over his goal, he did not bring midodrine with him, his blood pressure was running in 60's and 70's, and they were not able to get much fluid from the resident. The nursing home was notified. According to the facility, a new licensed practical nurse (LPN) was taking care of the resident and she forgot to send his midodrine. The facility was reminded that he needs this medication due to his blood pressure running so low. They agreed to make sure it is sent with him.

A dialysis treatment note for Resident 16, dated September 6, 2019, revealed that the resident did not receive midodrine as ordered because the facility did not send it. A nursing note, dated September 6, 2019, at 1:10 p.m. revealed that the resident missed his dose of midodrine while at dialysis on Monday, Tuesday, Wednesday and Friday (September 2, 3, 4 and 6, 2019). The note indicated that at times the resident needs to go to dialysis more than three times a week so the medication ran out before it was due for the pharmacy to send a refill. There was no documented evidence that the physician was notified of the need to have midodrine available to send with Resident 16 on extra dialysis days.

A nursing note for Resident 16, dated September 9, 2019, at 5:51 a.m. indicated that midodrine was not available, and a refill was requested from the pharmacy.

Physician's orders for Resident 16, dated October 7, 2019, included orders for the resident to receive 10 mg of midodrine by mouth two times a day every Monday, Wednesday and Friday, and to send two 10 mg tablets to every dialysis appointment.

A dialysis treatment note for Resident 16, dated October 23, 2019, revealed that the resident did not have his second dose of midodrine as ordered because it was not sent with him. A dialysis note dated October 23, 2019, at 7:48 a.m. revealed that a supervisor from the nursing home called the dialysis clinic to report, "Patient does not have any midodrine and they do not have any at the home. They would have to get it from the local pharmacy and bring it up when they open." The supervisor was informed that an order was faxed to them on October 7, 2019, to send two 10 mg tablets of midodrine to every dialysis treatment, so the resident could take one tablet at the start of dialysis treatment and one tablet mid-dialysis. The nursing home supervisor stated that they did not have that order. The order and confirmation from October 7, 2019, was refaxed at the supervisor's request. There was no documented evidence that the resident received his second dose of midodrine on October 9, 11, 14, 16, 18, 21 and 23, 2019, as ordered by the physician.

Interview with the Director of Nursing on December 11, 2019, at 2:16 p.m. confirmed that the reason there was no medication available for Resident 16 was because he was so non-compliant that he needed extra sessions of dialysis each week so he would run out of the medication; however, she also confirmed that there was no evidence that the physician was ever notified so that extra doses of midodrine could be ordered for the extra dialysis sessions.

Interview with the Administrator of Resident 16's dialysis clinic on December 11, 2019, at 2:45 p.m. revealed that they do not keep midodrine in stock because it is not a normal dialysis drug, and dialysis services would not be held unless a person's blood pressure drops into the 70's. The Administrator indicated that the dialysis center has definitely had issues with Resident 16 not having his medication when he comes, and they have had several conversations with the facility about the issue.

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

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 9/30/19, 6/13/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/30/19, 6/13/19.





 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
Resident 16's midodrine is sent with resident to the dialysis center on days receiving dialysis treatments.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All residents receiving dialysis were reviewed and no other resident was found to be affected by the finding. Licensed (Registered Nurse and Licensed Practical Nurse) nursing staff will be re-educated on medication administration procedures by 1/24/20. Any scheduled agency licensed nurses will be re-educated prior to their next shift worked.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Director of Nursing/designee will audit the records of 3 dialysis patients weekly to ensure appropriate medication administration. The audits will continue until 3 consecutive months of compliance is a achieved.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Director of Nursing/designee will present the findings of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and compliance.

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 review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of 65 residents reviewed (Resident 301).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.

A nursing note for Resident 301, dated September 3, 2019, revealed that the resident was having a small amount of vaginal bleeding and her vital signs were stable. The physician on call was made aware and gave no new orders.

A nursing note for Resident 301, dated September 6, 2019, and completed by a licensed practical nurse (LPN), revealed that staff reported a large amount of blood in the resident's brief. There were no clots and the resident continued to deny abdominal/pelvic/vaginal pain/discomfort.

A nursing note for Resident 301, dated September 7, 2019, and completed by a LPN, revealed that staff reported a large amount of blood in the resident's brief. There were no clots, the resident denied pain, and her vital signs were stable.

There was no documented evidence that a registered nurse completed an assessment of Resident 301's change in condition on September 6 and 7, 2019.

Interview with the Director of Nursing on December 11, 2019, at 9:45 a.m. confirmed that there was no documented evidence that Resident 301's change in condition was assessed timely by a registered nurse.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/30/19, 6/13/19.









 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
Resident no longer resides in facility.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
A 30 day look back of condition changes was completed. Any resident identified as having a condition change in that time period was assessed by an Registered Nurse. Identified issues were communicated to the physician as appropriate. Registered Nurses and Licensed Practical Nurses will be re-educated on scope of practice and Registered Nurse Assessment requirements by January 24, 2020. Any agency nurses working will be re-educated prior to the start of their next shift worked.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Director of Nursing/designee will audit 3 condition changes identified during daily Clinical Meeting (M-F) to ensure assessments were completed by the appropriate staff member. Audits will continue until 3 consecutive months of compliance are achieved.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Director of Nursing/designee will present the results of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and 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 review of policies, clinical records and facility investigation documents, as well as staff interviews, it was determined that following falls the facility failed to implement new and/or revised interventions to prevent further falls and/or injury for one of 65 residents reviewed (Resident 33).

Findings include:

The facility's care plan policy, dated June 28, 2019, indicated that assessments of residents were ongoing and care plans were to be revised as information about the residents and the residents' conditions changed.

A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated September 28, 2019, revealed that the resident was cognitively intact and had a history of recent falls. The resident's care plan, dated December 6, 2019, revealed that he was at risk for falls related to a history of falls and a diagnosis of vertigo (feeling dizzy), noncompliance with the use of assistive devices, and declining to wear appropriate footwear at times. The care plan revealed that the resident experienced falls in 2019 on January 28, June 7, August 12, August 14, October 5, November 27 and December 6, 2019.

Resident 33's care plan, dated December 6, 2019, revealed no documented evidence that new and/or revised interventions to prevent further falls and/or injury were developed and implemented following the falls on August 12, August 14 and October 5, 2019.

Interview with the Director of Nursing on December 11, 2019, at 3:30 p.m. confirmed that there was no documented evidence new and/or reviewed fall interventions were developed and implemented for Resident 33 following his falls on August 12, August 14 and October 5, 2019.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 9/30/19, 6/13/19.

28 Pa. Code 211.10(d) Resident care policies.
Previously cited 9/30/19, 6/13/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/30/19, 6/13/19.




 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
Resident 33's Care Plan was reviewed by the Interdisciplinary Team and updated as appropriate.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All residents with falls have the potential to be affected by the finding. Licensed nursing staff will be re-educated by January 24, 2020, on updating resident care plans after falls. Any licensed nursing staff working will be re-educated prior to the start of their next scheduled shift.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
Falls will be reviewed by the Clinical Team during daily Clinical Meeting (M-F). A Care Plan review will be completed for any resident having a fall to ensure an intervention has been implemented. The Director of Nursing/designee will audit 4 falls per week to ensure new interventions have been implemented and the care plan update appropriately until 3 consecutive months of compliance is achieved.


4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Director of Nursing/designee will present the finding of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and 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 on review of manufacturer's instructions and facility policies, as well as observations and staff interviews, it was determined that the facility failed to discard expired medications on one of three medication carts reviewed (B wing long hall) and one of two medication rooms reviewed (B wing).

Findings include:

The manufacturer's instructions for Humalog insulin (used to lower blood sugar levels), revised November 2019, indicated that opened and in-use vials were to be discarded in 28 days.

The manufacturer's instructions for Lantus insulin, revised November 2019, indicated that vials that were in use should be thrown away after 28 days, even if there was still insulin left in it.

The facility's medication administration policy, dated June 28, 2019, indicated that the expiration date/beyond use date on the medication label must be checked prior to administering the medication.

Observations of B wing, long hall medication cart on December 10, 2019, at 4:13 p.m. revealed that one vial of Humalog insulin for Resident 126 was opened on November 7, 2019; was still in use as of December 10, 2019; and had a label with an expiration date of December 4, 2019. One vial of Humalog insulin for Resident 29 was opened on October 7, 2019; was still in use as of December 10, 2019; and was labeled with an expiration date of November 11, 2019. A vial of nitroglycerin tablets (medication used for chest pain) for Resident 94 was opened and dated with a dispensed date of January 12, 2018, and an expiration date of August 2019. There was also one vial of Lantus insulin for Resident 97 that was labeled with an expiration date of December 9, 2019.

Interview with Licensed Practical Nurse 4 on December 11, 2019, at 4:45 p.m. confirmed that the vials of insulins and the nitroglycerin tablets were expired and should have been removed from the cart and discarded.


Observations in the B wing medication room on December 11, 2019, at 1:32 p.m. revealed that five bottles of multivitamin with iron had an expiration date of November 2019.

Interview with Licensed Practical Nurse 5 on December 11, 2019, at 1:45 p.m. confirmed that the bottles of multivitamin with iron were expired and should have been removed from stock and discarded.

Interview with the Director of Nursing on December 11, 2019, at 2:40 p.m. confirmed that expired medications should have been removed from the medication cart and medication room.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 6/13/19.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 6/13/19.







 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
The Humalog insulin for resident 126 was destroyed and a new supply obtained. The Lantus insulin for resident 97 was destroyed and a new supply obtained.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All medication carts were reviewed and no other insulins or vitamins were found to be expired, therefore, no other residents were affected by the finding. The vitamins were unopened identified, were unopened, therefore, no resident was found to be affected. Licensed (Registered Nurse and Licensed Practical Nurse) staff will be re-educated on medication expiration dates by 1/24/20. Any licensed nurse agency staff scheduled will be re-educated prior to the start of their next shift worked. The night shift Licensed Practical Nurses will conduct weekly medication cart audits and medication room audits to ensure there are no expired medications available.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Director of Nursing/designee will conduct random audits of 2 medication carts and 1 medication room twice monthly to ensure there are no expired medications. Audits will continue until 3 consecutive months of compliance are achieved.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Director of Nursing/designee will present the findings of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and compliance.

483.50(a)(2)(i)(ii) REQUIREMENT Lab Srvcs Physician Order/Notify of Results: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.
483.50(a)(2) The facility must-
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident's physician was notified about the inability to obtain a laboratory test as ordered for one of 65 residents reviewed (Resident 301).

Findings include:

A progress note by a certified registered nurse practitioner (CRNP - a registered nurse with advanced medical training) for Resident 301, dated September 10, 2019, revealed that the resident was being seen at the request of nursing staff due to several episodes of vaginal bleeding. The resident was noted to have small clots in her brief at times and her vital signs have remained stable. A consultation was requested with a gynecologist (doctor who specializes in women's health) and the resident has an appointment in December 2019. The note indicated that a complete blood count (CBC - a blood test that measures several components and features of your blood) would be obtained that day.

The CRNP's orders for Resident 301, dated September 10, 2019, included an order for the resident to have a CBC obtained that day.

A daily lab sheet provided by the facility, dated September 11, 2019, revealed that they were unable to obtain a CBC for Resident 301.

There was no documented evidence that Resident 301's physician and/or CRNP were contacted and advised regarding the inability to obtain the resident's CBC on September 11, 2019, until CRNP's orders dated September 19, 2019, included an order to obtain a CBC that day if it was not completed on September 11 or 12, 2019.

Interview with the Director of Nursing on December 11, 2019, at 9:45 a.m. confirmed that there was no documented evidence that Resident 301's physician and/or CRNP were contacted about not being able to obtain her CBC.

28 Pa. Code 211.12(d)(3)(5) Nursing services.
Previously cited 9/30/19, 6/13/19.








 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
Resident 301 no longer resides in facility.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
A 30 day look back/audit was completed of ordered labs. The ordering physician was notified of any ordered labs not obtained as appropriate. Licensed (Registered Nurses and Licensed Practical Nurses) staff will be re-educated on lab follow up; ensuring ordered labs were performed or physician/physician extender are notified of labs not obtained. Any licensed nursing agency staff scheduled will be re-educated prior to the start of their next scheduled shift.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Director of Nursing/designee will audit 4 random ordered lab results per week to ensure lab completion and/or appropriate follow-up was completed. Audits will continue until 3 consecutive months of compliance is achieved.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Director of Nursing/designee will present the findings of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and compliance.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on review of policies and clinical records, as well as resident interviews, observations and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures.

Findings include:

The facility's policy regarding food temperatures, dated June 28, 2019, indicated that the temperature of potentially hazardous cold foods would not be greater than 40 degrees Fahrenheit (F) during tray assembly and 45 degrees F when served to the resident.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated September 28, 2019, indicated that the resident was cognitively intact. Upon interview with Resident 33 on December 9, 2019, at 10:50 a.m., he indicated that sometimes the facility's hot food was not served hot.

A quarterly MDS assessment for Resident 62, dated October 25, 2019, indicated that the resident was cognitively intact. Upon interview with Resident 62 on December 9, 2019, at 12:05 p.m., she indicated that the food was not always good, including that the hot foods were not always served hot.

An admission MDS assessment for Resident 126, dated October 10, 2019, indicated that the resident was cognitively intact. Upon interview with Resident 126 on December 9, 2019, at 12:00 p.m., she indicated that the food was not always good and sometimes the hot food was not served hot.

During an interview with a group of residents on December 10, 2019, at 2:20 p.m., the resident indicated that the foods served to them were not tasty.

A test tray at the lunch meal on December 11, 2019, revealed that the tray left the kitchen at 11:45 a.m., arrived on the unit at 11:47 a.m., the last resident was served and eating at 12:22 p.m., and the food items were tasted at 12:23 p.m. The temperature of a small carton of milk was 50 degrees F and it tasted chalky, and a small glass of apple juice was 59 degrees F and tasted lukewarm.

Interviews with Dietary Manager and Dietitian on December 11, 2019, at 12:34 p.m. confirmed that the milk and apple juice were served at temperatures that were too warm.

42 CFR 483.60(d)(1)(2) Nutritive Value/Appear, Palatable/Prefer Temp.
Previously cited 6/13/19.





 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
Resident 33 is receiving food at appropriate temperature. The facility Diet Tech met with resident 62 to review food likes and dislikes. Resident 62 is receiving food at appropriate temperatures. The facility Diet Tech met with resident 126 to review food likes and dislikes. Resident 126 is receiving food at appropriate temperature.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All residents have the potential to be affected by the finding. The Dietary Staff will be re-educated on proper food temperatures by 1/24/20.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Dietary Manager will conduct 2 random audits of test tray food temps per week to ensure proper temperature of food when served. The Dietary Manager/designee will attend monthly Food Committee Meeting with residents to identify ongoing or new issues with meals.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Dietary Manager/designee will present the findings from the food temp audits and the Food Committee Meetings to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and compliance.

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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while providing medications to the residents.

Findings include:

The facility's policy regarding infection control, dated June 28, 2019, revealed that staff were to follow established infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. The facility's handwashing/hand hygiene policy, dated June 28, 2019, revealed that an alcohol-based hand rub or soap and water should be used before preparing or handling medications, and hand hygiene was to be completed after removing gloves.

Observations during medication administration on December 10, 2019, from 11:59 a.m. to 12:21 p.m. revealed that Licensed Practical Nurse 2 prepared and administered oral medications and an insulin injection to several residents, and she did not wash her hands or use hand gel between residents.

Interview with Licensed Practical Nurse 2 on December 10, 2019 at 12:26 p.m. revealed that she forgot to wash her hands between residents and that she should have.

Observations during medication administration on December 10, 2019, at 12:39 p.m. revealed that Licensed Practical Nurse 3 did not wash her hands or use hand gel prior to applying gloves and administering eye drops to a resident. Observations of Licensed Practical Nurse 3 on December 10, 2019, at 12:52 p.m. revealed that the nurse washed her hands, dried her hands with a clean towel, and then turned the dirty faucet off with her clean hand instead of with a paper towel.

Interview with Licensed Practical Nurse 3 on December 10, 2019, at 1:05 p.m. revealed that she should have used a towel to turn the faucet off and not her clean hand.

Interview with the Director of Nursing on December 11, 2019, at 2:40 p.m. confirmed that staff are to wash their hands or use sanitizing hand gel between residents while administering medications, and that they should never touch the faucet with their clean hands.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/30/19, 6/13/19.





 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
No resident was identified to be affected by the finding.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All residents have the potential to be affected by the finding. Licensed (Registered Nurses and Licensed Practical Nurses) staff will be re-educated on hand washing and alcohol gel use related to medication administration. Any licensed nursing agency staff scheduled will be re-educated prior to the start of their next scheduled shift.

3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Director of Nursing/designee will conduct 4 random medication pass audits/observations weekly to ensure proper procedure. Random audits/observations will continue until 3 consecutive months of compliance is achieved.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Director of Nursing/designee will present the results of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and compliance.

201.20(b) LICENSURE Staff development.:State only Deficiency.
(b) An employe shall receive appropriate orientation to the facility, its policies and to the position and duties. The orientation shall include training on the prevention of resident abuse and the reporting of the abuse.
Observations:


Based on review of personnel files, as well as staff interviews, it was determined that the facility failed to provide orientation to the duties of their positions for ten of ten new employees reviewed (Employees 6-15).

Findings include:

Personnel files for Registered Nurses 6 and 14, hired on September 13, 2018, and August 10, 2019, respectively, revealed no evidence that the nurses were provided with orientation to the duties of their positions.

Personnel files for Licensed Practical Nurses 9, 11 and 13, hired on October 15, 2019; August 17, 2019; and October 15, 2019, respectively, revealed no evidence that the nurses were provided with orientation to the duties of their positions.

Personnel files for Nurse Aides 7, 8, 10, 12 and 15, hired on November 2, 2018; May 3, 2019; November 21, 2019; June 24, 2019; and August 13, 2019, respectively, revealed no evidence that the nurse aides were provided with orientation to the duties of their positions.

Interview with the Director of Nursing on December 11, 2019, at 3:00 p.m. revealed that she could provide no evidence that the above employees received orientation to the duties of their positions.

Previously cited 6/13/19.



 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
No resident was found to be affected by the finding.
2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
All residents have the potential to be affected by the finding. All department heads will be re-educated on the need for completion of job specific orientation check list for new employees. Employee files will be audited for job specific orientation. For employee files found to be without job specific orientation check lists, lists will be completed with employees by 1/24/20. The Business Office Manager/designee will complete audits on all newly hired employee files to ensure employee file is complete.
3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The facility Administrator/designee will audit 4 random new employee files per month to ensure job specific orientation check lists have been completed with the employee. Audits will continue until 3 consecutive months of compliance is achieved.

4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The facility Administrator/designee will present the results of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee Meetings to ensure completion and compliance.

211.5(f) LICENSURE Clinical records.:State only Deficiency.
(f) At a minimum, the resident's clinical record shall include physicians' orders, observation and progress notes, nurses' notes, medical and nursing history and physical examination reports; identification information, admission data, documented evidence of assessment of a resident's needs,
establishment of an appropriate treatment plan and plans of care and services provided; hospital diagnosis authentication--discharge summary, report from attending physician or transfer form--diagnostic and therapeutic orders, reports of treatments, clinical findings, medication records and discharge summary including final diagnosis and prognosis or cause of death. The information contained in the record shall be sufficient to justify the diagnosis and treatment, identify the resident and
show accurately documented information.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that clinical records of discharged residents contained a discharge summary that included cause of death for one of two closed records reviewed (Resident 151).

Findings include:

A nursing note for Resident 151, dated October 30, 2019, indicated that the resident expired at the facility. There was no documented evidence that a discharge summary was completed.

Interview with the Nursing Home Administrator on December 12, 2019, at 12:46 p.m. confirmed that they were unable to find a discharge summary for Resident 151 and that there should have been one.



 Plan of Correction - To be completed: 01/27/2020

1. What corrective action(s) will be accomplished for those residents found to have been affected by the finding;
The facility is unable to complete a discharge summary for resident who expired 10/30/19.

2. How will you identify other residents having the potential to be affected by the same finding and what corrective action will be taken;
A chart audit of residents discharged in the past 30 was completed. Any chart found not having a completed discharge summary had one completed as appropriate. The Medical Records Coordinator will be re-educated by 1/24/20, on the requirement for discharge summaries for all discharges. The Medical Records Coordinator will ensure discharge summaries are completed on all discharged residents.
3. What measures will be put into place or what system changes will you make to ensure the finding does not recur;
The Director of Nursing/designee will audit up to 3 discharge records per month to ensure a discharge summary was completed and is present in the closed record. Audits will continue until 3 consecutive months of compliance is achieved.
4. How the corrective action will be monitored to ensure that the finding will not recur; i.e., what quality assurance programs will be established;
The Director of Nursing/designee will present the findings of the audits to the Quality Assurance Performance Improvement Committee during monthly Quality Assurance Performance Improvement Committee meeting to ensure completion and compliance.


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