Nursing Investigation Results -

Pennsylvania Department of Health
MAPLEWOOD NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations

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MAPLEWOOD NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  96 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.
MAPLEWOOD NURSING 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 Civil Rights Compliance Survey, and an abbreviated survey in response to two complaints, completed on February 11, 2020, it was determined that Maplewood Nursing 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 as they relate to the health portion of the survey process.



























 Plan of Correction:


483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on review of clinical records and facility policies and procedures and interviews with staff, it was determined that the facility failed to ensure that residents were provided the opportunity to formulate an Advance Directive (one's wishes on life-sustaining medical or surgical treatment) for one of 37 residents reviewed (Residents R36).

Findings include:

Review of the facility policy "Advance Directives/ Pennsylvania Orders for Life-Sustaining Treatment (POLST)/ Resuscitation Code Status " dated reviewed September 2019, indicated that the purpose of the policy is to support the rights of the resident in making decisions regarding their care and treatment. It defined an Advance Directive as the written instructions to express a person's choice on treatment or to designate someone else to make healthcare decisions when the resident is unable to do so. It maintained that the POLST form is used for the physician to write orders that indicate what type of life sustaining treatment the resident wants or does not want, during their stay at the facility, during transfer to the hospital, and during their hospital stay.

Further review of the facility policy revealed that upon admission, the admission coordinator and/or social worker will determine if the resident has an appropriately executed Advance Directive (Power of Attorney, Living Will etc.) or POLST; 2-If the resident does not have an Advance Directive or POLST, the Social Worker or designee) will introduce the POLST. The Social worker will assist the resident and resident representative in completing the Advance Directive and POLST. Additionally, the policy indicated that the completed POLST must be signed by physician/PA/CRNP and the resident/resident representative to be valid and that POLST forms, living wills, durable Power of attorney forms will be kept in the resident's medical record

Review of the clinical record for Resident R36 revealed that the resident was admitted to the facility on September 12, 2016, with diagnoses including, but not limited to, Schizophrenia (major mental illness characterized by thoughts that are out of touch with reality, disorganized speech or behavior and decreased participation in daily activities) and Mild Intellectual Disabilities.

Review of the physician's order for Resident R36, dated September 27, 2017, revealed that the Code Status for Resident R36 was Full Code (desires all medical interventions be performed to restore breathing or heart function, including Cardiopulmonary resuscitation (CPR) in the event of a medical emergency)

Review of the Social Worker Care Plan note dated November 21, 2019, indicated that " resident POLST will continue to reflect the wishes of the resident". Further examination of the Clinical Records for the Resident R36, revealed that there was no POLST form present in the resident's clinical record.

Interview with the Director of Nursing on February 9, 2020, approximately at 10:27 a.m., confirmed that no POST form was available for review to verify the advance directive wishes of Resident R36.

The facility failed to ensure that one resident was provided the opportunity to formulate an Advanced Directive.

42 CFR 483.10(c)(6)(g)(12) Right to Request/Refuse/Discontinue Treatment; Formulate Advance Directives
Previously cited 12/20/18, 2/8/18

28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(1) Management
28 Pa Code 201.29(j) Resident rights
28 Pa Code 211.12(d)(5) Nursing services












 Plan of Correction - To be completed: 03/13/2020

Submission of this plan of correction is not a legal admission by Maplewood Nursing & Rehabilitation Center that a deficiency exists or that this Statement of Deficiencies was correctly cited. In addition, preparation and submission of this POC does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the survey agency.

1. R36 was given the opportunity to make an advance directive/POLST.
2. An audit will be conducted to identify other residents who may not have been given the opportunity to make an advance directive/POLST.
3. To ensure proper practices continue:
a. Social Services staff have been inserviced on providing residents an opportunity to make advance directives/POLST.
b. The Administrator or designee will monitor compliance with this POC by auditing newly admitted residents and those with an annual assessments' advance directives/POLST weekly for four weeks and then monthy for four months.
4. The results of the reviews and audits completed under this POC will be reviewed at the QAPI committee meeting for review and follow-up.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ: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.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:

Based on observation and staff interviews, it was determined that the facility failed to maintain a safe, sanitary and comfortable environment for residents in one of six nursing units (4th Floor) and in one of four dining rooms in the facility. (1st Floor)

Findings include:

During a tour of the facility on February 11, 2020, at 10:15 a.m. of the 4th floor at 10:15 a.m., revealed the following observations: peeled paint on the walls in the bathroom walls of rooms 410, 412, and 414.
-the cove-base molding to doors of bathrooms of rooms 401, 404, 407, and 414 peeled out or protruded out.

During a tour of the facility in the first-floor dining room on February 11, 2020, at 11:41 a. m., revealed the following observations: peeled paint and dented and/or missing cove-base molding on the wall of the first-floor dining room;
peeling paint on the wall of the first-floor bathroom, located adjacent to the dining room.

Interviews conducted on February 11, 2020, at 11:36 a.m.,with Employee E8 , licensed nursing staff, and the Dietary Director at 11:55 a.m., confirmed the presence of the observations made during the tour.


28 Pa Code 201.14(a) Responsibility of Licensee.

28 Pa Code 201.18(b)(1)(4) Management.

28 Pa Code 207.2(a) Administration







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

Submission of this plan of correction is not a legal admission by Maplewood Nursing & Rehabilitation Center that a deficiency exists or that this Statement of Deficiencies was correctly cited. In addition, preparation and submission of this POC does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the survey agency.

1. The bathroom walls of room 410, 412, and 414 will be painted as well as the first-floor dining room and bathroom. The cove-base molding to the doors of bathrooms of room 401, 404, 407, and 414 will be repaired.
2. An audit will be conducted to identify other areas where painting needs to be completed and where cove-base molding needs repaired.
3. To ensure proper practices continue:
a. Maintenance Staff will be inserviced on ensuring painting is completed and cove-base molding is repaired as necessary.
b. The Administrator or designee will monitor compliance with this POC by auditing resident areas two times per week for four weeks and then weekly for four months.
4. The results of the reviews and audits completed under this POC will be reviewed at the QAPI committee meeting for review and follow-up.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to provide appropriate services to maintain personal hygiene for three of 37 residents reviewed (Residents, R55, R78 and R119).

Findings include:

Review of the facility's policy, Bath-Shower, (not dated) stated, "If resident refuses shower or tub bath offer bed bath instead and document."

Review of Resident R78's Annual Minimum Data Set (MDS-assessment of resident care needs) dated September 3, 2019 revealed that the resident needed supervision with one staff assisting him with bathing.

Observation with Employee E13, Registered Nurse/Supervisor, on February 8, 2020 at 9:28 a.m. standing in the hallway, outside of Resident R78's room revealed an unpleasant, strong odor. Interview with Employee E13. Registered Nurse/Supervisor revealed, "It's Resident R78, he does not like to take baths. Continued observation revealed the same smell on Resident R78 as the resident was approached. Employee E 13, registered Nurse/ Supervisor further indicated that the resident always refuses his showers.

Review of facility's documentation related to Resident R78's daily hygiene revealed that the resident refused five times from January 31, 2020 to February 9, 2020. The bathing schedule further revealed that the resident refused five times from January 15, 2020 to February 8, 2020 in which the resident took two baths in a 24 day period.

Interview with the Nursing Home Administrator, NHA, on February 9, 2020 at approximately 2:00 p.m., confirmed that there was no evidence available for review confirming that the facility attempted to re-approach Resident R78 with alternative bathing options.

Observation of Resident R119 on February 8, 2020 at approximately 10:00 a.m. revealed that the resident had a large amount of facial hair. Interview with Resident R119, at the time of the observation, revealed that the resident would like to get shaved.

Review of care plan for Resident R119 dated December 31, 2019 revealed that the resident required assistance of one staff with personal hygiene and oral care.

Interview with Employee E5,unit manager, on February 11, 2020 at approximately 10:30 p.m. confirmed that the resident needed to be shaved.

Review of Resident R55's Quarterly, Minimum Data Set (MDS -assessment of resident care needs) dated November 20, 2019 revealed the resident needed extensive assistance with all personal hygiene.

Observation of Resident R55 with Employee E15, Nursing Assistant (NA), on, February 8, 2020 at approximately 11:00 a.m. revealed that the resident had unkept fingernails which appeared to have a red and brown colored substance under all the nails. The NA confirmed the resident's nails were dirty and needed to be trimmed and washed.

The facility failed to provide appropriate services to maintain personal hygiene for three residents reviewed.

28 Pa. Code 211.11(d)(e) Resident care plan.

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




 Plan of Correction - To be completed: 03/13/2020

Submission of this plan of correction is not a legal admission by Maplewood Nursing & Rehabilitation Center that a deficiency exists or that this Statement of Deficiencies was correctly cited. In addition, preparation and submission of this POC does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the survey agency.

1. R78 has received a shower. R119 was shaved. R55's fingernails have been trimmed and washed.
2. An audit will be conducted to identify other residents who need to be bathed, shaved, and provided nailcare.
3. To ensure proper practices continue:
a. Nursing Staff will be inserviced on daily grooming and bathing of residents, and the policy to follow if a resident refuses care.
b. The Director of Nursing or designee will monitor compliance with this POC by randomly auditing resident grooming and bathing weekly for four weeks and then monthly for four months.
4. The results of the reviews and audits completed under this POC will be reviewed at the QAPI committee meeting for review and follow-up.

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

Based on review of facility policy and procedure, review of clinical records and interviews with resident and staff, it was determined that the facility failed to follow physician orders related to bowel management protocol and elevated blood sugar results for two of 37 residents reviewed (Residents R74, and R89).

Findings include:

Review of facility policy "bowel protocol" dated, October 2, 2016 revealed "If no bowel movement in 3 days (72 hours) licensed nurse will notify the physician or Certified Registered Nurse Practitioner".

Interview with Resident R89 on February 8, 2020 at approximately 9:21 a.m. revealed that she was constipated and she had been suffering from constipation for almost 4 months.

Review of bowel elimination record for Resident R89 for the month of December 2019 revealed that the resident did not have a bowel movement for 4 days from December 5, 2019 to December 8, 2019. Review of the clinical record revealed no evidence that the physician was notified of Resident R89's no bowel movement for greater than three days from December 5, 2019 to December 8, 2019.

Interview with Employee E5, director of nursing, on February 11, 2020 at approximately 12:00 p.m. confirmed that the clinical record contained no documented evidence that the physician was notified that Resident R89's had no bowel movement for greater than three days from December 5, 2019 to December 8, 2019.

A review of Resident R74's clinical record revealed that the resident was admitted to the facility on May 23, 2012, with a diagnosis including diabetes (failure of body to produce adequate amounts of Insulin to enable sugar to pass from the blood stream into cells for nourishment), stroke and depression. A review of the resident's quarterly Minimum Data Set (MDS-a periodic review of resident care needs) dated October 7, 2019, revealed that the resident was moderately independent in decision making skills.

Further review of Resident R74' clinical record revealed physician orders dated November 22, 2019, which directed staff to check the resident's blood sugar levels four times a day. Additionally, the order indicated that the physician was to be notified if the resident's blood sugar was below 70 milligrams/deciliters and above 300 milligrams/deciliters.

A review of the Medication Administration Record (MAR) for the month of December 2019, revealed that on December 2, 2019, at 4:00 p.m. the residents' blood sugar was recorded as 306 milligrams /deciliters. On December 6, 2019, at 10:00 p.m. the residents' blood sugar was recorded at 306 milligrams /deciliters. And on December 7,2019, at 10:00 p.m. the residents' blood sugar was recorded at 324 milligrams/deciliters.

Continued review of Resident R74's clinical record revealed no documented evidence that the physician was notified of the resident's blood sugars readings of over 300 milligrams /deciliters on December 4, 6 and 7, 2019, as ordered.

Interview with Employee E2, a nurse, on February 11, 2020, at 1:15 p.m., confirmed that there were no documentation available for review that the physician had been notified of Resident R74's elevated blood sugar readings on December 4, 6 and 7, 2019, as ordered.
.
The facility failed to follow physician orders related to bowel protocol and blood sugar testing for two residents.

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
















 Plan of Correction - To be completed: 03/13/2020

Submission of this plan of correction is not a legal admission by Maplewood Nursing & Rehabilitation Center that a deficiency exists or that this Statement of Deficiencies was correctly cited. In addition, preparation and submission of this POC does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the survey agency.

1. R89 has had no further instances of going 72 hours without a bowel movement. R74 has had no further instances of their blood sugar below 70 milligrams/deciliters or above 300 milligrams/deciliters.
2. An audit will be conducted to identify other residents with no bowel movements for 24 hours or with blood sugars outside of parameters.
3. To ensure proper practices continue:
a. Nursing Staff will be inserviced on notifying the physician when a resident has not had a bowel movement in 72 hours and with occurrences of blood sugar results outside of parameters.
b. The Director of Nursing or designee will monitor compliance with this POC by auditing the dashboard for alerts three times per week for four weeks and then weekly for four months.
4. The results of the reviews and audits completed under this POC will be reviewed at the QAPI committee meeting for review and follow-up.

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 a review of facility policy and procedure, review of facility documentation and clinical records, and interviews with staff, it was determined that the facility failed to ensure that staff utilized a hoyer lift properly for one of 34 residents reviewed (Resident R103).

Findings include:

Review of facility policy, "Equipment: Mechanical Lift", undated, revealed that for safety, two or more personnel must be in attendance when a mechanical lift is used.

Review of the clinical record for Resident R103 revealed diagnoses including, but not limited to, dementia, (progressive brain disorder characterized by confusion, impaired memory and judgement and reasoning abilities), diabetes (metabolic disorder in which the body has high sugar levels for prolonged periods of time) and heart failure (excessive body/lung fluid caused by a weakened heart muscle).

Review of Resident R103's annual Minimum Data Set (MDS-assessment of a resident's needs) completed on December 22, 2019, indicated that the resident was cognitively impaired and required two person physical assistance for transfers. The resident was assessed with no ambulatory (ability to walk) capabilities.

Review of information submitted by the facility revealed that on April 4, 2019 during the 3:00 p.m. to 11:00 p.m. nursing shift, Resident R94 slid out of her wheelchair, while in her room. It was also noted that while attempting to transfer the resident alone with a mechanical lift (mechanical lift-a device that is used to move residents who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually), the resident slid out of the mechanical lift sling and fell to the floor (mechanical lift sling-made of soft materials such as fabric, mesh, nylon, and polyester that support and wrap around part of the resident's body, and attach to the mechanical lift by the use of multiple straps).

Review of the facility's investigation into Resident R103's fall revealed that Employee E10, nursing assistant, reported that while she was assisting Resident R103, the resident became anxious and began to slide out of her wheelchair. Employee E10 stated that she utilized the call bell system in the resident's room, to obtain staff assistance but no one responded to the call bell. Employee E10 further stated that she made a" bad judgement call and try to maneuver the lift alone."

Interview with the Director of Nursing (DON) on February 10, 2020 at approximately 12:26 p.m. confirmed that Resident R103 had fallen from the hoyer lift on April 4, 2019. The DON further confirmed that Employee E10 did not use an additional personnel to assist her, during there transfer and the the resident subsequently fell from the sling.

The facility failed to ensure that one resident was properly transferred by a mechanical lift which resulted in a fall for one resident.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

28 Pa. Code 211.10(c) Resident care policies

28 Pa Code 201.8(a)(3) Management

28 Pa Code 211.12 (c) Nursing services

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

28 Pa Code 211.12 (d)(2) Nursing services

28 Pa Code 211.12 (d)(3) Nursing services

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




















 Plan of Correction - To be completed: 03/13/2020

Submission of this plan of correction is not a legal admission by Maplewood Nursing & Rehabilitation Center that a deficiency exists or that this Statement of Deficiencies was correctly cited. In addition, preparation and submission of this POC does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the survey agency.

1. R103 has had no further incidents related to mechanical lift transfers. E10 is no longer employed by the facility.
2. An audit will be conducted to identify other incidents that may have been related to improper transfers.
3. To ensure proper practices continue:
a. Nursing staff will be inserviced on utilizing two nursing staff for all hoyer lift transfers.
b. Unit Managers and Supervisors will observe two hoyer lift transfers per week, per shift for four weeks and then one weekly for four months.
4. The results of the reviews and audits completed under this POC will be reviewed at the QAPI committee meeting for review and follow-up.

483.40 REQUIREMENT Behavioral Health Services: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.
483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on clinical record review and staff and resident interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 34 resident records reviewed (Resident 89).

Findings include:

Interview with Resident R89 on February 8, 2020 at approximately 9:21 a.m. stated she was feeling depressed and she would like to see a psychiatrist or a psychologist.

Review of clinical record for Resident R89 revealed that the resident was admitted to the facility on August 7, 2019 with diagnoses, including but not limited to, cerebro-vascular disease (Damage to the brain from interruption of its blood supply), cirrhosis of the liver (Chronic liver damage from a variety of causes leading to scarring and liver failure.) and major depressive disorder.

Review of Minimum Data Set (MDS-periodic assessment of resident's care needs), dated December 10, 2019 indicated that the resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in in determining cognitive impairment) score of 15 which indicated that the resident's cognitive status was intact.

Review of resident mood interview for Resident R89 dated December 12, 2019 revealed that resident had symptoms such as little interest or pleasure in doing things, feeling down, depressed or hopeless, trouble falling or staying asleep or sleeping too much and feeling bad about herself.

Review of social work assessment dated December 12, 2019 revealed that the resident had presented with feeling depressed and the recommendation to follow-up with the psychiatric nurse practitioner was made for additional support.

Review of progress note for Resident R89 dated January 1, 2020 revealed the resident was not compliant with fluid restriction (a number of ounces of fluids to be taken during the day as ordered by the physician).

Review of progress note for Resident R89 dated January 3, 2020 revealed the resident stated she needed a sleeping pill and something for anxiety. Resident was also tearful.

Review of progress note for Resident R89 dated January 5, 2020 at 11:28 a.m. revealed the resident did not always follow the diet ordered by the physcian.

Review of progress note for Resident R89 dated January 10, 2020 at 11:49 a.m. revealed the resident did not comply with the medication regimen ordered by the physician.

Review of dietary progress note for Resident R89 dated January 10, 2020 at 1:07 p.m. revealed the resident reported a poor appetite.

Review of progress note for Resident R89 dated January 18, 2020 at 11:06 a.m. revealed the resident refused all her medications and stated, "Its not doing anything for me."

Review of progress notes for Resident R89 revealed that the resident refused her ordered medications on January 19, 2020, January 20, 2020, January 21, 2020, January 22, 2020, January 24, 2020, January 25, 2020, January 26, 2020, January 27, 2020, January 31, 2020, February 1, 2020 and February 8, 2020.

Review of the care plan for Resident R89 revised on December 31, 2019, revealed that the resident had a potential psychosocial well-being problem related to major depressive disorder with an intervention to consult with pastoral care, social service or psych service as appropriate.

Review of clinical record for Resident R89 revealed no evidence that the resident was seen by the psychiatric nurse practitioner as recommended by the social service. Continued review of clinical record for Resident R89 revealed no evidence that the resident was offered appropriate and timely behavioral health services or psychiatric services.

Interview with Employee E5, director of nursing, on February 11, 2020 at approximately 11:30 a.m. confirmed that the resident was not seen by mental health services since December 10, 2019 when she had a psychiatric gradual dose reduction review.

The facility failed to ensure that each resident was provided with the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being.

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













 Plan of Correction - To be completed: 03/13/2020

Submission of this plan of correction is not a legal admission by Maplewood Nursing & Rehabilitation Center that a deficiency exists or that this Statement of Deficiencies was correctly cited. In addition, preparation and submission of this POC does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the survey agency.

1. R89 was evaluated by the psych Nurse Practitioner.
2. An audit will be conducted to identify other residents with signs or symptoms of depression or behavioral symptoms who may not have received a psych evaluation as appropriate.
3. To ensure proper practices continue:
a. Unit Managers and Social Services Director will be been inserviced on ensuring psych evaluations are requested and followed-up on as appropriate.
b. The Director of Nursing or designee will monitor compliance with this POC by randomly auditing the charts of residents with behavior symptoms and signs and symptoms of depression two times per week for four weeks and then weekly for fours months.
4. The results of the reviews and audits completed under this POC will be reviewed at the QAPI committee meeting for review and follow-up.

483.40(d) REQUIREMENT Provision of Medically Related Social Service:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:

Based on review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure that medically related social services related to the authorization for dental treatment was provided to the resident and/or the resident's responsible party for one of 37 residents reviewed. (Resident R94)

Findings include:

Review of Resident R94's quarterly Minimum Data Set Assessment (MDS-an assessment of a resident's needs) dated December 19, 2019 indicated that the resident was cognitively intact.

Interview with Resident R94 on February 10, 2020 at approximately 10:30 a.m. revealed that the resident reported that she was missing parts of her two front teeth, and that she felt embarrassed smiling. The resident also reported that it was hard for her to eat her favorite foods, such as corn-on-the cob.

Review of a dental consult indicated that Resident R94 was seen for treatment on February 7, 2019. The resident capacity was noted as "oriented." Further review of the dental consult treatment notes revealed that Resident R94 "fractured #8, 9 .... She should have theses teeth extracted [sic]."

Review of the dental consult dated February 21, 2019 treatment notes indicated that "consent for extraction form prepared." Additonal review of the dental consult dated May 16, 2019 treatment notes indicated "Pt (patient) wants to have #8, 9 extracted, CFE (consent for extraction) prepared."

Interview with the Director of Nursing (DON) on February 10, 2020 at approximately 10:00 a.m. revealed that that the dental company sends letters out to the resident's family/responsible party to notify them of the dental work that is recommended, along with consent forms to sign so that the recommended treatment can be completed.
The DON also reported that if the resident is alert and oriented, the dental company will notify the resident of what needs to be done and obtain a consent from the resident. Further interview with the DON revealed that there was no one at the facility who followed up with the dental company regarding any problems that they have in getting in contact with the family/responsible party for the recommended treatment.

On February 11, 2020 at approximately 11:00 a.m. documentation was provided by the DON, and it was confirmed that the treatment that was recommended for Resident R94 was not provided because the dental company could not get in touch with the resident's family/responsible party.

The facility failed to ensure that medically related social services regarding dental treatment was provided to Resident R94 and/or the resident's responsible party.


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

28 Pa Code 201.8(a)(3) Management

28 Pa Code 201.29(j) Resident rights

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

28 Pa Code 211.12 (c) Nursing services

28 Pa Code 211012 (d)(1) Nursing services

28 Pa Code 211.12 (d)(2) Nursing services

28 Pa Code 211.12 (d)(3) Nursing services

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

28 Pa Code 211.15(a) Dental services








 Plan of Correction - To be completed: 03/13/2020

Submission of this plan of correction is not a legal admission by Maplewood Nursing & Rehabilitation Center that a deficiency exists or that this Statement of Deficiencies was correctly cited. In addition, preparation and submission of this POC does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the survey agency.

1. R94 has received follow-up treatment from the dentist.
2. An audit was conducted to identify other residents who have not received follow-up dental treatment as necessary.
3. To ensure proper practices continue:
a. Nurse Management will be inserviced on obtaining authorization for dental treatment in a timely manner as needed.
b. The Director of Nursing or designee will monitor compliance with this POC by auditing the dental schedule once per week for four weeks and then monthly for four months.
4. The results of the reviews and audits completed under this POC will be reviewed at the QAPI committee meeting for review and follow-up.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

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

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

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

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

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

Based on observation, review of facility policy, review of the facility's Infection Prevention Control Program Manual and interviews with staff, it was determined that the facility failed to ensure that the infection prevention control program was executed for one of 37 residents (Resident R160) and failed to review the Infection Control and Prevention program manual at least annually.

Findings include:

Review of facility policy, "Infection Prevention and Control Program (IPCP)" dated (11/2017) stated "The facility will 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."
Transmission-based precautions will be used when a resident has a laboratory confirmed infection which is potentially transmissible. When transmission-based precautions are implemented:
Notification will be posted outside the resident's door.
Personal Protective Equipment (PPE) will be used by staff and placed to be readily available for caregivers and visitors.
Disposable or dedicated, non-critical care items will be used for the resident.

Observation on February 8, 2020 at approximately 10:30 a.m., revealed an overbed tray present in the hallway in front of Resident 160's room supplied with gowns/gloves. Interview with Employee E13, Registered Nurse (RN) Supervisor, revealed, "The resident should have been on isolation precautions since he was admitted from the hospital on Thursday (February 6, 2020)". The employee further confirmed that the facility failed to implement isolation precautions for the resident and failed to place a notification sign outside the resident's door.

Review of the Infection Control Program manual revealed that it was dated 2012. Interview with Employee 2, the Infection Preventionist, and the Director of Nursing on February 11, 2020 at approximately 11:30 a.m., revealed that the Infection Prevention and Control program manual was kept in the Director of Nursing's office and it was also online for all staff to access. There was no documented evidence that an annual review of this program manual had been completed.

The facility failed to ensure that an annual review of the Infection Prevention and Control Program was implemented as required.

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







 Plan of Correction - To be completed: 03/13/2020


Submission of this plan of correction is not a legal admission by Maplewood Nursing & Rehabilitation Center that a deficiency exists or that this Statement of Deficiencies was correctly cited. In addition, preparation and submission of this POC does not constitute an admission or agreement of any kind by the facility of the truth of any facts set forth in this allegation by the survey agency.

1. The Infection Prevention Manual has been reviewed. R160 no longer has physician's orders for isolation precautions.
2. An audit will be conducted to ensure isolation precautions are carried out appropriately for other residents with physicians' orders.
3. To ensure proper practices continue:
a. Infection Preventionist was inserviced on ensuring annual review of manual. Nursing staff will be inserviced on implementing and carrying out isolation precautions.
b. The Director of Nursing of Designee will audit isolation rooms for appropriate set-up two times per week for four weeks and then weekly for four months.
4. The results of the reviews and audits completed under this POC will be reviewed at the QAPI committee meeting for review and follow-up.


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