Nursing Investigation Results -

Pennsylvania Department of Health
CANTERBURY PLACE
Patient Care Inspection Results

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CANTERBURY PLACE
Inspection Results For:

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CANTERBURY PLACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey and Civil Rights Compliance Survey completed on February 13, 2020, it was determined that Canterbury Place, was not in compliance with the 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:


483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.35(g) Nurse Staffing Information.
483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:

Based on observation and staff interview it was determined that the facility failed to post current nurse staffing information in one of three resident areas (Main Lobby).

Findings include:

During an observation on 2/10/20, at 7:00 a.m. the posted nurse staffing information was dated 2/7/20.

During an interview on 2/10/20, at 8:00 a.m. Staffing Coordinator Employee E1 confirmed that the facility failed to post current staffing information


28 Pa Code: 211.12 (a)(4)(k) Nursing services.

Previously cited 3/1/2019.






 Plan of Correction - To be completed: 03/25/2020

The nursing staffing information sheets detailing the facility name, current date total and actual hours worked by RN, LPN and certified nursing assistants as well as the resident census is now posted accurately daily.
All involved in the posting of the schedule (receptionists and scheduler) are receiving additional education.
Random audits of the posted nursing staffing information sheet will be conducted four times per week for three weeks to insure the daily accurate posting of the required information will be conducted by the Director of Nursing or designee. Then the audits will be conducted three times per week for three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee to determine the need for additional education and/or monitoring

the education will be conducted the Director of Nursing or designee and the audits will cover all units in the facility
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 facility policy review, observation and staff interview, it was determined that the facility failed to properly store medications and failed to properly label a medication in one of three medication rooms (First Floor medication room).

Findings include:

The facility policy "Medication Distribution System" dated 12/10/19, indicated that refrigerated medications are kept in closed labeled containers, with internal and external medications separated, and separate from fruit juices, applesauce and other foods used in administering medications. Other foods such as refreshments or employee lunches are not stored in this refrigerator.

The facility policy "Expiration Dates" dated 12/10/19, indicated that all multi-dose medications should be labeled by the facility with the date of first use so that expiration dates or date for last use can be determined.

During an observation on 2/11/20, at 10:22 a. m. in the First Floor medication room revealed six containers of nutritional supplements stored in the medication refrigerator next to medications. One vial of Tubersol (a solution injected into the skin to determine the presence of tuberculosis, an infectious bacterial disease of the lungs) that was open and in use without a date opened rendering the expiration date of 6/10/22, inaccurate.

During an interview on 2/11/20, at 10:25 a. m. Licensed Practical Nurse Employee E2 confirmed that the facility failed to properly store and label medications as required.

28 Pa. Code: 211.9 (h) Pharmacy services.

28 Pa. Code: 211.12 (d) (1) (2) (3) (5) Nursing services.


 Plan of Correction - To be completed: 03/25/2020

The six nutritional supplements found in the first-floor medication refrigerator were removed immediately,
The undated Tubersol solution was immediately discarded
Professional nursing staff were re-educated on the facility's policy on the appropriate storage of drugs and biologicals including the dating of all items in the medication refrigerator once opened.
Random audits of the medication refrigerators will be conducted four times per week for three weeks to ensure compliance with the policy will be conducted by the Director of Nursing or designee. Then the audits will be conducted three times per week for three weeks. Any deficient practice will be immediately Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee to determine the need for additional education and/or monitoring.
the audits will be conducted by the Unit managers or designee.
the audits will be conducted on all medication refrigerators in the facility.

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