Nursing Investigation Results -

Pennsylvania Department of Health
MOUNTAIN VIEW CARE AND REHABILITATION CENTER
Patient Care Inspection Results

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MOUNTAIN VIEW CARE AND REHABILITATION CENTER
Inspection Results For:

There are  102 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 VIEW CARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on March 5, 2021, it was determined that Mountain View Care 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(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 observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

During the initial tour of the food and nutrition services department on March 2, 2021, at 9:00 AM, the following deficient sanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

In the walk - in freezer, there was debris on the floor and under shelving. There was an opened bag of unbreaded chicken breasts with ice crystals observed inside the opened bag. An opened stick of salami that was not labeled or dated when initially opened was observed in the walk-in cooler .

At the bottom of the entryway wall of the dish room, there was a metal covering with sharp edges and was observed to be pulling away from the wall and tiles.

A dry white flaky matter was observed coating the top the streamer in the cook's area. The food service director identified the white matter as calcium deposit build up.

The upper shelves located in the cook's prep area were found to be covered with dust and were sticky to the touch. Debris and spilled food was observed in the drawers that stored clean serving utensils in the cook's prep area. The shelves used to store seasoning and spices were covered in dust and the surface felt sticky. A black hooded sweatshirt, identified by the food service director as a staff member's personal item, was found on the shelf along with the spices.

The stainless-steel rack that was used for holding clean cooking pans and lids was observed to have sticky surfaces with debris stuck to the surfaces. Also, the metal rack used to store the resident's plate covers was sticky and had debris stuck to the racks.

Dusty electrical cords plugged into the ceiling were observed hanging over the tray line serving area. The food service director confirmed that the cords were for the plate warmers.

The steamtable wells in the residents' main dining room was observed to contain dirty water along with spilled food inside each well. The metal steamtable covers were sticky with debris caked on the covers. Smeared food was observed on sneeze guard over the steamtable. The floor in this area was observed to be littered with debris and felt sticky.

Interview with the Director of Food Service on March 2, 2021, at 9:20 AM, verified observations and confirmed the above food safety and sanitation concerns. Further confirmation of the facility's food safety and sanitation concerns were confirmed with the Nursing Home Administrator (NHA) on March 5, 2021, at 1:00 PM.



28 Pa. Code 211.6 (f) Dietary services.

28 Pa. Code 207.2(a) Administrator's responsibility.





 Plan of Correction - To be completed: 04/06/2021

0812 The walk-in freezer was cleaned. Food covered, labeled and dated. The metal that was pulling away from the tile was corrected. The top of the steamer, shelves, the drawers cleaned, the sweatshirt was removed. The rack that holds the clean pans was cleaned. The cords were cleaned. The steamtable in the dining room was drained and cleaned along with the table and floor. This was completed that day.
Daily audits will be completed by the dietary supervisor or cook in charge.
Cleaning duties will be developed to include but not limited to the examples during the survey.

The dietitian will do weekly audits and all findings will be reported to the centers QAPI team for review and recommendations times 2 months.
In service and education will be completed for all dietary staff on the policy and procedure of sanitation.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to consistently provide services planned to maintain range of motion/mobility for four of 25 sampled residents (Resident 10, 11, 33, and 48).

Findings include:

A review of Resident 10's clinical record revealed that the resident was admitted to the facility on September 18, 2017, with diagnoses that included osteoporosis (a condition in which bones become weak and brittle).

Further review of Resident 10's clinical record revealed the resident was to receive a restorative nursing program to include ambulation up to 200 feet with rolling walker and assist of 1 staff five to seven times a week.

Review of the facility documentation of the restorative nursing program for January 2021 revealed that services were not rendered to Resident 10 on 20 scheduled occassions during the month of January 2021.

Review of the facility documentation of the restorative nursing program for February 2021 revealed the services were not provided to the resident as planned 21 times during the month of February 2021.

A review of Resident 11's clinical record revealed that the resident was admitted to the facility on December 2, 2020, with diagnoses that included Type 2 diabetes (high blood sugar).

Further review of Resident 11's clinical record revealed the resident was to receive a restorative nursing program to include ambulation up to 100 feet with rolling walker and assist of 1 staff five to seven times a week.

Review of the facility documentation of the resident's restorative nursing program for January 2021 revealed that Resident 11 did not receive the services as planned 9 times in the month of January 2021.

Review of the facility documentation of the restorative nursing program for February 2021 revealed that the planned restorative nursing services were not provided to the resident on 18 occassions during the month of February 2021.

A review of Resident 33's clinical record revealed that the resident was admitted to the facility on September 24, 2020, with diagnoses that included Type 2 diabetes (high blood sugar).

Further review of Resident 33's clinical record revealed the resident was to receive a restorative nursing program to include ambulation up to 75 feet with a platform walker five to seven times a week.

Review of the facility documentation of the restorative nursing program for January 2021 revealed that these restorative services were not provided to the resident on 14 scheduled occassions during the month of January 2021.

Review of the facility documentation of the restorative nursing program for February 2021 revealed the restorative nursing services were not provided to the resident 12 times in the month of February 2021.

A review of Resident 48's clinical record revealed that the resident was admitted to the facility on September 14, 2020, with diagnoses that included congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should).

Further review of Resident 48's clinical record revealed the resident was to receive a restorative nursing program to include ambulation up to 75 feet with rolling walker and assist of 2 staff five to seven times a week.

Review of the facility documentation of the restorative nursing program for January 2021 revealed that Resident 48 did not receive these 23 times during the month of January 2021 as planned.

Review of the facility documentation of the restorative nursing program for February 2021 revealed the services were not rendered 19 times in the month of February 2021 as scheduled.

An interview with the Director of Nursing (DON) on March 5, 2020, at approximately 2:00 PM confirmed the residents were not consistently receiving restorative nursing services as planned.



28 Pa. Code 211.5(f) Clinical records


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



 Plan of Correction - To be completed: 04/06/2021

0688 Residents 10, 11, 33 and 48 Restorative programs were evaluated by the rehabilitation team. The plan of care was adjusted to reflect the recommendations for the restorative program.
The physical therapist or designee an audit will be completed on residents that are on a restorative program to see that the program is being completed as order.
Weekly audits will be completed times 2 months and all findings will be reported to the centers QAPI team for review and recommendations.
In service and education will be provided to the restorative team on the centers restorative policy and procedure, the importance of proper documentation.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to clinically justify the use of antipsychotic medication for three resident (Resident 61, 41, and 48) out of five sampled residents.

Findings include:

A review of Resident 61's clinical record revealed admission to the facility on January 17, 2020, with diagnoses to include vascular dementia without disturbances.
A physician order dated June 12, 2020, included Zyprexa (an antipsychotic used to treat mental disorders) 2.5 mg daily to treat the diagnosis of mood disorder. On July 22, 2020, the medication was discontinued.

A physician order dated September 3, 2020, reinitiated Zyprexa 2.5 mg daily for vascular dementia without behavior disturbance.

Review of the resident's clinical record revealed two incidents of increased behaviors displayed the resident, one on August 28, 2020, and one on September 3, 2020. The physician was notified of these two instances and Zyprexa 2.5 mg was ordered.

There was no physician documentation of the clinical necessity of the Zyprexa to treat the resident's vascular dementia without behavioral disturbances.

During an interview with the Director of Nursing (DON), she was unable to provide resident-specific individualized documentation by the physician to clinically justify the use of the Zyprexa to treat vascular dementia without behavior disturbances.

Clinical record review revealed that Resident 41 was admitted to the facility on November 10, 2016 with diagnosis to include diabetes, dementia and chronic pain syndrome.

A review of a quarterly Minimum Data Set assessment (a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated January 21, 2021, revealed that Resident 41 was cognitively impaired and received antipsychotic and antianxiety. daily during the 7 day look back period.

A physician order, initially dated September 10, 2019, was noted for Seroquel (an antipsychotic used to treat mental disorders) 50 mg daily at 2 PM and Seroquel 100 mg at bedtime for dementia. The clinical record indicated that Resident 41 has received this medication at the same dose from the initial order date of September 10, 2019, to the time of the survey ending March 5, 2021.

Review of the resident's monthly behavior monitoring records dated October 2020 through March 2021 (survey ending March 5, 2021), revealed one incident of targeted behaviors displayed by the resident (verbal abuse, name calling) being treated with the antipsychotic medication Seroquel; these instances occurred on November 19, 2020 and October 30, 2020.

A physician order, initially dated July 25, 2019, was noted Klonopin 1 mg ( an antianxiety medication) twice a day for panic disorder/anxiety.

Review of the resident's monthly behavior monitoring records dated October 2020 through March 2021 (survey ending March 5, 2021), revealed three episodes of the targeted behaviors(yelling out and extreme tearfulness) displayed by the resident being treated with the antianxiety medication Klonopin during December (December 5, 24 and 29, 2020), twice in November 2020 (November 5 and 24, 2020) and 8 episodes during October 2020.

There was no physician documentation of the clinical necessity of the Seroquel to treat vascular dementia without behavioral disturbances and Klonopin to treat the panic disorder/anxiety.

A review of a pharmacy "note to attending Physician/prescriber" dated September 14, 2020, requesting a gradual dose reduction of Klonopin and Seroquel. The note indicated that Resident 41 had been receiving Klonopin 1 mg twice daily and Seroquel 50 mg daily and Seroquel 100 at hour of sleep. The pharmacist asked that the physician "Please consider an attempted dose reduction or trial discontinuation as you deem appropriate. If this cannot be accomplished, please document risk vs benefit of continued therapy with current regimen."

The request for a GDR was denied, signed and dated September 25, 2020 by Resident 41's attending physician. The physician statement on the form revealed "followed by psychiatry, meds necessary per psych recommendations."

A review of consultant psychiatry notes dated October 13, 2020, revealed that a GDR was considered, but contraindicated. The note stated "adequate symptom/behavior management/control on current plan and medication, recommend no adjustment at this time."

There was no indication that a gradual dose reduction had been attempted on either the Seroquel or the Klonopin in the past 12 months.

During an interview with the Director of Nursing (DON) the DON confirmed that a gradual dose reduction of the psychoactive drugs prescribed for Resident 41 was not attempted.

A review of Resident 48's clinical record revealed admission to the facility on September 14, 2020, with diagnoses to include anxiety, dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).

Admission physician orders included Alprazolam 0.25 mg (used to treat anxiety disorder) one tablet, as needed, every eight hours for anxiety.

On September 28, 2020, the physician renewed the order for prn Alprazolam 0.25 mg to continue until October 22, 2020.

On October 22, 2020, the physician renewed the order for prn Alprazolam 0.25 mg to continue until November 3, 2020.

On November 4, 2020, the physician renewed the order for prn Alprazolam 0.25 mg and remains in effect currently.

A review of a pharmacist's recommendation to the physician dated October 19, 2020, revealed that the pharmacist identified that "as needed psychotropic drugs are limited to 14 days and for the physician to evaluate the as needed Alprazolam to see if it can be discontinued or a 14 day stop date could be added to the order."

The physician's response indicated that the resident has been using the medication and will reevaluate in 14 days.

There was no physician documentation that the prn Alprazolam was reevaluated after the 14 days. At the time of the survey ending March 5, 2021, the Alprazolam remained an active order with no stop date.

The physician failed to document justification for the prolonged use of as needed Alprazolam.

An interview with the director of nursing on March 4, 2021, at 1:53 PM confirmed the physician failed to justify and reevaluate the as needed Alprazolam.


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







 Plan of Correction - To be completed: 04/06/2021

0758 Residents 61,41, and 48 will have a medication review completed by the consultant pharmacist. All recommendations will be review by the attending physician for his recommendation. The physician will document the reason for continuation or discontinue of the medication. There will be an appropriate diagnosis for each medication. There will be appropriate justification for a denied of recommendation of the pharmacist. There also will be follow up if the physician notes a follow update.
Audit will be completed on residents using anti-psychotic meds for appropriate diagnosis and physician justification of medication. This will be conducted by the consultant pharmacist.
Audit will be completed on any new orders for anti-psychotic meds for appropriate diagnosis and justification of medication, all findings will be reported to the centers QAPI team for review and recommendations times 2 months.
A monthly meeting will be held with the medical director or designee, pharmacist and the interdisciplinary team to review resident on anti-psychotic medication.
In-service and education will be completed for the medical director, pharmacist, and interdisciplinary team.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interviews, it was determined that the pharmacist failed to identify drug irregularities in the drug regimen of three of 25 sampled residents (Resident 61,48, 41)

Findings included:

A review of the clinical record revealed that Resident 61 was admitted to the facility on January 20, 2020.

The resident had a physician order dated September 3, 2020, for Zyprexa (an antipsychotic) 2.5 mg daily for a diagnosis of vascular dementia without behavioral disturbance.

A review of the monthly pharmacy reviews conducted by the pharmacist from September 2020, through February 2021, revealed no indication the pharmacist identified the use of an antipsychotic medication (Zyprexa) for a diagnosis of dementia without supporting prescribing
physician documentation of the clinical necessity (Antipsychotic drugs are most commonly prescribed for behavioral and psychological symptoms, such as aggression or hallucinations, in people with dementia).

Interview with the Director of Nursing on March 5, 2021, at 12:57 PM, confirmed there was no evidence the pharmacist had identified the use of an antipsychotic medication for dementia without behavioral disturbance.

A review of the clinical record revealed that Resident 48 was admitted to the facility on September 14, 2020 .

A review of a physician order, dated September 22, 2020, revealed an order for Oxycodone HCL 5 mg tablet (opioid pain medication) one tablet by mouth every 12 hours, as needed, for pain.

A review of the resident's October 2020 MAR revealed that staff administered this prn pain medication 32 times during the month of December 2020.

A review of the resident's November 2020 MAR revealed that staff administered the prn pain medication 41 times during the month of January 2021.

A review of the resident's December 2020 MAR revealed that staff administered this prn pain medication 42 times during the month of December.

A review of the resident's January 2021 MAR revealed that staff administered the prn pain medication 43 times during the month of January 2021.

A review of the resident's February 2021 MAR revealed that staff administered the prn pain medication 31 times during the month of February.

A review of the monthly drug regimen reviews completed by the pharmacist from October 2020 through February 2021 revealed no documented evidence at the time of the survey ending March 5, 2021, that the pharmacist identified Resident 48's excessive use of the as needed opioid pain medication.

During an interview on March 5, 2021 at approximately 1:00 PM, the Director of Nursing confirmed that the resident's excessive use of the as needed opioid pain medication was not identified by the pharmacist during monthly drug regimen reviews.

Clinical record review revealed that Resident 41 was admitted to the facility on November 10, 2016 with diagnosis to include diabetes, dementia and chronic pain syndrome.

A review of current Physicians orders dated July 25, 2019 revealed Morphine Sulfate (a narcotic, opioid pain medication) 15 mg by mouth, three times a day for chronic pain syndrome.

Corresponding monthly medication administration records (MAR) dated from April 2020 through March 2021 (survey ending March 5, 2021) indicated that Resident 41 received the narcotic medication as per the physicians orders three times a day.

A review of comprehensive pain assessments revealed that a comprehensive assessment was completed on February 27, 2021. The assessment indicated that Resident 41 stated that she had "moderate" pain , rated as a 4 on a 1-10 scale, 1 being the least pain and 10 the worst. The pain description was noted to be an "ache" and was successfully relieved with Tylenol and the Physician prescribed narcotic medication

The previous pain assessment noted in the clinical record was dated October 10, 2019. There was no evidence at the time of the survey of any additional comprehensive pain assessments in Resident 41's clinical record.

A review of pain assessments completed every shift by licensed nurses and documented in the monthly MAR dated September 2020 through March 5, 2021, revealed that Resident 41 did not experience any pain, on any shift, on any date in this time frame.

A review of the monthly drug regimen reviews completed by the pharmacist from April 2020 through February 2021 revealed no documented evidence at the time of the survey that the pharmacist identified Resident 41's daily use of the opioid pain medication and the lack of ongoing comprehensive pain assessments.

During an interview on March 5, 2021 at approximately 1:10 PM, the Director of Nursing confirmed that the resident's long term daily use of the opioid pain medication was not identified by the pharmacist during monthly drug regimen reviews.


28 Pa. Code 211.9 (k) Pharmacy services

28 Pa. Code 211.12 (c) Nursing services












 Plan of Correction - To be completed: 04/06/2021

0756 Resident 61, The physician will evaluate the use of Zyprexa and make a recommendation to discontinue or continue the medication. If he continues, he will document the reason for the med. Resident 48, The physician will evaluate the extensive use of a PRN pain medication and make recommendations for a pain management program. Resident 41, The physician will evaluate the resident for the long-term use for pain medication and make a recommendation and document justification for a long-term pain management program.
Audit will be completed on residents using anti-psychotic meds for appropriate diagnosis, PRN pain and the use of long-term pain medication. This will be conducted by the consultant pharmacist.
Audit will be completed on any new orders for anti-psychotic meds for appropriate diagnosis, PRN pain and the use of long-term pain medication, all findings will be reported to the centers QAPI team for review and recommendations times 2 months.
In-service and education will be completed for the medical director, pharmacist, and interdisciplinary team.

483.25(k) REQUIREMENT Pain Management: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.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on clinical record and select policy review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for two residents (Resident 11 and 48) of 25 residents reviewed.

Findings include:

A review of a facility policy for pain management reviewed January 21, 2021 revealed, it is the policy of the facility to ensure that every resident that is admitted to the facility is assessed for pain/or the potential for pain for the resident to retain or maintain his or her practicable level of physical, mental and psychosocial wellbeing in accordance with the comprehensive assessment and the plan of care. A licenses nurse will evaluate each resident for pain upon admission/readmission/quarterly and change in condition. A resident will be evaluated each shift for pain. Non pharmalogical interventions will be attempted prior to the administration of PRN (as needed) pain medication.

A review of Resident 11's clinical record revealed current physician's orders, initially dated December 5, 2020, for Tramadol HCL 50 mg tablet (Tramadol is in a class of medications called opiate (narcotic) analgesics) one tablet by mouth every 8 hours, as needed, for pain.

A review of the resident's December 2020 Medication Administration Record (MAR) revealed that staff administered this pain medication 19 times during the month of December 2020. Of the 19 doses given, all were administered without attempting non-pharmacological interventions prior to giving the pain medication.

A review of the resident's January 2021 MAR revealed that staff administered the pain medication 41 times during the month of January 2021. Of the 41 doses given, all were administered with no non-pharmacological interventions attempted prior to giving the pain medication.

A review of the resident's February 2021 MAR revealed that staff administered the pain medication 10 times during the month of February 2021. Of the 10 doses given, all were administered without evidence that non-pharmacological interventions were attempted prior to administering the pain medication.

A review of Resident 48's clinical record revealed current physician's orders, initially dated September 22, 2020, for Oxycodone HCL 5 mg tablet (Oxycodone is a semisynthetic opioid analgesic pain medication) one tablet by mouth every 12 hours, as needed, for pain.

A review of the resident's December 2020 MAR revealed that staff administered this pain medication 42 times during the month of December 2020. Of the 42 doses given, all were administered without first attempting non-pharmacological interventions prior to giving the pain medication.

A review of the resident's January 2021 MAR revealed that staff administered the pain medication 43 times during the month of January 2021. Of the 43 doses given, all were administered with no non-pharmacological interventions attempted prior to giving the pain medication.

A review of the resident's February 2021 MAR revealed that staff administered the pain medication 31 times during the month of February. Of the 31 doses given, all were administered without evidence that staff attempted non-pharmacological interventions prior to giving the pain medication.

Interview with the Director of Nursing on March 5, 2021, at approximately 1:00 PM confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of prn pain medication.

Clinical record review revealed that Resident 41 was admitted to the facility on November 10, 2016, with diagnoses to include diabetes, dementia and chronic pain syndrome.

A review of a quarterly Minimum Data Set assessment (MDS, a comprehensive, standardized assessment of each resident's functional capabilities and health needs) dated January 21, 2021, revealed Resident 41 was cognitively impaired and had received pain medication during the 7 day look back timeframe.

Physician orders, initially dated July 25, 2019, which remained current, revealed Morphine Sulfate (a narcotic, opioid pain medication) 15 mg by mouth, three times a day for chronic pain syndrome.

Corresponding monthly medication administration records (MAR) dated from April 2020 through the time of the survey ending March 5, 2021, revealed that Resident 41 received the narcotic medication as per the physicians orders three times a day during that time frame.

A review of comprehensive pain assessments revealed that a comprehensive assessment was completed on February 27, 2021. The assessment indicated that Resident 41 stated that she had "moderate" pain , rated as a 4 on a 1-10 scale, 1 being the least pain and 10 the worst. The pain description was noted to be an "ache" and was successfully relieved with Tylenol and the physician prescribed narcotic medication

The previous pain assessment present in the clinical record was dated October 10, 2019.

There was no evidence at the time of the survey of any additional comprehensive pain assessments in Resident 41's clinical record to demonstrate ongoing assessment of the resident's chronic pain syndrome.

A review of pain assessments completed every shift by licensed nurses and documented on the resident's monthly MAR dated September 2020 through March 2021, revealed that Resident 41 did not experience any pain, on any shift, on any date during this time frame.

During an interview March 5, 2021 at approximately 1 PM The Director of Nursing confirmed that comprehensive pain assessments were not regularly completed by licensed staff routinely in maintain effective pain management for Resident 41, including re-evaluation of the ongoing administration, and dosage, of opioid pain medication.



28 Pa. Code 211.5(f)(g) Clinical records

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing Services











 Plan of Correction - To be completed: 04/06/2021

0697 Residents 11,41 and 48 pain assessments will be completed for their pain management program and the use non-pharmacological interventions. The Plan of care will be adjusted.
Residents on a pain medication will be audited to make sure that non-pharmacological interventions are being completed before administering pain medication.
Audits will be completed weekly times 2 months and all findings will be reported to the centers QAPI team for review and recommendations.
In service and education will be completed on the centers policy and procedure on pain management and non- pharmacological interventions procedures.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to timely consult with the physician regarding a significant weight loss displayed by one resident out of 25 sampled (Resident 11).

Findings include:

A review of facility policy entitled "Physician Notification and Response" last reviewed by the facility January 2021, revealed that the physician will be notified immediately if a resident presents with a change in condition.

A review of the clinical record revealed that Resident 11 was admitted into the facility on November 2, 2020, with diagnoses including COPD (chronic obstructive pulmonary disease a chronic inflammatory lung disease that causes obstructed airflow from the lungs) and Type 2 diabetes (high blood sugar).

A review of the resident's weight record revealed the resident weighed 288 pounds on November 3, 2020. Further review revealed that when the resident was weighed on December 3, 2020, it was noted the resident weighed 272.5 pounds. The resident had a 15.5 pound weight loss in one month, which was a 5.38% weight loss in 30 days.

There was no documented evidence that the physician was notified of the resident's significant weight loss recorded on December 3, 2020.

Interview with the Director of Nursing on March 6, 2021, at approximately 1:00 PM confirmed that the facility failed to timely notify the physician of the resident's significant wight loss.


28 Pa Code 211.12 (a)(c)(d)(3)(5)Nursing services



 Plan of Correction - To be completed: 04/06/2021

0580 The weight loss of resident 11 was communicated to their primary physician and NNO orders noted.
An audit will be completed to be assured that all residents with weight loss was communicated to the primary physician and progress note written.
Weekly audits will be conducted times 2 months and all findings reported to the Center's QAPI team for review and further education.
To prevent this from occurring to any other residents, an in service and education will be completed to all clinical staff.
Nurse managers will be responsible for monitoring the POC.

483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 25 sampled (Residents 48).

Findings include:

According to the RAI User's Manual, Section N0410, "Medications Received", items in this section assesses, the number of days a resident received medications during the seven day look back period.

A review of Resident 48's January 2021 medication administration record revealed that the resident received Xarelto (an anticoagulant medication used to help prevent blood clots) 15 mg (milligrams) by mouth daily beginning September 14, 2020.

A Medicare 5 day MDS Assessment of Resident 48 dated January 31, 2021, revealed Section N0410 indicated that the resident did not receive any anticoagulant medications during the look back period.

Interview with the DON (director of nursing) on March 3, 2021, at approximately 11:30 AM confirmed that Resident 48's MDS assessment was not accurate.



28 Pa. Code 211.5(g)(h) Clinical records

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







 Plan of Correction - To be completed: 04/06/2021

0641 Resident 48 MDS was corrected immediately.
Residents who are receiving anticoagulants their MDS was checked to make sure they were code correctly.
MDS personnel will be in serviced regarding MDS accuracy, specifically for section N, anticoagulants.
All MDS's that are completed for next quarter will be audited at time of submission for accuracy and all findings by the RNAC and will be reported to the centers QAPI team for review and recommendations.

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records, observations, and staff and resident interview it was determined that the facility failed to assure the development and implementation of person-centered care plan and ready availability of necessary emergency supplies for one resident out of one sampled resident receiving hemodialysis. (Resident 312)

Findings include:

According to the National Kidney Foundation patients receiving hemodialysis should keep emergency care supplies on hand.

A review of the facility's policy "Dialysis Care" with a review date of January 20, 2021, revealed that the facility will be responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing for all non-dialysis needs of the resident including during the time period when the resident is receiving dialysis. The facility will arrange for dialysis care as ordered by the attending physician. The care plan will document the resident's renal condition and necessary precautions. Also, the policy indicates all documentation concerning dialysis services and care of the dialysis resident will be maintain in the resident's medical record.

A review of the clinical record revealed that Resident 312 was admitted to the facility on December 15, 2020, with diagnoses that included end stage chronic kidney disease (stage 4) with dependence on hemodialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood).

During an interview with Resident 312 in her room on March 3, 2021, at 12:15 PM, the resident stated that she goes to dialysis three times per week. The resident allowed the surveyor to look around her room to observe for an emergency kit. No emergency supplies were readily available in the event of an emergency dialysis access site. Employee 1 confirmed this observation.

Review of Resident 312's orders in place at the time of the survey ending March 5, 2021, revealed that the facility failed to obtain orders for dialysis that specified the resident's individualized dialysis care.

Review of the resident's current care plan in place at the time of the survey ending March 5, 2021, revealed that the plan of care failed to be individualized for a resident requiring dialysis address the care and emergency care.

Interview with the Director of Nursing (DON) conducted at the time of the survey revealed that the resident's comprehensive care plan was not person-centered as it did not accurately reflect the necessary approaches for emergent care of the resident's dialysis access site. The DON stated that Resident 312 care plan should have included the approach of maintaining emergency supplies, that include gauze and tape at the resident's bedside and back of wheelchair in the event of a bleeding emergency (You should be able to control the bleeding by putting pressure on the spot. Apply firm pressure to the area, using gauze from your emergency kit. Hold the spot for at least 10 minutes. If the bleeding stops, apply fresh gauze and tape or a clean pressure pad).

The resident's care plan related to dialysis did not include emergency procedures in the event of a bleed from the access site, which was confirmed during interview with the DON on March 5, 2021, at 2:20 PM.



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



 Plan of Correction - To be completed: 04/06/2021

0698 Resident 312 Plan of care was adjusted and individualized for her dialysis and to include but not limited for emergency procedure in case of a bleed.
An emergency clamp was placed and the back of the headboard and on the wheelchair.
Any new dialysis residents, the policy and procedure will be in service to the clinical team.
A weekly audit will be completed by the unit manager times 2 months to make sure the clamp is available on the headboard and wheelchair. All findings will be reported to the centers QAPI team for review and recommendations.
The interdisciplinary team will be educated on the policy and procedure concerning dialysis.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:

Based on clinical record and select policy review and staff interviews, it was determined that the facility failed to ensure that for one resident (Resident 97) out of 25 sampled was free from unnecessary drugs (antibiotic).

Findings include:

Review of the facility's policy "Antibiotic Stewardship Program (ASP)" with a review date of January 20, 2021 revealed that antibiotics will be prescribed and administered to residents under the guidance of the facility's ASP. It noted that appropriate indications for use of antibiotics include criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility based on culture and sensitivity. The policy included minimum criteria for initiating antibiotics for a urinary tract infection for residents without an indwelling catheter to include one of three situations along with a positive urine culture:

Acute dysuria alone or a fever of 100 degrees Fahrenheit or two repeated temperatures of 99 degrees Fahrenheit and at least one of the following:
Urgency
Frequency
Back or flank pain
Suprapubic pain
Gross hematuria
Without the presence of an elevated temperature, two of the following criteria:
Urgency
Frequency
Incontinence
Gross hematuria
Suprapubic pain
Delirium (sudden onset of confusion, disorientation, dramatic change in mental status)

Lastly, the policy noted that urine cultures should not be used to identify urinary tract infections (UTI's) in the absence of symptoms and smelly or cloudy urine is not a symptom of a UTI. According to the policy urine cultures should be used to identify the most appropriate antibiotic and resident's with acute dysuria it may be appropriate to initiate empirical antibiotic.

A review of Resident 97's clinical record revealed admission to the facility on June 30, 2020, with diagnoses to have included cerebral infarction (is an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), dysphagia (difficulty swallowing), adult failure to thrive (occurs when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), sepsis (is an infection of the blood stream resulting in a cluster of symptoms such as drop in a blood pressure, increase in heart rate and fever, and urinary tract infection (UTI) [is an infection of any part of the urinary system, including kidneys, ureters, bladder, and urethra].

Nursing progress notes dated February 22, 2021, at 1:37 PM, revealed that the physician's assistant performed an examination due to the resident poor food acceptance with progressive weight loss. Orders were obtained for a UA (urinalysis - is a urine test used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes; urinalysis involves checking the appearance, concentration and content of urine), and a C&S (culture & sensitivity- a culture is used to diagnose a UTI and to identify the bacteria or yeast causing the infection and sensitivity helps find the most effective antibiotic to kill an infecting microorganism).

Nursing progress notes dated February 23, 2021, at 6:51 AM, revealed that the UA C&S was obtained via straight catherization (is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine). The urine was golden yellow in color, cloudy without apparent sediment, and no foul-smelling odor. The progress noted that Resident 97 did not have a temperature and offered no complaints of pain upon urination (all vital signs noted to be within normal parameters).

Review of Resident 97's physician orders dated February 25, 2021, revealed an order for Cipro tablet (an antibiotic) 500 milligrams one tablet twice a day due to bacteriuria for thirteen administrations.

Review of Resident 97's urinalysis laboratory results dated February 23, 2021, at 7:36 AM, revealed amber and turbid urine with the presence of protein, white blood cells, and red blood cells. Urine culture results dated February 26, 2021, at 3:55 PM, revealed the presence of Escherichia Coli (E. coli)[bacteria that normally live in the intestines of healthy people and animals] ESBL-E coli [are the largest group of multidrug-resistant pathogens from bacteremia's].

Further review of Resident 97's physician orders dated February 27, 2021, at 11:38 AM, revealed an order to discontinue orders for Cipro and begin Macrobid Capsule 100 milligram by mouth twice per day for thirteen administrations due to bacteriuria.

Review of Resident 97's Medication Administration (MAR) for February 2021 revealed that the resident received four doses of Cipro from February 23, 2021 through February 27, 2021, prior to receiving the culture and sensitivity (C & S) results.

During an interview March 3, 2021, at approximately 11:46 AM, the Director of Nursing (DON) confirmed that the antibiotics were administered without identifying the infectious organism prior to starting an identified antibiotic medication for a urinary tract infection and that the physician had failed to document in the clinical record the rationale for initiating Cipro prior to receiving the results of the C & S.



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

28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.9(a)(1)(k) Pharmacy services





 Plan of Correction - To be completed: 04/06/2021

0757 Resident 97. There was no ill effects from the original order for the antibiotic.
The infection control nurse completed an audit to make sure antibiotics are only ordered with a sensitivity report or by the criteria in the centers policy and procedure.
The infection control nurse will complete weekly audits and report her findings to the centers QAPI team for review and recommendations times 2 months.
The medical Director will mail a letter will to all physicians with information on the antibiotic stewardship program and the criteria of ordering antibiotics.
The infection control meetings will include review of all antibiotics that are prescribed, the Medical Director will be attending meetings.
In service and educate the interdisciplinary team and physicians on the policy and procedure for antibiotics.



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