Nursing Investigation Results -

Pennsylvania Department of Health
FULTON COUNTY MEDICAL CENTER
Patient Care Inspection Results

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FULTON COUNTY MEDICAL CENTER
Inspection Results For:

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FULTON COUNTY MEDICAL 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, Civil Rights Compliance survey, and a complaint survey completed on June 8, 2022, it was determined that Fulton County Medical 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 and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(i) Food safety requirements.
The facility must -

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

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


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety, by failing to ensure that food items stored in the kitchen were off the floor, not stored with cleaning products, and that outdated food was discarded.

Findings include:

The facility's policy regarding food storage, dated March 9, 2022, revealed that food will be maintained in a manner that prevents damage, spoilage, infestations and bacterial contamination by ensuring that food supplies were never stored with chemicals and shelving should be no closer than six inches from the floor.

Observations in the kitchen's cooler on June 6, 2022, at 8:51 a.m. revealed spinach wrapped in plastic wrap, dated as opened on May 11, 2022, with a "use by" date of May 18, 2022.

Observations in the kitchen's freezer on June 6, 2022, at 8:56 a.m. revealed a white box of frozen turkey on the floor of the freezer.

Observations in the kitchen's dry storage area on June 6, 2022, at 9:02 a.m. revealed that there was one box of EcoLab pantastic (a concentrated liquid pot and pan detergent), one box of EcoLab lime-a-way (a harmful chemical cleaner used to clean build up on dish machines), and two boxes of 96 individual servings of frosted corn flakes stacked on the floor.

Interview with the Dietary Manager on June 6, 2022, at 8:53 a.m., 8:58 a.m., and 9:03 a.m. confirmed that any expired or outdated food items should be discarded, that all food items were to be stored off the ground, and that the chemical cleaning products were to be stored in an area away from the dry foods.

Interview with the Nursing Home Administrator on June 7, 2022, at 5:24 p.m. confirmed that chemical cleaning products should never be stored in food storage areas, that food items should not be stored on the floor, and that all outdated food should be used or disposed of by the labeled date.

28 Pa. Code 211.6(f) Dietary services.



 Plan of Correction - To be completed: 07/12/2022

1. The Spinach was properly disposed of in trash. Turkeys and food items that were on the floor were disposed of properly. Chemicals were immediately removed from the dry foods area.
2. The freezer, dry goods storage area and kitchen were inspected for outdated items, any other items on the floor and chemicals storage. None were found during the inspection by the Food Service Director.
3. Dining staff will be in serviced on proper storage, labeling and dating of food items based on professional standards. Dining staff will receive education on proper storage location of chemical cleaners used in dining services.
4. Random weekly audits for 4 weeks will be completed to visualize food storage and labeling of food items by the Food Service Director or designee. These audits will be completed during daily safety and sanitation rounds as part of their routine daily duties. Daily visual audits for items on the floor will be completed for 2 weeks, then weekly x2 weeks. Results of the audits will be brought and reviewed at monthly Quality Assurance Committee.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:


Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that meals were served in a manner that maintained or enhanced each resident's dignity by feeding meals together for one of 25 residents reviewed (Resident 23).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated April 5, 2022, indicated that she was cognitively impaired, had long-term memory problems, had range of motion limitation of one side upper extremity, and she required extensive assistance of one for eating

The plan of care for Resident 23, dated April 15, 2022, indicated that she was to be assisted with all meals as needed and that she required assistance with her care needs due to her cognitive impairment.

Observations during lunch in the Shimer Trail dining area on June 6, 2022, at 11:45 a.m. revealed that there were seven residents (including Resident 23) seated around the dining tables. The first resident at the table was served her meal at 11:45 a.m. and Resident 23 was served at 12:07 p.m. (22 minutes later). Resident 23 was set up to eat and was fed her meal by the nursing staff.

Observations during lunch in the Shimer Trail dining are on June 7, 2022, at 11:47 a.m. revealed that there were six residents (including Resident 23) seated around the dining tables. The first resident was served her meal at 11:47 a.m. and Resident 23 was served at 12:09 p.m. (22 minutes later). Resident 23 was set up to eat and staff began to feed her, at which time the resident beside her had already eaten his full meal.

Interview with Nurse Aide 1 on June 7, 2022, at 12:28 p.m. revealed that the first meal cart to the unit was for the residents who feed themselves and the second cart was for the residents who need staff assistance. She indicated that Resident 23 was the only resident in the dining area who needed staff assistance with eating that day and that all of the other residents who needed assistance were in their rooms. She confirmed that Resident 23 was not served timely at the dining table with the other residents and that she should have been assisted with her meal first when the second cart came.

Interview with the Nursing Home Administrator on June 7, 2022, at 12:43 p.m. confirmed that when residents are dining together they should be provided their meals timely and not have to wait while others are eating.

28 Pa. Code 201.29(j) Resident rights.




 Plan of Correction - To be completed: 07/12/2022

1.Resident 23 will receive and eat her meal at the same time as the other residents seated at her table.
2.There were no other residents identified not eating at the same time as others at their table.
3.Education will be provided to the nursing staff with updates of new protocols to ensure residents seated at the same table are served at the same time. Residents who aren't eating won't be at the tables to avoid waiting for serving trays while others at the table are eating. Similar to a homelike environment table clothes and or placemats have been added to enhance the dining room experience.
4.Director Of Nursing or designee will audit dining room during random meal times weekly x 4 weeks with results to Quality Assurance Committee.
5.Date certain 7/12/22

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on review of clinical records and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls, by failing to follow physician-ordered interventions for one of 25 residents reviewed (Resident 37) resulting in a fall, and failed to complete safety assessments for one of 25 residents reviewed (Resident 4) who used air mattresses.

Findings include:

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated February 2, 2022, revealed that the resident was sometimes understood, sometimes understands, and required extensive assistance from staff for his daily care tasks. The resident had a diagnosis which included Cerebral Palsy (a group of disorders that affect a person's ability to move and maintain balance and posture). A care plan for the resident, dated January 30, 2017, and revised February 22, 2022, revealed that the resident was at risk for falls related to spastic movements (a condition in which muscles stiffen or tighten, preventing normal fluid movement), impaired mobility, and a need for assistance. The resident had an Activities of Daily Living (ADL - activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) deficit and required extensive assistance with his care needs related to his muscle spasms and Cerebral Palsy.

Physician's orders for Resident 37, dated January 30, 2017, included an order for the resident to have a self-releasing lap belt for positioning while in chair and on the toilet due to spasticity from Cerebral Palsy.

A progress note for Resident 37, dated March 16, 2022, at 10:05 p.m. revealed that at 9:40 p.m. the nurse aide was bringing the resident out of his bathroom in his wheelchair after assisting with p.m. care. When turning the resident's wheelchair the resident started to slide. The nurse aide was supporting his right shoulder, but he started to slide to the left toward the floor. The nurse aide was unable to stop him from falling. She then notified the licensed practical nurse/registered nurse. The resident was assessed and no injury noted. The resident had non-skid shoes on.

A progress note for Resident 37, dated March 17, 2022, at 9:09 a.m. revealed that the fall from March 16, 2022, was reviewed in a clinical meeting. The resident's safety belt was not in place prior to moving the wheelchair. Staff is to ensure that the lap belt is in place prior to moving wheelchair.

An investigation report for Resident 37, dated March 16, 2022, revealed that at 9:40 p.m. the nurse aide was bringing the resident out of his bathroom in his wheelchair after assisting with p.m. care. When turning the resident's wheelchair the resident started to slide. The nurse aide was supporting his right shoulder, but he started to slide to the left toward the floor. The nurse aide was unable to stop him from falling. Additional comments by the Registered Nurse Supervisor revealed a failure to put the lap belt on prior to backing/turning wheelchair. New measures that were initiated to prevent recurrence included nurse aide education and alert charting to monitor the presence of a lap belt. It was determined that the root cause of the accident was due to the lap belt not being attached prior to moving the resident's wheelchair.

Interview with the Nursing Home Administrator on June 7, 2022, at 2:45 p.m. confirmed that on March 16, 2022, the nurse aide failed to attach Resident 37's lap belt in accordance with the resident's physician's orders.


An annual MDS assessment for Resident 4, dated May 24, 2022, revealed that the resident rarely/never understands, rarely/never understood, and was totally dependent on staff for her daily care tasks including with bed mobility. The resident had a diagnosis which included aphasia (loss of ability to understand or express speech, caused by brain damage) and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A care plan for the resident, dated March 22, 2022, revealed that the resident was at risk for falls/injury.

Observations on June 6, 2022, at 11:14 a.m. revealed that Resident 4's bed was equipped with an air mattress.

Review of Resident 4's clinical record revealed no documented evidence that a physician's order was obtained and/or that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 4's bed.

Interview with the Nursing Home Administrator on June 7, 2022, at 2:25 p.m. indicated that Resident 4 had the air mattress applied to her bed on November 5, 2021, when she was diagnosed with COVID-19, as a precautionary measure. She confirmed that there was no assessment for potential safety hazards prior to the air mattress being placed on Resident 4's bed.

28 Pa. Code 201.14(a) Responsibility of licensee.

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

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

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









 Plan of Correction - To be completed: 07/12/2022

1.A safety air mattress assessment was completed for Resident 4 and the air mattress was determined appropriate for this resident. A physician's order was obtained. The fall risk assessment of Resident 37 was reviewed. The care plan was reviewed and the appropriate interventions are in place. The Staff member received education on securing the lap belt.
2.Residents that have an air mattress now have a physician order and air mattress assessment completed. Air mattress assessments will be completed quarterly with their Minimum Data Set after the initial assessment. Physician orders were reviewed and show that Resident 37 is the only resident that uses a lap belt for positioning. A quarterly assessment is completed by therapy on Resident 37 for the lap belt use.
3.Mandatory education will be held for staff on Patient Safety and Use of Physical Device and Equipment. Education will include care plan and updates, fall risk, safety and supervision of residents. On the Spot Education is completed for all new changes in resident care and devices that are being implemented.
4.Random weekly audits will be completed to visualize the residents who currently have air mattresses for bed safety and bed mobility. Random weekly audits will be completed to visualize and verify placement of Resident 37's lap belt and that it is properly secured to avoid an accident. Each audit will be completed weekly x4 weeks. Audit results will be taken to Quality Assurance Committee for review.
5.Date certain 7/12/22

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 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(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 a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological behavioral interventions were attempted prior to the administration of anti-psychotic medications for one of 25 residents reviewed (Resident 26).

Findings include:

The facility's policy for "as needed" use of psychoactive medications such as an antianxiety, dated March 9, 2022, indicated that a psychoactive medication will be administered only as a last resort after at least three alternative methods/interventions have failed. If administered, the medication administration record is to be signed and a corresponding entry made on the behavior/intervention flow record.

A diagnosis record for Resident 26, dated January 26, 2022, included dementia, metastatic cancer (spread form the primary site to other areas) to the brain and Von Willebrand disease (blood clotting disorder).

A physician's progress note for Resident 26, dated April 25, 2022, indicated that she had anxiety and depression secondary to her dementia.

A physician's order for Resident 26, dated June 3, 2022, included an order for her to receive 0.5 milligrams (mg) of Ativan three times a day as needed for anxiety.

The medication administration record (MAR) for Resident 26 for June 2022, indicated that she received the Ativan on June 4, 2022, at 3:18 p.m. and June 5, 2022, at 10:44 a.m. The MAR documentation further indicated that she had no specific behaviors at that time. There was no documented evidence that there were non-pharmacological interventions attempted prior to the administration of Ativan on these dates.

Interview with the Nursing Home Administrator on June 7, 2022, at 10:47 a.m. confirmed that there was no documented evidence of a behavior and/or non medicinal interventions provided prior to the administration of Ativan on June 4, 2022, at 15:18 and on June 5, 2022, at 10:44 a.m. She further indicated that the staff are to give the medication for behaviors only when other interventions were not effective and to document on the record.

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

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



 Plan of Correction - To be completed: 07/12/2022

1.A medication review was completed to determine continued use of the prn anti-anxiety medication. Based upon review of past and current behaviors it was determined to maintain prn use of medication after other interventions have been attempted and failed.
2.Upon review of physician orders, it was determined that Resident 26 is the only current resident to receive a prn anti-anxiety medication.
3.Mandatory education will be held to review the facilities Administration of Medications Policy & Procedures, providing at least (3) interventions and the importance of documenting those interventions prior to medication administration.
4.The Director Of Nursing or designee will conduct an audit at random weekly for 4 weeks. All findings of concern will be immediately addressed. The findings of this audit will be reported to the Quality Assurance Committee monthly for further review.
5.Date certain 7/12/22

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on review of facility policies and observations, as well as staff interviews, it was determined that the facility failed to store medications appropiately labeled in one of two medication carts reviewed (Overly Meadows).

Findings include:

The facility's policy regarding labeling medication, dated March 9, 2022, revealed that all medications, chemicals, and biologicals shall be clearly and accurately labeled as to contents. Also, all medications dispensed shall be be labeled adequately with the name of the patient, room number, and the expiration date must also appear which would be six months unless it expires prior to that date.

Manufacturer's instructions for Tresiba Flextouch, 100 units per milliliters (ml), dated November, 2019, indicated that opened and not refrigerated medication was to be disposed of after 56 days.

A physican's order for Resident 44, dated April 18, 2022, included and order for the resident to receive 75 units of Tresibra Flextouch, (100 units per ml) insulin if blood sugar was greater than 100 milligrams per deciliter (mg/dl), 30 units if the blood sugar was between 70 mg/dl and 100 mg/dl, and to be held if the blood sugar was less than 70 mg/dl.

Observations of the medication cart on the front hall of Overly Meadows on June 8, 2022, at 9:18 a.m. revealed an opened and unlabeled Tresiba Flextouch (100 units per milliters) insulin pen. There was no indication of patient name, room number or expiration date.

Interview with Registered Nurse 2 on June 8, 2022, at 9:18 a.m. confirmed that the Tresiba Flextouch insulin pen was opened and in use for Resident 44, and that it was unlabeled and not stored in a container with a label. Registered Nurse 2 confirmed that the medication should have a label either on the insulin pen or its storage container.

Interview with the Nursing Home Administrator on June 8, 2022, at 10:35 a.m. revealed that the nursing home used the hospital pharmacy, and sticker labels were usually provided for insulin pens. She also confirmed that all medication should have a label containing information for the resident's name, room number and expiration date.

28 Pa. Code 211.9(h) Pharmacy services.






 Plan of Correction - To be completed: 07/12/2022

1. The residents' insulin pen was discarded. A labeled and dated pen was obtained for the resident.
2. Upon medication order review it was determined that there are no other residents that receive an insulin pen.
3. Pharmacy was consulted to provide separate bags for insulin pens with labels and expiration date to be included with each insulin pen when the box of insulin pens is dispensed. Licensed staff will have a mandatory in-service to discuss labeling of medications. They will be taught to make sure that the correct medication order and expiration date is on each medication and insulin pen.
4. Each medication cart and storage area will be audited random weekly x 4 by the Director Of Nursing or designee. Expired medications will be discarded. Results will be reviewed monthly at Quality Assurance Committee.
5. Date certain 7/12/22


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