Nursing Investigation Results -

Pennsylvania Department of Health
CONCORDIA AT VILLA ST. JOSEPH
Patient Care Inspection Results

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CONCORDIA AT VILLA ST. JOSEPH
Inspection Results For:

There are  66 surveys for this facility. Please select a date to view the survey results.

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CONCORDIA AT VILLA ST. JOSEPH - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on 5/27/22, it was determined that Concordia at Villa St. Joseph, 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 related to the health portion of the survey process.



 Plan of Correction:


483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:This is a less serious (but not lowest level) deficiency and 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.
483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

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

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

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to include advance directives in the clinical record for four of eight residents reviewed (Resident R31, R79, R266,and R268).

The facility's policy regarding advance directives, dated 1/13/22, are defined as written instructions to express an individual's choice of treatments or to designate someone else to make healthcare decisions when the resident is unable. An advance directive can take the form of a living will or a Durable Power of Attorney for healthcare.

A review of Resident R31's clinical record revealed the resident was admitted to the facility 1/20/17 and has diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles which causes fatigue and shortness of breath) and depression (a common mental disorder, characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, feelings of tiredness and poor concentration.)

A review of Resident R31's Advance Directive Acknowledgement form revealed Resident R31 has an advance directive.

There was no documented evidence that Resident R31's advance directives were part of her clinical record.

A review of Resident R79's clinical record revealed the resident was admitted to the facility 5/18/20 and has diagnoses of chronic obstruction pulmonary disease (characterized by persistent respiratory symptoms like progressive breathlessness and cough)
and congestive heart failure (a progressive heart disease that affects pumping action of the heart muscles which causes fatigue and shortness of breath.)

A review of Resident R79's Advance Directive Acknowledgement form revealed Resident R79 has an advance directive.

There was no documented evidence that Resident R79's advance directives were part of her clinical record.

A review of Resident R266's clinical record revealed the resident was admitted to the facility 5/12/22 and has diagnoses of encephalopathy ( a broad term for any brain disease that alters brain function or structure)
and Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood).

A review of Resident R266's Advance Directive Acknowledgement form revealed Resident R266 has an advance directive.

There was no documented evidence that Resident R266's advance directives were part of her clinical record.

A review of Resident R268's clinical record revealed the resident was admitted to the facility 5/5/22 and has diagnoses of joint replacement surgery aftercare, muscle wasting, and hypertension ( high blood pressure).

A review of Resident R268's Advance Directive Acknowledgement form revealed Resident R268 has an advance directive.

There was no documented evidence that Resident R268's advance directives were part of her clinical record.

During an interview with the Social Services Coordinator, Employee E2, on 5/26/22 at 11:44 a.m., verified that there was no documented evidence that the advance directives were part of Resident R31, R79, R266,and R268 clinical record.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 201.29(d) Resident rights.











Resident #266

Advance Directives
05/26/22 12:13 PM Record review shows that resident does have an advance directive but is not here at the facility.



Resident #268

Advance Directives
05/25/22 11:10 AM No advance directive found.
05/26/22 01:09 PM Record review shows resident has a advance directive but it is not on the campus.





 Plan of Correction - To be completed: 07/05/2022

R31 has a signed active Pennsylvania Orders for Life-sustaining Treatment on the chart dated 04/22/2022. R79 has a signed active Pennsylvania Orders for Life-sustaining Treatment on the chart dated 03/03/2022. R417 has a signed active Pennsylvania Orders for Life-sustaining Treatment on the chart dated 05/17/2022. R416 was discharged home on 6/7/2022.

Licensed nursing staff will be re-educated by Director of Nursing/Designee on the policy of advanced directives and use of Pennsylvania Orders for Life-sustaining Treatment form by 6/20/2022.
Facility policy includes use of Pennsylvania Orders for Life-sustaining Treatment as active advanced directives.

Director of Nursing/Designee will review all resident records for admission advanced directive and medical record to reflect that paperwork is completed appropriately. All residents are encouraged to complete a Pennsylvania Orders for Life-sustaining Treatment upon admission. A baseline audit of all current resident records will be completed to determine presence of a POLST. The resident will take their Pennsylvania Orders for Life-sustaining Treatment upon discharge from the facility.

Director of Nursing or designee will inspect 2 resident charts daily for 5 days then weekly for two weeks and monthly for advanced directive completion per admission paperwork for a total of 2 months or until substantial compliance is achieved. Results will be shared with the Quality Assurance Committee.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:

Based on review of facility policies, observations and resident and staff interviews, it was determined that the facility failed to determine if it was safe to self-administer medications and failed to obtain a physician order to store medications at the bedside for one of six residents (Resident R416).

Findings include:

Review of the facility policy "Preparation for Medication Administration Self Administration of Medications by Residents" reviewed 1/13/22, indicated that bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of residents who self-administer. Coumadin, narcotics and injectables are the exception and cannot be stored at bedside. All nurses and nurse aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or resident representative. The following conditions are met for bedside storage to occur:
1.The manner of storage prevents access by other residents. Lockable drawers or cabinets are required.
2.The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy.
3.If the nurse dispenses the medications, the resident must keep them within eyesight or lock them in their drawer or cabinet until self-administered.
4.The nurse will obtain confirmation of all doses self-administered and documents this on the EMAR (electronic medication administration record).

During observations of Resident R416's overbed table, 5/24/2022, 5/25/202 and 5/26/2022, revealed an open bottle of over the counter eye drops.

During an interview with Resident R416, at 1:30 p.m. on 5/26/2022, resident R416 stated "I brought these eye drops from home. I take them because my eyes get dry."

During an interview on 5/26/2022, at 1:49 p.m., Registered Nurse (RN) Unit Manager Employee E4 confirmed that the facility failed to complete a self medication assessment by the interdisciplinary team regarding the resident's cognitive, physical, and visual ability to carry out this responsibility and failed to obtain a physician order for the medication being kept at Resident R416's bedside.

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













 Plan of Correction - To be completed: 07/05/2022

Eye drop bottle that was left in resident's room was removed. This resident was not impacted by the storage of eye drop bottle.

The Director of Nursing/designee will re-educate licensed staff on facility policy for self-administration of medication by 6/20/2022.

All resident rooms will be inspected by Director of Nursing/designee for improper medication storage by 6/20/2022.

Resident was not assessed for self administration of medications as this resident did not indicate a desire for self-administration of medications.

All residents who indicate a desire to self-administer medications are assessed for safety of self-administration of medications per our policy.

The Director of Nursing/designee will inspect two random resident rooms daily for 5 days, then weekly for 2 weeks, then monthly. Audits will continue for a total of 2 months or until substantial compliance is achieved. Results will be shared with the Quality Assurance Committee.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on clinical record and facility policy review, observation, and staff interview, it was determined that the facility failed to obtain a physician order for an indwelling catheter and its care for one of four residents (Resident R182).

Findings include:

A review of the facility policy "Catheter Reduction Program" dated 1/13/22, indicated the physician must document in the clinical record the need for an indwelling catheter.

A review of the clinical record revealed that Resident R182 was admitted to the facility on 5/23/22, with diagnoses that included heart failure, and obstructive uropathy (condition in which the flow of urine is blocked).

A review of an admission progress note dated 5/23/22, indicated Resident R182 had an indwelling catheter in place.

During an observation on 5/24/22 at 10:00 a.m., revealed Resident R182 had an indwelling catheter in place.

A review of nurse progress note dated 5/26/22, indicated that Resident R182 had an indwelling urinary catheter in place.

A review of the physician orders dated May 2022, did not include an order for an indwelling catheter.

During an interview on 5/26/22, at 2:30 p.m. the Assistant Director of Nursing (ADON) Employee E1 confirmed the above findings and that the facility failed to obtain a physician order for an indwelling catheter for Resident R182.

28 Pa. Code 201.14 (a) Responsibility of licensee.
28 Pa. Code: 211.10 (c) (d) Resident care policies.
28 Pa. Code 211.12 (d) (1) (3) (5) Nursing services.









 Plan of Correction - To be completed: 07/05/2022

A physician order was obtained from the physician 05/26/2022 for the use of the Foley for R182. The continued use of the Foley catheter was to be maintained for the resident per the physician progress notes until the consult with urology could be set up.

All licensed staff will be reeducated on the necessity of a physician order for use of a foley catheter by the Director of Nursing/designee by June 20, 2022. Education will include use of appropriate/justified diagnosis for foley catheter use.

All residents that have a Foley catheter will have their record reviewed for proper physician orders for continued Foley catheter use by June 20, 2022.

The Director of Nursing/designee will inspect 2 residents with a foley catheter daily for 5 days, then weekly for 2 weeks then monthly for Foley catheter use and audit the medical record for proper physician orders and appropriate/justified diagnosis for foley catheter use. Inspections and audits will continue for a total of 2 months or until substantial compliance is achieved. Results will be shared with the Quality Assurance Committee.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:



Based on facility policy review, observations and staff interviews, it was determined that the facility failed to make certain a physician order for oxygen use was in place for one of three residents. (Resident R417).

Findings include:

A review of the facility policy "Oxygen Administration" dated 1/13/22, indicated that staff should verify that there is a physician's order for oxygen administration, to include liter flow and route of administration.

A review of the clinical record indicated that Resident R417 was admitted to the facility on 5/16/22.

A review of admission diagnoses indicated atherosclerotic heart disease and anemia.

During an observation on 5/26/22, at 1:44 p.m., Resident R417 has an oxygen concentrator and nasal canula in her room, at the bedside.

During an interview with Resident R417 at 1:44 p.m., Resident R417 stated she uses 2 liters of oxygen at night, when she sleeps.

Interview with Registered Nurse Employee E5 on 5/27/22, at 2:10 p.m., stated she observed the oxygen concentrator in Resident R417's room set at 2 liters with oxygen tubing and nasal canula at the bedside. Confirmation was obtained from nursing Employee E5 that there was not a physician order for oxygen in Resident R417 physician orders.

During an interview on 5/27/22, at 2:10 p.m., RN Unit Manager E4 confirmed the facility failed to review physician orders and make certain there was a physician order for Resident R417 to include liters, when to administer, and flow rate.

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

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


 Plan of Correction - To be completed: 07/05/2022

A physician order was obtained for R417 to receive oxygen as needed.
All licensed staff will be reeducated by the Director of Nursing/designee on the policy of oxygen administration to ensure that a physician order is obtained when oxygen is applied even as a nursing measure by June 20, 2022.

All residents' rooms will be inspected for oxygen use by the Director of Nursing/Designee for oxygen use and the medical record audited for proper physician orders by June 20, 2022.

The Director of Nursing/designee will inspect 2 residents a day for 5 days, then weekly for 2 weeks then monthly for oxygen use and proper physician orders. Inspections and audits will continue for a total of 2 months or until substantial compliance is achieved. Results will be shared with the Quality Assurance Committee.

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 policy, observations, and staff interview it was determined the facility failed to properly dispose of expired biologicals and medications and properly store medications in one of four medication rooms (1st Floor Carondelet Unit).

Findings include:

Review of facility policy titled "Medication Storage in the Facility" last reviewed 1/13/22, indicated medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations of those of the supplier.

Review of facility policy titled "Preparation for Medication Administration - Vials and Ampules of Injectable Medications" last reviewed 1/13/22, indicated vials and ampules of injectable medications are used in accordance with the manufacture's recommendations or the provider's pharmacy directions for storage, use, and disposal. The open date is recorded on multidose vials on the vial label or an accessory label affixed for that purpose.

During an observation on 5/26/22, at 2:15 p.m. in the first floor medication room on Carondelet Hall, the following was observed:

(1) Bactec 40ml bottle expired 3/31/22
(1) 25mg Hydrochlorothiazide bottle expired 1/14/22
(8) 19g 1/2 filter needles expired 6/1/20
(2) J-loop tubing expired 9/30/21
(2) Insulin 1/2 ml 29g safety glide expired 4/1/21
(1) 3ml syringe expired 1/1/21
(5) 5ml 22g 1/2 syringes expired 6/1/20
(8) 25mg x1 BD needle expired 3/1/21
(1) 24fr foley catheter expired 3/21/21

During an observation on 5/26/22, at 2:20 p.m. in the first floor medication room on Carondelet Hall, the following was observed:

(1) Lorazepam liquid vial dispensed 4/22/22, was not dated when opened. Doses were documented as administered on 4/25/22, and 4/27/22.

During an interview on 5/26/22, at 3:01 p.m. the Assistant Director of Nursing Employee E1, confirmed the facility failed to properly dispose of expired biologicals and medications on the first floor, Carondelet Hall, medication room.

During an interview on 5/26/22, at 2:35 p.m. Licensed Practical Nurse Employee E3, confirmed the facility failed to record the open date on a vial of liquid Lorazepam.

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

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









 Plan of Correction - To be completed: 07/05/2022

Expired items were removed from the medication room and disposed.

All licensed staff will be re-educated by the Director of Nursing/Designee to remove any expired items timely and to properly date medication vials when opened by June 20, 2022.

All medication rooms will be inspected for expired items and undated open bottles by June 20, 2022.

The Director of Nursing/designee will inspect one medication room a week for one monthly, then one medication room monthly for expired items and undated open medication. Inspections will continue for a total of 2 months or until substantial compliance is achieved.

Results will be shared with the Quality Assurance Committee.


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