Nursing Investigation Results -

Pennsylvania Department of Health
REDSTONE HIGHLANDS HEALTH CARE CTR
Patient Care Inspection Results

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REDSTONE HIGHLANDS HEALTH CARE CTR
Inspection Results For:

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REDSTONE HIGHLANDS HEALTH CARE CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on June 23, 2022, it was determined that Redstone Highlands Health Care 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:


483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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.
483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

483.20(b) Comprehensive Assessments
483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

483.20(b)(2) When required. Subject to the timeframes prescribed in 413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in 413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:


Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required time frame for two of 45 residents reviewed (Residents 58, 60) and annual Minimum Data Set assessments were completed in the required timeframe for nine of 45 residents reviewed (Residents 11, 13, 25, 27, 28, 29, 35, 47, 68).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that an admission MDS assessment was to be completed no later than 14 days following admission (admission date + 13 calendar days), and that an annual comprehensive MDS assessment was to be completed no later than the assessment reference date (ARD - the last day of the assessment's look-back period) plus 14 calendar days.

An admission MDS assessment for Resident 58, dated September 23, 2021, revealed that the resident was admitted to the facility on September 10, 2021, and the resident's admission MDS assessment was dated as completed on November 12, 2021, which was 64 days after admission.

An admission MDS assessment for Resident 60, dated February 21, 2022, revealed that the resident was admitted to the facility on February 14, 2022, and the resident's admission MDS assessment was dated as completed on February 28, 2022, which was 15 days after admission.

An annual MDS assessment for Resident 11, with an ARD of March 10, 2022, was due to be completed on March 24, 2022, but was not signed as completed until March 25, 2022, which was 16 days from ARD until completion.

An annual MDS assessment for Resident 13, with an ARD of December 30, 2021, was due to be completed on January 12, 2022, but was not signed as completed until March 18, 2022, which was 79 days from the ARD until completion.

An annual MDS assessment for Resident 25, with an ARD of April 13, 2022, was due to be completed on April 26, 2022, but was not signed as completed until May 3, 2022, which was 21 days from the ARD until completion.

An annual MDS assessment for Resident 27, with an ARD of March 24, 2022, was due to be completed on April 7, 2022, but was not signed as completed until May 3, 2022, which was 41 days from the ARD until completion.

An annual MDS assessment for Resident 28, with an ARD of April 12, 2022, was due to be completed on April 25, 2022, but was not signed as completed until May 3, 2022, which was 22 days from the ARD until completion.

An annual MDS assessment for Resident 29, with an ARD date of April 14, 2022, was due to be completed April 27, 2022, but was not signed as completed until May 5, 2022, which was 22 days from the ARD until completion.

The annual MDS assessment for Resident 35 with an ARD of January 13, 2022, was due to be completed on January 27, 2022, but was not signed as completed until March 14, 2022, which was 46 days from the ARD until completion.

An annual MDS assessment for Resident 47, with an ARD of February 23, 2022, was due to be completed on March 9, 2022, but was not signed as completed until March 15, 2022, which was 21 days from the ARD until completion.

The annual MDS assessment for Resident 68 with an ARD of January 17, 2022, was due to be completed on January 31, 2022, but was not signed as completed until March 18, 2022, which was 60 days from the ARD until completion.

Interview with the RNAC (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on June 23, 2022, at 1:42 p.m. confirmed that the admission MDS assessments for Residents 58, 60, and annual assessments for Residents 11, 13, 25, 27, 28, 29, 35, 47, and 68 were completed late.

28 Pa. Code 211.5(f) Clinical records.



 Plan of Correction - To be completed: 07/18/2022

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Redstone Highlands Healthcare Center agrees with the allegations and citations listed on the statement of deficiencies. Redstone Highlands Healthcare Center maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Redstone Highlands Healthcare Center's written credible allegation of compliance.
By submitting this plan of correction, Redstone Highlands Healthcare Center does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Redstone Highlands Healthcare Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
1. Minimum Data Set assessments (MDS) have been completed and submitted for the residents 58, 60,11,13,25,27,28,29, 35,47and 68.
2. A sweep of Minimum Data Set assessments was conducted going back 30 days to ensure timely completion of the assessments. Any late assessments were completed at the time of discovery.
3. The Registered Nurse Assessment Coordinator (RNAC) was re-educated on the long term care facility resident assessment instrument (RAI) manual Chapter 5 Submission and Correction of the MDS assessments user manual by the director of Risk Management.
4. The RNAC will utilize the Clinical MDS Scheduler daily on business days to ensure there are no late submissions. In addition, the DON or designee will conduct audits to ensure that MDS assessments are completed timely weekly for 4 weeks, then monthly for 2 months. Identified issues are addressed at the time of discovery.
5. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months: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.
483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for 13 of 45 residents reviewed (Residents 13, 14, 15, 16, 19, 20, 22, 31, 32, 35, 58, 59, 68).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days.

A quarterly MDS assessment for Resident 13 with an ARD of March 22, 2022, was completed on April 13, 2022, eight days late.

A quarterly MDS assessment for Resident 14 with an ARD of March 18, 2022, was completed on April 5, 2022, four days late.

A quarterly MDS assessment for Resident 15 with an ARD of March 10, 2022, was completed on April 11, 2022, seven days late.

A quarterly MDS assessment for Resident 16 with an ARD of March 17, 2022, was completed on April 11, 2022, eleven days late.

A quarterly MDS assessment for Resident 19 with an ARD of December 27, 2022, was completed on March 14, 2022, 63 days late; and a quarterly MDS with an ARD of March 22, 2022, was completed on April 13, 2022, eight days late.

A quarterly MDS assessment for Resident 20 with an ARD of March 11, 2022, was completed on April 27, 2022, 32 days late.

A quarterly MDS assessment for Resident 22 with an ARD of March 14, 2022, was completed on April 28, 2022, 30 days late.

A quarterly MDS assessment for Resident 31 with an ARD of January 19, 2022, was completed on March 17, 2022, 43 days late; and a quarterly MDS with an ARD of April 15, 2022, was completed on May 5, 2022, five days late.

A quarterly MDS assessment for Resident 32 with an ARD of April 19, 2022, was completed on May 6, 2022, two days late.

A quarterly MDS assessment for Resident 35 revealed an ARD of October 1, 2021, requiring the ARD of the next quarterly MDS assessment to be on or before December 25, 2021. However, the ARD of the next quarterly MDS assessment was January 13, 2022 (19 days late).

A quarterly MDS assessment for Resident 58, with an ARD of April 1, 2022, was due to be completed by April 15, 2022, but was not signed as completed until April 21, 2022, which was 20 days from the ARD until completion.

A quarterly MDS assessment for Resident 59, with an ARD of March 8, 2022, was due to be completed by March 22, 2022, but was not signed as completed until March 25, 2022, which was 17 days from the ARD until completion.

A quarterly MDS assessment for Resident 68 revealed an ARD of September 24, 2021, requiring the ARD of the next quarterly MDS assessment to be on or before January 1, 2022. However, the ARD of the next quarterly MDS assessment was January 17, 2022 (16 days late).

Interview with the RNAC (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on June 23, 2022, at 1:42 p.m. confirmed that the quaterly MDS assessments for Residents 13, 14, 15, 16, 19, 20, 22, 31, 32, 35, 58, 59, 68 were completed late.

28 Pa. Code 211.5(f) Clinical records.





 Plan of Correction - To be completed: 07/18/2022

1. Minimum Data Set assessments (MDS) have been completed and submitted for the residents 13, 14, 15, 16, 19, 20, 22, 31, 32, 35, 58, 59, and 68. There were no adverse reaction to the residents.
2. A sweep of Minimum Data Set assessments was conducted going back 30 days to ensure timely completion of the assessments. Any late assessments were completed at the time of discovery.
3. The Registered Nurse Assessment Coordinator (RNAC) was re-educated on the long term care facility resident assessment instrument (RAI) manual Chapter 5 Submission and Correction of the MDS assessments user manual by the director of Risk Management.
4. The RNAC will utilize the Clinical MDS Scheduler daily on business days to ensure there are no late submissions. In addition, the DON or designee will conduct audits to ensure that MDS assessments are completed timely weekly for 4 weeks, then monthly for 2 months. Identified issues are addressed at the time of discovery.
5. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education

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


Based on review of the Resident Assessment Instrument (RAI) User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for four of 45 residents reviewed (Residents 5, 35, 60, 71).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section N0410F (Antibiotic Medications) was to be coded with the number of days the resident received an antibiotic medication during the seven-day assessment period.

Physician's orders for Resident 5, dated February 12, 2022, included an order for the resident to have 2 percent mupirocin ointment (antibiotic ointment) applied topically to the right buttock wound daily. The resident's Treatment Administration Record (TAR) for February 2022 revealed that the resident received 2 percent mupirocin ointment daily to her right buttock from February 13-28, 2022. However, a quarterly MDS assessment for Resident 5, dated February 22, 2022, revealed that Section N0410F was coded (5), indicating that the resident received an antibiotic medication for only five days during the seven days of the assessment period, instead of seven days.

The RAI User's Manual, dated October 2019, revealed that if a wander/elopement alarm was used, then Section P0200E was to be coded as (0) not used, (1) used less than daily, or (2) used daily.

Physician's orders for Resident 5, dated January 14, 2022, included orders for the resident to use a wanderguard (alarm that sounds when approaching exits) every shift, and the resident's Treatment Administration Record (TAR) for February 2022 revealed that a wander/elopement alarm was used during February 1-28, 2022. However, a quarterly MDS assessment for Resident 5, dated February 22, 2022, revealed that Section P0200E was coded with a (0), indicating that the resident did not use a wander/elopement alarm.

The RAI User's Manual, dated October 2019 revealed that Section N was to record the number of days during the last seven days (or since admission/entry or reentry if less than seven days) that specific types of medications were received by the resident. Section N0410A was to indicate how many days the resident received an antipsychotic during the seven-day review period.

Physician's orders for Resident 35, dated March 9, 2022, included an order for the resident to receive 2 milligrams (mg) of Abilify (an antipsychotic) daily, and the resident's Medication Administration Record (MAR) for April 2022 revealed that she received Abilify daily from April 1 to 30, 2022. However, a quarterly MDS assessment, dated April 22, 2022, revealed that Section N0410A was coded with a zero (0), indicating that the resident did not receive an antipsychotic during the review period.

Interview with the Nursing Home Administrator on June 23, 2022, at 5:26 p.m. confirmed that Resident 35's antipsychotic medication use was not coded on the MDS.

The RAI User's Manual, dated October 2019, revealed that Section N was to record the number of days during the last seven days (or since admission/entry or re-entry if less than seven days) that specific types of medications were received by the resident. Section N0300 was to be coded to show how many days the resident received an injection during the past seven days.

Physician's orders for Resident 60, dated February 14, 2022, included orders for the resident to receive 0.1 milliliters (mL) of Tuberculin PPD solution (used to diagnose Tuberculosis - lung disease) intradermally (injection under the skin) at bedtime every 12 months. The resident's Medication Administration Record (MAR) for February 2022 revealed that the resident received Tuberculin PPD solution on February 15, 2022. However, an admission MDS assessment, dated February 21, 2022, revealed that Section N0300 was coded with a zero (0), indicating that the resident did not receive an injection during the review period.

The RAI User's Manual, dated October 2019, revealed that Section A2100 (discharge status) was to be coded to show where the resident was discharged to, and included codes (01) through (09) and (99). Code (01) was to be used when the resident was discharged to the community, and Code (03) was to be used when the resident was discharged to an acute care hospital.

Resident 71's clinical record revealed that the resident was discharged to a personal care home on May 26, 2022. However, an MDS discharge assessment, dated May 26, 2022, revealed that Section A2100 was coded (03), indicating that the resident was discharged to the hospital.

Interview with the RNAC (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on June 23, 2022, at 2:52 p.m. confirmed that the MDS's for Resident 5, 60 and 71 were coded incorrectly.




 Plan of Correction - To be completed: 07/18/2022

1. Minimum Data Set assessment (MDS) corrections for section N0410F and section P0200E were submitted for resident 5; correction for section N0410A was submitted for resident 35; correction for section N0300 was submitted for resident 60; and correction for section A2100 was submitted for resident 71.
2. The Registered Nurse Assessment Coordinator (RNAC) will audit most recent MDS assessment for current residents to validate sections N0410F, P0200E, N0300, A2100 and N0410A. Concerns will be corrected on discovery.
3. The Registered Nurse Assessment Coordinator (RNAC) was re-educated on the long term care facility resident assessment instrument (RAI) on sections N0410F, P0200E, N0300, A2100 and N0410A by the director of Risk Management.
4. The contracted RNAC service is reviewing sections N0410F, P0200E, N0410A, N0300, A2100 for accuracy on 5 residents weekly for 4 weeks, then monthly for 2 months. Identified issues are addressed at the time of discovery.
5. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on review of clinical records, as well as staff interviews and observations, it was determined that the facility failed to develop care plans that addressed the individualized care needs for two of 45 residents reviewed (Residents 38, 58).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated April 29, 2022, revealed that the resident was cognitively impaired, received anti-anxiety medication daily, and had diagnoses that included anxiety (a feeling of worry, nervousness, or unease).

Physician's orders for Resident 38, dated April 18, 2022, included an order for the resident to receive one 0.5 milligram (mg) tablet of Ativan (medication used to treat anxiety) daily related to her anxiety disorder. As of June 21, 2022, there was no documented evidence that a care plan was developed to address Resident 38's care needs related to anxiety.

Interview with the Nursing Home Administrator on June 23, 2022, at 5:23 p.m. confirmed that a care plan to address anxiety for Resident 38 was not developed.


A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58, dated April 1, 2022, revealed that the resident was cognitively impaired, received anti-coagulant and anti-depressant medications daily, and had diagnoses that included atrial fibrillation (irregular heart beat) and depression.

Physician's orders for Resident 58, dated January 13, 2022, and May 10, 2022, included orders for the resident to receive one 5 milligram (mg) tablet of apixaban (medication to thin the blood) twice daily for atrial fibrillation and one half tablet of 30 mg of Remeron (used to treat depression) daily for major depressive disorder. There was no documented evidence that care plans were developed to address the resident's care needs for anti-coagulation and anti-depressant use.

Interview with the Nursing Home Administrator on June 22, 2022, at 10:00 a.m. confirmed that care plans to address the use of an anti-coagulant and anti-depressant for Resident 58 were not developed.

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





 Plan of Correction - To be completed: 07/18/2022

1. Resident 38 had no adverse effects from not having a care plan developed for anxiety and Ativan use, the care plan was updated. Resident 58 had no adverse effects from not having a care plan developed for atrial fibrillation and anticoagulant Apixaban; and depression and antidepressant Remeron; care plan was updated.
2. A sweep was conducted of other resident care plans to ensure that diagnoses of depression, anxiety and atrial fibrillation is care planned as applicable with the medication associated.
3. The Registered Nurse Assessment Coordinator (RNAC) was re-educated regarding care planning of diagnosis with the medication by the Director of Risk Management.
4. Director of Nursing or designee will conduct audit of anticoagulant, depression and anxiety care plans of 5 residents weekly times 4 weeks, then monthly times 2 months.
5. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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.
483.80(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:


Based on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident received influenza immunizations for one of 45 residents who were reviewed related to immunization concerns (Resident 58).

Findings include:

The facility's policy regarding influenza vaccines, dated September 19, 2021, revealed that all residents and employees who had no medical contraindications to the vaccine were to be offered the influenza (flu) vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Between October 1st and March 31st each year, the influenza vaccine was to be offered to residents and employees, unless the vaccine was medically contraindicated or the resident or employee was already immunized. For those who receive the vaccine, the date of the vaccination, lot number, expiration date, person administering, and the site of vaccination were to be documented in the resident's/employee's medical record.

An influenza consent form for Resident 58, dated September 10, 2021, revealed that the resident gave permission to receive the influenza vaccine annually.

A quarterly MDS assessment for Resident 58, dated April 1, 2022, revealed that the resident was admitted to the facility on September 10, 2021, and the resident's influenza vaccine was not received in the facility for the current influenza season due to not being in the facility. There was no documented evidence that the facility offered or administered the influenza vaccine to the resident.

An interview with the Nursing Home Administrator on June 22, 2022 at 1:55 p.m. revealed that Resident 58 signed the consent to receive the flu vaccine; however, there was no documented evidence that she received it and there should have been.

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

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

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





 Plan of Correction - To be completed: 07/18/2022

1. Resident 58 had no ill effects for not receiving the influenza vaccine; they will be offered the vaccination for the next influenza season. Physician is aware.
2. No other residents were identified as being offered the influenza vaccine and not receiving the vaccination.
3. Infection Control Preventionist was re-educated and has developed a spreadsheet to track seasonal influenza administration for the residents.
4. Director of Nursing will audit the spreadsheet documentation weekly during in the influenza season.
5. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for quality improvement and needs for additional education.


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