Nursing Investigation Results -

Pennsylvania Department of Health
PROVIDENCE REHAB AND HEALTHCARE CENTER AT MERCY FITZGERALD
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PROVIDENCE REHAB AND HEALTHCARE CENTER AT MERCY FITZGERALD
Inspection Results For:
There are 177 surveys for this facility. Please select a date to view the survey results.

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PROVIDENCE REHAB AND HEALTHCARE CENTER AT MERCY FITZGERALD - 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 on May 6, 2022, it was determined that Providence Rehabilitation and Healthcare Center at Mercy Fitzgerald 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 as they relate to the health portion of the survey process.

Plan of Correction:

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, observations, and resident and staff interviews, it was determined that the facility failed to maintain resident dignity during the lunch meal service for two of 66 residents on the second floor (Resident R52 and R24).

Findings Include:

Review of Resident R52's physician order dated February 15, 2021, revealed the resident was ordered a regular diet with consistency modifications. Review of Resident R52's quarterly Minimum Data Set (MDS - assessment of resident care needs) dated March 21, 2022, revealed the resident required set-up assistance with meals.

Review of Resident R24's physician order dated February 14, 2022, revealed the resident was ordered a regular diet with consistency modifications. Review of Resident R24's quarterly MDS dated February 20, 2022, revealed the resident required set-up assistance with meals.

Observations on May 4, 2022, at 12:30 p.m. during the lunch time meal service revealed approximately 10 residents having lunch in the dining room.

Continued observations during the lunch time meal service revealed Resident R52 was in his wheelchair in the dining room placed near the door and Resident R24 was in his wheelchair placed at a spot at the table, and neither resident was provided with a lunch tray.

Interview on May 4, 2022, at 12:30 p.m. with Resident R24 revealed the resident was hungry and wanted lunch.

Interview on May 4, 2022, at 12:35 p.m. with activities aide, Employee E14, revealed Resident R52 and R24 were in the dining room for an activity before lunch and staff were supposed to assist resident's back to their room for lunch. Continued interview with Employee E14 revealed they did not have the resident's meal tickets to be able to serve them in the dining room.

Interview on May 4, 2022, at 12:45 p.m. with the cook, Employee E13, revealed they started serving lunch in the 2nd floor dining room at approximately 12:05 p.m.

Observations on May 4, 2022, at 12:45 p.m. revealed Resident R52 and R24 sat in the dining room throughout the duration of the lunch meal without being offered a meal tray, while their peers had lunch.

28 Pa. Code 201.29 (j) Resident Rights

28 Pa. Code 211.12 (d)(1) Nursing Services

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

Plan of Correction - To be completed: 06/10/2022

The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated.
1.
Items listed in deficient practice were corrected immediately.

2.
The facility has determined that residents at Providence have the potential to be affected.

3.
Nursing, dietary, and activities staff will be in serviced on maintaining a resident's dignity by offering each resident in the dining room a meal tray.

4.
The Director of Nursing/Designee will conduct random audits on five residents weekly for four weeks and monthly for three months. Audit will include dining room observation of residents to ensure they are receiving their meal trays timely. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints:

�483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

�483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with �483.12(a)(2).

�483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

�483.12(a) The facility must-

�483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.

Observations:

Based on review of facility policy, review of clinical records, observation, and staff interviews, it was determined that the facility failed to conduct initial and ongoing monitoring and evaluation for the use of a physical restraint for one of two residents with restraints reviewed (Resident R30).

Findings include:

Review of facility policy "Use of Restraints" revealed prior to placing a resident in restraints, there will be a pre-restraining assessment to determine the need for restraints and possible underlying causes of the medical symptom. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need of restraints will be documented. Restrained individuals shall be reviewed at least quarterly to determine whether they are candidates for restraint reduction or total elimination.

Continued review of facility policy revealed use of restraints should include full documentation of the episode leading to the use of the restraint and a description of the resident's medical symptoms that warranted the use of restraints.

Review of Resident R30's clinical record revealed the resident was admitted to the facility on November 24, 2021, and had diagnoses of tracheostomy status (a tube placed into the windpipe to allow for airflow), aphasia (language disorder that affects a person's ability to communicate), and hemiplegia (muscle weakness or paralysis of one side of the body).

Review of Resident R30's care plan dated November 24, 2021, revealed the resident was resistive to care and had a history of pulling out trach.

Observations on May 3, 2022, at 10:30 a.m. revealed the resident had bilateral hand mitt restraints in place.

Review of Resident R30's physician orders revealed an order for "Bilateral hand mitts to be worn at all times. Remove every 2 hours to assess skin" dated January 3, 2021.

Review of Resident R30's clinical record revealed no documented evidence that the facility conducted an initial restraint assessment or full documentation of the episode leading up to the use of restraint.

Further review of Resident R30's clinical record revealed no documented evidence of ongoing monitoring or quarterly evaluation, per facility policy, for continued use of the restraint.

Review of Resident R30's physical medical record on May 5, 2022, at 9:45 a.m. with Registered Nurse, Employee E11, revealed a signed restraint consent form, however the restraint assessment form was blank.

Interview on May 5, 2022, at 9:45 a.m. with the Director of Nursing, Employee E2, confirmed they were not able to locate an initial or ongoing restraint evaluation. Employee E2 stated restraint assessments should be kept in the physical clinical record.

28 Pa. Code 211.8 (f) Use of restraints.

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

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

Plan of Correction - To be completed: 06/10/2022

1.
Items listed in deficient practice were corrected immediately.

2.
The facility has determined that residents at Providence have the potential to be affected.

3.
Licensed nursing staff will be in serviced to conduct initial and ongoing monitoring and evaluation for the use of physical restraints.

4.
The Director of Nursing/Designee will conduct random audits on five residents weekly for four weeks and monthly for three months. Audit will include residents with physical restraints to ensure that initial and/ or ongoing restraint evaluations are being completed timely. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:

�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 facility policy, review of clinical record, observations, and staff interviews, it was determined that the facility failed to develop comprehensive care plans for 3 of 22 residents reviewed (Resident R30, R89, R250).

Findings include:

Review of facility policy "Care Plans, Comprehensive Person-Centered" revealed the comprehensive care plan will include measurable objectives and time frames, and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Review of Resident R30's clinical record revealed the resident was admitted to the facility November 24, 2021, and had diagnoses of tracheostomy status (a tube placed into the windpipe to allow for airflow), vascular dementia (brain damage caused by multiple strokes), and cerebral infarction (stroke - a result of inadequate blood flow to the brain).

Review of Resident R30's clinical record revealed a physician order dated April 26, 2022, for use of intravenous antibiotic through May 5, 2022.

Continued review of Resident R30's clinical record revealed documentation by licensed practical nurse, Employee E17, dated April 26, 2022, that the resident was started on intravenous antibiotic to treat Pseudomonas (a germ that can cause infections in the human body).

Review of Resident R30's clinical record revealed no documented evidence that a comprehensive care plan was developed to address the care and services to treat the infection and use of intravenous antibiotic.

Review of physician orders for Resident R89 dated May 3, 2022, revealed that the resident was on dialysis (a process of purifying the blood of a person whose kidneys are not working normally) on Monday, Wednesday, and Friday. Physician orders also revealed that the resident had a right AV site (a procedure that connects an artery to a vein in preparation for dialysis) that required frequent monitoring from the staff to prevent bleeding and infection.

Review of care plan for Resident R89 dated May 1, 2022, revealed no evidence that the facility developed a comprehensive care plan related to the care and monitoring of the resident's dialysis site.

Review of physician orders for Resident R250 dated April 26, 2022, revealed that the resident was ordered for an indwelling catheter (catheter drains urine from your bladder into a bag outside your body). Physician orders also revealed that the resident required care and monitoring of urinary catheter by the staff.

Review of care plan for Resident R250 dated April 22, 2022, revealed no evidence that the facility developed a comprehensive care plan related to the care and management of urinary catheter.

28 Pa Code 211.11(d) Resident care plan.

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

Plan of Correction - To be completed: 06/10/2022

1.
Items listed in deficient practice were corrected immediately.

2.
The facility has determined that residents at Providence have the potential to be affected.

3.
Licensed nurses will be in serviced in developing comprehensive care plans for residents.

4.
The Director of Nursing/Designee will conduct random audits on five residents weekly for four weeks and monthly for three months. Audit will include the resident's care plan to ensure that a comprehensive care plan was developed timely. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

�483.21(b) Comprehensive Care Plans
�483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on the review of clinical records, facility policies and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised with when a resident had a significant weight loss for one of 22 residents reviewed (Resident R97)

Findings include:

Review of an undated facility policy titled, "Weight Assessment and Intervention" revealed, "Care planning: 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the dietician, the consultant pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plan shall address, to the extent possible. a. the identified cause of weight loss b. goals and benchmarks for improvement and c. time frame and parameters for monitoring and reassessment".

Review of Resident R97's clinical record revealed that on April 19, 2022, the resident weighed 90.4 lbs. On April 26, 2022, the resident weighed 82.5 pounds which is a -8.74 % loss.

Review of a nutritional care plan for Resident R97 dated January 20, 2022, revealed no evidence that the facility updated Resident R97's care plan related to the weight loss identified on April 26, 2022.

Interview with Dietician, Employee E7, on May 5, 2022, at 11:30 a.m. confirmed that there was no evidence that Resident R97's care plan was updated when resident was identified with a significant weight loss on April 26, 2022.

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

Plan of Correction - To be completed: 06/10/2022

1.
Items listed in deficient practice were corrected immediately.

2.
The facility has determined that residents at Providence have the potential to be affected.

3.
Licensed nursing staff and the dietitian will be in serviced to update/ revise a resident's care plan if a resident has a significant weight loss.

4.
The Director of Nursing/Designee will conduct random audits on five residents weekly for four weeks and monthly for three months. Audit will include residents who have experienced a significant weight loss to ensure that their care plan was updated/ revised. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:

�483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

�483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

�483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

�483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

�483.24(b)(2) Mobility-transfer and ambulation, including walking,

�483.24(b)(3) Elimination-toileting,

�483.24(b)(4) Dining-eating, including meals and snacks,

�483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.

Observations:

Based on reviews of policies and procedures, interviews with residents, family members and staff, reviews of clinical records and observations of care and services, it was determined that the facility failed to ensure that personal hygeine and grooming services were maintained for nine of 22 residents reviewed (R4, R42, R31, R27, R14, R46, R74, R6, and R44.).

Findings include:

A review of the policy entitled "Activities of Daily Living" indicated that all residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who were unable to carry out activities of daility living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

During an initial tour of the facility on May 3, 2022 at 10:30 a.m. Resident R74 was observed in his room. The resident's beard was unkept. The resident's facial hair and head of hair were over grown. Interview with the resident's family member on May 6, 2022 at 10:00 a.m. confirmed that the residents' traditional style was not with a long beard and long head of hair. The family said their father had very little facial hair and liked his head of hair neat and clean cut. The family thought that Resident R74's grooming and personal hygiene, after eating meals was difficult to maintain with the mustache and beard over grown near his mouth. The resident's son was interested in the barber services for his father.

Resident R6's quarterly Minimum data set (MDS - an assessment of care needs) dated April 25, 2022, revealed the resident had cognitive impairments and required extensive assistance with personal hygiene. Interview with Resident R6 on May 3, 2022, at 11:00 a.m. revealed the resident was very happy he just had a shower but kept repetitively asking for a haircut. Resident R6 kept grabbing the long piece of hair covering his forehead and asking for it to be trimmed. Observations revealed Resident R6 had long untrimmed hair.

A group meeting was held with alert and oriented Residents R4, R42, R31, R27, R14, R46 on May 4, 2022 at 11:30 a.m.

Clinical record review for Resident R4 revealed a quarterly assessment (MDS-an assessment of care needs) dated April 17, 2022 that indicated that this resident was cognitively intact.

Clinical record review for Resident R42 revealed an admission assessment (MDS-an assessment of care needs) dated March 1, 2022 that indicated that this resident was cognitively intact.

Clinical record review for Resident R31, revealed a quarterly comprehensive assessment (MDS-an assessment of care needs) dated March 2, 2022 that indicated that this resident was independent with decision making.

Clinical record review for Resident R27 revealed a quarterly comprehensive assessment (MDS-an assessment of care needs) dated February 28, 2022 that indicated that this resident was independent with decision making.

Clinical record review for Resident R46 revealed a quarterly comprehensive assessment (MDS-an assessment of care needs) dated March 17, 2022 that this resident was cognitively intact.

The residents reported during the group meeting that they had not had hair dresser or barber services at the facility since November, 2021. The residents were all interested in these services to maintain their personal hygiene and grooming needs.

Clinical record review for Resident R14 revealed an annual comprehensive assessment (MDS-an assessment of care needs) dated February 6, 2022 that indicated that this resident was cognitively intact. Resident R14 reported that his head of hair could use a trim especially with the Spring and Summer warmer weather quickly approaching. Observations of Resident R14 on May 4, 2022 at 11:30 a.m. confirmed that his grooming needs were not as he wished and wanted.

Observations on May 4, 2022, at 2:30 p.m. revealed Resident R44 had long untrimmed hair and beard. Interview with Resident R44 revealed he has been asking for the barber so he could have a haircut and get his beard trimmed.
Review of Resident R44's quarterly MDS dated March 16, 2022 revealed the resident was cognitively intact and required supervision with personal hygiene.

Interview with the Nursing Home Administrator, Employee E1, on May 4, 2022 at 2:45 p.m. confirmed the hair dresser has not been in the facility since December 21, 2021.

28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 06/10/2022

1.
Items listed in deficient practice were corrected immediately.

2.
The facility has determined that residents at Providence have the potential to be affected.

3.
A contracted hairdresser will be obtained by the facility. Nursing staff will be in serviced regarding providing personal hygiene and grooming services to the residents.

4.
The Director of Nursing/Designee will conduct random audits on five residents weekly for four weeks and monthly for three months. Audit will include ensuring that a resident's personal hygiene and grooming choices are met. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

�483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

�483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

�483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

�483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on review of clinical records, review of facility policies and procedures, facility documentation and interviews with staff, it was determined that the facility failed to ensure that body weights were obtained timely for one of 22 residents reviewed (Resident R97).

Findings include:

Review of an undated facility policy, "Weight Assessment and Intervention" undated, revealed, "Policy Statement: The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. 3. any weight change of 5% or more since the last weight assessment will be retaken by the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Verbal notification must be confirmed in writing. 4. The dietician will respond within 24 hours of receipt of written notification. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria, a. 1 month-5% weight loss is significant, greater than 5% is severe. b. 3 months-7.5% weight loss is significant; greater than 7.5 is severe. c. 6 months-10 % weight loss is significant, greater than 10% is severe.

Review of Resident R97's clinical record revealed that on April 19, 2022, the resident weighed 90.4 lbs. On April 26, 2022, the resident weighed 82.5 pounds which is a -8.74 % weight loss.

Review of a nutritional progress note for Resident R97 dated April 27, 2022, revealed that the resident had unplanned, undesired clinically significant weight loss of 8.7% x 1 week and 7.9% x 1 month. Dietician requested re-weigh to ascertain accuracy of weight change which was documented as pending.

Review of weight documentation for Resident R97 revealed no evidence that the facility obtained a reweigh as ordered by the dietician and according to the facility policy until May 3, 2021, which confirmed the weight loss.

Interview with Dietician on May 5, 2022, at approximately 12:30 p.m. confirmed that there was no evidence that Resident R97's reweigh was appropriately obtained as ordered.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(1) Nursing services

28 Pa. Code 211.12(5) Nursing services

Plan of Correction - To be completed: 06/10/2022

1.
Items listed in deficient practice were corrected immediately.

2.
The facility has determined that residents at Providence have the potential to be affected.

3.
Licensed nursing staff will be in serviced to ensure that body weights are obtained timely.

4.
The Director of Nursing/Designee will conduct random audits on five residents weekly for four weeks and monthly for three months. Audit will include residents and their obtained weights to ensure that body of the residents are obtained timely. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

� 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 observations, review of clinical records, facility policy and interviews with staff, it was determined the facility failed to ensure that the tracheostomy tube ordered by the physician was utilized for one of four clinical records review of residents with a tracheostomy (Resident R97).

Findings include:

Review of an undated facility's policy titled, "Tracheostomy Care" revealed, "Tracheostomy tubes should be changed as ordered and as needed. Procedure guidelines, Preparation and Assessment. 1. Check physician order."

Review of Resident R97's physician orders revealed the resident had a physician order which dated January 19, 2022, revealed that tracheostomy type: Shiley tracheostomy (a type of tracheostomy tube) size: #8.

Continues review of physician orders revealed an order dated January 19, 2022, to change trach ties twice a week every evening shift, every Tuesday and Friday and check the Spare Trach-Same type & size.

During the survey a tracheostomy care observation was requested by the surveyor on May 5, 2022, at 10:05 a.m. with Registered Nurse, Employee E9. Prior to the procedure Employee E5 stated she would be providing tracheostomy care and change the tracheostomy tube (inner cannula). Employee E5 had a #6 shiley tracheostomy tube ready for the procedure. Surveyor asked the nurse to hold the procedure and requested Employee E9 for the trach size which the Resident R97 was wearing. Employee E9 stated that the resident was wearing a Shiley #6 tracheostomy tube. Observation of resident's room with Employee E9 revealed that there was no Shiley #8 tracheostomy tube available.

During an interview with Respiratory therapist, Employee E10, on May 5, 2022, at 10:11 a.m. stated she changed the tracheostomy inner cannula for the resident at around 9:00 a.m. on May 5, 2022. She stated she used tracheostomy tube #6.

Interview with Registered Nurse, Employee E9, on May 5, 2022, at 10:45 p.m. confirmed that the resident was ordered Shiley #8 tracheostomy tube.

28 Pa. Code 211.10(c) Resident care policies

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

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

Plan of Correction - To be completed: 06/10/2022

1.
Items listed in deficient practice were corrected immediately.

2.
The facility has determined that residents at Providence with a tracheostomy have the potential to be affected.

3.
Licensed nursing staff and the respiratory therapist will be in serviced on following physician orders in regards to tracheostomy tubes.

4.
The Director of Nursing/Designee will conduct random audits on five residents with tracheostomy tubes weekly for four weeks and monthly for three months. Audit will include visualization of the employee performing tracheostomy care to ensure that physician orders are being followed. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

�483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

�483.70(i) Medical records.
�483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

�483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

�483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

�483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

�483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under �483.50.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that body weights were accurately recorded for one of 22 clinical records reviewed. (Resident R29)

Findings include:

Review of Resident R29's clinical record revealed that the resident was admitted to the facility on August 18, 2021 with the diagnoses of hydrocephalus (build up of fluid in the cavities of the brain); recurrent depressive disorder; muscle wasting and atrophy (progressive degeneration of muscles); dysphagia (difficulty swallowing); cognitive communication deficit (difficulty with thinking and how someone uses language); and aphasia (language disorder that affects a person's ability to communicate).

Review of clinical record for Resident R29 revealed an Minimum Data Set (MDS- an assessment tool completed at specific intervals to determine resident care needs) dated February 24, 2022 indicated a BIMS score (Brief Interview for Mental Status) of 00, which identified the resident with severe cognitive impairment. Further review of the MDS assessment revealed Resident R29 required extensive assistance with eating.

Further review of Resident R29's clinical record revealed the following recorded weights: October 2021- 179 pounds (lbs.), November 2021-179 lbs., December- 155 lbs., January 2022 -148 lbs; February- 150 lbs., March- 185 lbs., April- 141 lbs., May-148 lbs.

Interview on May 6, 2021 at approximately 10:30 a.m. with Employee E18 Corporate Registered Dietician and Employee E19, Registered Dietician revealed, "We know these weights are not accurate. The resident was hospitalized from September 29-October 12, 2021. The hospital recorded her weight as 160 lbs. Our recorded weight for October is 179 lbs. November's weight is inaccurate. We also scratched March's recorded weight of 185 lbs. For whatever reason, there was a communication breakdown and Resident R29 was not re-weighed as per our policy. However, we were aware that Resident R29 was losing weight and she was started on Remeron to stimulate her appetite. She receives Ensure Plus twice per day and magic cup twice per day. She also receives fortified cereal and fortified mashed potatoes."

28 Pa. Code 211.5(f) Clinical records

Plan of Correction - To be completed: 06/10/2022

1.
Items listed in deficient practice were corrected immediately.

2.
The facility has determined that residents at Providence have the potential to be affected.

3.
Licensed nursing staff and the dietitian will be in serviced to ensure that body weights are accurately recorded in the resident's record.

4.
The Director of Nursing/Designee will conduct random audits on five residents weekly for four weeks and monthly for three months. Audit will include visualization of the resident's weight, along with documentation of the resident's weight in the record, to ensure the weight is accurately recorded. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.

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