Pennsylvania Department of Health
THORNWALD HOME
Patient Care Inspection Results

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THORNWALD HOME
Inspection Results For:

There are  57 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
THORNWALD HOME - 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 survey completed on Janary 18, 2024, it was determined that Thornwald Home was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(i) Food safety requirements.
The facility must -

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

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

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and two of two dining areas.

Findings include:

Review of facility policy, titled "Food Storage", revealed, "Food storage areas shall be maintained in a clean, safe, and sanitary manner."

The surveyor requested a food storage labeling policy that pertains to labeling and dating of food items on January 17, 2024, at 2:20 PM. No further policies were provided.

Observation of the walk-in freezer unit on January 16, 2024, at 11:51 AM, revealed three packs of onion rings not dated.

Interview with Employee 1 (Food Service Director) on January 16, 2024, at 11:52 AM, revealed food items should be labeled with the date they are received if they are removed from the original package.

Observation of the walk-in refrigerator on January 16, 2024, at 11:53 AM, revealed a container of shredded mozzarella cheese labeled "12-18" and some of the cheese had turned blue; one bin of celery dated "12-24" that was brown and wilted; one bin of cabbage labeled "12-23" and the outer leaves of the cabbage were black; and one box of tomatoes without a date, and half of the tomatoes were rotten.

Interview with Employee 1 on January 16, 2024, at 11:55 AM, revealed produce is labeled with the date it was received, and should be used before it goes bad or tossed when it goes bad.

Observation in the main kitchen on January 16, 2024, at 11:56 AM, revealed two containers of crisped rice cereal, one was dated "9-21" and one was dated "7-24".

Interview with Employee 1 on January 16, 2024, at 11:57 AM, revealed the bins have been filled since those dates and should be relabeled.

Observation during initial tour of the Sadler dining area refrigerator on January 16, 2024, at 12:05 PM, revealed one container of apple juice labeled "11-3" that was open; one container of apple juice labeled "12-29" that was open; one container of cranberry juice labeled "11-7" that was open; and two containers of thickened orange juice labeled "12-15" that were open.

Observation of the Sadler dining area freezer on January 16, 2024, at 12:07 PM, revealed one box of ice cream sandwiches without a date, and they appeared freezer burned; two lime sherbet without a date; and one orange sherbet without a date.

Observation during initial tour of the Courtyard dining area on January 16, 2024, at 12:17 PM, revealed 29 boxes of cereal varieties all not labeled with use by dates.

Observation of the Courtyard dining area refrigerator on January 16, 2024, at 12:17 PM, revealed two containers of tomato juice labeled "12-26" and they were open; one container of grape juice labeled "1-2" and it was open; one container of cranberry juice labeled "9-29" and it was open; one container of ketchup without a date; and one container of mustard without a date.

Observation of the pantry in the Courtyard dining area on January 16, 2024, at 12:19 PM, revealed one bag of wheat bread with a best by date of January 14, 2024; one bag of white bread with a best by date of January 14, 2024; and one bag of bagels not dated.

Observation of the Courtyard dining area refrigerator on January 16, 2024, at 12:21 PM, revealed one bin of ice cream sandwiches without a date; and 10 lime sherbet without a date.

Interview with Employee 1 on January 16, 2024, at 12:24 PM, revealed the facility's process is to label juices with their received date once removed from the original package; juices should be labeled with an open date once open and discarded after seven days; freezer items not dated should be labeled with a use by date; cereals, condiments, and breads should be dated; and food items should be discarded once past their best by date.

Interview with the Nursing Home Administrator on January 17, 2024, at 12:20 PM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility process, and that food and beverage items are stored and utilized in accordance with professional standards, and discarded once expired.

28 Pa. Code 211.6(f) Dietary services


 Plan of Correction - To be completed: 03/05/2024

1. No individual resident has been identified.
2. The NHA/designee and the Dietary Manager conducted inspections of the refrigerators and freezers in the main kitchen as well as the satellite dining rooms to identify and remove any items that were not properly labeled or expired. On 1/16/2024, bagels, bread, various juices, tomatoes, cabbage, cheese, bulk cereals, sherbet, and ice cream sandwiches that were expired or unlabeled were discarded.
3 The facility has reviewed and revised its Food Storage Policy to include dating items removed from originally packaging, labeling items upon delivery, removing and discarding expired items, and open, dated containers of food/fluids will be discarded within 7 days. Fresh produce will be dated when received and discarded based on visual appearance and freshness. Dietary Services staff will be re-educated on revised policy and procedures by Dietary Manager or designee.
4 Random audits of kitchen and food storage areas will be conducted at least 3x/week x 12 weeks by Dietary Manager or designee. The Dietary Manager/designee will review the results of the audits to identify/track trends or patterns and present to the Quality Assurance Performance Improvement (QAPI) committee for further review and/or recommendation.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for one of 22 residents reviewed (Resident 75).

Findings Include:

Review of Resident 75's clinical record revealed diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating), benign prostatic hyperplasia (an enlarged prostate), and chronic kidney disease (a condition characterized by a gradual loss of kidney function).

Review of Resident 75's physician orders revealed orders for checking and irrigation of a foley catheter, starting December 14, 2023.

Review of Resident 75's care plan revealed a focus area "[Resident 75] does have continence issues" with a subsection, "[Resident 75] uses: Bathroom, pull-ups, foley", with a start date of December 14, 2023.

Review of Resident 75's Comprehensive MDS assessment (Minimum Data Set- assessment tool utilized to identify residents' physical, mental, and psychosocial needs), with an ARD (assessment reference date - last day of the assessment period) of December 21, 2023, revealed, "Section H: Bowel and Bladder", subsection "H0100. Appliances," Resident 75 was coded "Z. None of the above" under subsection H0100, which included an indwelling catheter.

During an interview with the Nursing Home Administrator (NHA) on January 17, 2024, at 12:25 PM, the surveyor inquired about the accuracy of Resident 75's comprehensive assessment regarding the catheter.

Email correspondence with the NHA on January 17, 2024, at 7:29 PM, revealed the MDS assessment had been modified to reflect that Resident 75 had a catheter.

Follow-up interview with the NHA on January 18, 2024, at 11:40 AM, revealed it was the facility's expectation that the Resident MDS would be coded accurately.

28 Pa. Code 211.5(f) Clinical records


 Plan of Correction - To be completed: 03/05/2024

1. R75'S 12/21/23 Minimum Data Set (MDS) was modified on January 17, 2024, to include in Section H: the indwelling catheter used within the look-back period.
2. The interdisciplinary team will identify residents with indwelling or intermittent catheters to validate accurate coding at Section H: Bladder and Bowel. Modifications will be completed as necessary.
3. The Registered Nurse Assessment Coordinators (RNAC's) will receive individualized education on proper completion of MDS items to include accurate coding of Section H by the Executive Director or Designee.
4. Random audits of 3 MDS's/week x 12 weeks will be completed by NHA or designee to validate accurate coding at Section H of the MDS. The NHA/designee will review the results of the audits to identify/track trends or patterns and present to the Quality Assurance Performance Improvement (QAPI) committee for further review and/or recommendation.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(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 observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's care plan was reviewed and revised to reflect the resident's current status for two of 22 residents reviewed (Residents 57 and 75).

Findings include:

Review of Resident 57's clinical record revealed diagnoses that included vascular dementia (condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain that causes problems with reasoning, planning, judgment, and memory) and chronic kidney disease (CKD - gradual loss of kidney function).

Review of Resident 57's current care plan on January 17, 2024, at 11:02 AM, revealed the following information: Resident 57 wore bilateral hearing aides, and staff were to ensure that the appliances were clean and in working order; Resident 57 was actively being treated for a UTI (Urinary Tract Infection); and Resident 57 was at risk of dehydration due to a 1600 cc per day fluid restriction.

Observation of Resident 57 on January 17, 2024, at 1:00 PM, revealed he was not wearing any hearing aides.

During an immediate interview with Employee 2, she confirmed that Resident 57 was not wearing hearing aides and that his wife had taken them home.

Review of Resident 57's physician orders revealed no current orders for treatment of a UTI.

Review of nursing progress notes revealed that the last notation made regarding treatment/tracking of a UTI was November 21, 2023, when it was noted that there were not signs or symptoms of a UTI or adverse reactions to previous antibiotic treatment.

Review of Resident 57's current physician orders revealed an order for 1800 cc per day fluid restriction, effective December 19, 2023.

During an interview with the Nursing Home Administrator (NHA) on January 18, 2024, at 11:50 AM, she revealed that Resident 57's care plan was updated to reflect that his hearing aides were not in use, and that Resident 57's care plan was under revision to ensure it reflected the correct fluid restriction amount.

During a later interview with the NHA on January 18, 2024, at 2:40 PM, she acknowledged that Resident 57's care plan still included information about active treatment of a UTI, confirmed that Resident 57 was not currently receiving treatment for a UTI, and revealed that the care plan would be updated.

Review of Resident 75's clinical record revealed diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating), benign prostatic hyperplasia (an enlarged prostate), and pressure ulcer of sacral region (injury to skin and underlying tissue resulting from prolonged pressure on the skin).

Review of Resident 75's current care plan on January 16, 2024, at 2:00 PM, revealed the following information: Resident 75 was actively being treated for a UTI; and that he had an unstageable pressure ulcer.

Review of Resident 75's Comprehensive MDS assessment (Minimum Data Set- assessment tool utilized to identify residents' physical, mental, and psychosocial needs), with an ARD (assessment reference date - last day of the assessment period) of December 21, 2023, revealed Resident 75 was coded as having a stage III pressure ulcer.

Email correspondence with the NHA on January 17, 2024, at 11:56 AM, the surveyor inquired about when Resident 75's pressure ulcer changed stages, and if he currently had an UTI.

Review of select facility documentation provided on January 17, 2024, at 1:05 PM, revealed Resident 75's pressure ulcer changed from unstageable to stage III on December 21, 2023, and that Resident 75's UTI had resolved on January 8, 2023.

Follow-up interview with the NHA on January 18, 2024, at 11:40 AM, revealed she would expect Resident 75's care plan to be updated to reflect the current stage of his wound and that he no longer has an UTI.

28 Pa. Code 211.12(d)(1)(5) Nursing services
28 Pa. Code 211.5(f) Clinical records


 Plan of Correction - To be completed: 03/05/2024

1. R 57's care plan has been revised to include hearing aides are no longer in the facility, resolution of UTI, and fluid restriction as ordered. R 75's care plan has been revised to reflect current pressure ulcer stage and resolution of UTI.
2. The Interdisciplinary team will identify Residents with Hearing Aides, Residents with Antibiotics in last 30 days, Residents with physician ordered fluid restrictions, and Residents with Deep tissue injuries in last 30 days to validate resident care plans are updated to reflect current needs and status. Revisions will be made as necessary.
3. The Licensed Staff, RNAC's and the Daily Clinical Team will be re-educated by NHA or designee on role and responsibility of updating resident care plans as status changes. The Daily Clinical team will review physician orders and progress notes to validate care plans have been revised to meet the residents' needs.
4. Random audits of 3 Residents' medical records and care plans per week x 12 weeks will be completed by NHA or designee to validate the care plan is reflective of current needs and status. The NHA/designee will review the results of the audits to identify/track trends or patterns and present to the Quality Assurance Performance Improvement (QAPI) committee for further review and/or recommendation.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of the clinical records and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards that met the residents needs; and failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for two of 22 residents reviewed (Resident 70 and 75).

Findings include:

Review of Resident 70's clinical record revealed diagnoses that included noninfective gastroenteritis and colitis, unspecified (inflammation of the stomach and intestines), and hypomagnesemia (electrolyte imbalance caused by a low level of magnesium in the blood).

During an interview with Resident 70 on January 17, 2024, at 10:10 AM, she stated she has been suffering from diarrhea for several weeks. She reported the diarrhea to be severe causing her to be incontinent at times, and she stated, "they can't seem to figure out what is causing it."

Further review of Resident 70's clinical record on January 18, 2024, at approximately 10:30 AM, revealed a hospital discharge summary indicating she was admitted December 17, 2023, to December 26, 2023, for electrolyte derangement (an imbalance of electrolytes in the blood) and diarrhea.

Review of the hospital discharge summary revealed multiple stool tests were collected on December 18, 2023, and the results were pending at the time of discharge. The discharge summary also instructed to follow-up with outpatient gastroenterology (physicians that focus on the digestive system and disorders).

Further review of Resident 70's clinical record failed to reveal results from any stool testing and a follow-up appointment for outpatient gastroenterology.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on January 18, 2024, at 11:50 AM, results of the stool testing and information on a follow-up gastroenterology appointment were requested.

In a follow-up interview with the NHA and DON on January 18, 2024, at 2:47 PM, the NHA stated a call had been placed to the hospital requesting results of the stool testing. She also stated a call had been placed to the facility physician and Resident 70's family to check if further gastroenterology follow-up and treatment is wanted.

During an additional interview with the DON on January 18, 2024, at 3:54 PM, results from the stool testing were provided.

Review of the results provided revealed Resident 70's calprotectin stool test (a test used to check for inflammation in the intestines) results were 525 mcg/g (micrograms/gram). The reference range indicated a normal calprotectin level is less than 50 mcg/g and levels greater than 120 mcg/g are elevated. The DON stated that after the facility physician reviewed the results of the testing, he had ordered a follow-up with gastroenterology and the facility has placed a call to schedule an appointment. The DON confirmed the result of testing should have been obtained and reviewed, and the follow-up appointment should have been scheduled when Resident 70 returned from the hospital.

Review of Resident 75's clinical record revealed diagnoses that included pressure ulcer of sacral region (injury to skin and underlying tissue resulting from prolonged pressure on the skin), basal cell carcinoma of skin (skin cancer), and obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating).

Review of Resident 75's care plan revealed a focus area for skin conditions "[Resident 75] is at risk for skin impairment/pressure ulcers related to impaired mobility and incontinence; unstageable pressure on coccyx", with an intervention for "treatment as ordered", with a start date of December 14, 2023.

Further review of Resident 75's care plan focus area for skin conditions revealed, "[Resident 75] has a lower back wound that may be a malignancy", with an intervention for, "Be seen by MD and receive debridement until healed", with a start date of December 28, 2023.

Review of Resident 75's physician orders revealed an order for "Sacral wound care- Once daily night shift. Cleanse with NSS and pat dry. Fluff and apply Calcium Alginate with Ag and cover with bordered gauze daily at night. May replace if soiled or lifted. Code: 1 = no sign of infection, 2 = sign of infection, note required, 3 = small amount of drainage, 4 = moderate amount of drainage, 6 = no pain, 7 = signs/symptoms of pain. For sacral wound once daily."

Review of Resident 75's TAR (Treatment Administration Record - documentation for treatment administered or monitored) failed to reveal documentation to indicate the treatment order was completed on January 9, 2024.

Review of Resident 75's physician orders revealed an order for "Dressing change LL (left lower) back ...once daily wash area of LL back and pat dry. Fluff and apply Ca Alg (Calcium Alginate- wound treatment) to wound bed and cover with bordered gauze. May replace if soiled or lifting. For back wound once daily", with a start date of December 21, 2023.

Review of Resident 75's TAR failed to reveal documentation to indicate the treatment order was completed on January 2 and 9, 2024.

Interview with the NHA on January 18, 2024, at 11:40 AM, revealed she did not have any information to provide related to the missing documentation, and she would expect physician orders to be followed and documented as completed.

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


 Plan of Correction - To be completed: 03/05/2024

1. R 70's stool testing results were received by the facility and reviewed by the Medical Director. A Gastroenterology consult order was received. R75's wounds continue to heal without complication. Licensed Nurses responsible for treatments on January 2 and January 9 will be re-educated on role and responsibility of completion and documentation of treatments as ordered.
2. Discharge Summaries of residents admitted to the facility in the last 30 days will be reviewed to validate pending labs/studies have been received, and follow-up consults have been scheduled. Treatment records for last 7 days will be reviewed to validate treatments have been completed as ordered. Resident assessment and Licensed nurse re-education will occur based on findings.
3. Licensed staff will receive education on role and responsibilities of reviewing discharge summaries for follow-through with pending labs and consults, and completion of treatments as ordered in accordance with professional standards.
4. Audits of New Admissions will be completed weekly x 12 weeks by the Director of Nursing or designee to validate pending labs received, and consults have been scheduled. In addition, audits of at least 3 residents with treatment orders per week x 12 weeks will be conducted by the Director of Nursing or designee to validate treatments have been completed as ordered. The DON/designee will review the results of the audits to identify/track trends or patterns and present to the Quality Assurance Performance Improvement (QAPI) committee for further review and/or recommendation.




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 review and staff interview, it was determined that the facility failed to ensure physician orders were followed for catheter care for one of two residents reviewed for catheters (Resident 75).

Findings include:

Review of Resident 75's clinical record revealed diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating), benign prostatic hyperplasia (an enlarged prostate), and chronic kidney disease (a condition characterized by a gradual loss of kidney function).

Review of Resident 75's physician orders revealed an order for "Catheter Protocol Foley Check: Code 1=Patent, output good, No sediment; 2=Low output; 3=sediment- Every shift", with a start date of December 14, 2023, and an end date of December 28, 2023.

Review of Resident 75's TAR (Treatment Administration Record - documentation for treatment administered or monitored) failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on December 21, 2023, day shift; and December 23 and 26, 2023, night shift.

Review of Resident 75's physician orders revealed an order for "Catheter Foley tubing Stabilization Adhesive Anchor Type - Catheter Care - Every shift. Anchor site check, change anchor as needed. Code 0 = Skin intact, 1 = Red, 2 = Pink, 3 = Open area, once daily", with a start date of December 14, 2023, and an end date of December 18, 2023.

Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed for the duration of the order.

Review of Resident 75's physician orders revealed an order for "Catheter Graduated Container Change Type - Catheter Care - Once daily (weekly on Saturday)".

Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on January 16, 2023.

Review of Resident 75's physician orders revealed an order for "Catheter Protocol Foley Check: Code 1=Patent, output good, No sediment; 2=Low output; 3=sediment- Every shift", with a start date of December 28, 2023.

Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on January 12, 2024, day shift; January 8, 12, and 14, 2024, evening shift; and December 30, 2023, and January 9, 2024, night shift.

Review of Resident 75's physician orders revealed an order for "Catheter Foley tubing Stabilization Adhesive Anchor Type - Catheter Care - Every shift. Anchor site check, change anchor as needed. Code 0 = Skin intact, 1 = Red, 2 = Pink, 3 = Open area, every shift", with a start date of December 18, 2023.

Review of Resident 75's TAR failed to reveal documentation to indicate Resident 75's aforementioned catheter order was completed on December 21, 2023, and January 12, 2024, day shift; December 18, 2023, and January 8, 12, 14, 2024, evening shift; and December 18, 23, 26, and 30, 2023, and January 9, 2024, night shift.

Interview with the Nursing Home Administrator on January 18, 2024, at 11:40 AM, revealed she would expect physician orders to be followed and documented as completed.

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


 Plan of Correction - To be completed: 03/05/2024

1. R 75's foley catheter has been evaluated for patency, output and proper securement. Resident has experienced no ill effects from missing documentation.
2. Residents with foley catheters will have their physician orders and documentation over last 7 days reviewed for completeness. Evaluations will be completed as necessary.
3. Licensed staff will be re-educated on completion and documentation of physician orders by the Director of Nursing or designee.
4. Random audits of residents with foley catheters will be completed weekly x 12 weeks by Director of Nursing or designee to validate physician ordered catheter orders are completed as ordered. The DON/designee will review the results of the audits to identify/track trends or patterns and present to the Quality Assurance Performance Improvement (QAPI) committee for further review and/or recommendation.


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