Nursing Investigation Results -

Pennsylvania Department of Health
HUNTINGDON PARK REHAB CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HUNTINGDON PARK REHAB CENTER
Inspection Results For:

There are  75 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.
HUNTINGDON PARK REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and Complaint survey completed on September 12, 2019, it was determined that Huntingdon Park Rehab 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:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that preventive pressure ulcer interventions were in place for one of 32 residents reviewed (Resident 54), and failed to provide pressure ulcer treatments as ordered by the physician for one of 32 residents (Resident 56).

Findings include:

An annual comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated August 6, 2019, indicated that the resident was cognitively impaired, required assistance with bed mobility, had limited range of motion (joint movement) of his lower extremities on one side, and was at risk for developing pressure ulcers. Physician's orders, dated September 9, 2017, included an order for the resident to wear gel boots at all times, every shift, for protection. The resident's care plan, dated November 11, 2018, included that the resident was to wear gel boots at all times, they were to be removed for care, and staff were to report any new skin impairment. Resident 56's Treatment Administration Record (TAR) for September 2019 revealed no evidence that the resident refused the use of the gel boots.

Observations of Resident 56 on September 8, 2019, at 8:35 a.m. revealed that the resident was in bed without gel boots on and his right heel was in direct contact with the mattress. Observations at 11:48 a.m. revealed that he was in a modified wheelchair and did not have gel boots on.

Interview with Licensed Practical Nurse 8 on September 12, 2019, at 11:50 a.m. confirmed that Resident 54 was to have gel boots on at all times.


A diagnosis record for Resident 56, dated March 2, 2019, revealed that the resident had a Stage IV pressure ulcer (skin breakdown caused by pressure that involves underlying tissue) of her sacral area (base of the spine). Physician's orders, dated July 31, 2019, included an order to irrigate the pressure ulcer with 30 milliliters (ml) of acetic acid 0.25 percent (synthetic acid with antibacterial and antifungal properties), loosely pack the ulcer with acetic acid 0.25 percent half-inch gauze, apply antifungal cream to the peri-wound (the skin surrounding the ulcer), cover with dry gauze and an ABD (large, gauze) pad and secure with tape, two times per day every day and evening shift, and as needed for soilage and dislodgement.

Resident 56's Treatment Administration Record (TAR) for August 2019 revealed no documented evidence that the physician-ordered treatment to the sacral ulcer was provided during the day shift on August 3, 4, 17, 18 and 31, 2019, and during the evening shift on August 7 and 31, 2019.

Physician's orders for Resident 56, dated September 4, 2019, included an order to cleanse the site and irrigate the cavity with 30 ml of normal saline solution (sterile salf and water), apply the house antifungal cream to the skin around the wound, loosely pack the cavity with half-inch gauze moistened with 0.25 percent acetic acid two times a day every day and evening shift, and as needed for soilage and dislodgement.

Resident 56's TAR for September 2019 revealed no documented evidence that the physician-ordered treatment was provided during the evening shift on Septemeber 6, 2019, and during the day shift on September 7, 2019.

Interview with the Director of Nursing on September 11, 2019, at 4:36 p.m. confirmed that Resident 56's TAR's did not contain documented evidence that treatments were completed to the sacral wound on the above dates, as ordered by the physician.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/16/18.




 Plan of Correction - To be completed: 11/04/2019

The care plans for Residents R54 & R56 will be reviewed and updated. R54's device is currently in place. R56 is no longer ordered this treatment.

The facility will review the current wound report to ensure that all facility wounds have appropriate adaptive equipment in place, as well as, in use as ordered.

The Director of Nursing or designee will review the Treatment records for residents with current wounds for the past month to see if there are any other missed observations.

The Clinical Educator will provide education on the wound policy and procedure to licensed nursing staff. This education will also be provided for newly hired licensed staff members and will be provided during agency staff orientation.

The Director of Health Information Management or designee will complete a random audit monthly on 10% of the wound report for 3 months to ensure that the Treatment Records are completed according to policy.

The facility will add a line item to the non-clinical rounds to monitor implementation of preventative devices. These rounds take place weekly.

The Clinical Educator or designee will complete random wound care competencies monthly for 3 months.

The results of these audits will be reported to the Quality Assurance Steering Committee monthly for 3 months. Following the 3 months, the committee will determine the frequency of the audits.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for a State Survey and Certification (Department of Health) survey ending August 16, 2018, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending September 12, 2019, identified repeated deficiencies related to failing to develop individualized care plans, revising residents' care plans to include current care needs and interventions, ensuring that medications were properly labeled, and not storing and preparing food under sanitary conditions.

The facility's plan of correction for a deficiency regarding a failure to ensure that residents had individualized care plans, cited during the survey ending August 16, 2018, revealed that residents' care plans would be audited and theses audits would be reported to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding developing individualized care plans.

The facility's plan of correction for a deficiency regarding revising residents' care plans to include current care needs, cited during the survey ending August 16, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee was ineffective with maintaining compliance with the regulation regarding revising residents' care plans to include current care needs.

The facility's plan of correction for a deficiency regarding a failure to ensure that medications were properly labeled, cited during the survey ending August 16, 2018, revealed that the facility developed a plan that included monitoring by the QAPI committee to ensure that medications were properly labeled. The results of the current survey, cited under F761, revealed that the facility's QAPI committee was ineffective with maintaining compliance with the regulation regarding medication labels.

The facility's plan of correction for a deficiency regarding labeling and storing food under sanitary conditions, cited during the survey ending August 16, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective with maintaining compliance with the regulation regarding food storage and preparation.

Refer to F656, F657, F761, F812.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 6/1/19.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 6/1/19.



 Plan of Correction - To be completed: 11/04/2019

The Regional Director of Operations will re-educate the department head team on Quality Assurance and Performance Improvement including the documents from Centers for Medicare and Medicaid Services related to performance improvement projects.

The Administrator will oversee the next Quality Assurance Steering Committee meeting, guiding the team in root cause analysis to determine what approaches or different approaches and/or interventions can be implemented to address the deficient areas noted.

The Administrator will report these findings to the Governing Board for review.

Monthly the minutes of the meeting will be sent to the Regional Director of Operations for review.

A random audit will be completed quarterly for the first year by AristaCare to ensure that the plan of correction is still be executed by the facility.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were accurately documented for two of 32 residents reviewed (Residents 42, 70).

Findings include:

A significant change comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated July 29, 2019, revealed that the resident had moderately impaired cognition, had diagnoses that included diabetes (disease that interferes with blood sugar control), and received daily insulin (medication that lowers blood sugar levels). Physician's orders dated July 25, 2019, included orders for the resident to receive 18 units of Novolog (fast-acting) insulin if the resident ate 50 to 74 percent of the meal, and 34 units if the resident ate 75 to 100 percent of the meal. Orders on August 2, 2019, were for the resident to receive 12 units of Novolog (fast-acting) insulin if the the resident ate 50 to 74 percent of the meal, and 25 units if the resident ate 75 to 100 percent of the meal.

Resident 42's meal percentage records and Medication Administration Records (MAR's) for July and August 2019 revealed that the resident ate 50 to 74 percent, or 75 to 100 percent of the breakfast meal on July 26, 27 and 30, and August 1, 2, 3, 4, 6, 7, 8, 10 and 12; the lunch meal on July 30 and August 1, 4, 6, 8 10, 11 and 12; and the supper meal on July 29 and 30, and August 2, 3, 5, 6, 7, 8, 9, 10 and 11, 2019. However there was no documented evidence regarding how many units of insulin were administered to the resident based on the percentage of meal consumed.

Interview with Registered Nurse Assessment Coordinator 7 on September 11, 2019, at 1:43 p.m. confirmed that the amount of insulin that was administered based on Resident 42's percentage of the meal consumed was not documented.


The facility's policy regarding wound care, dated April 10, 2019, indicated that after completing a wound dressing, staff were to complete the appropriate documentation in the resident's electronic medical record.

A diagnosis record for Resident 70, dated April 8, 2019, revealed that the resident had diagnoses that included peripheral vascular disease (disease or disorder of the circulatory system outside of the brain and heart.). A wound note dated August 20, 2019, indicated that the resident had vascular arterial ulcerations (a sore caused by poor circulation) of the first, second, third and fifth toes of the right foot and also the right heel. Physician's orders, dated August 27, 2019, included an order for the first, second, third and fifth toes of the right foot to be treated by applying betadine, covering with a non-adherent dressing, wrapping with Kerlix (gauze wrap), and changing the dressing daily every day shift and as needed for dislodgement/soilage

Observations of Resident 70 on September 9, 2019, at 1:52 p.m. revealed that the resident was sitting in her wheelchair in her room. She had a dressing to that right foot that had a 3-inch area of red-colored drainage on it in the area of the small toe, the side of the foot, and the area under the toes.

Interview with Licensed Practical Nurse 10 on September 9, 2019, at 4:00 p.m. revealed that bloody draining seeps through Resident 70's right foot dressing at times, and the resident bumps it a lot.

As of September 10, 2019, there was no documented evidence that any "as needed" dressing changes due to drainage and/or bleeding were completed for Resident 70's right foot dressing since September 7, 2019, and there was no other documented evidence of bleeding at the wound site that required dressing changes for the month of September 2019.

Interview with Registered Nurse 4 on September 10, 2019, at 5:18 p.m. revealed that she assisted with an "as needed" dressing change for Resident 70's right foot during the evening shift on September 9, 2019, but there was no documentation regarding this dressing change on the resident's clinical record. She also indicated that the nurse who worked on September 8, 2019, indicated that the dressing was changed due to drainage that day, but this was not documented.

Interview with the Director of Nursing on September 11, 2019, at 10:36 a.m. confirmed that there was no documentation on Resident 70's clinical record, including on the Treatment Administration Record (TAR) regarding the "as needed" dressing changes that were completed, and nurses were to document on the TAR when the dressing was changed.

28 Pa. Code 211.5(f) Clinical Records.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/16/18.



 Plan of Correction - To be completed: 11/04/2019

There is no evidence that Resident R42 had any adverse effects from improper documentation.

Staff interviewed stated they administer the proper amount of insulin according to the meal percentage, however, they admit to not documenting according to policy.

There is no evidence that R70 was negatively affected by the findings of inaccurate documentation. Upon review, R70's wound had shown improvement.

Staff interviewed regarding the lack of documentation revealed the Infection Prevention Nurse was assisting the Licensed Practical Nurse with the dressing change. Both failed to document on the day of the dressing change. A late entry was submitted.

The Clinical Educator or designee will provide education to licensed nurses as to the procedure for complete and accurate documentation in the Electronic Medical Record specific to administering insulin in accordance with resident meal consumption. This education will also be provided for newly hired licensed staff members, as well as, for any licensed agency staff during their orientation.


The Director of Nursing or designee will complete a random audit monthly for 3 months on proper documentation of insulin administration based on meal percentage.

The Director of Nursing or designee will provide education to licensed nurses as to the procedure for Wound Dressing documentation as per facility policy.

The Director of Nursing or designee will complete a chart review of current residents whom have wounds to ensure documentation is compliant.

The Director of Nursing or designee will complete a random audit monthly for 3 months to determine compliance of proper documentation of wound dressings according to facility policy.

Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed.

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 observations and staff interviews, it was determined that the facility failed to ensure that food was prepared and stored under sanitary conditions related to the presence of insects and the proper labeling of opened food items.

Findings include:

Observations in the kitchen on September 9, 2019, at 10:41 a.m. revealed that there were three gnats flying around the bread.

Observations in the kitchen on September 12, 2019, at 9:48 a.m. revealed that there was a large, uncovered garbage can in a food preparation area, and a gnat was flying around it and landing on items in the can. There was also a second uncovered garbage can located by the dietary office. In the cart cleaning area, there were approximately ten to twelve gnats flying around and landing on open, empty cans of peaches, and there were over twenty gnats on the walls and ceiling near the dishwashing area.

Interview with the Dietician on September 12, 2019, at 2:08 p.m. revealed that to help the issue with gnats, staff were to use one gallon of hot water and a cleaning solution in the drains as part of the cleaning routine every night; however, there was no documentation to show that staff were using the drain cleaning solution.


Observations in the kitchen on September 9, 2019, at 10:41 a.m. revealed that there was an opened 32 ounce box of baking soda on a wire rack in a food preparation area. The opened box was in a plastic baggie; however, the baggie was open. There was also a plastic, one-handled shaker with a powder in it; however, the shaker was not labeled. A previously opened plastic container of pink sprinkles, a box of corn muffin mix, and a bottle of Tabasco sauce were not labeled with the date(s) they were opened. In the two-door refrigerator there were yellow cheese slices wrapped in plastic that were not labeled and dated. In the walk-in freezer there were two bags of blueberries, a bag of salmon, and a box of muffins that were previously opened and not dated and/or labeled.

Observations in the kitchen on September 12, 2019, at 9:48 a.m. revealed that there was an opened box of sliced garlic bread in the freezer and the inner plastic bag was opened and not resealed.

Interview with the Dietary Manager on September 9, 2019 ,at 11:22 a.m. revealed that all opened food items should be labeled, dated, and/or sealed properly.

42 CFR 483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve
Previously cited 8/16/18.

28 Pa. Code 211.6(f) Dietary services.
Previously cited 8/16/18.



 Plan of Correction - To be completed: 11/04/2019

No residents were found to be affected.

The timeframe the gnats were observed in the dish room and trash area the outdoor temperatures were seasonably high at approximately 92 degrees outdoors. At the time of the visit the contracted food service provider was unable to provide extermination records due to the recent change in ownership the extermination company was changing the records into the new ownerships name. Later, the records were provided to the facility Administrator for verification of treatment. The exterminator for the contracted food service provider explained that "gnats" or "drain flies" live in all drains both commercial and residential. He provided additional "drain traps" and drain solution to help resolve the issue.

All items found to not be properly stored, dated and/or labeled were disposed of.

The contracted food service provider will implement a tracking log for drain cleaning.

The contracted food service Dietary Manager will re-educate all kitchen staff on the proper food safety requirements for sanitation, storing, dating and labeling procedures for foods including; frozen, refrigerated, and dry goods.

The contracted food service provider's Dietary Manager and/or Dietician will conduct a Food Safety and Sanitation Audit weekly for 2 months, and bi-weekly for an additional 2 months.

Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial four months are completed and results are reviewed.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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


Based on review of policies, clinical records, refrigerator temperature logs and drug manufacturer's guidelines, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 32 residents reviewed (Resident 50), failed to store medications in accordance with manufacturer's instructions in one of two medication refrigerators (first floor), and failed to ensure that Schedule IV medications (controlled drugs that have a potential to be abused) were stored in a separately locked, permanently affixed compartment in one of two medication refrigerators (second floor).

Findings include:

The facility's policy regarding medication labels, dated April 10, 2019, indicated that if the physician's directions for the use of a medication changed, or the medication's label was inaccurate, the nurse may place a "Change of Order - Check Chart" label on the medication container, indicating that there was a change in the directions for use, taking care not to cover important label information with the sticker.

Physician's orders for Resident 50, dated August 8, 2019, included an order for the resident to receive 5 milliliters (ml) of 250 milligrams (mg)/5 ml of Vancomycin suspension (an antibiotic) four times a day for 14 days for clostridium difficile (a bacterial infection that causes diarrhea and inflammation of the colon), then 5 ml twice a day for 10 days, then 5 ml daily for 10 days, then 5 ml every other day for 14 days.

Observations during medication administration for Resident 50 on September 10, 2019, at 7:52 a.m. revealed that the resident's bottle of Vancomycin was dated as being opened on August 20, 2019, and the pharmacy label indicated that the resident was to receive 5 ml four times a day; however, the resident's Medication Administration Record (MAR) revealed that the resident was to receive 5 ml of Vancomycin daily on September 10, 2019.

Interview with Licensed Practical Nurse 6 on September 10, 2019, at 5:06 p.m. confirmed that the label on Resident 50's bottle of Vancomycin was incorrect, and a "Change in Direction" label should have been placed on the bottle.


The facility's medication storage policy, dated April 10, 2019, indicated that the medication refrigerator temperature should be between 36-46 degrees Fahrenheit (F); however, the facility's medication refrigerator temperature documentation form indicated that the maintenance department was to be notified if the temperatures were below 33 degrees F or above 40 degrees F.

The medication refrigerator temperature log for the first floor nursing unit for September 2019 indicated that the temperature was 32 degrees F on September 2, 2019; was 33 degrees F on September 1, 6 and 10, 2019; was 34 degrees F on September 3, 5, 9 and 12, 2019; and was 35 degrees F on September 8, 2019.

Observations of the first floor medication refrigerator with Licensed Practical Nurse 8 on September 12, 2019, at 8:39 a.m. revealed that the temperature was 26 degrees F. At 10:37 a.m., medications stored in the refrigerator included a facility supply of Pneumovax (pneumonia vaccine) .5 ml vials and a 1 ml vial of Aplisol (a solution injected just under to skin to test for tuberculosis - a bacterial lung infection), 12 packets of brovana (inhaled medication to aid in breathing) 15 mcg/2 ml nebulas, a 10 ml vial of Levemir insulin (injected medication that lowers blood sugar levels) labeled for Resident 183, a 10 ml vial of Lantus insulin, Novolog insulin and a 3 ml pen of Basagler insulin labeled for Resident 182, Latanoprost eye drops 2.5 ml labeled for Resident 10, 3 ml Basagler insulin pens labeled for Resident 42 and for Resident 55.

The pharmacy information for the above medications, provided by the facility on September 12, 2019, indicated that they were to be stored in the refrigerator at 36 to 46 degrees F.

Interview with the Director of Nursing on September 12, 2019, at 12:42 p.m. revealed that staff were following the directions on the facility's refrigerator temperature log.


The facility's policy regarding medication storage, dated April 10, 2019, indicated that controlled medications/substances that require refrigeration were to be stored within a locked box within the refrigerator.

Physician's orders for Resident 181, dated October 5, 2018, included an order for the resident to receive 0.25 milliliters (ml) of lorazepam intensol concentrate (a controlled liquid antianxiety medication) 2 milligram/milliliter (mg/ml) by mouth every 4 hours as needed for anxiety.

Observations of the second floor medication refrigerator on September 12, 2019, at 8:26 a.m. revealed that there was a separate box secured in the refrigerator; however, the box was unlocked and contained Resident 181's lorazepam intensol.

Interview with Licensed Practical Nurse 5 on September 12, 2019, at 8:31 a.m. confirmed that the box should have been locked.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 8/16/18.

28 Pa. Code 211.9(h) Pharmacy services.
Previously cited 8/16/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 8/6/18.







 Plan of Correction - To be completed: 11/04/2019

Resident R50 medication was updated to reflect the current order for Vancomycin.

Resident R181's medication was secured in the medication refrigerator lock box.
Medication in the 1st Floor Medication Refrigerator was destroyed.

New medication was replaced and stored according to the policy of temperatures between 36 46 degrees. New refrigerator temperature logs were immediately replaced and in use.
The facility will pull medication changes for the past 7 days to ensure their labels reflect the current physician orders.

Administration will provide education/discipline to the staff
member(s) whom were directly responsible for not updating the label.

Upon investigating the root cause for the lock box affixed inside of the medication refrigerator not being locked was due to a new agency licensed practical nurse claimed she did not have the proper key to lock the box. The medication was delivered to the facility around 12:00am. She reported the medication and it's location to the 1st shift nurse. The medication was immediately secured. The agency nurse was educated on the location of the lock box key and the facility policy in the event she returns to the facility for future shifts.

The staff will be re-educated on the facility policy for discarding medication, refrigerator temperature storage for medication refrigerators, and re-labeling medications post a change in current orders.

The Clinical Educator or designee will complete random monthly medication administration audits specifically focusing on the accuracy of medication labeling and storage for 3 months.

Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed.

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that facility failed to determine if residents were safe to self-administer medications for one of 32 residents reviewed (Resident 50).

Findings include:

The facility's self-administration of medications policy, dated April 10, 2019, indicated that if a resident desired to self-administer medications, a self-medication administration assessment would be initiated to assess the resident's cognitive, physical, and visual capability to self-administer medications.

The facility's medication administration policy, dated April 10, 2019, indicated that medications were to be administered in a safe and timely manner, and as prescribed.

A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated July 31, 2019, indicated that the resident had severe cognitive impairment, required extensive assistance from staff with care, had impaired movement of both upper extremities, and had diagnoses that included Parkinson's disease (progressive nervous system disorder that affects movement). Current physician's orders included orders for the resident to receive 20 milliequivalents (meq) of potassium chloride powder daily. The resident's record contained no documented evidence that an evaluation was completed to determine if the resident was capable of self-administering medications.

Observations during medication administration on September 10, 2019, at 7:52 a.m. revealed that Licensed Practical Nurse 1 prepared 20 meq's of potassium chloride powder in a cup with 5 ounces of water, placed the cup on Resident 50's bedside table, and left the room.

Interview with Licensed Practical Nurse 1 on September 10, 2019, at 7:55 a.m. confirmed that she left the potassium chloride with Resident 50 and should not have.

Interview with the Director of Nursing on September 10, 2019, at 3:00 p.m. confirmed that Licensed Practical Nurse 1 should not have should not have left the cup of potassium chloride and water with Resident 50, and that an assessment to determine if Resident 50 was safe to self-administer her medications was not completed.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 8/16/18.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 8/16/18.





 Plan of Correction - To be completed: 11/03/2019

Resident R50 had no adverse effects from findings. R50 did not meet the requirements for self-administration of medication according to the facility policy. Residents that express a desire to self-medicate will be reviewed by the medical director and interdisciplinary team for appropriateness according to the facilities policy.

Nurse 1 has been provided in-servicing regarding the facility policy on medication administration highlighting that medications are not to be left at bedside or without supervision.

Non-clinical room rounds will continue to be completed in which staff members will observe resident rooms to identify any medications left at bedside. Any findings will be reported immediately to the Director of Nursing. Non-clinical room round findings are documented and tracked through the Quality Assurance Steering Committee.

Licensed staff will be educated on the facility policy for Medication Administration and Self-Administration of Medication Policy, this education will include new hires and will be included in new agency staff members orientation training.

Non-Clinical Room Round observations will be completed weekly for 3 months to identify compliance in accordance to the Medication Administration Policy.
The Clinical Educator or designee will complete random medication pass audits monthly for 3 months.

The results of these audits will be reported to the Quality Assurance Steering Committee monthly for 3 months. Following the 3 months, the committee will determine the frequency of the audits.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a call bell was in reach for one of 32 residents reviewed (Resident 18) who required assistance with care.

Findings include:

The facility's policy regarding call bells, dated April 10, 2019, indicated that staff were to ensure that the call light was plugged in and within a resident's reach at all times.

A diagnosis record for Resident 18, dated September 19, 2018, revealed that the resident had diagnoses that included generalized osteoarthritis, difficulty walking, abnormal posture and lack of coordination. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated July 2, 2019, indicated that the resident was cognitively intact, required extensive assistance with bed mobility and transfers, and assistance with ambulation (walking). The resident's care plan, dated June 25, 2019, included that due to her risk of falls, her call bell was to be within her reach, and she was to ambulate with the extensive assistance of one with a wheeled walker.

Observations of, and interview with, Resident 18 on September 9, 2019, at 12:58 p.m. revealed that she was sitting in a Broda chair (specialized wheelchair) to the right side of her bed. The resident indicated that she wanted to go back to bed. She stated, "I use the call bell, but it is behind me and I can't reach." The resident's call bell was attached to a side rail on the bed which was located behind the resident's chair and was not within the resident's reach.

Interview with Licensed Practical Nurse 5 on September 9, 2019, at 1:39 p.m. confirmed that Resident 18's call bell was not within reach and that it should have been. The nurse indicated that the resident called out to her in the hallway because she wanted to go back to bed.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/16/18.



 Plan of Correction - To be completed: 11/04/2019

Staff assisted Resident R18 back to bed and placed her call bell within reach according to resident preference.

To address proper call bell placement the facility will continue to complete non-clinical room rounds in which department managers are assigned specific rooms to monitor for safety and customer satisfaction. Staff have been educated on the importance of appropriate call bell placement for accessibility.

The Administrator or designee will conduct an All Staff Meeting to educate all employees on proper call bell placement for resident safety and accessibility. Due to the fact that call bells can be moved frequently during re-positioning, assistance out of bed, or adjustment of blankets call bell safety must be a team approach. Education will continue to be educated to newly hired employees and new agency staff reporting to the facility during their orientation.

A random audit will be conducted via rounds monthly that will capture a minimal of 20 observations a month. This audit will take place off shifts.

Results of the non-clinical rounds and the random audits will be reported monthly to Quality Assurance Steering Committee.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing: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 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 one of 32 residents reviewed (Resident 132), and failed to ensure that the Care Area Assessment Process of the comprehensive admission Minimum Data Set assessments was completed in the required time frame for one of 32 residents reviewed (Resident 131).

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 2018, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, and that the Care Area Assessment (CAA) was the process of completing an in-depth assessment of triggered, potentially problematic care areas, and the CAA completion date (Item V0200B2) was to be no later than the resident's admission date plus 13 calendar days.

A comprehensive admission MDS assessment for Resident 131 revealed that the resident was admitted on February 13, 2019, and the resident's admission MDS assessment CAA was dated as completed on February 27, 2019, which was 15 days after admission.

A comprehensive admission MDS assessment for Resident 132 revealed that the resident was admitted on July 15, 2019, and the resident's admission MDS assessment was dated as completed on August 1, 2019, which was 18 days after admission.

An interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on September 12, 2019, at 9:30 a.m. confirmed that the CAA process and admission MDS assessment were not completed within the required time frames for Residents 131 and 132.

28 Pa. Code 211.5(f) Clinical records.





 Plan of Correction - To be completed: 11/03/2019

There is no evidence that Residents R131 & R132, were negatively affected by the late completion of the MDS Assessment.

Moving forward, the Nurse Assessment Coordinator will ensure timely completion of the Minimum Data Set Assessments and the Care Area Assessments in compliance with the timeframes for completion set by the Resident Assessment Instrument Compliance Manual. Minimum Data Set Assessments will be reviewed at morning meeting with the interdisciplinary team to ensure they are completed on time and submitted. Assessments will be submitted on date due by the end of business day.

The Nurse Assessment Coordinator will review the last 30 days of submitted Minimal Data Sets (MDS's) to identify if there were any other late assessments.

The results of these audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed and results are reviewed.

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 clinical record reviews and staff interviews, it was determined that the facility failed to develop a comprehensive care plan that included specific and individualized interventions to address the services to be furnished for one of 32 residents reviewed (Resident 65).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated May 24, 2019, revealed that the resident was cognitively impaired, required the extensive assistance of two staff members to perform most daily care tasks, and received an anticoagulant (blood thinning) medication. Physician's orders dated March 19, 2019, included orders for 5 milligrams (mg) of Eliquis (an anticoagulant) to be administered twice a day, and the resident's Medication Administration Records (MAR's) for July and August 2019 revealed that the resident received the Eliquis twice a day, up to and including August 28, 2019.

There was no documented evidence that a care plan regarding the use of Eliquis was developed for Resident 65.

Interview with the Director of Nursing on September 11, 2019, at 2:20 p.m. confirmed that a care plan related to the use of anticoagulant medication was not developed for Resident 65 and should have been.

42 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plan.
Previously cited 8/16/18.

28 Pa. Code 211.11(d) Resident care plan.
Previously cited 8/16/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/16/18.





 Plan of Correction - To be completed: 11/04/2019

Resident R65's care plan was reviewed by the interdisciplinary team and updated to include specific anticoagulant medication, according to the physician order. Resident received proper medication, and no adverse effects were found.

The facility will conduct an audit of anti-coagulant medications that there is an appropriate care plan.

Nursing Staff will be educated on care planning for specific medications. This education will be included for newly hired licensed nurses, as well as, agency staff licensed nurses during orientation. The interdisciplinary team will review resident care plans in accordance with their quarterly minimum data set assessment for review to monitor services furnished are addressed in the care plan.

The Director of Nursing or designee will conduct random audits monthly for 3 months to review resident care plans for those currently ordered anti-coagulant medications.

Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed.

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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents' care plans were updated to reflect their current care needs for four of 32 residents reviewed (Residents 47, 56, 60, 70).

Findings include:

The facility's policy regarding ongoing care plan updates, dated April 10, 2019, indicated that the nursing staff were to update the care plan related to the physician's orders and/or changes in the resident's care needs.

A diagnosis record for Resident 70, dated April 8, 2019, revealed that the resident had diagnoses that included peripheral vascular disease (impaired circulation). The resident's care plan, initiated on May 3, 2019, indicated that she was to have her legs elevated when sitting or sleeping.

Observations of Resident 70 on September 9, 2019, at 3:41 p.m. and September 10, 2019, at 5:21 p.m. revealed that she was sitting in her wheelchair in her room with stationary footrests in use on the wheelchair, and her legs were not elevated.

Interview with the Director of Nursing on September 11, 2019, at 3:39 p.m. revealed that Resident 70's care plan should have been updated to indicate that her legs were to be elevated "as tolerated" because sometimes the resident likes them elevated and sometimes she does not.


A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 60, dated August 12, 2019, indicated that the resident was cognitively impaired and dependent for bathing. The resident's care plan, dated March 28, 2018, indicated that the resident preferred to be showered twice a week in the evenings. However, bathing records for August and September 2019 revealed that the resident received a sponge bath/bed bath on August 14, 18, 21, 25, 28, and September 1, 4 and 8, 2019.

Interview with the Director of Nursing on September 11, 2019, at 4:35 p.m. revealed that Resident 60 was now receiving hospice (end-of-life services) and preferred to receive a sponge/bed bath; however, the care plan was not updated to reflect this change and it should have been.


A diagnosis record for Resident 70, dated May 9, 2019, revealed that the resident had diagnoses that included atrial fibrillation (abnormal heart rhythm), high blood pressure and congestive heart failure. Physician's orders, dated May 21, 2019, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils) every shift.

Observations on September 9, 2019, at 1:23 p.m. revealed that Resident 70 was using oxygen at 2 liters per minute.

Resident 70's care plan, dated July 22, 2019, indicated that her oxygen flow rate was to be between 1 to 3 liters to maintain saturations (blood oxygen levels) greater than 90 percent. There was no documented evidence that the care plan was updated to reflect the physician's order for oxygen to be delivered continuously at 2 liters per minute.

Interview with Licensed Practical Nurse 11 on September 10, 2019, at 3:40 p.m. confirmed that Resident 70's care plan should have been updated to reflect the resident's current oxygen needs of 2 liters continuously.


A quarterly MDS assessment for Resident 47, dated August 2, 2019, indicated that she was alert and oriented, required the extensive assistance of one person for bed mobility and hygiene, the extensive assistance of two for transfers, and she had an indwelling urinary catheter (tube inserted and held in the bladder to drain urine). Physician's orders, dated August 23, 2019, revealed that the urinary catheter was to be changed every three months and as needed for clogging/displacement.

Resident 47's care plan, dated August 26, 2019, indicated that the catheter was to be changed yearly as ordered.

Interviews with Licensed Practical Nurse 11 on September 10, 2019, at 3:33 p.m. and with the Nursing Home Administrator on September 11, 2019, at 10:59 a.m. confirmed that Resident 47's care plan should reflect the current physician's orders for changing the catheter.


A nursing note for Resident 56, dated August 20, 2019, and the resident's current care plan, revealed that the resident had a Stage IV pressure ulcer (skin breakdown caused by pressure that involves the full thickness of the skin and that exposes muscle and/or bone) to the coccyx (tailbone) and a Stage II pressure ulcer (open, superficial) on the left heel. A wound consultation note, dated September 3, 2019, recommended that the resident be put back to bed after meals, for the resident to be up no longer than one hour at a time for a maximum of three occurances when possible, and that she was not to have shoes to the left foot until the ulceration was healed.

There was no documented evidence that Resident 56's care plan was updated to include the wound consultant's recommendations.

Interview with the Director of Nursing on September 12, 2019, at 10:17 a.m. confirmed that Resident 56's care plan should have been updated with the wound consultant's interventions.

42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision.
Previously cited 8/16/18.

28 Pa. Code 211.11(d) Resident care plan
Previously Cited 8/16/18.

28 Pa. Code 211.12(d)(5) Nursing services
Previously Cited 8/16/18.




 Plan of Correction - To be completed: 11/04/2019

There is no evidence that Residents R 47, R56, R60, R70 were negatively affected by their care plans having not been updated timely.

The care plans for R47, R56, R60, and R70 were immediately reviewed and updated to reflect the most current resident need and/or orders.
Licensed nursing staff will be re-educated on the care plan process specific to changes in resident care needs by the Clinical Educator and/or designee. This education will also be provided for newly hired licensed staff members and will be provided during agency staff orientation. The interdisciplinary team will review care plans in accordance with the residents minimum data set assessment to ensure they are updated accordingly.

The RN Supervisor will be assigned to review the clinical dashboard to ensure orders are printed and care plans are updated accordingly before the end of each day.

During Morning Clinical Rounds the interdisciplinary team will verify with the nursing staff on each unit that the care plans have been updated according to the physician orders and/or resident need.

A random audit of care plans will be completed by the Director of Nursing/Designee monthly for 3 months. Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that nurses followed professional standards regarding the administration of medications for one of 32 residents reviewed (Resident 50).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.

The facility's policies regarding medication administration, dated April 10, 2019, revealed that medications were to be administered in a safe and timely manner, and as prescribed. Residents could self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determined that they had the decision making capacity to do so safely.

A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated July 31, 2019, indicated that the resident had severe cognitive impairment, required extensive assistance from staff with care, had impaired movement of both upper extremities, and had diagnoses that included Parkinson's disease (progressive nervous system disorder that affects movement). Current physician's orders, included orders for the resident to receive 20 milliequivalents (meq) of potassium chloride powder daily. The resident's record contained no documented evidence that an evaluation was completed to determine if the resident was capable of self-administering medications.

Observations during medication administration on September 10, 2019, at 7:52 a.m. revealed that Licensed Practical Nurse 1 prepared 20 meq's of potassium chloride powder in a cup with 5 ounces of water, placed the cup on Resident 50's bedside table, and left the room.

Interview with Licensed Practical Nurse 1 on September 10, 2019, at 7:55 a.m. confirmed that she left the potassium chloride with Resident 50 and should not have.

Interview with the Director of Nursing on September 10, 2019, at 3:00 p.m. confirmed that Licensed Practical Nurse 1 should not have left the cup of potassium chloride and water with Resident 50.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 8/16/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/16/18.






 Plan of Correction - To be completed: 11/04/2019

R50 does not meet the criteria for self-administering medications.

Administration will provide education and/or discipline to employee E1.

Licensed nursing staff will be re-educated on the professional standards regarding administration of medication and not leaving medication at the bedside. This education will also be provided for newly hired licensed staff members and will be provided during agency staff orientation.

The Clinical Educator/ designee will complete monthly medication competencies equaling 8 per month. During the competency he/ she will focus on the five rights of medication and ensuring that medication is not left at bedside.

Results of the competencies will be reported and trended to the facility's Quality Assurance Steering Committee. Following the three months, the Quality Assurance Steering Committee will determine the need and frequency for future monitoring.

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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper care to prevent infection was provided to one of 32 residents reviewed (Resident 47) who had an indwelling urinary catheter.

Findings include:

The facility's policy regarding care for indwelling urinary catheters (a tube placed and held in the bladder to drain urine), dated April 10, 2019, indicated that the drainage bag (collects urine) must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and bag from flowing back into the bladder.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated August 2, 2019, indicated that the resident was cognitively intact, required extensive assistance with daily care tasks, and had an indwelling urinary catheter. Physician's orders dated August 23, 2019, included an order for the resident to have an indwelling urinary catheter.

Observations of Resident 47 on September 9, 2019, at 12:33 p.m. revealed that while being transferred from her bed to a wheelchair with a mechanical lift, Nurse Aides 3 and 12 placed the resident's catheter bag on a sling hook of the mechanical lift, which caused the bottom of the bag to be approximately eight inches above the level of the abdomen, and causing urine in the tubing to flow back toward the bladder.

Interview with Nurse Aide 3 on September 9, 2019, at 1:11 p.m. revealed that they should have hooked the catheter bag on her abdomen area not on the sling hook

Interview with Infection Control Registered Nurse 4 on September 10, 2019, at 3:01 p.m. confirmed that the nurse aides shoud not have hooked Resident 47's catheter bag onto the mechanical lift, which caused the bag to be above the level of the bladder.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 8/16/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/16/18.





 Plan of Correction - To be completed: 11/04/2019

Resident R47 had no ill effect from catheter bag placement.

The Director of Nursing reviewed all current residents with indwelling catheters and the need for extensive assistance for care tasks in order to provide specific education to care staff regarding catheter bag placement while transferring with mechanical lift. Resident R47 is currently the only resident with this specific care need.

Nurse Aide 3 and Nurse Aide 12 were interviewed and stated they knew as soon as they did it they shouldn't have. Both Nurse Aides will receive education on the proper procedure and the reasoning for doing so.

Additionally, the Nurse Aides will receive appropriate discipline for their action, as they have been trained according to the professional standard.
The Clinical Educator will conduct in-service training for nurse aides on in-dwelling catheter standard of care procedures specifically addressing the appropriate placement of the catheter bag during transfers. This education will also be provided for newly hired licensed staff members and will be provided during agency staff orientation.

The Clinical Educator will conduct a lift demonstration competency for both Nurse Aide 3 and Nurse Aide 12.

A random lift competency will occur monthly with residents utilizing an indwelling catheter. Due to the limited amount of opportunities to perform this competency the facility will report such attempts when trending results of audits.

Results of the audits will be reported monthly to the Quality Assurance Steering Committee. Following the three months the committee will determine the frequency needed.

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide pain relief for one of 32 residents reviewed (Resident 65).

Findings include:

The facility's policy regarding pain management, dated April 10, 2019, indicated that unrelieved pain had negative physical and psychological consequences, including the potential for a decrease in the resident's functional ability.

Physician's orders for Resident 65, dated June 18, 2019, included orders for the resident to receive two 325 milligram (mg) tablets of acetaminophen (over-the-counter pain medication) three times a day for pain management.

A nursing note, dated September 5, 2019, at 8:42 p.m. and Medication Administration Record (MAR) for September 5, 2019, at 8:00 p.m. revealed that Resident 65 had a pain level of 3 (on a scale of 1 to 10, with 10 being the worst pain); however, it was unsafe for the resident to take anything by mouth at that time. A nursing note, dated September 5, 2019, at 9:45 p.m. revealed that the resident was admitted under hospice (end-of-life) care and Tylenol (acetaminophen) suppositories were ordered for pain/fever. However, there was no documented evidence that the resident received any medication for pain on September 5, 2019.

Physician's orders for Resident 65, dated September 5, 2019, included an order for the resident to receive 5 milligrams (mg)/0.25 milliliters (ml) of Morphine concentrate (a narcotic pain medication) every hour as needed for pain/shortness of breath. Resident 65's MAR for September 2019 revealed that staff administered Morphine to the resident on September 6, 2019, at 2:36 p.m. for a pain rating of 5, and at 3:46 p.m. the resident's pain rating was 6 and the medication was not effective for pain relief.

There was no documented evidence that Resident 65's physician was notified regarding the resident's unrelieved pain.

Interview with the Director of Nursing on September 12, 2019, at 2:23 p.m. confirmed that there was no documented evidence that Resident 65 was medicated for pain on September 5, 2019, and that Resident 65's physician should have been notified when Morphine was not effective for relieving her pain on September 6, 2019, at 3:46 p.m.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 8/16/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/16/18.





 Plan of Correction - To be completed: 11/04/2019

Resident R65 was on hospice and is no longer at the facility.

Administration will provide education on the pain management policy and/or discipline to nurse who provided care to resident R65 on the referenced date. The education will be on the pain management policy.

The Director of Nursing will review residents on hospice for the past 15 days to ensure that they have a pain scale for administration, medication was administered as ordered by the physician, and the physician is notified for pain unable to be managed.

Nursing staff will be re-educated on the pain management policy (including but not limited to; pain scale, pain medication effectiveness and comfort, and medication administration), and notifying the physician when pain is not managed.

The Director of Nursing or designee will complete a random monthly audit for 3 months on resident's with pain orders to ensure that they have a pain scale for administration, medication was administered as ordered by the physician, and the physician is notified for pain unable to be managed. This education will also be provided for newly hired licensed staff members, as well as, for any licensed agency licensed staff during their orientation.

Results of the audits will be reported and trended to the facility's Quality Assurance Steering Committee. The Quality Assurance Steering Committee will determine the frequency of the audits after the initial three months are completed and results are reviewed according to the trends recommendations and guidance via facility Quality Assurance Performance Improvement Plan (QAPI).

483.90(i)(3) REQUIREMENT Corridors have Firmly Secured Handrails: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.
483.90(i)(3) Equip corridors with firmly secured handrails on each side.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to ensure that a handrail was properly secured on one of two nursing units (second floor).

Findings include:

Observations of the handrail on the second floor nursing unit on the right side of the long hallway on September 9, 2019, at 12:50 p.m. revealed that one of the three brackets was loose from the wall, and when the rail was lightly touched, it moved away from the wall. The plaster behind the bracket was broken.

Interview with the Maintenance Director on September 9, 2019, at 4:09 p.m. revealed that the handrails were last checked three months ago. He indicated that the handrail appeared to be hit, which caused it to come loose from the wall, and it should have been reported.

Interview with Licensed Practical Nurse 2 on September 9, 2019, at 4:14 p.m. revealed that there was a resident on the second floor nursing unit who ambulated independently in the hall.

28 Pa. Code 207.2(a) Administrator's responsibility.








 Plan of Correction - To be completed: 11/04/2019

The handrail on the second floor nursing unit on the right side of the long hallway was repaired and properly secured. No residents were negatively affected.

The Maintenance Director or designee will complete a full facility audit for handrails to ensure their safety.
Handrails will continue to be checked weekly during non-clinical rounds and monthly during Safety Committee Rounds.

In addition, the facility will implement an additional audit that will be completed by the maintenance department for 3 months. This task will be entered into the electronic work order System to ensure compliance of handrails.

Results of the Handrail Audits will be addressed at the monthly Safety Committee Meeting. The Safety Officer will report findings to the Quality Assurance Steering Committee for 3 months. The Steering Committee will determine the need and frequency of the Handrail Audit at that time.


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