Nursing Investigation Results -

Pennsylvania Department of Health
HIGHLAND PARK CARE CENTER
Patient Care Inspection Results

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HIGHLAND PARK CARE CENTER
Inspection Results For:

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HIGHLAND PARK CARE 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, and a Civil Rights Compliance Survey completed on November 18, 2021, it was determined that Highland Park Care Center, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


































































 Plan of Correction:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations and staff interview, it was determined that the facility failed to maintain a homelike environment on one of two nursing units (Second floor nursing unit).

Findings include:

During an observation on 11/16/21 from 8;30 a.m., through 10:15 a.m. the following was observed:

Resident rooms 214, 216, 217, 218, 219, 220, 221, 222 and 223 had dusty heating/ air conditioning units.

Resident rooms 216 and 221 had floor boards entering the bathrooms with broken edges exposing sharp edges and plaster.

During an interview on 11/16/21, at 11:08 a.m. the Nursing Home Administrator confirmed that the facility failed to provide a homelike environment for the residents of the second floor nursing unit.

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

28 Pa. Code: 201.29(j) Resident rights.



 Plan of Correction - To be completed: 12/21/2021

The HVAC Systems in Resident rooms 214, 216, 217, 218, 219, 220, 221, 222 and 223 were cleaned by maintenance.

Director of Nursing provided education to all staff to monitor areas for cleanliness and safety/needed repairs. Also educated staff that any findings are to be reported to RN supervisor/DON and/or Maintenance director immediately. Maintenance director will address all issues/repairs.

The floor boards, entering the bathrooms in Resident rooms 216 and 221, were inspected by maintenance and repaired as needed.

The Maintenance Director/Designee will audit the HVAC systems for dust, and the floor boards near the bathrooms in the 2nd floor resident rooms. Cleaning and repairs will be completed as needed.

The Maintenance Director/Designee will monitor the 2nd floor, Resident room HVAC Systems for dust and the floor boards near the bathrooms for safety; daily x 2 weeks, weekly x 2 weeks, and monthly x 2 months.

Audit results will be reviewed, quarterly, by the QAPI Committee for recommendations, as necessary.


483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:
Based on an observation and staff interview it was determined that the facility failed to secure the personal privacy and confidentiality of the residents' medical information for one of two medication carts ( Medication Cart B, Second Floor Nursing Unit).

Findings include:

During an observation on 11/15/21, at 9:23 a.m. the computer screen containing resident medical information was left open and unattended for any passerby to see.

During an interview on 11/15/21, at 9:27 a.m. Registered Nurse Employee E2 confirmed that the screen was left open and resident personal confidential information was left unattended for any passerby to see.

28 Pa. Code: 211.5(b) Clinical records.


 Plan of Correction - To be completed: 12/21/2021

Disclaimer: The following is submitted for plan of correction purposes only and is not to be construed as an admission.

E2 was inserviced, by the DON, on Personal Privacy/Confidentiality of Records with respect to the med cart computer screen.

The Don/Designee will inservice nurses to include Personal Privacy/Confidentiality of records of med cart computers.

The DON/Designee will audit medication cart computers on the 2nd and 4th floors; daily x 2 weeks, weekly x 2 weeks, and monthly x 2 months to ensure privacy and confidentiality. Audits will not be performed on the 3rd floor due to unit being unoccupied by residents at this time.

Audit results will be reviewed, quarterly, by the QAPI Committee for recommendations, as necessary.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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

Based on facility policy, observation and staff interview, it was determined that the facility failed to make certain medications were properly secured for one of three Medication carts ( Medication cart B, Second floor nursing unit).

Findings include:

Review of the facility policy " Medication Storage" last reviewed on 6/1/21, indicated that medications are stored safely, securely and properly. The medications are accessible only to licensed staff lawfully authorized to administer medications.

During an observation on 11/15/21, at 9:23 a.m. the Second Floor Mediication Cart B was left unlocked, unattended, accessible to anyone passing by.

During an interview on 11/15/21, at 9:27 a.m. Registered Nurse Employee E2 confirmed that the medication cart was left unlocked, unattended and unsecured.

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

28 Pa. Code: 211.12(D)91)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 12/21/2021

The DON inserviced E2 to ensure unattended medication carts are locked.

The DON/Designee will inservice nurses to ensure unattended medication carts are locked.

The DON/Designee will audit medication carts on the 2nd and 4th floors to ensure unattended medication carts are locked; daily x 2 weeks, weekly x 2 weeks, and monthly x 2 months. Audits will not be completed on the 3rd floor as the unit is unoccupied by residents at this time.

Audit results will be reviewed, quarterly, by the QAPI Committee for recommendations as necessary.


483.10(j)(1)-(4) REQUIREMENT Grievances:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on a review of facility policy, observations, and staff interviews, it was determined the facility failed to provide grievance forms for filing anonymous grievances on two of two units (second and fourth floors).

Findings include:

The facility policy "Grievances", last reviewed 8/15/21, the facility will have postings in prominent locations of the resident's right to file grievances anonymously. The postings indicated the grievance forms are available at the grievance boxes for filing anonymous grievances.

During an observation on 11/18/21, at 10:20 a.m. the fourth floor grievance box did not have grievance forms available to file an anonymous grievance.

During an interview on 11/18/21, at 10:20 a.m. RN (Registered Nurse) Unit Manager Employee E5 confirmed the facility failed to make certain grievance forms for filing anonymous grievances were available to residents on the fourth floor.

During an observation on 11/18/21, at 10:40 a.m. the second floor grievance box did not have grievance forms available to file an anonymous grievance.

During an interview on 11/18/21, at 10:40 a.m. RN (Registered Nurse) Unit Manager Employee E6 confirmed the facility failed to make certain grievance forms for filing anonymous grievances were available to residents on the second floor.

28 Pa. Code: 201.18(e)(4) Management
Previously cited 9/18/18

28 Pa. Code: 201.29(i) Resident Rights






 Plan of Correction - To be completed: 12/21/2021

Grievance forms were placed in the grievance boxes in the 2nd and 4th floor lounges.

RN unit managers are to monitor boxes and refill as needed. Education provided to Unit managers.

The DON/Designee will monitor the grievance boxes in the 2nd and 4th floor lounges to ensure forms are available; daily x 2 weeks, weekly x 2 weeks, monthly x 2 months.

Audit results will be reviewed, quarterly, by the QAPI Committee, for recommendations as necessary.

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