Nursing Investigation Results -

Pennsylvania Department of Health
INGLIS HOUSE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
INGLIS HOUSE
Inspection Results For:

There are  127 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.
INGLIS HOUSE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure Survey, and Civil Rights Compliance Survey, and an abbreviated survey in response to three complaints completed on August 19, 2019, it was determined that Inglis House 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 related to the health portion of the survey process.




 Plan of Correction:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observation, review of facility policy and clinical records, it was determined that the facility failed to ensure that staff maintained proper infection control techniques during wound care for one of three residents observed (Resident R202) and during medication administration on one of six nursing units (One South Nursing Unit - Resident R52).

Findings included:

Review of Resident R202's clinical record revealed the resident was admitted to the facility on May 7, 2008, with a diagnosis of peripheral vascular disease (A circulatory condition in which narrowed blood vessels reduces blood flow). Additionally, the clinical record identifed that the resident had four different wound areas on her skin. The resident's wound care physician orders included: 1. every day shift for left Ischium suspected deep tissue injury cleanse l ischium with normal saline (salt solution), pat dry. Apply Skin Prep No Sting (reduce friction during the removal of tape) and cover with foam dressing daily; 2. cleanse sacrum (lower back) wound with Dakins solution 0.125% (wound cleanser), pat dry. pack wound with Dakins solution 0.125% soaked; 3. every day shift for right inferior ischium suspected deep tissue injury cleanse with normal saline, pat dry. apply skin prep no sting, and cover with foam dressing; 4. cleanse right ischium pressure injury with Dakins solution 0.125%, pack/cover wound with Dakins Solution 0.125% soaked gauze packing, and cover with foam dressing daily.

Observation of Employee E4, LPN, perform wound care treatment on Resident R202 on August 16, 2019, at 9:45 a.m. revealed the following findings:

Employee E4, LPN, applied the skin prep no sting applicator film to the inside of the left ischium wound, then with the same applicator applied the film to the outer perimeter of the wound, then with the same applicator applied the no sting prep film to the inside of the wound, which potentially contaminated the wound by bringing in contaminates from outside of the wound to the inside of the wound.

Then Employee E4, LPN, moved to the left gluteal wound, where she donned clean gloves, then picked up the Dakins bottle and moved the Dakins bottle. Then, with the same gloves, picked up Dakins soaked gauzes and packed the soaked gauzes into the wound using the same gloves, which potentially contaminated the wound because the gloves used to pack the wound came into contact with potentially contaminated surfaces to include the bottle of Dakins solution.

Employee E4, LPN, then moved to the right inferior ischial wound, where she used a Dakins soaked gauze to cleanse the inside of the wound, then with the same gauze she cleansed the outer perimeter of the wound, and continuing with the same gauze cleansed the inside of the wound, again which potentially contaminated the wound by bringing in contaminates from outside of the wound to the inside of the wound.

Then, Employee E4, LPN, moved to the last right ischium wound where she donned clean gloves, then picked up the Dakins bottle and moved the Dakins bottle. Then, with the same gloves she picked up the Dakins soaked gauzes with the same gloves and packed the soaked gauzes into the wound, which potentially contaminated the wound because the gloves used to pack the wound came into contact with potentially contaminated surfaces to include the bottle of Dakins solution.

Interview with the DON on August 19, 2019, at 12:00 p.m. confirmed that the facility does not have policies on the correct technique of performing wound care to not contaminate the wounds.

The facility failed to perform wound care treatment in a manner that would not potentially contaminate the resident's wound.

Observation on August 19, 2019, at 9:30 a.m. of Employee E7, LPN, administering medications to Resident R52, revealed that the employee picked up two medications with her bare fingers/hands and touched the inside of the resident's water cup and the medication souffle cup.

The facility failed to adhere to effective infection control practices related to medication administration.

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







 Plan of Correction - To be completed: 10/17/2019

Residents R202 and R52 were monitored and no negative outcomes were observed.

1. E4 received standard of card education. Nursing practice reviewed. Treatment observed and competency checked by Education Director. Observed by infection control officer for proper wound cleaning technique. E4 will be observed for wound treatment and infection control competency during wound rounds weekly for 4 weeks, monthly for 4 months, and randomly.

2. House education was provided for all professional nurses on infection control and wound treatment policy. Treatment audit for infection prevention and control technique and wound care technique for professional nurses will be completed. Licensed nurses will be observed and audited for standard nursing practice.

3. E7 - received education on medication administration and infection control. Will be observed for medication pass and competency weekly for a month and monthly after.

4. Results of treatment and wound care audits will be reported to the facility Care and Services committee as part of the facility's QAPI program.Nurses identified as using improper infection control or wound care technique during audits or observation will receive additional education.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on review of clinical records and facility policies and procedures, and interviews with staff, it was determined that the facility failed to ensure that residents' wishes, as indicated in their Advance Directives was reflected accurately in the clinical record for four of 40 clinical records reviewed (Residents R43, R79, R191, and R228).

Findings include:

Review of facility policy, "Advance Directives," dated, revised November 28, 2019 stated that the it is the facility policy "to honor Advance Directives/Living Wills as indicated by the resident/health care agent." The policy also stated that the facility" will inform residents and their resident representatives of the right to execute an Advance Directive (One's wishes on life-sustaining medical or surgical treatment).'"

Review of Resident R43 physician's orders dated, August 1, 2019, revealed a code status of full code (resident's wishes for medical interventions- cardiopulmonary resuscitation). Continued review of Resident R43's clinical record revealed a Living Will Declaration, completed and signed by Resident R43 on May 22, 2007, indicating a DNR (Do Nor Resucitatie) code status.

An interview with licensed nursing staff, Employee E10, on August 16, 2019, at 10:00 a.m. confirmed that R43's code status, were conflicting, with what was indicated on current physician order's and Resident R43's completed Living Will Declaration.

Review of Resident R228's physician's order dated May 14, 2019, and monthly thereafter, indicated the Advance Directives as DNR (Do Not Resuscitate-do not perform chest compressions to keep the heart beating). Review of the "Advance Medical Directive - Resident Responsibility/Advance Directive Status," dated and signed by the resident's responsible representative and the physician revealed that Resident R228 wishes were for DNR (Do Not Resuscitate - do not perform chest compressions to keep the heart beating)) and no intubation (DNI - use of a tube or machine to help a person breathe).

Interview with the Director of Nursing on August 15, 2019 at approximately 4:20 p.m., confirmed that the physician's orders for Resident R228 was DNR (Do Not Resuscitate), and did not include the additional wishes of the resident for no invasive airway techniques (DNI - do not use a tube or machine to help a person breathe).

Review of Resident R191's physician's order revealed the diagnoses but not limited to, cerebral infarct (damage to tissues in the brain due to a loss of oxygen to the area), left sided weakness, and seizure disorder (neurological disorders that cause brief episodes of spasms, unresponsiveness). Further review of the clinical record revealed that the resident's mother who is the power of attorney completed a Living Will Declaration on September 20, 2007. The Living Will Declaration stipulated that the resident did not want cardiac resuscitation, mechanical respiration or kidney dialysis.

Review of Resident 191electronic health record revealed that the resident code status was " full code with full treatment" denoting to employ cardiopulmonary resuscitation and intubation if the resident is not breathing and when the heart is not beating.

Interview the Director of Nursing on August 16, 2019 at approximately 11:00a.m. revealed that the facility was in the process of reviewing the code status of all residents and waiting for the physician to verify the resident's code status with his Mother/POA.

Review of Resident R79's clinical record revealed a current physician's order to do not resuscitate (do not employ cardiopulmonary resuscitation).

Review of Resident R79's clinical record revealed an "Advance Directive Acknowledgement," form signed and dated by Resident R79 on March 13, 2019, that revealed "I have an Advance Directive and have supplied Inglis House with a copy for my active medical records". Further review of Resident R79's clinical record revealed no evidence of an advance directive.

Interview on August 19, 2019, at 9:00 a.m. with the DON, where she confirmed there was no advance directive in the resident's clinical record indicating the resident's wishes regarding her code status

The facility failed to ensure that the resident's decision regarding life sustaining treatment measures were reflected in the physician's orders.

A review of Resident R222's clinical record revealed the diagnoses of cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) and/or other disabilities, typically caused by damage to the brain before or at birth), quadriplegia (paralysis of all four limbs), and congenital hydrocephalus (is caused by a brain malformation or birth defect that causes excessive cerebrospinal fluid (CSF) to accumulate in brain cavities).

Further review of the Resident R222's clinical record revealed an April 25, 2019 physician's order for DNR/Do not attempt resuscitation (allow natural death).

Continued review of Resident R222's clinical recor revealed an Inglis House Advance Medical Directive which was not complete other than a note at the bottom stating that the resident did not wish to complete and advance directive dated August 19, 1996, with an "X" in the resident signature/mark and witnessed by two licensed social workers.

An interview with Employee E2, Director of Nursing, on August 19, 2019 at 1:15 p.m. confirmed that there was no evidence in the clinical record to support the current physician's order for DNR.

The facility failed to ensure accurate documentation was maintained regarding residents' wishes for resuscitation upon life-threatening medical conditions.

28 Pa. Code 201.18(b)(1) Management
Previously cited 10/18/18 and 5/16/19

28 Pa. Code 201.29(i) Resident rights

28 Pa. Code 211.5(f) Clinical records
Previously cited 10/18/18

28 Pa. Code 211.10(a)(c) Resident care policies

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(c)(d)(1) Nursing services
Previously cited 05/16/19

28 Pa. Code 211.12(d)(3)(5) Nursing services
Previously cited 02/08/18



 Plan of Correction - To be completed: 09/17/2019

All 4 resident's advance directive reviewed, and updated.



All resident's advance directives and MD order' will be reviewed along with resident's living wills and code status by social services and Life Leader and those who do not match nursing will be notified. New residents will educated on advance directives at admission and POLST completed at admission. POLSTs and orders will be checked at care conference quarterly by social services, and any necessary changes will be made per facility policy. Resident POLST completion to be monitored by social services lead or designee and reportedly quarterly as part of facility QAPI program.



483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(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 interviews with staff, it was determined that the facility failed to maintain the resident rooms in a safe, clean, comfortable and homelike condition on one of six nursing units (One South Nursing Unit).

Findings include:

Observation in Room 115 South on August 14, 2019 at 9:20 a.m. revealed a triangular hole in the floor approximately 5in.(inch) wide by 7in. long by 1.5in. deep where a portion of the floor tile chipped off.

Observation in Room 111 South on August 14, 2019 at 10:00 a.m. revealed paint peeling on the wall next to the bed approximately 12in. by 12 in. in size.

Observation in Room 120 South on August 14, 2019 at 11:00 a.m. revealed a chipped missing piece of floor tile approximately 4in. by 8in. in size.

Observation in Room 132 South on August 14, 2019 at 2:00 p.m. revealed paint peeling and wall material crumbling near the window approximately 6in. by 6in. in size and crumbling baseboard trim directly across from the bed approximately 5in. by 12in. in size.

Observation in Room 104 South on August 16, 2019 at 1:00 p.m. revealed a wall across from the bed, to the right of the folding sink, where the paint was dry, cracking and peeling with loose and crumbling wall material showing and a white substance protruding from under the peeling paint.

Interview with Employee E3, Director of Engineering Services on August 16, 2019 at 1:10 p.m. confirmed the chipped floor tiles and peeling paint.

The facility failed to maintain resident rooms in a safe, clean, comfortable and homelike condition on one of six nursing units.

28 Pa Code: 201.18(b)(1) Management
Previously cited 5/16/19 and 10/18/18

28 Pa Code: 201.18(b)(3) Management
Previously cited 5/16/19 and 10/18/18

28 Pa Code 207.2(a) Administrator's responsibility



 Plan of Correction - To be completed: 10/17/2019

The floor tile in Room 115S was replaced.

The paint on the wall of Room 11S was corrected.

The floor tile in Room 120S was replaced.

The wall and baseboard in Room 132S were repaired.

The wall in room 104S was repaired.

Director of Engineering services (or designee), Director of Environmental Services (or designee) and ANHA to conduct weekly rounds on all units to ensure a safe, clean, comfortable and home like condition on all units. Results of rounds will be reported to appropriate staff, rooms requiring repairs to be entered into facility work order system and logged. Work order system to be monitored by facility Engineering Director to ensure timely completion of work orders. Results of monitoring to be reported as part of facility QAPI program.
483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:

Based on review of facility policy and personnel records and interviews with staff, it was determined the facility failed to complete criminal background and FBI checks and failed to provide abuse training for three of three contracted employees (Employees E5, E6 and E8).

Findings include:

Review of facility policy, "Abuse Neglect and Exploitation Reporting and Investigation", dated December 20, 2018, indicated, "Screening", "Person making application for employment will be informed of this policy and be required to sign a release giving the facility the right to conduct such investigations." Continued review of the facility policy, indicated, "Training", "Employees will be trained in and will be knowledgeable about how to appropriately intervene in situations involving residents who have aggressive or catastrophic reactions." "Employees will be knowledgeable regarding what, when, and who to report according to the facility policy, and without fear of reprisal." "Employees will be knowledgeable about recognizing signs of burnout, frustration from stress that may lead to abuse."

Review of Employee E5's personnel record, revealed that the employee was hired to work at the facility on April 4, 2019. Continued review of Employee E5's personnel record revealed no documentation indicting that Employee E5 received abuse trainng, at the time of hire.

Review of Employee E6's personnel record, revealed that the employee was hired to work at the facility on July 22, 2019. Continued review of Employee E6's personnel record revealed no documentation indicting that Employee E6 received abuse training, at the time of hire.

Review of Employee E8's personnel record, revealed that the employee was hired to work at the facility on January 30, 2019. Continued review of Employee E8's personnel record revealed no documentation indicting that Employee E8 received abuse training, at the time of hire. Continued review of Employee E8's personnel record revealed Employee E8, lived outside of Pennsylvania within the last two years, and no FBI check and/or a Pennsylvania Criminal background were completed prior to Employee E8 working at the facility.

Interview with Employee E9, Human Resource Director, on August 19, 2019, at 1:00 p.m. confirmed that each of the three contracted employee's did not receive Abuse training prior to working at the facility and one employee did not have a Pennsylvania Criminal Background check and/or a FBI check completed prior to working at the facility.

The facility failed to complete Abuse training, Criminal Background check and FBI check prior to working at the facility.

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

28 Pa. Code: 201.18(b)(1) Management
Previously cited 5/16/19 and 10/18/18.

28 Pa. Code: 201.19 Personnel policies and procedures




 Plan of Correction - To be completed: 10/17/2019




In result of failing to run background checks and failure to properly follow Policy # 101.09; section "Screening" and "Training". Employee's E5, E6, E8, will all receive abuse training from facility's Clinical Educator; they must also sign and acknowledge Policy # 101.09, "Abuse, Neglect, and Exploitation Reporting". As a systematic change to our process, temporary, agency, or any employees will receive abuse training from our Clinical Educator and have a complete criminal background check prior to starting their roles at Inglis. Furthermore, all current temporary, agency, or other employees will have their criminal background checks and onboarding training referenced for abuse training and valid, up-to-date clearances.



Employee files will be audited and reported quarterly as part of the facility's QAPI program, with changes made as appropriate.


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on observations, review of clinical records and staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained related to safety devices for three of 5 clinical records reviewed (Residents R43, R84, and R184).

Findings include:

Review of the facility policy "Restraints, Bedrails, and Safety Device Usage," dated revised November 14, 2017, stated that the interdisciplinary (IDT) will assess the need for positioning devices or interventions intended to help a resident attain or maintain his or her highest practicable physical and psychosocial well-being." The policy further stated that the devices would include but were not limited to "side rails (Full and split), seatbelt, chest strap, and lap tray. If just (used) appropriately, these devices and other enabling devices are not to be considered as physical restraints." The same policy also indicated that the rehabilitation staff would assess the resident to determine the least restrictive device to be used and that the assessment would include a review of the resident's functional range of motion, bed mobility, wheelchair positioning, and ability to transfer between positions. The rehabilitation staff would "obtain a primary care provider's (resident's physician) order for these devices which include medical symptoms of conditions that justify usage."

Review of the clinical record for Resident R184 revealed that the resident was admitted to the facility on November 21, 2017 with diagnoses including polyneuropathy (damage or disease affecting the peripheral nerves - nerves that connect link the brain and spinal cord to the rest of the body - usually to the same areas on both sides of the body, featuring weakness, numbness, and burning pain) and muscle weakness. Observation of the resident's bed on all days of the survey revealed that there was a full side rail attached to the right side of resident's bed and two one half siderails attached to the left side of resident's bed. Review of a Rehabilitation Services Joint Evaluation dated June 11, 2019 completed by physical therapy for Resident R184 revealed that both bed rails were recommended due to a balance disturbance and to promote security and safety for the resident.

Review of the physician's orders August, 2019 for Resident R184 revealed that there was no order by the physician for bedrails (siderail) for safety for the resident.

During an individual resident interview with Resident R43, on August 14, 2019, at 10:15 a.m. an observation was made of Resident R43, laying in bed with both sides of the bed rails in the up position. Interview with Employee E10, Licensed nurse, it was confirmed that both side rails were up while Resident R43 was in bed.

An indivual interview with Resident R84, on August 15, 2019, at 9:15 a.m., while he was laying in his bed, the observation was made that both side rails were in the up position, when Resident R84 was in his bed. At the end of the interview an interview with licensed nursing staff, Employee E10, confirmed that both sides rails were up and that Residnet R84, was laying in the bed with the side rails up.

A follow up interview with Employee E10, on August 16, 2019, at 9:25 a.m. revealed that both Residents R43 and Resident R84, prefer to have both side rails up while they are in bed, as it makes them feel safer. At the time of this interview, Employee E10, confirmed that no physician's order, was obtained for either Resident R43 and Resident R84, to have side rails up while in bed to promote safety.

Interview with the Director of Nursing on August 19, 2019, at approximately 12:30 p.m., confirmed that there was no physician's order for the bedrails for Residents R184, Resident R43 and Resident R84.

The facility failed to ensure that each resident achieved the highest possible level of functioning and well-being related to physician's orders for safety devices.

CFR(s): 483.25 Quality of Care

28 Pa. Code 201/14(a) Responsibility of Licensee

28 Pa. Code 201.18(b)(1) Management
Previously cited 10/18/18 and 5/16/19.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(c)(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 10/18/18 and 5/16/19.





 Plan of Correction - To be completed: 10/17/2019



Side Rails order- IDT will assess above residents and Therapy will assess ADL status to determine if SR is needed per facility policy.



Therapy will complete communication to nursing to obtain Physician order and update care plan as to why Side Rail is needed for positioning or safety purposes.



Side rail/Restraint policy and procedure to be reviewed and updated if appropriate.


All residents will be re-evaluated for appropriateness of side-rails.


All appropriate staff will receive education on side rail/restraint policy.

SR order will be reviewed as needed and quarterly at care conference.

Assessments to be uploaded to EMR.

Side rails to be audited quarterly as part of facility QAPI process.


483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on review of clinical records, interviews with staff, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous, (IV - tube inserted into a vein), lines, for two of four residents reviewed with an IV in place (Residents R84 and R101).

Findings include:

Review of an online document, "American Nurse Today (official journal of the American Nurse's Association)," Volume 8, Number 11, dated November 2013, revealed a complication of a PICC line includes, but is not limited to, catheter-tip migration (assessed by external length of the catheter-amount of catheter tubing that is visible outside of the vein moves from original insertion and may cause medical complications).

During the initial tour of the facility on August 14, 2019, an interview with Resident R84, at 1:45 p.m. revealed that he had an IV, in his right arm, related to antibiotic treatment.

Review of Resident R84's clinical record revealed that Resident R84, was readmitted to the facility on August 10, 2019, from the hospital with a midline, (a catheter is a vascular access device measuring 8 inches or less with the distal tip dwelling in the basilic, cephalic, or brachial vein, at or below the level of the axilla, and distal to the shoulder). An interview with Employee E10, Licensed nurse, on August 15, 2019, at 11:50 a.m. confirmed Resident R84, had a midline in place for antibiotic treatment.

Further review of Resident R84's clinical record revealed, on August 15, 2019, revealed no documentation since Resident R84, was readmitted to the facility on August 10, 2019, related to the measurements of the midline at the access site.

Resident interview conducted with Resident R101, on August 15, 2019, at 1:30 p.m. revealed that she was recently readmitted to the facility after being hospitalized for an infection. Resident R101, indicated that she currently was with an IV access site in her upper left chest area. An interview with Employee E10, on August 15, 2019, at 4:25 p.m. confirmed, that Resident R101, had a PICC line, (peripherally inserted central catheter. It is a central vascular access device inserted into an extremity and advanced in the venous system until the distal tip is positioned in the vena cava. in left chest area, related to antibiotic treatment).

Review of Resident R101 clinical record revealed a readmission date of, July 30, 2019, from the hospital. Continued review of Resident R101's clinical record revealed a physician order's dated July 30, 2019, which indicated Resident R101, had a PICC placed in upper left chest area, for antibiotic treatment. Continued review of Resident R101's clinical record revealed no documented evidence to indicate that nursing staff was measuring, the length of the insertion site.

An interview with the Director of Nursing on August 16, 2019, at 2:15 p.m. confirmed that professional standards of practice were not maintained for a resident with a PICC line and a resident with a midline.

The facility failed to maintain professional standards of practice related to monitoring of a PICC and Midline at the insertion site.

28 Pa. Code: 211.10(c) Resident care policies

28 Pa. Code: 211.12(d)(1) Nursing services
Previously cited 10/18/18 and 5/16/19.

28 Pa. Code: 211.12(d)(5) Nursing services
Previously cited 10/18/18 and 5/16/19.








 Plan of Correction - To be completed: 10/17/2019


I.V. R84- Midline, document. R101- I.V. L.C.W. Picc line documented, measurement completed.


2.) Audit all residents who have IV orders to ensure the documentation: orders Measured, Care Planned.


3.) Education I.V. Documentation ( Measurement and S/S infection.) All RN Supervisors.


4.) I.V. Audit will be completed weekly. Results audited quarterly and reported ongoing as part of facility QAPI program.

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 clinical record review and resident and staff interviews, it was determined that the facility failed to provide the highest practicable pain management for one of 37 residents reviewed (Resident R118).

Findings include:

A review of Resident R118's clinical record revealed the resident was admitted to the facility on January 11, 2019, with a diagnosis to include malignant neoplasm of the left kidney (A disease in which abnormal cells divide uncontrollably and destroy kidney cells). The resident's clinical record revealed the resident was readmitted to the facility on August 13, 2019, at 8:08 p.m. related to a status post nephrectomy (surgical removal of the kidney). A review of the resident's hospital discharge medication list revealed the resident medications on the hospital discharge form included Tramadol (narcotic-like drug similar to opioids) 50 milligrams every six hours four times a day as needed.

A review of the resident's clinical record revealed a nurse progress noted dated August 14, 2019, at 1:42 a.m., which revealed the resident complained of abdominal pain and the resident requested Tramadol, and " ... Supervisor called pharmacy and was told that resident needed a written script. I called MD (physician) spoke with ... CRNP [certified nurse practitioner] told her that he was in pain. She stated she would not be able to send script until morning. Supervisor made aware."

A review of the resident's clinical record revealed a nurse progress noted dated August 14, 2019, at 2:19 a.m., which revealed "Checked on resident at 2am and 4am resident sleeping. No s/s [signs / symptoms] of distress."

During the initial tour of the facility on August 14, 2019, Resident R118 stated that he returned from the hospital yesterday related to a nephrectomy and the resident was observed with abdominal sutures. The resident stated that since his return from the hospital he was not given Tramadol because he was told the doctor had not signed off on the script. The resident stated that he spoke with the facility's supervisor last night.

Further, review of the resident's clinical record revealed a nurse progress note dated August 14, 2019, which revealed that the charge nurse brought his pain medication, Tramadol into his room at 2:30 p.m.

Interview on August 19, 2019, at 8:30 a.m. where the Director of Nursing (DON) confirmed that Tramadol 50 mg was included on the hospital discharge medication list. The DON confirmed that when the resident returned from the hospital on August 13, 2019, at 8:08 p.m., facility staff and the contracted pharmacy were unable to obtain a script from the on call practitioner. The DON confirmed that the resident received the Tramadol on August 14, 2019, at 2:30 p.m..

The facility failed to ensure the highest practicable pain management.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 5/16/19, 10/18/18

28 Pa. Code 211.12(d)(5) Nursing service
Previously cited 5/16/19










 Plan of Correction - To be completed: 10/17/2019



Resident R118 was assessed for pain by the Registered Nurse and pain medication Tramadol 50mg was administrated on 8/14/2019. R118 stated his pain level was 2/10.




R118's primary care physician was in the facility on 8/15/2019, R118 was assessed by his doctor and his pain medication Tramadol was reviewed and changed to routine every 6 hours.

All residents upon of admission and re-admission will receive pain assessment by the licensed nurse and pain medication will be addressed according to the physician orders.

The facility will ensure the highest practicable pain management to all residents by:

Education will be provided to all licensed nurses that in the event of inability to obtain a prescription for controlled substance. The Medical Director can be contacted.

The local hospital will be reached out for sending the script with the admission upon of their discharge from the hospital.

The on-call physicians will be educated that in the event of script needed for controlled substance, they can call the Pharmacy to provide verbal order to release the controlled pain medication for 72 hours immediately.

Pain management to be monitored continuously as part of the facility's QAPI for Quality of Life and Services. Results of audited to be reported quarterly and changes made as appropriate.

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