Nursing Investigation Results -

Pennsylvania Department of Health
REHABILITATION & NURSING CENTER AT GREATER PITTSBURGH, THE
Patient Care Inspection Results

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REHABILITATION & NURSING CENTER AT GREATER PITTSBURGH, THE
Inspection Results For:

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REHABILITATION & NURSING CENTER AT GREATER PITTSBURGH, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on November 8, 2019, it was determined that The Rehabilitation and Nursing Center at Greater Pittsburgh 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:


483.10(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 review of facility policies, observation and staff interview it was determined that the facility failed to maintain the facility in good repair and properly secure cleaning chemicals in one of four shower rooms, failed to properly secure the soiled utility room and properly store clean supplies in one of four soiled utility rooms (100 Nursing Unit Shower Room and Soiled Utility Room).

Findings include:

A review of facility policy "Maintenance Service" dated 11/4/19, indicated that the Maintenance Department is responsible for maintaining the buildings and equipment in a safe operable manner at all times

During an observation on 11/4/19, at 10:45 a.m. of the 100 Nursing Unit, it was revealed that
- the shower entrance door contained gouges and splintering wood.
- the chemical storage cupboard located within the shower room was unsecured and contained a spray bottle of odor eliminator, cleaning wipes and disinfecting spray that contained bleach.
- stored on the grab bars and shelves within the shower rooms were open, unlabeled bottles of body wash and shampoo.
- the soiled utility room door was unlocked.
- the cupboards in the soiled utility room contained clean paper towels and toilet paper.

During an interview on 11/4/19, at 10:55 a.m,. Licensed Practical Nurse (LPN) Employee E2 confirmed that the facility failed to maintain the shower room door in good repair, properly secure cleaning chemicals, body wash, shampoo, and entrance door of the soiled utility room and properly store clean supplies.


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


 Plan of Correction - To be completed: 01/07/2020

1.All facility residents were identified to have been potentially affected by the findings as follows: Shower room door located on unit 100 was identified with gouges and splintering hazard, spray containing bleach, cleaning wipes, and bottle of odor eliminator, body wash, and shampoo were removed from the shower room. Soiled utility room door identified on unit 100 was unlocked to date a punch key lock system has been placed on it for safety presently, and all paper towels and toilet tissue was removed and disposed of.
2. To avoid other resident's from being affected by the deficient practice identified an audit of all shower room doors has done and door edge guards will be placed on them, removal of any chemicals and/or personal resident toiletry items stored in shower rooms. Soiled Utility room doors were audited for a not locking, and key pad locks have been installed to date. Paper towels and tissue being stored in soiled utility were removed.
3.Administrator/ Designee will have all shower room doors audited once a month on-going. Staff will educated on reporting any identified door gouges or splintering in maintenance electronic reporting system, "TELS" and/or supervisor and maintenance department will be educated on monthly auditing requirement. To sustain the facility exercising reasonable care for the protection of resident property from loss or theft a shower room daily audit on ensuring no chemicals or resident personal items are being stored in shower room once a day for two months then; consecutively once a week for two months. Education will be done with staff on this process. Soiled utility room doors have been audited and key lock pad has been placed on the doors. A monthly audit will be done on doors to ensure they are operational.
4.Administrator/Designee will report the monitoring of all audits monthly in Quality Assurance Performance Improvement meeting on-going.
5.Corrective action date is January 7, 2020

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 facility policies, observations and staff interviews, it was determined that the facility failed to date multi-dose medication vials and failed to dispose of medications after the use by date in two of four medication rooms (200 Unit and 300 Unit).

Findings include:

The facility policy "Medication Storage in the Facility" dated 11/4/19, indicated medications are stored following the manufacturer's recommendations, that multiple dose injectable vials require an expiration date shorter than the manufacturer's expiration date, and that when the original seal of the manufacturer's container or vial is initially broken, it will be dated.

During an observation of the 200 Unit medication room on 11/7/19, at 12:50 p.m. revealed
one Trulicity (injectable diabetic medication) injection pen open, and not labeled with a resident's name,

During an observation of the 300 Unit medication room on 11/7/19, at 1:15 p.m. revealed
one vial of Vancomycin (antibiotic) attached to a 250 ml bag of normal saline, with a pharmacy printed use-by date of 10/22/19,
one opened, and undated bottle of vancomycin liquid, with a manufacturer's label stating that the medication must be used by 14 days after opening, and a pharmacy applied label stating "14 DAY",
one Humulin (insulin to treat diabetes) injection pen, with a use-by date of 10/25/19,
one Humalog (insulin to treat diabetes) vial open, and undated,
one vial of ampicillin and sulbactam (a combination of antibiotics), with an expiration date of 9/2019,
four piston irrigation trays, including sterile sodium chloride, with expirations dates of 11/30/18, and 8/31/19,

During an interview on 8/28/18, at 1:39 p.m. Licensed Practical Nurse (LPN) Employee E12 confirmed that facility staff failed to dispose of expired medications, and accurately label medications as required.

During an observation of the 300B medication cart on 11/7/19, at 1:43 p.m. revealed one Lantus vial open, and undated.

During an interview on 11/7/19, at 1:45 p, at 1:39 p.m. Licensed Practical Nurse (LPN) Employee E12 confirmed that facility staff failed to accurately label medications as required.

During an observation of the 200A medication cart on 11/7/19, at 1:43 p.m. revealed
one Lantus (insulin to treat diabetes) vial open, with a use-by date of 7/2/19,
one Lantus vial open, and undated,
two Humalog vials open, and undated,
one bottle of hemocult solution (liquid used in testing stool for the presence of blood), with a manufacturer's expiration date of 11/2017.

During an interview on 11/7/19, at 1:45 p, at 1:39 p.m. Licensed Practical Nurse (LPN) Employee E13 confirmed that facility staff failed to dispose of expired medications, and accurately label medications as required.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 6/2/17.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 6/2/17.


 Plan of Correction - To be completed: 01/07/2020

1. Residents affected on unit 200 and 300 medications not labeled, expired, and/or dated were disposed of properly. New medications reordered after med room audit conducted and resident reordered identified. All residents on 200 and 300 medications were labeled and dated and facility educator provide education to licensed nursing on compliance of labeling and dating medications
2. The Director of Nursing/ Designee will complete a house wide audit of all medication in-house ensuring resident medication labeling meet the requirement for proper labeling, resident identification, dating and expiry dates for all multi-dose vials, inhalers, eye-drops and syringes to facilitate safe administration.
3. Director of Nursing/Designee will have weekly audits performed of all medication carts and medication supply rooms for proper labeling and dating for two months. A random audit will be done monthly by Facility Educator, the Facility Infection Preventionist, and the Clinical Pharmacist (on monthly reviews). Facility Educator will educate licensed nurses on proper labeling, resident identification, dating and expiry dates for all multi-dose vials, inhalers, eye-drops and syringes to facilitate safe administration. Director of Nursing/Designee will have added education on audit requirements and follow-up with nursing administration.
4. Director of Nursing /Designee will report monthly audit findings in Quality Assessment Performance Improvement (QAPI) meeting monthly on-going.
5. Corrective date of completion January 7, 2020

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg: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(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Observations:
Based on review of the Resident Assessment Instrument (RAI) instructions, clinical records and staff interviews it was determined that the facility failed to complete a Minimum Date Set (MDS- periodic assessment of care needs) for one of 24 residents with a significant change in condition (Resident R24).

Findings include:

The RAI instructions to code Section A0310 Type of Assessment Section Coding Tips and Special Populations Section indicated that nursing homes are required to complete a significant change in condition assessment when a resident no longer receives (revoke) hospice benefits.

A review of facility hospice document dated 8/21/19, revealed a recommendation to discharge Resident R24 from hospice effective 8/22/19, due to extended prognosis. Last day of service is 8/21/19. The document was signed by the physician on 8/22/19.

A review of the MDS assessment history for Resident R24 failed to provide evidence of the completion of significant change assessment due Resident R24 being discharged from hospice services.

During an interview on 11/8/19, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to complete a MDS significant change in condition for Resient R24 as required.

28 Pa Code: 211.5(f) Clinical records.


 Plan of Correction - To be completed: 01/07/2020

1.The facility recognizes resident R24 as the identified resident to this deficiency and the MDS has been updated in writing and a progress note to reflect the significant change from her revocation/discharge of Hospice Benefit. A letter will be sent to CMS on this resident to show we have recognized this error in coding for resident R24.
2.An audit will be done for all residents who were on hospice form August 1, 2019 to present date to review MDS
3.Director of Nursing/Designee has scheduled monthly meetings with attending hospice care companies to review the current status of each resident they are providing care for at the facility and discussing any change in condition and to implement the residents hospice/nursing home coordinated care plan. Scheduled facility weekly meetings will occur to review the hospice care nursing documentation in regards to the resident's physical, intellectual, emotional, and spiritual needs on-going. The facility has met with hospice to inform them when discharging (revocation) of a resident from Hospice Care a 24 hour notification is required to be sent to Director of Nursing and MDS coordinator on-going.
4.The Significant Change in Status Assessment (SCSA) will be monitored in month Quality Assessment Performance Improvement (QAPI) meeting monthly on-going.
5.Corrective date of completion is January 7, 2020


483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:
Based on review of the Resident Assessment Instrument (RAI) instructions, facility clinical records and staff interviews it was determined that the facility failed to accurately complete a Minimum Data Set (MDS - periodic assessment of care needs) assessment for one of three closed records (Resident CR87).

Findings include:

A review of the RAI instructions for the coding of Section A2100 Discharge Status indicated that a resident that is discharged to the community (private home/apt, board/care. assisted living, group home) the section is coded 01.

A review of the Admission Record for Resident CR87 revealed that Resident CR87 was admitted to the facility on 8/16/19, with the diagnoses of aftercare following joint replacement surgery and muscle weakness.

A review of the physician orders dated 8/28/19, at 2:15 p.m. indicated Resident CR87 was to be discharged from the facility on 8/29/19, to a group home with home care services of a registered nurse (RN), nursing assistant (NA), physical and occupational therapy (PT/OT) and a wheeled walker.

A review of the facility document dated 8/29/19, at 11:55 a.m. indicated that Resident CR87 was discharged from the facility with physician approval to a group home via automobile.

A review of the progress notes dated 8/29/19, revealed that Resident CR 87 was discharged from the facility to a group home.

A review of Resident CR87's MDS dated 8/29/19, revealed that Section A2100 Discharge Status was coded 03 indicating that Resident CR87 was discharged to an Acute Hospital.

During an interview on 11/8/19, at 11:08 a.m. Case Manager Employee E3 confirmed that Resident CR 87's MDS dated 8/29/19, was inaccurate and that Section A2100 should have been coded 01 indicating that the resident discharged to a group home.

28 Pa Code: 211.12(d)(1)(2)(5) Nursing services.


 Plan of Correction - To be completed: 01/07/2020

1.Resident CR87 resident records have been reviewed. Records for CR87 resident have been updated to reflect proper coding of his discharge to a group home.
2.An audit of resident discharges from August 2019 to Present date will be done to ensure accuracy in discharge coding of those resident discharged location is correct.
3.Administrator/Designee will have all discharges on-going audited by way of discharge checklist in AM meeting to ensure accurate documentation has been recorded for each residents discharge location.
4.Administrator/Designee will report monthly discharge location audit results in Quality Assurance Performance Improvement meeting monthly.
5. Corrective date of completion. January 7, 2020

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 a review of facility policies, clinical records, and staff interviews it was determined that the facility failed to revise the care plan with a change in condition for one of 24 residents (Resident R24).

Findings include:

A review of facility policy "Care Plans, Comprehensive Person Centered" dated 11/4/19, indicated that the Interdisciplinary Team updated and revised the care plan when there was a significant change in the resident's condition.

A review of the facility policy "Hospice Program" dated 11/4/19, indicated that the hospice representative and the coordinating facility staff participate in hospice care planning for resident's receiving hospice services.

A review of Resident R24's hospice document "Recommendation/Symptom Management" dated 8/21/19, indicated that the resident was recommended for discharge from hospice service due to extended prognosis. Last day of hospice service was 8/21/19.

A review of Resident R24's current plan of care revealed that the continued to have goals and interventions in place for hospice services.

During an interview on 11/8/19, at 2:25 p.m. the Director of Nursing confirmed that the facility failed to revise Resident R24's plan of care to reflect the change related to being discharged from hospice services.

28 Pa. Code: 211.11(a) Resident care plan.


 Plan of Correction - To be completed: 01/07/2020

Resident R24's Care plan has been updated to reflect the significant change from her revocation/discharge of Hospice Benefit.
2. An audit will be done of all residents from August 1, 2019 to present date to identify any residents care plan that does reflect revocation/discharge of Hospice Benefit and resident record updated as needed.
3. Director of Nursing/Designee has scheduled monthly meetings with hospice care coordinator to review the current status of each resident they are providing care for at the facility and discussing any change in condition to implement the resident's hospice/nursing home coordinated care plan. Scheduled facility weekly meetings will occur to review the hospice care nursing documentation in regards to the resident's physical, intellectual, emotional, and spiritual needs to ensure the facility care plan is in alignment.
4. All hospice resident's Care Plans monthly audit results will be reviewed in Quality Assurance Performance Improvement meeting for 6 months.
5. Corrective date of completion is January 7, 2020.

483.30(b)(1)-(3) REQUIREMENT Physician Visits - Review Care/Notes/Order: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.
483.30(b) Physician Visits
The physician must-

483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;

483.30(b)(2) Write, sign, and date progress notes at each visit; and

483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
Observations:
Based on review of facility documents and staff interviews it was determined that the facility failed to make certain that the physician signed and dated orders for medication and treatment for one of 24 residents (Resident R84).

Findings include:

Review of Resident R84's clinical record on 11/8/19, revealed:
- a physician order dated 8/30/19, for Potassium 20 milligrams not signed and dated by the physician.
- a recapitulation of orders dated 8/31/19, not signed by the physician.
- a recapitulation of orders dated 9/30/19, not signed by the physician ,
- a recapitulation of orders dated 11/1/19, not signed by the physician.
- Occupational Therapy order dated 10/8/19, for wheelchair management and fitting was not signed by the physician.
- Occupational Therapy order dated 10/8/19, for Medium Complexity Evaluation and treatment was not signed by the physician.
- Occupational Therapy order dated 10/23/19, to discontinue occupational therapy was not signed by the physician.

During an interview on 11/8/19, at 10:30 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed that the facility failed to make certain that the physician signed and dated Resident R84's orders for medication and treatment as required.

28 Pa Code:211.2 (D)(2) Physician services

28 Pa. Code: 211.3(b)(c)(d) Oral and telephone orders


 Plan of Correction - To be completed: 01/07/2020

1.Resident R84's entire clinical records will be reviewed for forms that required physician signature. All orders identified will be addressed (signed) accordingly such as labs, physician orders, and therapy orders.
2.A complete chart audit of all active residents will be done to identify resident records requiring physician signatures.
3.Director of Nursing/Designee will educate licensed nursing, unit clerks, and medical records on the purpose of getting the physician signature, understanding the physician's responsibility of managing the residents total program of care, timelines, and follow through. A designated binder will be placed on each unit for all attending physicians for their resident's orders, labs, and other medical documents requiring their signature, the Director of Nursing/Designee will educate Physicians and Nurse Practitioner on knowing the location of their binders, contents enclosed requiring their signature, and timelines for their signature. Medical Records clerk will perform concurrent audits of resident charts. Education will be done by Director of Nursing/Designee with Medical Records clerk on this process change and reporting requirements.
4.Administrator/Designee will review and monitor audits in Quality Assurance Performance Improvement meeting monthly.
5.Corrective date of completion January 7, 2020

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 review of facility policy, observations and staff interviews, it was determined that the facility failed to maintain infection control practices to prevent the potential for cross contamination during a dressing change for one of one residents (Resident R47).

Findings include:

Review of the facility policies "Handwashing/Hand Hygiene" dated 11/4/19, indicated staff will staff will follow the handwashing/hand hygiene procedures to help prevent the spread of infections. The policy further states that either an alcohol-based hand rub or soap and water should be used to clean hands after handling used dressings and after removing gloves.

During an observation on 11/6/19, at 10:40 a.m. Licensed Practical Nurse (LPN) Employee E4 did not remove all items and clean Resident R47's overbed table then placed dressing supplies on the table without placing a clean field under the supplies. LPN Employee E4 put on clean gloves, without sanitizing her hands, and removed the soiled dressing. LPN Employee E4 then removed the soiled gloves, did not sanitize her hands, put on clean gloves, and proceeded to clean the wound. LPN Employee E4 then opened a package of calcium alginate (a type of wound dressing) without changing her gloves, and applied the dressing and optifoam (dressing covering).

During an interview on 11/6/19, at 10:52 a.m. LPN Employee E4 confirmed the above observations and confirmed that the facility failed to maintain infection control practices to prevent the potential for cross contamination.

28 Pa. Code: 201.20(c) Staff development.

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

28 Pa. Code: 201.18(b)(1)(e)(1) Management.

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

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 01/07/2020

1.Resident identified R47 had her wound dressing changed using the proper infection control facility process on the day this deficient practice was identified. Nurse received on-on-one coaching regarding standard precautions and including hand hygiene, the use of PPE along with sterile dressing, and wound care management policy and procedure.
2.The facility will identify all residents who have wounds in facility currently and new admissions who admit with wounds. Nurses will be educated on Infection control prevention inclusive of hand hygiene, standard precautions, and wound management.
3.Director of Nursing/Designee will educate and establish a wound care task team focusing on a twice a week observation of wound management/dressing changes to ensure licensed clinical team are compliant with infection control practices to prevent the potential of cross contamination for two months. The task force will do wound observations once a week on-going. Director of Nursing/Designee will educate Licensed nursing team on infection control, wound dressing procedures, and resident dignity.
4. Director of Nursing/Designee will implement a reporting system for nurses who have been observed with wound task force, for education and clinical compliance each month on-going in Quality Assurance Performance Improvement committee meeting.
5.Corrective date of completion January 7, 2020

205.67(e) LICENSURE Electric requirements.:State only Deficiency.
(e) Night lights shall be provided in bedrooms, stairways, corridors, bathrooms and toilet rooms used by residents.
Observations:
Based on observations and staff interviews, it was determined the facility failed to provide functioning night lights in resident rooms and adjoining bathrooms on one of four nursing units (300 unit).

Findings include:

During observations of resident rooms and bathrooms on the 300 unit from 11/4/19 to 11/7/19, it was revealed that facility did not have functioning night lights in the resident rooms or bathrooms.

During an interview on 11/5/19, at 11:30 a.m. Licensed Practical Nurse (LPN) Employee E1 indicated that there were no functioning night lights in any of the resident rooms or bathrooms on the 300 unit. LPN Employee E1 indicated that not having night lights made it hard for residents to get up in the evenings to use the bathroom.

During an interview on 11/5/19, at 2:20 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to have functioning night lights in resident rooms and bathrooms on the 300 nursing unit.


 Plan of Correction - To be completed: 01/07/2020

1.The facility identified night lights were not functioning on the 300 unit and not providing a means of required lighting affecting residents. The resident rooms identified non-functioning night lights in rooms have been changed and are functioning in the resident rooms. Bathroom night lights will be provided for each resident.
2. Maintenance Director/Designee will do a facility resident room audit of all resident to identify all resident rooms that do not have a night light operational and change bulbs along with resident bathrooms identified to have night lights installed.
3.Administrator/Designee will consult with a Licensed Electrician on options for night lights in identified areas each resident rooms and bathrooms throughout the facility. Upon nights installed and changed a weekly audit for two months will be done and then a monthly audit on-going will be done. Administrator/Designee will provide education on this process change with maintenance staff on audits and repairs. Administrator/Designee will educate staff on reporting lights not working immediately to Maintenance department and/or in electronic reporting maintenance system (TELS).
4.The Night Light project will reflect the audit of all rooms identified to have a night lights installed and operational monthly. The monthly report will be monitored in Quality Assurance Performance Improvement meeting monthly.
5.Corrective Action date is January 7, 2020.

35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.


Observations:
Based on review of facility policies, observations and staff interviews it was determined that the facility failed to make certain that all staff members wore identification badges that contained their photograph for 5 of 5 staff members (Licensed Practical Nurse (LPN) Employee E4, Dietary Aide Employee E5, Cook Employee E6, Registered Nurse (RN) Employee E7 and LPN Employee E9).

Findings include:

A review of facility policy "Dress Code" dated 11/4/19, indicated that an identification badge must be visible and worn at all times.

During an observation on 11/8/19, at 11:30 a.m. LPN Employee E4, Dietary Aide Employee E5, Cook Employee E6, RN Employee E7, and LPN Employee E9's identification badges did not contain their photograph.

During an interview on 11/8/19, at 11:30 a.m. Human Resources Director Employee E9 confirmed that facility failed to make certain that all staff member's identification badge contain their photograph and that LPN Employee E4, Dietary Aide Employee E5, Cook Employee E6, RN Employee E7 and LPN Employee E9's identification badge did not contain their photograph as required.


 Plan of Correction - To be completed: 01/07/2020

1.All facility residents were identified to have been potentially affected by the findings of staff not wearing a photo identification badge during survey were given a picture identification badge.
2.Administrator/Designee will do an employee wide notice and audit to ensure each employee has a photo id. All staff identified to not have a badge are directed to Human Resources Director for a replacement badge.
3.Administrator/Designee has posted a notice for all staff on photo identification requirement daily when working in facility. All department managers have been educated on the photo check of staff on duty in facility daily, if staff are identified to not have a badge they must be directed to Human Resources Office to receive a badge. All staff will also be educated on wearing their badge at all times and its requirement when on duty.Random photo identification audits will be done weekly for two months by Administrator/ Designee and then randomly weekly ongoing.
4.Administrator/ Designee will report monthly in Quality Assurance Performance Improvement meeting with results and monitoring of photo id audits.
5.Corrective Action date is January 7, 2020.



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