Nursing Investigation Results -

Pennsylvania Department of Health
OLD ORCHARD HEALTH CARE CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
OLD ORCHARD HEALTH CARE CENTER
Inspection Results For:

There are  151 surveys for this facility. Please select a date to view the survey results.

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OLD ORCHARD HEALTH 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, Civil Rights Compliance survey, and an Abbreviated survey in response to two complaints completed February 7, 2020, it was determined that Old Orchard Health Care Center, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey.



 Plan of Correction:


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on clinical record review, review of facility documentation, review of select facility policies and staff interviews, it was determined that the facility failed to prevent resident neglect that resulted in a serious injury and actual harm of a right hand sutured fourth finger that required transfer to hospital for medical intervention for one of 33 sampled residents. This deficiency is cited as past noncompliance. (Resident 206)

Findings include:

Review of facility policy entitled, "Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention," dated November 1, 2019, revealed that staff were to provide resident care necessary to avoid physical harm, pain, and mental anguish.

Clinical record review revealed that Resident 206 had been admitted to the facility on April 12, 2018, and had diagnoses that included dementia, pain, hypertension (high blood pressure) and hyperlipidemia (high fat level in the blood). A quarterly Minimum Data Set assessment (MDS-a periodic evaluation of resident care needs) dated December 5, 2019, reflected that the resident was cognitively impaired, required the extensive assistance of staff for activities of daily living, and was at risk for skin injury.

Review of documentation submitted by the facility revealed that on January 6, 2020, at 10:45 p.m., LPN1, a Licensed Practical Nurse, performed a dressing change to the Resident 206's right sutured finger. LPN1 noted drainage, "blood noted with puss" secreted from the sutured site, and then applied a sterile wound dressing treatment, without notifying the physician or supervisor of his findings (the resident had signs/symptoms of infection and a change in condition.) In addition to not notifying the physician or supervisor, LPN1 also documented "swelling noted around middle and wring finger". On January 8, 2020, (two days later) at 3:15 p.m., documentation revealed that Resident 206 had been seen by an orthopedic specialist and the findings indicated a swollen, red, infected right "ring finger" with sutures present and tender on involvement. The findings concluded with "exfoliation (come apart or to be shred from the surface) of epidermis (skin) right ring finger". The orthopedic specialist then recommended that the right "infected" finger be debrided (removal of the damaged tissue from the wound) today, and Resident 206 was to be sent directly to the hospital emergency department for treatment and "emergency surgery".

Review of information dated January 31, 2020, submitted by the facility following a telephone interview with LPN1 on January 18, 2020, at 3:00 p.m, revealed LPN1 admitted that Resident 206's "finger was more swollen" when he changed the dressing, and the "blood looked old, dry". In a second interview on January 23, 2020, LPN1 described the resident's sutured "ring finger" as swollen, dried blood at the tips, and drainage at the site after changing the dressing.

Review of the facility policy entitled "Skin Practice Guide," dated November 1, 2019, revealed that when staff identify a change in condition, such as a deterioration in or the development of new risk factors or skin alterations, the licensed nurse was to notify the physician, administration, and the legal representative and document the findings in the clinical record. Nursing documentation revealed that LPN1 performed wound care to compromised skin integrity without physician orders and without the required communication as outlined in the facility policy.

Review of information submitted by the facility as complete on January 31, 2020, reflected that the facility had substantiated the allegation of neglect of Resident 206 by LPN1.

This deficiency is cited as past non-compliance.

Information submitted by the facility to the Department included the following corrective actions in response to abuse and neglect by LPN1 to Resident 206. The facility implementation of the plan started January 23, 2020 and is ongoing. Documentation reviewed (audits, in-service record, staff interviews) revealed that the plan was being monitored for implementation by the Director of Nursing and Nursing Home Administrator.

A. All licensed nursing staff assigned to unit where LPN1 was located were interviewed by the facility to determine any additional individuals who may have been involved or have had knowledge of the incident.

B. All facility employees were reeducated regarding resident rights, confidentiality, and privacy. New employees receive education prior to beginning job assignments.

C. As of February 4, 2020, all licensed nursing staff had been educated on the skin practice guidelines and new licensed nursing staff are not permitted to work until they receive the education.

D. Nursing unit managers and the Director of Nursing/designee are required to monitor skin practice compliance and reported weekly to the Administrator/designee.

E. Personnel files reviewed revealed that criminal background checks were completed prior to hiring employees. Personnel files reviewed revealed all staff were properly trained on abuse and neglect prevention. Staff interviews completed on February 5, 2020, during the 7-3 shift revealed 23 of 23 employees were aware of all the facility abuse and neglect reporting requirements. The Personnel file for LPN1 included the required background checks prior to employment and reference checks and there were no disciplinary actions involving this employee.

F. The facility has terminated the employment of LPN1 and notified the Licensure Board.

This deficiency is cited as past non-compliance.


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

28 Pa. Code 201.29(a) Resident rights.

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








 Plan of Correction - To be completed: 02/22/2020

Past noncompliance: no plan of correction required.
483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review and staff interview it was determined that the facility failed to ensure that the pharmacy recommendations were reviewed and acted upon by the attending physician for two of 33 sampled residents. (Resident 20, 102)

Findings include:

Clinical record review revealed that Resident 20 had a diagnoses that included depression, and anxiety. A pharmacy review was completed on October 7, 2019. The consultant pharmacist reported a drug irregularity regarding the consideration of a gradual dose reduction of an antidepressant medication. The recommendation was not addressed. by the physician.

Clinical record review revealed that Resident 102 had diagnoses that include dementia, anxiety and psychosis (a thought disorder in which contact is lost with external reality). Pharmacy reviews were completed March 21, 2019, through September 30, 2019, by the consultant pharmacist and during that time span there were six different recommendations by the pharmacist for dose reductions. There was no documented evidence that the physician acknowledged the recommendations made by the consultant pharmacist regarding dose reductions.

In an interview on February 6, 2020, at 1:29 p.m., the Director of Nursing confirmed that the physician had not reviewed the pharmacist recommendations.

28 Pa. Code 211.2(a)(d)(2) Physician Services.



 Plan of Correction - To be completed: 03/17/2020

1. The pharmacy recommendations for Resident 20 and 102 were corrected by 2/10/2020.
2. Other residents that have the potential to be affected will have a comprehensive Pharmacy Services Audit Tool audit completed for Pharmacy recommendations for the previous 90 days, to ensure appropriate documentation and follow through of any pharmacy recommendations and physician acknowledgement.
3. The facility will take the following actions: The Quality Assurance Consultant will educate the DON and unit managers on the Medication Management Review policy. The consultant pharmacist will supply the DON with the pharmacy recommendations. The attending physicians will be notified to address the recommendations. The DON/designee will ensure the recommendations are addressed within 30 days and recommendations are signed.
4. DON/designee will conduct random audits weekly for 4 weeks in charts of residents with pharmacy recommendations with the Pharmacy Services Audit Tool to make sure these recommendations are acknowledged by the attending physician and carried out or documented as declined with rationale accordingly. Results of these audits will be taken through QAPI committee for further review and recommendation.

483.55(a)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in SNFs: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.
483.55 Dental services.
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(a) Skilled Nursing Facilities
A facility-

483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with 483.70(g) of this part, routine and emergency dental services to meet the needs of each resident;

483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services;

483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility;

483.55(a)(4) Must if necessary or if requested, assist the resident;
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services location; and

483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay.
Observations:

Based on clinical record review, staff interview and review of a grievance form, it was determined that the facility failed to ensure that dental services were provided in a timely manner for one of 33 sampled residents. (Resident 55)

Findings include:

Clinical record review revealed that Resident 55 had diagnoses that included dementia and heart failure. The Minimum Data Set assessment dated December 6, 2019, revealed that the resident had cognitive impairment and required extensive assistance from staff for most activities of daily living. Review of the care plan revealed the resident had a self care deficit related to physical limitations and staff was to provide oral care. Observation on February 4, 2020, at 9:30 a.m., revealed that Resident 55 was missing several bottom teeth. Review of a grievance form dated November 26, 2019, revealed a concern regarding the resident's dental care and reflected that the resident was previously on a list to be seen by the dentist in May 2019. The resolution to the November grievance was to place the resident on the list to be seen by the dentist in December, 2019. In an interview on Feburary 6, 2020, at 1:53 p.m., the Ancillary Clerk 1, (the person assigned to schedule medical appointments), stated resident 55 was scheduled to be seen by the dentist on April 22, 2020, and was removed from the list for unknown reasons. The clerk was not able to provide documentation to support that the resident was seen by the dentist in May or December 2019.

28 Pa. Code 211.5(a) Dental services.



 Plan of Correction - To be completed: 03/17/2020

1. Resident 55 remains in the facility, and was seen by Dental Services on 2/12/2020.
2. Other residents that have the potential to be affected will have a comprehensive Dental Services audit completed to ensure that residents requiring dental services are seen by the dentist in a timely manner.
3. The facility will take the following actions: DON/designee will review Dental Services visit summaries in coordination with Dental Services provider to ensure that residents on service are documented in a tracking system so residents are seen routinely, and in the case of need.
4. DON/designee using the Dental Services Audit Tool will audit 10 residents weekly for 4 weeks to ensure that dental needs and recommendations are documented and carried out. Results of these audits will be taken through QAPI committee for further review and recommendation.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observation, it was determined that the facility failed to properly dispose of garbage and refuse.

Findings include:

Observation of the dumpster area on February 4, 2020, at 9:13 a.m., revealed that on the ground next to the dumpster was a clear trash bag containing soiled incontinence briefs.

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



 Plan of Correction - To be completed: 03/17/2020

1. The trash bag containing the soiled incontinence briefs was disposed of properly at the time of identification. No residents cited as a result of this alleged deficient practice.
2. No like residents identified in this alleged deficient practice, all residents and visitors can be affected by failure to properly dispose of refuse.
3. The facility will take the following actions: Environmental Supervisor/designee will review the surrounding areas of dumpsters and refuse disposal areas for cleanliness and barriers to appropriate disposal and correct barriers.
4. Environmental Supervisor/Designee will conduct audits weekly for four weeks to ensure that refuse is being picked up without being dropped by waste management company, and that bagged garbage is being disposed of properly by staff removing it from the facility.


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