Nursing Investigation Results -

Pennsylvania Department of Health
MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC
Patient Care Inspection Results

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MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC
Inspection Results For:

There are  66 surveys for this facility. Please select a date to view the survey results.

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MAPLE WINDS HEALTHCARE AND REHABILITATION, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on March 4, 2020, it was determined that Maple Winds Healthcare and Rehabilitation, LLC 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:


483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors by failing to provide respiratory medications as ordered by the physician for one of five residents reviewed (Resident 2).

Findings include:

A diagnosis record for Resident 2, dated January 21, 2020, revealed that the resident had diagnoses that included pneumonia. Physician's orders dated January 22, 2020, included an order for the resident to receive Duoneb treatments (a combination of two medications provided by inhalation via a breathing device) four times a day.

There was no documented evidence that Duoneb treatments were provided as ordered until January 29, 2020, which was seven days after the medication was ordered.

Interview with the Director of Nursing on March 4, 2020, at 11:50 a.m. confirmed that Duoneb treatments were not provided as ordered by the physician for Resident 2.

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




 Plan of Correction - To be completed: 04/21/2020

Resident 2 no longer resides at the facility.

Any resident that has an order for DuoNeb treatments has the potential to be affected by this alleged deficient practice.
A whole house audit was completed on all residents who are ordered DuoNeb treatments to ensure that there is documented evidence of administration.

Licensed Nursing Staff as well as Agency staff were re-educated on the need to document DuoNeb treatments in the medical record upon administration in accordance with facility policy.

Employees identified were provided 1:1 reeducation on facility policy and procedure for any resident who is ordered duonebs including documentation of administration on the medical record and re educated on disciplinary process for not following the above

The Director of Nursing/Designee will perform random audits to ensure that all DuoNeb treatments are documented in the medical record per physicians orders and in accordance with facility policy.

Audits will be conducted bi-weekly times 4 and then monthly times 3 until substantial compliance. Results will be reviewed by Quality Assurance Performance Improvement Committee at the regularly scheduled meeting times three for results, areas of improvement and /or continuation of audits.


483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on review of policies, information provided by the facility, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for one of five residents reviewed (Resident 3) who received oxygen.

Findings include:

The facility's policy regarding care plans, dated March 5, 2019, revealed that all residents were to have individualized care plans that outlined the specific areas of care that each resident required. When any resident was admitted to the facility, the admitting nurse was to implement care plans that were specific to the resident, and the registered nurse was to update each resident's care plan upon receiving new orders that changed the prior plan.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 25, 2020, revealed that the resident was understood and could understand, and required extensive assistance from staff for daily care tasks.

A nursing note for Resident 3, dated February 22, 2020, at 2:02 p.m. revealed that the resident's oxygen saturation level decreased to 86 percent (normal readings usually range from 95 to 100 percent) that a.m. The resident denied any complaint of dyspnea (difficulty breathing). The note indicated that the resident previously wore oxygen, oxygen was placed at two liters per minute, and the resident's oxygen saturation was now stable at 95 percent with oxygen at two liters per minute. A nursing note on February 22, 2020, at 4:38 p.m. revealed that the resident was assessed due to a low oxygen saturation level on the previous shift, and she was resting in bed, was awake and alert, and her oxygen saturation level was 94 percent on oxygen at three liters per minute.

As of March 4, 2020, there was no documented evidence that a care plan was developed related to Resident 3's oxygen use.

Observations of Resident 3 on March 4, 2020, at 8:04 a.m. revealed that the resident was sitting in her room with oxygen in place via nasal cannula (tubes that deliver oxygen into the nostrils) at 2 liters per minute.

Interview with the Director of Nursing on March 4, 2020, at 11:45 a.m. confirmed that a care plan was not developed regarding Resident 3's oxygen use.

28 Pa. Code 211.11(d) Resident care plan.



 Plan of Correction - To be completed: 04/21/2020

Resident 3's Comprehensive Care Plan was updated to reflect her orders for oxygen.

Any resident who receives oxygen has the potential to be affected by this deficient practice. A whole house audit on residents who receive oxygen was completed to ensure that a care plan is in place.

Licensed Nursing staff including Agency were re-educated on the need to implement a Comprehensive Care Plan on all residents who are receiving oxygen.

The interdisciplinary care plan team reviews care plans on admission, quarterly, with changes in condition, and annually to ensure they reflect resident care needs

The Director of Nursing/Designee will perform random audits to ensure that all residents receiving oxygen have a care plan in place including new admissions These audits will be conducted bi-weekly times 4 weeks and then monthly times 3 months or until substantial compliance. Results from audits will be reviewed at scheduled Quality Assurance Performance Improvement Committee meetings, times three for results, areas of improvement and /or continuation of audits.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that respiratory care was provided in accordance with professional standards of practice, by failing to obtain physician's orders for the administration of oxygen for one of five residents reviewed (Resident 3), and failing to ensure that respiratory treatments were provided as ordered by the physician for one of five residents reviewed (Resident 2).

Findings include:

The facility's policy regarding care plans, dated March 5, 2019, revealed that oxygen was to be administered in accordance with the physician's order, and staff were to check the physician's order.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 25, 2020, revealed that the resident was understood and could understand, and required extensive assistance from staff for daily care tasks.

A nursing note for Resident 3, dated February 22, 2020, at 2:02 p.m. revealed that the resident's oxygen saturation level decreased to 86 percent (normal readings usually range from 95 to 100 percent) that a.m. The resident denied any complaint of dyspnea (difficulty breathing). The note indicated that the resident previously wore oxygen, oxygen was placed at two liters per minute, and the resident's oxygen saturation was now stable at 95 percent with oxygen at two liters per minute. A nursing note on February 22, 2020, at 4:38 p.m. revealed that the resident was assessed due to a low oxygen saturation level on the previous shift, and she was resting in bed, was awake and alert, and her oxygen saturation level was 94 percent on oxygen at three liters per minute.

As of March 4, 2020, there was no documented evidence that a physician's order was obtained for Resident 3's oxygen use.

Observations of Resident 3 on March 4, 2020, at 8:04 a.m. revealed that the resident was sitting in her room with oxygen in place via nasal cannula (tubes that deliver oxygen into the nostrils) at 2 liters per minute.

Interview with the Director of Nursing on March 4, 2020, at 11:45 a.m. confirmed that there were no physician's orders obtained for Resident 3's oxygen use, and an order should have been obtained when the resident initially received oxygen.


A diagnosis record for Resident 2, dated January 21, 2020, revealed that the resident had diagnoses that included pneumonia. Physician's orders dated January 22, 2020, included an order for incentive spirometry (device used to help you take slow deep breaths to expand your lungs to prevent lung problems) four times a day.

There was no documented evidence that incentive spirometry was provided as ordered by the physician.

Interview with the Director of Nursing on March 4, 2020, at 11:50 a.m. confirmed that incentive spirometry was not provided as ordered by the physician for Resident.

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




 Plan of Correction - To be completed: 04/21/2020

Order obtained for oxygen for Resident 3.
Resident 2 no longer resides at the facility.

All residents who receive oxygen or incentive spirometry have the potential to be affected by this alleged deficient practice. A whole house audit was completed for residents receiving oxygen and for residents on incentive spirometry with a physician's order and documentation of administration in place in accordance with facility policy.

Re-education was provided to licensed nursing staff, including agency staff , on the need to obtain a physician's order for any resident who receives oxygen and to document administration of incentive spirometry in accordance with facility policy.

Employees identified were provided 1:1 reeducation on facility policy and procedure for any resident who receives oxygen and to document administration of incentive spirometry and re educated on disciplinary process for not following the above

The Director of Nursing/Designee will perform random audits to ensure that all residents receiving oxygen have a physician's order in place and that there is documented evidence of administration for residents receiving incentive spirometry.

These audits will be conducted bi-weekly times 4 weeks and then monthly times three or until substantial compliance. Results from audits will be reviewed by Quality Assurance Performance Improvement Committee at its regularly scheduled meeting times 3 for results, areas of improvement and/or continuation of audits.


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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that hand hygiene procedures were followed by staff involved in direct resident contact for one of five residents reviewed (Resident 1).

Findings include:

The facility's policy regarding hand washing, dated March 5, 2019, indicated that hands were to be washed before applying and after removing gloves, and when visibly soiled.

A comprehensive significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated February 12, 2020, indicated that the resident was always incontinent of urine and bowel and required the extensive assistance of two staff for hygeine.

Observations of Resident 1 on March 4, 2020, at 8:30 a.m. revealed that Nurse Aides 1 and 2 assisted the resident to use the toilet. Afterward, Nurse Aide 1 performed hygeine care and her glove was visibly soiled. The nurse aide wiped her glove off with a cleansing wipe and then proceeded to apply protective cream to the resident's buttocks with the same glove on. She then removed her gloves, and without washing her hands she applied a clean incontinent brief and the resident's clothing.

Interview with Nurse Aide 1 on March 4, 2020, at 8:46 a.m. confirmed that she should have removed her gloves and washed her hands after providing hygiene care to Resident 1 and before applying the ointment.

Interview with the Assistant Director of Nursing on March 4, 2020, at 11:56 a.m. confirmed that after providing hygeine care, staff were to remove their gloves and wash their hands before providing further care.

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





 Plan of Correction - To be completed: 04/21/2020

Resident 1 suffered no ill effects
Immediate one to one education was done with the certified nurses aide.

All residents who receive incontinent care have the potential to be affected by this deficient practice.
A whole house audit was completed on certified nurses aides to ensure that after providing hygiene care, staff were to remove their gloves and wash their hands before providing further care.

Re-education was provided to certified nurses aides including agency staff on the need to remove their gloves and wash their hands before providing further care.

The Director of Nursing/Designee will perform random audits to ensure staff is removing their gloves and washing their hands before providing further care.
These audits will be performed bi-weekly times 4 weeks and then monthly times 3 months or until substantial compliance. Results from audits will be reviewed by Quality Assurance Performance Improvement Committee at its regularly scheduled meeting times 3 for results, areas of improvement and/or continuation of audits.




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