Nursing Investigation Results -

Pennsylvania Department of Health
GERMANTOWN HOME
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GERMANTOWN HOME
Inspection Results For:

There are  106 surveys for this facility. Please select a date to view the survey results.

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GERMANTOWN HOME - 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 two complaints, completed on February 6, 2020, it was determined that Germantown Home 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 as they relate to the Health portion of the survey process.





























 Plan of Correction:


483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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)(7) The right to self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:

Based on the review of the clinical records, interviewed with staff, and review of facility documentation, it was determined that the facility failed to ensure that a resident was assessed by the facility's interdisciplinary team for the self- administration of medication, for one out of 35 residents reviewed (Resident R100).

Findings include:

Review of the facility policy entitled, "Self Administration of Medications," with a revision date of, June 2007 stated that bedside medication storage is permitted for residents who are able to self-administer medications only upon the specific order of the prescribed and when it is deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. The policy also stated that a written order for the bedside storage of medication is placed in the resident's clinical record.

Review of the interdisciplinary notes for Resident R100 revealed that the resident was admitted into the facility on December 6, 2019 with diagnoses that included, but not limited to, chronic obstructive pulmonary disease (COPD-a group of progressive lung disorders characterized by increasing breathlessness); diabetes dysphagia (dysphagia-difficulty swallowing) and dementia (dementia-a group of symptoms that affects memory, thinking and interferes with daily life).

Review of the physician's orders for January 2020 for Resident R100 revealed revealed a order dated December 6, 2019, and monthly thereafter, for the administration of Incruse Ellipta aerosol powder breath activated 63.5 mcg 1 puff one time a day (inhaler medication for the treatment of chronic pulmonary disease) .

Review of nursing note dated January 10, 2020, stated "medication unavailable, will place call to pharmacy, however the resident does have his own personal inhaler from home and this nurse did witness the resident use the inhaler." Nursing note dated January 13, 2020 noted "medication unavailable until 1/16/20, informed the medication will be sent out this day, however the resident does have his own personal inhaler form home and this nurse did witness the resident use the inhaler." Nursing note date January 14, 2020 and January 16, 2020 indicated that the resident used his own personal inhaler due to medication not available for administration.

During interview with the Assistant Director of Nursing (ADON) on February 5, 2020 at approximately 1:37 p.m. it was confirmed that there was no assessment conducted by the interdisciplinary team for Resident R100 self-administration of medication,

The facility failed to ensure that Resident R100 was assessed by the facility's interdisciplinary team for the self- administration of an inhaler medication.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited, 7/11/2019













 Plan of Correction - To be completed: 03/22/2020

1. When offered, resident R100 declined opportunity for self-administration of medication.

2. Medication is currently stored in medication cart, per facility policy.

3. Residents will be identified on admission and when requested their interest in self-administration of medication via an assessment that will be completed in the electronic health record. A physician order will be obtained, and a care plan will be initiated if clinically appropriate.

4. Staff inservices regarding self-administration of medications and facility policy currently underway.

5. Audit currently underway monthly for three months and as needed thereafter by unit manager or designee to identify residents who self-administer medications and compliance with facility policy. Results will be reviewed during QAPI.
483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident 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(f) Automated data processing requirement-
483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on review of clinical records and interview with staff, it was determined that the facility failed to transmit a resident assessment to the Centers for Medicare and Medicaid Services, (CMS), within 14 days of completion, as required, for one of 35 resident reviewed (Resident R1).

Findings include:

Review of clinical record for Resident R1, revealed a Quarterly Minimum Data Set, (MDS - periodic assessment of needs), dated, January 17, 2020, was still not submitted at the time of review on February 5, 2020.

An interview with Employee E14, Registered Nurse Assessment Coordinator, on February 5, 2020, at 10:25 a.m. confirmed, that Resident R1's MDS, dated, January 17, 2020, was not submitted timely, to the CMS system within the required time frame.

The facility failed to ensure that Resident R1's assessment was submitted to CMS system within the required time frame.

28 Pa Code 201.14(a) Responsibility of licensee
Previously cited 1/8/19

28 Pa Code 201.18(b)(3) Management
Previously cited 1/8/19

28 Pa Code 211.12(c) Nursing services
Previously cited 1/8/19








 Plan of Correction - To be completed: 03/22/2020

1. MDS for resident R100 has been submitted.

2. Review of MDS' for all other residents have been reviewed. All have been submitted to CMS within the required time frame.

3. All RNAC's have been educated on encoding and transmission of resident assesssments.

4. Audits completed by DON or designee are currently underway monthly for three months and as needed thereafter. Results to be reviewed during QAPI to monitor compliance.
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, policy review, clinical record review, and staff interview, it was determined that the facility failed to followed a physician's order for the application of a splint and for a blood sugar medication for two out of thirty-five resident reviewed (Resident R125 and Resident R100)

Findings include:

Review of the undated "Fingerstick Blood Glucose Testing - With Sliding Scale Insulin Coverage" Policy indicates that a fingerstick blood glucose below 70 with a responsive resident to treat immediately with 15 grams of glucose or glucose equivalent, notify the physician, recheck the blood glucose in 15 minutes and document in the nurses notes, MAR and 24-hour report.

Review of Resident R16's May 2019 physician's orders revealed an order dated May 2, 2019 for Humalog solution (insulin) injection as per sliding scale, if blood glucose is 0 -70, give 1 tube of glucose gel or equivalent and call MD (physician. A review of Resident R16's Medication Administration Record for October 2019, revealed that on October 6, 2019, Resident R16's blood glucose reading at 6:30 a.m. was 69. Further review of Resident R16's progress notes revealed no documentation that the resident was given glucose gel, or that the physician was notified as ordered.

Interview with Employee E4, Assistant Director of Nursing on February 5, 2020 at approximately 11:50 p.m. confirmed that there was no documentation to review regarding the low blood sugar incident for Resident R16 on October 6, 2019, and stated that licensed nursing staff, Employee E14, did not administer the glucose gel and did not notify the physician and that he had reviewed the finger stick testing with sliding scale insulin coverage with this nurse.


Review of Resident R125's clinical record revealed that the resident was admitted to the facility on December 12, 2011. The resident's diagnosis included but not limited to a history of a Cerebrovascular Accident (Blood flow to part of the brain is stopped either by a blockage or by the rupture of a blood vessel), hemiparesis on the left dominant side (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) and oropharyngeal dysphagia (a swallowing disorder).

Review of the resident's clinical record revealed an order created by the occupational therapist on January 23, 2020 and signed by the resident's physcian on February 2, 2020 for the to application of an elbow brace for four hours after morning care and take off for two hours. Reapply elbow brace for four hours during 3-11 shift for four hours then remove at night.

Observation conducted of Resident R125 on February 4, 2020 at approximately 10:30 a.m. revealed that the elbow brace was not applied after morning care.

Interview conducted with licensed nursing staff, Employee E9, on February 4, 2020, at 10:30 a.m. confirmed that Resident R125 was not wearing the elbow brace as indicated by the occupational therapist on January 20, 2020.

42 CFR 483.25 Quality of care
Previously cited 01/08/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 01/08/19







 Plan of Correction - To be completed: 03/22/2020

1. Blood glucose for resident R16 was identified on 10/07/2019 during morning clinical and review of electronic health record. There was no negative outcome as evidenced by clinical record. The licensed nurse involved received and education regarding facility policy of blood glucose monitoring and following physician order.

2. All licensed nurses are being inserviced on facility policy for blood glucose monitoring and following physician orders.

3. Electronic medication administration records will continue to be reviewed daily during morning clinical.

4. Audits will be completed by Unit managers or designee and reported to QAPI for three months or as needed thereafter.

5. Order for splint for resident R125 was reviewed, and corrected to ensure licensed nurse verify placement. Nurse aide was educated on placement of splints.

6. Audit of splints completed facility-wide to ensure availability of splints.

7. Staff education currently underway regarding use, verifying application, and documentation of splints.

8. Audits completed by unit manager or designee are currently underway monthly, for three months to be reviewed during QAPI or as needed thereafter.
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 clinical record review, review of professional literature, review of facility policies and interviews with staff, it was determined that the facility failed to assess a PICC line in accordance with professional practice standards for one of one residents reviewed (Resident R33).

Findings include:

According to the Pennsylvania Nurse Practice Act for Licensed Practical Nurses (LPN), maintenance of IV (intravenous) therapy by an LPN shall include ongoing observation and focused assessment of the patient, monitoring the IV site and maintaining the equipment. Continued review revealed that an LPN who has met the education and training requirements relating to IV therapy curriculum requirements may perform IV therapy functions including: administration of IV fluids and medications, observation of the IV insertion site, performance of insertion site care, and performance of maintenance which includes dressing changes, IV tubing changes, and saline or heparin flushes.

Review of facility policy, "PICC Line Policy/Guidelines" revised December 2015, revealed that prior to each use of the PICC line (peripherally inserted central catheter - a thin soft tube inserted in a vein in the arm with the tip of the tube positioned in a large vein that carries blood to the heart), the PICC line must be measured from the point of insertion to the tip of the catheter. That length measurement must be recorded in the MAR (medication administration record) and compared to the baseline measurement. Notify the physician with any discrepancy in length measurement.

Review of facility policy, "PICC Line Dressing Change" revised December 2015, revealed that after removing old dressing, note the length of the catheter remaining externally, with a rationale to observe for catheter migration.

Clinical record review for Resident R33 revealed a physician order dated January 30, 2020, for a 2-lumen (2 tubes), 5 French (size of tube) RUE (right upper extremity - arm) PICC Line with internal catheter length of 30 cm, and external length of 13 cm, and a mid-arm circumference of 21 cm, and to measure the external catheter length (from insertion site to tip of needleless device) and arm circumference prior to administration of IV antibiotics, and to report abnormal findings to the physician.

Review of Medication Administration Record for February 2020, revealed that Resident R33's PICC line external length was documented as 0 cm at 9:00 a.m. on February 1st and 2nd, 2020 and was documented as 13 cm at 9:00 a.m. on February 4th and 5th, 2020; and the mid-arm circumference was documented as 13 cm at 9:00 a.m. on February 1st, 2020 and was documented as 20 cm at 9:00 a.m. on February 2nd and 3rd, 2020, and was documented as 21 cm at 9:00 a.m. on February 4, 2020 and February 5, 2020.

Interview with Employee E12, Infection Preventionist at approximately 10 a.m. on February 6, 2020, revealed that Resident R33's PICC line measurements were not consistent and that the staff were not measuring the external catheter length correctly, and that the physician had not been notified of the variances in the measurements. Resident R33's PICC line measurements were reviewed with the Director of Nursing at approximately 10:45 a.m. on February 6, 2020, and she confirmed that she needed to do more education with the staff.

The facility failed to assess PICC line catheter's in accordance with professional practice standards.

42 CFR Parenteral Fluids
28 Pa Code 211.5(f) Clinical records.
28 Pa Code 211.12(d)(5) Nursing services.










 Plan of Correction - To be completed: 03/22/2020

1. PICC line for resident R33 has been discontinued.

2. All other PICC lines currently in use have been identified and reviewed to ensure compliance with facility protocol.

3. Licensed nurses are currently being inserviced on facility policy regarding PICC line management.

4. Audits completed by unit manager or designee are currently underway monthly for three months and as needed thereafter. Audits will be reviewed during QAPI.
483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on the review of the clinical records, interviews with staff, and review of facility documentation, it was determined that the facility failed to ensure the timely availability of a medication for one of 35 residents reviewed (Resident R100).

Findings include:

Review of the interdisciplinary notes for Resident R100 revealed that the resident was admitted into the facility on December 6, 2019 with diagnoses that included, but not limited to, chronic obstructive pulmonary disease (COPD-a group of progressive lung disorders characterized by increasing breathlessness); diabetes dysphagia (dysphagia-difficulty swallowing) and dementia (dementia-a group of symptoms that affects memory, thinking and interferes with daily life).

Review of the physician's orders for January 2020 for Resident R100 revealed revealed a order dated December 6, 2019, and monthly thereafter, for the administration of Incruse Ellipta aerosol powder breath activated 63.5 mcg 1 puff one time a day (inhaler medication for the treatment of chronic pulmonary disease) .

Review of nursing note dated January 10, 2020, stated "medication unavailable, will place call to pharmacy, however the resident does have his own personal inhaler from home and this nurse did witness the resident use the inhaler." Nursing note dated January 13, 2020 noted "medication unavailable until 1/16/20, informed the medication will be sent out this day, however the resident does have his own personal inhaler form home and this nurse did witness the resident use the inhaler." Nursing note date January 14, 2020 and January 16, 2020 indicated that the resident used his own personal inhaler due to medication not available for administration.

During interview with the Assistant Director of Nursing on February 5, 2020 at approximately 1:37 p.m. it was confirmed that Resident R100 was utilizing the inhaler from his home, when the medication was not available from pharmacy for nursing to administer.

The facility failed to ensure that an inhaler medication was available for administration to Resident R100 as ordered by the physician.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 7/11/2019



 Plan of Correction - To be completed: 03/22/2020

1. It was verified that medication for resident R100 has been dispensed.

2. Facility policy regarding medication has been updated to clarify protocol for licensed to follow when medications are not available.

3. Education regarding updated policy currently underway with licensed nurses.

4. Missed medication report will continue to be reviewed daily during morning clinical for compliance. Audits completed by unit manager or designee are currently underway to be reviewed monthly for three months or as needed thereafter. Results will be reviewed during clinical.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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

Based on observation and staff interview, it was determined that the facility failed to ensure that the temperature of medication refrigerators were monitored consistently for one of three medication storage rooms reviewed.

Findings include:

Observation of the refrigerator located in the third-floor medication storage room on February 4, 2020, at approximately 11:10 a.m., with Employee E15, Licensed Practical Nurse, LPN, revealed that the morning temperature check of the refrigerator was not documented.

Continued observation of the refrigerator on February 4, 2020, with Employee E15 revealed that Influenza Vaccine containers were stored in the refrigerator.

A review of the refrigerator temperature log dated January 2020, revealed that 28 of 31 possible temperatures checks were not documented as completed and and two of three possible temperature checks were not documented as completed in February 2020.

Interview with Employee E15, Licensed Nurse, Employee, at the time of the findings, confirmed that the documentation of daily temperature checks of the medication refrigerator in the third-floor medication storage room for the months of January and February 2020 were incomplete.

The facility failed to ensure that the temperature of refrigerators used to store drugs and biologicals were monitored consistently.

28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 211.9(g)(h) Pharmacy services
28 Pa Code 211.12(d)1 Nursing services
28 Pa 211.12(d)(5) Nursing services










 Plan of Correction - To be completed: 03/22/2020

1. The refrigerator temperature log for the third floor is current as well as the remaining units.

2. Licensed nurses are currently receiving education regarding refrigerator temperature logs and facility policy for monitoring.

3. Audits are being completed monthly by unit manager or designee for three months and as needed thereafter. Results to be reviewed monthly at QAPI.

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