Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-KING OF PRUSSIA
Patient Care Inspection Results

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MANORCARE HEALTH SERVICES-KING OF PRUSSIA
Inspection Results For:

There are  129 surveys for this facility. Please select a date to view the survey results.

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MANORCARE HEALTH SERVICES-KING OF PRUSSIA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint completed on December 12, 2019, it was determined that Manorcare Health Services-King of Prussia was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.














 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of clinical records, facility documentation and staff interviews it was determined that the facility failed to ensure that interventions were consistently provided to promote the healing of pressure ulcers(Injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of seven residents reviewed (Resident R1).

Findings include:

Review of facility documentation "Skin Practice Guide" dated January 2013 revealed a Pressure ulcer prevention pathway which indicated at risk or current pressure ulcer to initiate a care plan for actual or potential problem with interventions including but not limited to turn/reposition schedule.

A review of the clinical record for Resident R1 revealed that resident was admitted to the facility on September 6, 2019, with diagnosis including, but not limited to, osteomyelitis (infection of the bone), chronic respiratory failure and stage IV pressure ulcer (ulcers extend deeper, exposing underlying muscle, tendon, cartilage or bone).

Continued review of the clinical record for Resident R1 indicated a nurse's note dated September 6, 2019 at 11:30 p.m. which revealed Resident R1 had a stage IV pressure ulcer on his left buttocks. Further review of nurse's note dated September 7, 2019 at 10:43 a.m. revealed unstageable pressure ulcer (ulcers which severity cannot be determined with a visual exam) to the sacrum.

Review of clinical record from September 6, 2019 to September 14, 2019 did not reveal any evidence that resident was consistently turned and/or repositioned to promote the healing of the pressure ulcer.

Interview with director of nursing on December 12, 2019 at approximately 2:30 p.m. confirmed that Resident R1's clinical record did not include a turning and/or reposition schedule per the facility policy.

The facility failed to ensure that interventions were consistently provided to promote the healing of pressure ulcers.

28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services.
Previously cited 10/18/19, 5/31/19




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

1. Resident R1 has been discharged from the facility

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the "Skin" QAPI tool current residents have been reviewed to ensure appropriate interventions are in place to prevent skin breakdown

3. To prevent the deficient practice from re-occurring the DON/designee will educate the nursing staff on the "Skin practice guide," specifically addressing interventions to prevent skin breakdown. New admissions will be reviewed for risk of skin breakdown and a plan of care will be developed.

4. Utilizing the "Skin" QAPI tool the DON/designee will audit 5 residents
per week x 4 weeks who have a pressure ulcers to ensure interventions to prevent skin breakdown are in place. Results will be reviewed with QA&A.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on review of the clinical record and facility policy and staff interview, it was determined that the facility failed to address a significant weight loss and failed to notify the physician of a significant weight loss for one of seven residents reviewed. (Resident R2).

Findings include:

Review of facility policy "Weight management Guideline" dated March 2018 revealed that "the key for effective weight management is to appropriately identify weight variance and initiate nutrition strategies when indicated in time to reduce nutrition related complication". Further review of the policy stated "While the RD has primary responsibility for assessing the nutritional status of the patient and weight status, the interdisciplinary team participates in evaluating and addressing the assessment steps identified above in an adjunct capacity. Input on changes in the patients clinical, psychological and functional condition or limitation will help in identifying appropriate intervention and goals for the care plan. The physician is also notified of the patient's status and provides input as well on the care plan".

Review of weight history for Resident R2 revealed that resident weighed 142.3 lbs. on November 22, 2019 and 124.0 lbs. on December 3, 2019. A reweigh completed on December 4, 2019 revealed that Resident R2 weighed 126.0 lbs. which is 11.445% (16.3 lbs.) loss over 11 days.

Review of nutritional progress note dated December 3, 2019 revealed "Per policy request re-weight for more accurate assessment, along with resident representative and physician notification. In the event that weight loss is accurate/confirmed, will increase nutritional treat to twice daily for extra support". Continued review of nutritional progress note dated December 4, 2019 revealed that the nutritional treat between meals were discontinued due to resident's refusal. Review of the nutritional progress note did not reveal any new interventions which provides increased nutritional needs.

A telephone interview with Employee E3, Dietician, on December 12, 2019 at approximately 3:00 p.m. stated she was waiting for the social worker to plan an interdisciplinary staff meeting to address the resident's weigh loss. Employee E3 further stated the interdisciplinary meeting did not occur and Resident R2's weight loss was not addressed.

Review of the clinical record for Resident R2 did not reveal any evidence that the physician was notified of the weight loss. Interview with director of nursing on December 12, 2019 at approximately 3:15 p.m. confirmed that the clinical record did not contain evidence of physician notification related to the weight loss.

The facility failed to address a significant weight loss and failed to notify the physician of a significant weight loss.

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

28 Pa. Code 201.18(e)(1) Management.
Previously cited 5/31/19

28 Pa. Code 211.6(d) Dietary services.



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

1.Resident R2's physician has been notified of resident's weight loss and appropriate interventions to prevent weight loss are in place

2. New admissions and current residents have the potential to be affected by the deficient practice. Utilizing the "Weight Change" QAPI tool current residents who have experienced significant weight loss have been reviewed, appropriate interventions put in place, and the physicians have been notified

3. To prevent the deficient practice from re-occurring the DON/designee will educate the nursing staff on the "weight management guide." New admissions will be reviewed by the dietitian for risk of weight loss and a plan of care will be developed.

4. Utilizing the "Weight Change" QAPI tool the DON/designee will audit 5 residents / week x 4 weeks who have had a significant weight loss ensuring appropriate interventions are in place and the physician has been notified of the weight loss. Results will be reviewed with QA&A.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to maintain complete and accurate records for one of two residents (Resident R1).

Findings include:

A review of the clinical record Resident R1 revealed that resident was admitted to the facility on September 6, 2019, with diagnosis including but not limited to osteomyelitis (infection of the bone), chronic respiratory failure and stage IV pressure ulcer (ulcers extend deeper, exposing underlying muscle, tendon, cartilage or bone).

Review of nutritional progress note for Resident R1 dated September 12, 2019 revealed that resident had a significant weight loss and recommended to monitor oral intake, weights, labs and skin integrity.

Review of Resident R1's "Amount of meal taken document" for the month of September revealed missing documentation for amount of meal consumed for breakfast on September 7, 2019, September 8, 2019, September 14, 2019, September 17, 2019, September 22, 2019, September 26, 2019 and September 27, 2019.

Review of Resident R1's "Amount of meal taken document" for the month of September revealed missing documentation for amount of meal consumed for lunch on September 7, 2019, September 8, 2019, September 14, 2019, September 17, 2019, September 22, 2019, September 26, 2019 and September 27, 2019.

Review of Resident R1's "Amount of meal taken document" for the month of September revealed missing documentation for amount of meal consumed for dinner on September 10, 2019, September 16, 2019, September 20, 2019, September 24, 2019, September 25, 2019, September 28, 2019 and September 29, 2019.

Review of Resident R1's "Amount of meal taken document" for the month of October revealed missing documentation for amount of meal consumed for breakfast for October 4, 2019, October6, 2019, October 10, 2019, October 11, 2019, October 24, 2019 and October 30, 2019.

Review of Resident R1's "Amount of meal taken document" for the month of October revealed missing documentation for amount of meal consumed for lunch on October 1, 2019, October 4, 2019, October 5, 2019, October 6, 2019, October 10, 2019, October 11, 2019, October 24, 2019 and October 30, 2019.

Review of Resident R1's "Amount of meal taken document" for the month of October revealed missing documentation for amount of meal consumed for dinner on October 3, 2019, October 8, 2019, October 22, 2019, October 24, 2019, and October 26, 2019.

Interview with director of nursing on December 12, 2019 at approximately 3:00 p.m. confirmed that the meal consumption documentation for Resident R1 for the month of September 2019 and October 2019 were incomplete.




28 Pa. Code: 211.5(f) Clinical records.

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



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

1.Resident R1 has been discharged from the facility

2. New admissions and current residents have the potential to be affected by the deficient practice. Current residents will be reviewed to ensure meal consumption for all meals is documented in PCC going forward.

3. To prevent the deficient practice from re-occurring the DON/designee will educate the nursing staff on Clinical Documentation Guidelines.

4. Utilizing the "Meal Completion " QAPI tool the DON/designee will audit 5 residents per week x 4 weeks for completion of meal consumption for all meals. Results will be reviewed with QA&A.


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