Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-PETERS TOWNSHIP
Patient Care Inspection Results

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MANORCARE HEALTH SERVICES-PETERS TOWNSHIP
Inspection Results For:

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MANORCARE HEALTH SERVICES-PETERS TOWNSHIP - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, Civil Rights Compliance and State Licensure Survey, completed on November 15, 2019, it was determined that ManorCare Health Services - Peters Township, was not in compliance with the 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) 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 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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:
Based on review of facility policies, observations and staff interviews, it was determined that the facility failed to properly restrain hair and beard and perform handing washing to prevent the potential for cross contamination in the Main Kitchen.

Findings include:

Review of the facility policy "Sanitation and Infection Control" last reviewed 10/2/19, indicated that all facilities will adhere to the food safety standards described in the HACCP Food Safety Manual. Employees must wash hands before beginning/returning to work or when necessary during work. Employees wear approved hair restraints. Ready to eat foods must not be touched with hands. All personnel shall wash hands each time before gloves are put on.

During an observation on 11/14/19, from 11:10 a.m. through 12:00 p.m. in the Main Kitchen the following was observed:

Dietary Aide Employee E8 was standing at trayline area, had a beard without a beard net and their hair was not properly restrained.

Dietary Aide Employee E8 did not wash their hands prior to trayline starting and did not utilize gloves during tray line.

Dietary Cook Employee E9 opened a bread bag with gloved hands, pulled out two slices of bread, opened cheese and placed the cheese onto the bread without hand washing and changing gloves.

Dietary Cook Employee E9 opened a bun bag with gloved hands, pulled out a bun, placed a burger on the bun opened the wrapped cheese and placed a piece of cheese, lettuce and tomato on the burger without changing gloves and washing hands.

During an interview on 11/14/19, at 12:10 p.m. the Nursing Home Administrator was made aware of observations and confirmed that the facility failed to make certain that proper hair restraints and hand washing occurred to prevent the potential for cross contamination.

28 Pa. Code: 211.6(c)(d)(f) Dietary services.


 Plan of Correction - To be completed: 12/23/2019

Employee E8 applied a beard restraint at the time of observation. Employee E8 and employee E9 were educated on the hair restraint procedure and the hand hygiene procedure.

Current residents and new admissions will receive meals that that have been prepared following the hair restraint procedure and hand hygiene procedure.

Dietary staff will be educated on the hair restraint procedure and the hand hygiene procedure by the Dietary Manager/Designee on or before the date of compliance. Dietary staff will follow the hair restraint procedures and hand hygiene procedures when preparing meals.

Audits using the Kitchen/Food Services QAPI tool will be completed by the dietary manager/ designee weekly X4 and Monthly X2 to ensure the hair restraint and hand hygiene procedures are being followed when preparing foods. Results will be submitted to the QAPI committee for review and recommendations. The QAPI Committee will determine ongoing monitoring for substained compliance.
483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for 12 of 21 residents (Resident R12, R15, R18, R25, R29, R36, R64, R75, R82, R87, R103 and R308).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, updated October 2019, indicated that Section C: Cognitive Patterns, Question C0100 "Should Brief Interview for Mental Status (BIMS) Be Conducted?" should be coded as "0" if the resident is rarely/never understood, and that it should be coded "1" and the BIMS assessment should be completed if the resident is at least sometimes understood.

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 8/13/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R12 is usually understood.

Review of Section C: Cognitive Patterns, revealed that Resident R12 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 8/10/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R15 is sometimes understood.

Review of Section C: Cognitive Patterns, revealed that Resident R15 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 8/16/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R18 is usually understood.

Review of Section C: Cognitive Patterns, revealed that Resident R18 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 8/21/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R25 is sometimes understood.

Review of Section C: Cognitive Patterns, revealed that Resident R25 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 8/25/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R29 is sometimes understood.

Review of Section C: Cognitive Patterns, revealed that Resident R29 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 9/17/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R64 is usually understood.

Review of Section C: Cognitive Patterns, revealed that Resident R64 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 10/11/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R75 is usually understood.

Review of Section C: Cognitive Patterns, revealed that Resident R75 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 10/12/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R82 is understood.

Review of Section C: Cognitive Patterns, revealed that Resident R82 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 10/15/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R87 is understood.

Review of Section C: Cognitive Patterns, revealed that Resident R87 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 10/18/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R103 is sometimes understood.

Review of Section C: Cognitive Patterns, revealed that Resident R103 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

A review of the MDS dated 10/27/19, Section B: Hearing, Speech, and Vision, Question G0700 indicated that Resident R308 is understood.

Review of Section C: Cognitive Patterns, revealed that Resident R308 is coded as "rarely/never understood" and that the Staff Assessment for Mental Status should be conducted.

During an interview on 11/15/19, at 10:30 a.m. Registered Nurse Assessment Coordinator Employee E 11 confirmed that the facility failed to accurately complete the Brief Interview for Mental Status when the resident is at least sometimes understood, as required in the RAI Manual, for Resident R12, R15, R18, R25, R29, R64, R75, R82, R87, R103 and R30811 residents.

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2018, updated October 2019, indicated that Section J1900: Falls Number of Fall since admission or prior assessment coding instruction indicated that staff should determine the number of falls that occurred since admission or prior assessment and code the level of fall-related injury for each. Code each fall only once. Coding Instructions for J1900C, Major Injury Code 1, one: if the resident had one major injurious fall since admission or prior assessment.

Review of the Change of Condition Note dated 7/16/19, indicated that at 12:50 a.m. Resident R36 had been "found by staff lying on floor on back next to bed. Left leg ecchymosis (bruising) noted from knee to mid shin, anteriorly. Resident stating "ouch" during assessment of left leg, stating "I can't feel my leg" pointing to left leg. Change of Condition Note indicated that the physican and family were called and that Resident R36 was transferred to the hospital via ambulance for evaluation.

Review of the Discharge MDS dated 7/16/19, indicated that Resident R 36 was admitted to the facility on 5/24/19 and was discharged to an acute care hospital. The 7/16/19, MDS Section J indicated that Resident R36 had no prior falls.

Review of a physician progress note dated 7/19/19, indicated that Resident R36 had a spiral fracture of left femur (upper large leg bone).

Review of the 9/1/19, Quarterly MDS indicated that Resident R36 was re-admitted to the facility on 7/18/19, from the hospital. Section J:1800 of the 9/1/19, MDS indicated that Resident R36 had no prior falls, Section J1900: was blank.

During an interview on 11/15/19, at 10:48 a.m. Registered Nurse Assessment Coordinator Employee E11 confirmed that Resident R36 had a fall resulting in a fracture on 7/16/19, and that the fall with major injury was not accurately coded on the 7/16/19, Discharge MDS or the 9/1/19, Quarterly MDS.

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

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


 Plan of Correction - To be completed: 12/23/2019

Resident R12,R15,R18,R25,R29,R64, R103, and R308 will have sections B and C of the last completed comprehensive assessment reviewed and modifications submitted as appropriate on or before the date of compliance. R36 will have the 7/16/19 MDS assessment reviewed for Section J and modifications submitted as appropriate.

Current residents who have had a comprehensive assessment in the last 30 days will have section B question B0700, C question C0100 and J question J1900 of the last completed comprehensive assessment reviewed to ensure the submissions are accurate on or before the date of compliance.

The Resident Assessment Coordinator and the Social Service staff will be educated on MDS sections B and C and the Resident Assessment Coordinator on Section J by the Clinical Reimbursement Specialist/designee using the RAI manual for section B,C and J. The resident assessment coordinator will review sections B, C and J of the comprehensive assessment prior to submission for accuracy on or before the date of compliance.

5 comprehensive assessments will be audited using the Resident Assessment Critical Element Pathway weekly X4 and Monthly X2 by the Clinical Reimbursement Specialist/designee to ensure Section B B0700, C0100, and J1900 are accurate. Results will be submitted to the QAPI committee for review and recommendations.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(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 observation and staff interviews, it was determined that the facility failed to maintain a homelike environment on one of three nursing units (Bethany Nursing Unit - Secured).

Findings include:

During observations of the Bethany Nursing Unit - Secured on 11/12/19, 11/13/19, and 11/15/19, the following was observed:

11/12/19:
- Room 130 black marks on the walls, a hole in the wall behind door
- Room 124 black marks on the wall from door to window
- Room 125 chipped paint on the wall

11/13/19:
- Room 128 closet door was off of the closet/ black marks on the wall
- Room 127 black marks on the wall/closet door for bed "B" has a curve and does not lay flat
- Room 126 bottom of cove base was missing/black marks on the wall/missing a closet door
- Room 129 black marks on the walls/the wall behind bed "A" has black marks and scrapes
The hallway has ripped wall paper at seams

11/15/19:
- Room 118 black marks on the wall
- Room 117 painting chipping on the wall/black marks on the wall cove base coming off wall
- Room 123 black marks on the wall
dining room cove base was missing/black marks on the walls/bottom of the wall has ripped wallpaper and missing wall paper.

During an interview on 11/15/19, at 12:30 p.m. the Nursing Home Administrator confirmed the above observations of resident rooms, hallways and dining room and that the facility failed to maintain a homelike environment for the residents of the Bethany Nursing Unit.

28 Pa. Code:201.2 Administrator's responsibility.


 Plan of Correction - To be completed: 12/23/2019

Maintenance Director or designee will correct the cited issues identified during the Department of Health's annual visit. If repairs require an outside contract for correction, this will be arranged.

Current residents and new admissions who reside on the dementia unit have the potential to be affected by the deficient practice. A comprehensive audit of the 3 Nursing Units using the Environmental Observations QAPI tool will be completed by the Maintenance Director/ designee to determine if there any other areas in need of repair on or before the date of compliance.

NHA or designee will educate Maintenance, Administrative and Nursing departments and newly hired nursing staff on 483.10-Environment, Safe/Clean/Comfortable/Homelike Environment. Newly identified areas in need of repair will be communicated to the maintenance director through the TELS system.

Maintenance Director or designee will audit the 3 Nursing Units using the Environmental Observations QAPI tool weekly x 4 then monthly x 2 to ensure the deficient practice does not recur. After this, items in need of repair will be entered into the facility electronic maintenance reporting system as needed in an effort to stay on top of items needing repaired. Results will be submitted to the QAPI committee for review and recommendations.
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 facility policies and clinical record review, observations and staff interviews, it was determined that the facility failed to make certain that proper infection control practices were followed during wound care for two of four residents (Resident R95 and R70).

Findings include:

Review of the facility "Dressing: Calcium Alginate" policy last reviewed on 10/2/19, indicated staff are to wash hands after cleansing wound, hand hygiene should occur, after dating items and cutting calcium alginate and applying. Hand hygiene and glove application should occur before placing calcium alginate and clean dressing.

Review of the facility policy entitled "Dressing Change: Non-sterile (Clean)" dated 10/02/19, indicated that in the event of multiple wounds, each wound is considered a separate treatment. Staff should perform hand hygiene each time you enter or leave and when going from dirty to clean, nurse should set up area by cleaning over bed table using EPA approved disinfectant, soiled trash bag should be set up, clean scissors which have been disinfected should be used to prepare dressings and that hand washing and re gloving should be done between removal of soiled dressing, cleaning of wound and application of new dressing.

During an observation on 11/13/19, from 10:48 a.m. to 11:15 a.m. the following occurred:

Registered Nurse (RN) Employee E10 pulled a pen from their pocket and dated dressing and placed the pen back into their pocket. RN Employee E10 removed a soiled incontinence pad and soiled dressing, removed gloves and placed the items in the residents garbage can. RN Employee E10 cleansed the wound, then wiped the area surrounding the wound with a skin prep pad, cut the calcium alginate and placed it onto the wound and applied the clean, dated outer dressing without hand washing between cleansing the wound and applying the clean dressing. RN Employee E10 did not wipe the table off after the dressing change and before leaving.

During an interview on 11/13/19, at 11:46 a.m. the dressing change observation was reviewed with the Director of Nursing (DON) who confirmed that the facility failed to maintain proper infection control practices during the dressing change which created the potential for cross contamination.

During an observation on 11/13/19, at 10:12 a.m. a dressing change was completed for Resident R70's wounds on the right and left heels and the following was noted:

Licensed Practical Nurse (LPN) Employee E4 failed to clean entire overbed table, left cell phones, water glass and miscellaneous items on the table. LPN Employee E4 placed a paper towel down as a barrier, opened all supplies and laid a pair of scissors that had not been cleaned on the barrier. LPN Employee E4 removed the soiled dressings from Resident R70's bilateral heels, cleansed the right heel and applied skin prep, cut a piece of Progran with the uncleaned scissors, and applied the clean outer dressing without handwashing between tasks. LPN Employee E4 then cleansed the left heel, cut a piece of Progran again with uncleaned scissors, and applied the clean outer dressing to the left heel without hand washing between treatments. LPN Employee E4 placed all soiled items in Resident R70's garbage bag, took the bag out to the soiled utility room and did not clean off the scissors or the residents bedside table before leaving the room.

During an interview on 11/13/19, at 10:35 a.m. LPN Employee E4 confirmed that she failed to properly clean the entire overbed table before and after use, did not perform separate dressing changes on the right and left heels, failed to clean scissors properly before and after each use and to set up a soiled trash bag in the area of the dressing change. LPN Employee E4 confirmed that the above listed actions result in potential cross-contamination of Resident R70's wounds.

During an interview on 11/13/19, at 11:05 a.m. the DON confirmed that the above-listed actions of LPN Employee E4 failed to use appropriate infection control procedures to prevent the potential for cross-contamination.

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

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

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

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: 12/23/2019

There were no adverse reactions to the residents who had their dressings changed r/t infection control.
Current residents who receive dressing changes in the center will have their dressings changed following the nursing procedure Dressing Change: Non-sterile (Clean)

Licensed staff and newly hired licensed staff will be educated by the Director of Nursing/Designee on the procedure for Dressing Change: Non-Sterile (Clean) on or before the date of compliance.

Licensed nursing staff will be individually observed for proper procedure for Dressing Change: Non-Sterile (Clean) for compliance.

Observations of three dressing changes will be completed weekly X4 and monthly X2 using the nursing procedure Dressing Change: Non-Sterile (Clean) as the audit/observation tool by the DON/designee to ensure the dressing change procedure is adhered to. Results will be submitted to the QAPI committee for review and recommendations

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 observations and staff interviews, it was determined that the facility failed to discard expired biologicals and failed to properly store a medication on two of three medication rooms (Vintage and Transitional Care nursing units).

Findings include:

Review of the facility policy "Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles", last reviewed 10/2/19, indicated that the nursing center should make certain that drugs and biologicals have not been retained longer than recommended by manufacturer or supplier guidelines and that drugs and biologicals should be stored at their appropriate temperatures.

During an observation of the Transitional Care Unit medication room on 11/13/15, at 10:17 a.m. a container of red capped vials for blood draws dated as expired on 9/30/19, a container of blue capped vials for blood draws dated as expired on 10/31/19, and three flu swabs dated as expired 10/31/19, were stored in the medication room.

During an interview on 11/13/19, at 10:17 a.m. Registered Nurse Employee E7 confirmed the vials and flu swabs were expired.

During an observation on 11/14/19, at 1:40 p.m. a bottle of liquid Gabapentin, with a manufacture's applied label stating to refrigerate, was stored in a medication cart.

During an interview on 11/14/19, at 1:41 p.m Licensed Practical Nurse Employee E5 confirmed that she was dispensing medication from the unrefrigerated bottle on the medication cart.

During an interview on 11/14/19, at 2:30 p.m. Pharmacist Employee E12 confirmed that liquid Gabapentin is to be stored in the medication refrigerator per manufacturer's guidelines.

28 Pa. Code: 211.9(a)(1)(h)(j) Pharmacy services.


 Plan of Correction - To be completed: 12/23/2019

The expired blood draw vials and the expired flu swabs from the Transitional Care Unit medication room were disposed of.

The liquid gabapentin that was stored in the medication cart was disposed of.

A comprehensive audit of the medication rooms on the units and of the liquid medications in the medication carts will be completed using the Medication Storage and Labeling CMS tool to ensure there are no expired specimen collection supplies and that liquid medications that require refrigeration are refrigerated on or before the date of compliance.

Licensed staff and newly hired licensed staff will be educated on labeling and storing of drugs and biological using the Focus on F-Tag 761 by the Director of Nursing/Designee on or before the date of compliance.

Liquid medications that require refrigeration will be stored in the refrigerator and expired specimen collection supplies will be disposed of on or before the date of compliance.

An audit of three medication rooms and three medication carts will be completed weekly X4 and monthly X2 using the Medication Storage and Labeling CMS tool by the Director of Nursing/Designee to ensure liquid medications that require refrigeration is stored in the refrigerator and that there are no expired specimen collection supplies stored in the medication rooms. Results will be submitted to the QAPI committee for review and recommendations.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on facility policy and clinical record review, and staff interview, it was determined that the facility failed to ensure that alternate interventions were attempted prior to the administration of psychotropic medications for two of two residents (Resident R93 and R258).

Findings include:

Review of the facility policy "Psychotropic Medication Use" reviewed on 10/2/19, indicated facility staff should document the number and/or intensity of symptoms and the resident's response to staff interventions.

Review of the clinical record indicated Resident R93 was admitted to the facility on 3/19/18, with unspecified dementia with behavioral disturbance, and depressive episodes. The Minimum Data Set (MDS - periodic assessment of needs) dated 10/19/19, indicated these diagnoses remained current.

Review of Resident R93's physician recapitulation orders dated 4/24/19, revealed an order Ativan Solution (anti anxiety medication) 2mg/ml inject 1 mg intramuscularly every 4 hours as needed for agitation/aggression first dose now may repeat in 4 hrs.

Review of Resident R93's progress notes for eMAR (electronic Medication Administration Record) note text: dated 4/19/19, revealed Ativan solution 2 mg/ml inject 1 mg intramuscularly every four hours as needed for agitation/aggression, first dose now may repeat in four hrs. Pt (patient) very agitated swearing, pounding on door and desk raising fist and threatening to hit staff and other residents.

Review of Resident R93's progress notes "Mood/Behavioral Note Text:" dated 5/12/19, revealed pt gradually aggressive behavior escalating approx 17:30 ... pt has continued to be verbally abusive and raise fist at both staff and peers... order given by M.D. ativan 1 mg now ... ativan given at 19:30.

Review of Resident R93's clinical record revealed that no non-pharmacological interventions were attempted before the administration of the PRN Ativan.

Review of the clinical record indicated Resident R258 was admitted to the facility on 11/7/19, with diagnoses of unspecified dementia with behavioral disturbance.

Review of Resident R258's physician order dated 11/7/19, revealed an order of Xanax (an anti anxiety medication) 0.5 mg give 1 tablet by mouth every 6 hours as needed for anxiety.

Review of Resident R258's progress notes for eMAR note text dated 11/13/19, 21:17 revealed Xanax tablet 0.5 mg - give 1 tablet by mouth every 6 hours as needed for anxiety, resident distressed, experiencing anxiety.

Review of Resident R258's progress notes for eMAR note text dated 11/14/19, at 18:55 revealed Xanax tablet 0.5 mg - give 1 tablet by mouth every 6 hours as needed for anxiety - agitated.

Review of Resident R258's progress notes for eMAR note text dated 11/15/19, 06:43 revealed Xanax tablet 0.5 mg give 1 tablet by mouth every 6 hours as needed for anxiety prn administration was effective.

Review of Resident R258's clinical record revealed that no non-pharmacological interventions were attempted before the administration of the PRN Xanax.

During an interview on 11/15/19, at 10:08 a.m. Unit Manager Registered Nurse Employee E21 confirmed that the facility failed to attempt non-pharmacological interventions prior to administering the PRN medication for Resident R93 and Resident R258.

28 pa. Code:201.18(b)(1)Management.

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

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



 Plan of Correction - To be completed: 12/23/2019

R93 will have care plan reviewed for non-pharmacological interventions for behaviors, careplan will be updated as needed

R258's medications were reviewed by the physician and the prn Xanax was discontinued.

A comprehensive audit of current residents with prn antianxiety medications will be completed using the Psychoactive Medications QAPI tool to determine if non pharmacological are included on the careplan on or before the date of compliance.

Licensed staff and newly hired licensed staff will be educated on implementing non pharmacological interventions prior to the administration of prn antianxiety medications using the Non-Pharmacological Interventions Power Point by the Director of Nursing/designee on or before the date of compliance.

Current resident and new admissions who require the use of prn antianxiety medications will be offered non-pharmacological interventions prior to the use of prn antianxiety medications per their plan of care on or before the date of compliance.

An audit of seven residents using the Psychoactive Medications QAPI tool will be completed by the Director of Nursing/Designee weekly X4 and Monthly X2 to ensure non-pharmacological interventions are implemented prior to the administration of prn antianxiety medications. Results will be submitted to the QAPI committee for review and recommendations.
483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:
Based on review of staff education records and staff interview, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary as required for three of five nurse aides (Employees E1, E2, and E3).

Finding include:

Review of Nurse Aide (NA) Employees E1, E2, and E3's education records with hire date greater than 12 months revealed the following:

NA Employee E1 had a hire date of 6/2/08, with 5.61 hours in-service education between 6/2/18, and 6/2/19.
NA Employee E2 had a hire date of 10/25/10, with 8.04 hours in-service education between 10/25/18, and 10/25/19.
NA Employee E3 had a hire date of 8/15/16, with 3.5 hours in-service education between 8/15/18, and 8/15/19.

During an interview on 11/15/19, at 12:30 p.m. the Director of Nursing confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for NA Employee E1, E2, and E3.

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

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


 Plan of Correction - To be completed: 12/23/2019

Facility agreed with the Department of Health's finding's as it relates to E1, E2, and E3. Findings will be submitted to the QAPI committee on or before the date of compliance.

A comprehensive audit will be completed of current certified nursing assistants to ensure that they have 12 hours of inservicing using the Training QAPI tool on or before date of compliance

NHA or designee to educate Human Resource Director on 483.35-Nursing Aide Performance review-12 hours of in-service using the Ftag 730 on or before the date of compliance. Nursing assistant in-service hours will be tracked through our online system to ensure 12 hours of in-service training.

Human Resources Director or designee will audit 7 CNA's files weekly X 4 week, then monthly X2 using the training QAPI tool. Results will be submitted to the QAPI committee for review and recommendations.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:
Based on resident group and staff interviews and review of facility documentation, it was determined that the facility failed to provide the opportunity to vote for two of five residents (Residents R405 and R403).

Findings include:

During the group meeting, on 11/14/19, at 10:30 a.m. it was revealed that Resident R405 and R403 were interested in voting but were not provided the opportunity during the 11/5/19, election.

A review of facility documentation, failed to show that all residents were asked about voting for the 11/5/19, election. The documention provided was a form with residents names (by unit) that had they word "yes" by 10 of the 64 residents names.

During an interview on 11/15/19, at 1:26 p.m. Activities Director Employee E20 confirmed that the facility could not provide documentation showing that all residents were asked about voting or provided the opportunity to vote in the 11/5/19, election.

28 PA. Code:201.29(j) Resident rights.


 Plan of Correction - To be completed: 12/23/2019

The right to vote will be reviewed with the resident council in the next scheduled resident council by the NHA/designee.

Current residents and new admissions in the center who are not adjudicated incompetent will be afforded the opportunity to vote as elections are scheduled.

The activities staff will be educated on patient voting using the Clinical FYI #51 Patient Voting by the NHA/Designee on or before the date of compliance.

During the next scheduled election, a current resident list will be utilized by the activities staff to ensure current residents who are not adjudicated incompetent are offered the right to vote if desired. This will be monitored by the NHA/designee. Results will be submitted to the QAPI committee for review and recommendations.

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