Nursing Investigation Results -

Pennsylvania Department of Health
SPRINGS AT THE WATERMARK, THE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SPRINGS AT THE WATERMARK, THE
Inspection Results For:

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SPRINGS AT THE WATERMARK, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil rights Compliance Survey and State Licensure Survey completed on February 28, 2020, it was determined that The Springs at the Watermark, 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 related to the health portion of the survey process.


 Plan of Correction:


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

483.12(a) The facility must-

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

Based on review of clinical records, facility documentation, staff interviews and review of facility policy, it was determined that the facility failed to ensure residents were free from neglect resulting in actual harm to Resident R78 sustaining multiple bruises on the right side of his chest, right eye, right thigh and right forearm for one of 26 clinical records reviewed. (Resident R78)

Findings include:

Review of facility policy, "Abuse, Neglect, Injuries of Unknown Source and Misappropriation of Property: Prevention" date revised October 25, 2017, revealed that the facility will identify, correct and intervene in situations in which abuse, neglect, injuries of unknown source and/or misappropriation of resident property is more likely to occur which includes the analysis of the deployment of staff on each shift in sufficient numbers to meet the needs of the residents and to assure that the staff assigned has knowledge of the individual resident's care needs. Further review revealed the assessment, care planning and monitoring of residents with needs and behaviors which might lead to conflict or neglect, injuries of unknown source, such as residents with a history of aggressive behaviors ...those that require heavy nursing care and are totally dependent on staff.

Review of the clinical record for Resident R78 revealed the resident was readmitted to the facility on November 14, 2018, with diagnoses including Heart Failure (condition in which the heart does not pump blood as well as it should), hypertension (high blood pressure), Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), anxiety (a disorder characterized by feelings of worry, anxiety, or fear that interfere with one's daily activities) and depression (a disorder characterized by depressed mood or loss of interest in activities, causing significant impairment in daily life).

Review of a quarterly Minimum Data Set assessment (MDS-periodic assessment of resident care needs) dated August 5, 2019, revealed a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment) score of 3, indicating the resident was severely cognitively impaired. Further review of the Minimum Data Set assessment revealed the resident required extensive assistance of two persons physical assist for bed mobility, personal hygiene, transfers (how a resident moves between surfaces including to or from bed, chair, wheelchair), dressing and toileting. The MDS assessment indicated that the resident exhibited verbal behaviors symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others).

Review of Resident R78's plan of care developed in September 18, 2014 for dementia and impaired thought revealed "Monitor/document/report PRN [as needed] any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status." In May 25, 2015, the following intervention was added to the care plan: "staff needs to approach resident gently and speak before touching him: if he is resistant allow him to rest and reapproach in a few minutes."

Review of facility documentation revealed that on August 21, 2019, the resident was found with bruises on his right side below his pacemaker, below his right eye, right thigh and right forearm. Further review of the facility investigation revealed a written statement obtained from the nursing assistant assigned to Resident R78 during the 3-11 shift which stated: "When I went to get him he was fine but when we got to his room he started to act up. Then around 8:40 I had him in his room trying to put on his nightgown he started to get violent by punching me, I had then try to restrain his hands from hitting me and hurting himself in the bed as well. I had went out of the room after putting on his nightgown to find another aid to [help] me put him in but I didn't see anyone, so I then I had gone back in to put him in so he wouldn't fall out of his wheel chair. After that I had started to change him but he was still violent by kicking and punching and he was hitting me [with] was his bed remote. during all that he was rolling around in his bed [screaming] but I gotten him to clam [calm] done [down] around 9:00 pm and the nurse ask me if he was ok and I said yes."

Continued review of the facility documentation revealed that Employee E11, nursing assistant assigned to Resident R78 attempt to continue with transfer without help and not in accordance with the facility protocol. The resident was placed in bed during an agitative state.

Employee E11 failed to follow the resident's care plan which stated that the resident was to be reapproach if resistant.

Further review of the investigation into this incident revealed Employee E11, nursing assistant assigned to Resident R78 was immediately suspended and terminated from employment due to the improper transfer and not applying the appropriate protocols.

Interview conducted with Employee E9, nursing assistant, on February 28, 2020, at 12:35 p.m. revealed that she worked the day before the incident and saw no bruises on the resident.

Interview conducted on February 28, 2020, at 1:04 p.m. with Employee E7, Licensed Practical Nurse, revealed that the resident often became combative when doing incontinence care and often he sundowned (a state of confusion in the late afternoon and spanning into the night) and his combative behavior included punches, screams and calling names.

Interview conducted on February 28, 2020, at 1:15 p.m. with Employee E8, nursing assistant, revealed that she saw him at 11:00 p.m. on August 20, 2019 and he had no bruises during his skin check. On August 21, 2019 during the night shift, when she was performing incontinence care on the resident, she pulled the sheets back and the resident showed her his bruises and said his chest hurt, pointing to the bruises on his chest.

The facility failed to ensure Resident R78 was free from neglect resulting in actual harm Resident R78 sustaining multiple bruises on the right side of his chest, right eye, right thigh and right forearm.


28 Pa Code 201.18(b)(1) Management

28 Pa Code 201.18(b)(3) Management

28 Pa Code 201.29(c) Resident rights

28 Pa Code 211.10(d) Resident care policies

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

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
















 Plan of Correction - To be completed: 04/28/2020

1. Employee E11 was identified for not following proper protocol for transfer of Resident R78 Employee E11 was terminated from employment.
2. All similar residents exhibiting combative behavior will be assessed and care plan will be updated to include allowing resident to rest and reapproach in a few minutes. All similar residents requiring 2 person assistance and transfers will have their Care plans reviewed by nursing staff prior to transfer.
3. All nursing staff will be re-educated on following resident plan of care for proper transfers and on approach for residents exhibiting behaviors.. All staff involved in resident assessment and care planning will receive training on the facility abuse prohibition policy and elements that constitute resident neglect by Polaris.
4. Random weekly transfer audits will be conducted by DON/designee to assure compliance for following protocol and care plan. Results will be reported to QAPI committee for 3 months or until substantial compliance.

483.25 REQUIREMENT Quality of Care:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25 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 review of clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to obtain physician's orders related to the administration of a seizure medication, which resulted in actual harm to Resident R38, who did not receive seizure medication, experienced a seizure, was transferred to the hospital via Emergency Medical Services and hospitalized for one of 26 resident's reviewed (Resident R38). The facility failed to ensure that a blood thinner medication was administered as order by the physician for two of 26 residents reviewed. (Resident R8)

Findings include:

Review of the facility policy, "Medication Pass Policy" date revised, January 09, 2020, revealed, "The "rights" of medication administration are important points to check for the medication managers when assisting with medications. Checking these points helps to protect the resident's right to: The Right Drug - When assisting with medications, always be sure that you give the correct drug. Compare the information about the drug on the MAR with the pharmacy label, the physician's order found in the MAR ..."


Review of Resident R38's quarterly Minimum Data Set (MDS- a periodic assessment of resident needs) dated September 29, 2019, revealed the resident had diagnoses including but not limited to, Dementia (progressive, degenerative disorder of the brain) and Seizure disorder (neurological disorder which causes episodes of spasms and unresponsiveness). Further review of the MDS revealed that Resident R38 needed extensive assistance with bed mobility, transfers, dressing, toileting, hygiene and was totally dependent on staff with baths.

Review of Resident R38's summary of neurology visits related to her seizure disorder dated August 9, 2019, indicated that the physician wanted to continue Resident R38's seizure medication, Lamotrigine (Lamictal), in titrating doses (gradually increasing the dose on a schedule) as follows:
Weeks 1+2 (7/30/19 - 8/12/19): take 25 milligrams (mg) daily
Weeks 3+4 (8/13/19 - 8/26/19): take 25 milligrams (mg) every 12 hours
Week 5 (8/27/19 -9/2/19): take 50 mg every 12 hours
Week 6 (9/3/19 -9/9/19): take 100 mg in the morning and 50 mg in the evening
Week 7 (9/10/19 -9/16/19): take 100 mg every 12 hours

Further review of this neurologist visit revealed, "Please follow-up after titration completed."

Review of Resident R38's neurological visit summary dated September 13, 2019, stated "Week 7: take 100 mg twice a day and continue at this dose."

Review of Resident R36's September 2019 Medication Administration Record revealed that the last administration of the seizure medication Lamictal was on September 16, 2019 at 9:00 p.m. The facility failed to communicate the recommendations of the neurologist to the resident's physician to continue to administration of the Lamictal 100 milligrams twice a day.

Review of the nursing progress note dated September 25, 2019 at 11:40 a.m. revealed, "The charge nurse called to room, res (Resident R38) having a seizure." "Res remains lethargic and unresponsive." The resident was transferred via Emergency Medical Services 9-1-1 to the hospital.

Review of the facility incident investigation dated September 25, 2019, noted "charge nurse called to room resident having a seizure while sitting on the toilet. Resident didn't hit her head resident held for safety. Resident placed on floor by CNA (nursing assistant) and charge nurse for safety while resident still having a seizure. Res (resident) airway maintained. Vital signs and O2 (oxygen) applied."

Review of the hospital report, signed by the doctor on September 27, 2019 stated per the facility "... patient stopped Lamictal on 9/16/19 due to miscommunication between outpatient neurologist and facility; outpatient neurologist did recommend continuing lamictal on 9/13 visit."

Interview with the Director of Nursing on February 26, 2019 at 11:30 a.m., confirmed that the facility failed to obtain Resident R38's seizure medication order, following the resident's neurology appointment on September 13, 2019. This resulted in serious harm to the resident, who did not receive the medication for a period of nine days, experienced a seizure and was subsequently hospitalized.

The facility failed to communicate and obtain orders for the resident's physician's related to the administration of a seizure medication, which resulted in actual harm to Resident R38, who did not receive seizure medication beyond September 16, 2020, experiencing a seizure on September 25, 2020 requiring transfer to the hospital via Emergency Medical Services and hospitalization.



Review of the clinical record for Resident R8 revealed the resident was readmitted to the facility on November 20, 2018, with diagnoses including, but not limited to, heart failure (condition in which the heart does not pump blood as well as it should), diabetes (a disease that affects the way the body processes blood sugar (glucose)) and dementia (a broad category of brain diseases most notable for decline in memory and other mental abilities).

Review of Resident R8's admission Minimum Data Set (MDS-periodic assessment of resident needs) dated July 7, 2019, revealed that the resident had a BIMS (Brief Interview for Mental Status, a brief screening tool that aids in detecting cognitive impairment) score of 3, indicating the resident was severely cognitively impaired.

Review of Resident R8's July 2019 Medication Administration Record (MAR) revealed an order on the paper chart dated July 01, 2019 through July 31, 2019 for Xarelto (a blood thinner medication), 15 milligrams, take 1 tablet by mouth daily for diagnosis of atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure). Review of the electronic order dated July 9, 2019 to August 18, 2019 revealed an order for Xarelto, 15 milligrams, take 1 tablet by mouth in the evening related to atrial fibrillation.

Further review of the Medication Administration Record dated July 2019 revealed that Resident R8 did not receive Xarelto, 15 milligrams, for nine days, from July 23, 2019 to July 31, 2019.

Interview with the Director of Nursing on February 29, 2020 at 11:20 a.m. revealed that the facility changed their process from paper charting for medication administration to electronic charting of medication administration on July 23, 2019. Further interview with the Director of Nursing revealed that Resident R8's order for Xarelto was incorrectly categorized in the new electronic system and was not seen during medication administration.

The facility failed to ensure that Resident R8 received the blood thinner as ordered by the physician.

28 Pa Code 201.18(b)(1) Management

28 Pa Code 211.10(e) Resident care policies

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

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


















 Plan of Correction - To be completed: 04/28/2020

1. Resident R38 was identified for not receiving seizure medication orders from admission of external facility resulting in missing seizure medication. Medication has been changed and properly ordered in EMAR system. Resident R8 was identified for missing blood thinner medication due to error in EMAR system. Medication is correctly entered into EMAR and system error has been corrected.
2. Facility will identify residents who transfer from external facilities with new medication orders for accuracy. PCC has been permanently corrected to eliminate the possibility of error repeating. All consults from external appointments will be review in morning clinical.
3. All nursing staff will receive training regarding obtaining and clarifying physician's orders. The training will emphasize communication between the facility, outside specialists and the resident's physician as it relates to medications. All staff must receive training in what their roles are as it relates to following physician's orders. All education will be provided by Polaris group in-service.
4. DON/ Designee will audit daily external consult recommendations and will verify with attending physician. Audits will be reported to QAPI x3 months or until substantial compliance.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
483.45 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 clinical records, review of facility documentation and review of facility policy, it was determined that the facility failed to ensure the timely availability of medication for administration as ordered by the physician, and failed to ensure that a controlled substance was documented as being reconciled for three out of 18 residents reviewed (Resident R11, R19, R61).

Findings include:

Review of the facility's policy entitled, "Controlled Substances Documentation," with a revision date of "12/29/14," stated that, it is the policy of the facility and its affiliates, to ensure accuracy in documenting-controlled substances in accordance with standard nursing practices and state and federal guidelines.

Review of the February, 2020 physician's orders for Resident R19 revealed a physician's order with a start date of July 9, 2019, and monthly thereafter, for a Fentanyl Patch 72 hour 12 micrograms, apply 12 micrograms transdermally every 72 hours for pain. The order stated, "please remove patch and document removal of patch."

Review of Resident R19's September, 2019 Medication Administration Record (MAR) revealed that there was no documentation of the removal of the Fentanyl Patch by nursing staff for September 3, 2019, September 6, 2019, September 9, 2019, September 12, 2019 and September 15, 2019.

During a discussion and a review of the MAR with licensed nursing staff, Employee E3, on February 28, 2020 at approximately 2:45 p.m., revealed that the patch should be witnessed by two nurses, and that the nurses should document that it was removed. During this time Employee E3 confirmed that no documentation could be produced to show the removal of the Fentanyl Patch, per the physician's order.

The facility failed to ensure that a controlled substance was documented as being reconciled for one resident.

Review of Resident R61's Annual Minimum Data Set (an MDS is a periodic assessment of needs) dated, November 16, 2019 revealed that, the resident had diagnoses that included, Alzheimer Disease, Seizures and Anxiety, had severe cognitive impairment, was incontinent of bowel and bladder, needed extensive assistance for toileting and ambulated with a wheelchair and a walker with the assistance of one person.

Review of Resident R61's January 2020 physician orders revealed an order for Quetiapine Fumarate Tablet, give 12.5 mg by mouth in the afternoon related to Resident R61's Dementia.

Further review of the orders revealed on January 17, 2020, that the resident R 61 did not receive her afternoon medication and the Registered Nurse (RN), Employee E5, stated in the nursing progress note, "Awaiting from Pharmacy."

Review of the medication's availability to nursing, in the facility's emergency medication supply, indicated that, Quetiapine was available.

During an interview on February 28, 2020 at 9:38 a.m. with the RN Employee E5 she stated that she was not aware of the facility's emergency stock of medications, as she said, "I am not sure, I don't use of often". Furthermore, she did not contact the physician when the medication-dose was missed.

The facility failed to ensure that medications including controlled substances were documented as being reconciled or administered as ordered.

Review of the interdisciplinary notes for Resident R11 revealed diagnoses that included, but not limited to atrial fibrillation (a disease of the heart characterized by irregular and often faster heartbeat); hypertension (high blood pressure); hyperlipidemia (high level of fats in the blood), and diabetes (disorder in which the body has high sugar levels for prolonged periods of time).

Review of the physician's orders for Resident R11, dated February, 2020 revealed an order for Spironolactone Tablet 25 milligrams, give 1 tablet by mouth one time a day related to hypertension starting August 10, 2019 and monthly thereafter; an order for Nesina Tablet 25 milligrams, give 1 tablet by mouth one time a day for diabetes mellitus starting September 4, 2019 and monthly thereafter; an order for Oxybutynin Chloride tablet give 2.5 milligrams by mouth two times a day for overactive bladder; Ezetimibe Tablet 10 milligrams, give 1 tablet by mouth in the morning related to hyperlipidemia, in addition to Vitamin D3 Tablet give 1 tablet by mouth in the morning for supplement.

Review of the nursing note dated October 3, 2019 indicated that the resident was not administered Nesina. The nursing note stated, "awaiting delivery from pharmacy."

Review of the nursing note dated October 6, 2019 indicated that the resident was not administered the Vitamin D3 Tablet. The nursing note stated, "med not available. Pharmacy contacted."

Review of the nursing note dated October 11, 2019 indicated that the resident was not administered Nesina. The nursing note stated the medication was, "not available."

Review of the nursing note dated October 11, 2019 indicated that the resident was not administered Sprionolactone Tablet. The nursing note stated that the medication was "not available."

Review of the nursing note dated December 20, 2019 stated that the resident was not administered the Ezetimibe Tablet and that the medication was "not available."

Review of the interdisciplinary notes for Resident R19 revealed diagnoses that included, but not limited to, anxiety (a feeling of worry, nervousness, or unease); hypertension (high blood pressure), and arthritis. Review of the interdisciplinary notes also revealed that the resident had dry eyes.

Review of the physician orders for February 2020 revealed an order for Clonazepam 1 milligram tablet, give 1 tablet by mouth at bed time for anxiety with a start date of July 23, 2019 and monthly thereafter; an order for Ocuvite Lutein 1 capsule, give 1 capsule by mouth one time a day for supplement eye support with a start date of July 23, 2019 and monthly thereafter and an order for Artificial tears 1.4% drops, instill 1 drop in both eyes six times a day for dry eyes.

Review of the nursing notes dated September 3, 2019 indicated that medication Clonazepam was not administered. The nursing note stated, "med not available, awaiting med from pharmacy."

Review of the nursing notes dated October 6, 2019 indicated that the resident's 8:00 a.m. treatment for artificial tears was not administered. The nursing note stated, "med not available. Pharmacy contacted."

Review of the nursing note dated November 7, 2019 indicated that the resident's 8:00 am treatment for artificial tears was not administered. The nursing note stated, "med is not avail pharmacy contacted."

Review of the nursing note dated November 11, 2019 indicated that the resident's Ocuvite Lutein was not administered. The nursing note stated, "not available. reordered."

During a discussion with the Director of Nursing (DON) on February 27, 2020 at approximately 11: 00 a.m., the DON reported that it was the nurse's responsibility to reorder the resident's medication on time. The DON also reported that if a resident's medication was missed, the physician needed to be notified.

During a interview with licensed nursing staff, Employee E3, on February 28, 2020 at approximately 12:45 p.m., the missed dosages of mediations for Residents R11 and Resident R19 were discussed. Employee E3 confirmed that the above referenced medications were not available from the pharmacy for nursing to administer to the residents, as ordered. Employee E3 also stated that the nurses can order the medications from pharmacy on the electronic system or via fax.


28 Pa Code 201.18(b)(1) Management

28 Pa. Code 211.9(a)(1) Pharmacy services

28 Pa Code 211.12 (c) Nursing services

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

28 Pa Code 211.12 (d)(2) Nursing services

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

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







 Plan of Correction - To be completed: 04/28/2020

1.R19 Fentanyl order has been corrected and witnessed by 2 nurses removal of patch has been added to the Fentanyl order. R61 physician has been notified on missed quetiapine dose on 1/7/2020/ R11 physician made aware of meds not given. R19 physician made aware med not given. Resident R19 physician was made aware that clonazepam, artificial tears, ocuvite lutein were not given as ordered. Physician was notified, no adverse effects no new orders. R11, physician made aware spirolactone, nesina, Vitamin D, Ezetimibe, were not given. Physician was notified. No new orders and no adverse effect.


2. Residents MAR documentation was audited, other concerns for missing entries were resolved.
3. Licensed nursing staff will be re-educated to re-order meds timely, reconciling removal of controlled substances, and in-service on emergency medication supply. Staff will also be educated to notify MD if medication is not given as prescribed.
4. DON/Designee will audit med administration daily x2 weeks, weekly x2 weeks, then monthly x3 months. Audits will be reported to QAPI x3 months or until substantial compliance

483.12 REQUIREMENT Free from Misappropriation/Exploitation: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.
483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations:


Based on interviewed with staff, the review of the clinical record, facility policy and the review of facility documentation, it was determined that the facility failed to ensure that one resident was free from misappropriation of property for one out of 18 resident's reviewed (Resident R78).

Findings include:

Review of the facility's policy entitled," Abuse, Neglect, Injuries of Unknown Source and Misappropriation of Property: Prevention," with a revision date of "10/25/17, stated that it is the policy of the facility and its affiliates to not condone and actively address any allegation of resident abuse, neglect, injuries of unknown source or misappropriation of property by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies servicing the family, family members, legal guardians, sponsors, friends or any other individuals.

Review of the interdisciplinary notes for Resident R78 revealed the resident was admitted to the facility on November 14, 2018 with diagnoses, that included, but not limited to, heart failure (heart failure-condition in which the heart doesn't pump blood as well as it should), hypertension (high blood pressure), Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), anxiety (a disorder characterized by feelings of worry, anxiety, or fear that interfere with one's daily activities) and depression (a mood disorder characterized by a persistent feeling of sadness and loss of interest or loss of interest in activities, causing significant impairment in daily life).

Review of information submitted by the facility revealed that on July 6, 2019, the facility was notified by Resident R78's son that a check was written in the amount of $700.00 and was signed and cashed on July 5, 2019 by a nursing assistant (Employee E10) at the facility.

During a discussion with the Nursing Home Administrator on February 27, 2020 at approximately 1:30 p.m. it was confirmed that the above-referenced incident occurred, and that the investigation was found to be substantiated for misappropriation of patient/resident property.

The facility failed to ensure that one resident was free from misappropriation of property for one resident reviewed.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 201.18(b)(1) Management

28 Pa Code 201.18(b)(2) Management

28 Pa Code 201.29(j) Resident rights

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











 Plan of Correction - To be completed: 04/28/2020

1. Employee E10 was identified for not following facility policy for misappropriation of property, and was immediately terminated from employment. R78 had checkbook removed from facility by family member.
2. All similar residents with checkbooks in their possession will be encouraged to use locked bedside table. Families will be encouraged not to leave checkbooks in LTC rooms.
3. All staff involved in resident assessment and care planning will receive training on the facility abuse prohibition policy and elements that constitute misappropriation of property by Polaris.
4. DON/ Designee will randomly audit staff weekly on knowledge and accountability of abuse/misappropriation policy. Audits will be reported to QAPI committee x3 months or until substantial compliance.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on observations, review of clinical record review, review of facility documentation, review of facility policy and staff interviews, it was determined that the facility failed to revise a care plan for weight loss management, for one of 26 residents reviewed (Resident R21).

Findings include:

Review of the facility's policy titled, "Fall Reduction Program" revised on October 21, 2019 stated, "Assess for risk of fall on admission, quarterly, and at a change of condition." "Interventions are to be established and documented on the Skilled Nursing plan of care," " Residents are to be observed regularly for signs of unsteady gait and declines," "Investigate cause of fall," "Update care plan with new interventions appropriate for cognitive levels and related to the conditions involving the fall," and "Identify potential breakdowns that lead to the fall."


Reviewof Resident 21 clinical record revealed that the resident was admitted to the facility on February 6, 2017 with the diagnoses including but not limited to vascular dementia without behavioral disturbance (a decline in memory or other thinking loss), and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions).

A review of the Comprehensive Minimum Data Set ( MDS-a periodic review of a resident's assessment and care needs) dated September 19, 2019, revealed a BIMS (Brief Interview for Mental Status- a brief screening tool that aids in detecting cognitive impairment) score as 3, indicating that the Resident R21 had severe cognitive impairment.

Review of Resident 21's dietician notes dated February 18, 2020 revealed "visited resident at dining room with 2 friends' presence. -9% weight loss in 6 months per record. No further weight loss in past 5 months. Friends reported resident refused food, usual for her. PO (by mouth) intake ~25% per visit. Resident accepted magic cup (nutritional supplement) and mighty shake (nutritional supplement) after meal. Fluid intake is good. Accepts snacks between meals sometimes per staff. Nutrition & weight loss risk communicated with interdisciplinary team."

Review Resident R 21's care plan dated February 28, 2020, revealed that the care plan had not been reviewed, and updated to address the care needs related weight loss management.

On February 28, 2020, at 11:19 a.m., the Director of Nursing conducted an independent verification of the care plan and confirmed that Resident R21's care was not updated to reflect interventions related to weight loss management

.


28 Pa Code 211.11(d) Resident Care Plan

28 Pa Code 211.12(c)(d)(3) Nursing services

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










 Plan of Correction - To be completed: 04/28/2020

1.Resident R21 was identified for not having her care plan updated to address care needs in relation to weight loss management R21 had care plan updated and identified weight loss management.
2. All residents who trigger for weight loss will have care plan updated to include weight loss management. All areas of weight loss will have care plan reviewed to ensure weight loss is addressed.
3. All staff who monitor weight loss and management will receive education on care plan revisions, comprehensive, and quarterly assessments in relation to weight loss management.
4. DON/ Designee will audit care plans weekly for those who trigger. Audits will be reported to QAPI x3 months or until substantial compliance.

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 observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to assess a midline line catheter in accordance with professional standards of practice for one of one residents reviewed. (Resident R 236).

Findings include:

Review of facility policy, "Flushing Midline and Central Line IV Catheters" revised June 29, 2017, revealed that "insertion site assessment should be done as part of flushing process to monitor for complications."

Clinical record review for Resident R 236 revealed an Admission Summary, dated February 14, 2020, at 9:38 p.m., which indicated that the resident was admitted to the facility on February 14, 2020, and that the resident had a left upper extremity single lumen midline (catheter placed into a vein by the bend in the elbow or upper arm. The midline tube ends in a vein below the armpit. Having a midline catheter may allow to receive long-term intravenous (IV) medicine or treatments)

Review of Resident R236's physician order dated February 14, 2020, revealed an order to monitor the single lumen midline every shift for signs and symptoms of infiltrate or infection.

Review of the resident February 2020 Treatment Administration Record (TAR) revealed no documented evidence that the resident left upper extremity midline catheter was assessed every shift for signs and symptoms of infiltrate or infection on February 15, 18, 19, 22, 23, and 27, 2020.

Further review of the February 2020 TAR revealed no recording of the size of the midline catheter.

The facility failed to assess and monitor Resident R236's midline catheter in accordance with professional practice standards.


28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.12(c) Nursing services

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

28 Pa Code 211.12(d)(2) Nursing services


).




 Plan of Correction - To be completed: 04/28/2020

1. R236 has been discharged for the facility. Catheter was removing according to physician order prior to DC. No complications or adverse effects
2. Residents with midline catheter will be assessed for signs and symptoms of infections and record size of midline catheter in care plan.
3. Licensed nursing staff will be re-educated on assessing for signs and symptoms of infections for midline catheters. Length will be addressed in care plan.
4. Audits of midline catheters will be conducted weekly and results reported to QAPI x3 months or until substantial compliance.

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training: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.
483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12.

483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

483.95(c)(3) Dementia management and resident abuse prevention.
Observations:

Based on the review of facility policy, facility records, and interviews with staff, it was determined that the facility failed to maintain an effective training program for staff on abuse, neglect, exploitation, and misappropriation of resident property.

Findings include:

Review of the facility's policy entitled," Abuse, Neglect, Injuries of Unknown Source and Misappropriation of Property: Training," with a revision date of "10/25/17," stated that it is the policy of the facility and its affiliates to not condone and actively address any allegation of resident abuse, neglect, injuries of unknown source or misappropriation of property by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies servicing the family, family members, legal guardians, sponsors, friends or any other individuals.

Review of the interdisciplinary notes for Resident R78 revealed the resident was admitted to the facility on November 14, 2018 with diagnoses, that included, but not limited to, Heart Failure (a condition in which the heart does not pump blood as well as it should, Hypertension (high blood pressure), Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), Anxiety (a disorder characterized by feelings of worry, anxiety, or fear that interfere with one's daily activities), and Depression (a mood disorder characterized by depressed mood or loss of interest in activities, causing significant impairment in daily life).

Review of information submitted by the facility revealed that on July 6, 2019, the facility was notified by Resident R78's son that, a check of Resident R78 was written in the amount of $700.00 and was signed and cashed on July 5, 2019, by a nursing assistant (Employee E10) at the facility.

During a discussion with the Nursing Home Administrator on February 27, 2020 at approximately 1:30 p.m., it was confirmed that the above-referenced incident occurred, and that the investigation was found to be substantiated for misappropriation of resident property.

Review of the annual training records for Employee E10 provided by the facility revealed that, the last documented training for Employee E10 for abuse, neglect, exploitation, and misappropriation of resident property was August 16, 2017.

During a discussion with the Director of Nursing on February 28, 2020, at approximately 3:05 p.m., it was confirmed that there was no additional documentation to show evidence of any additional training for Employee E10 on abuse, neglect, exploitation and misappropriation of resident property after August 16, 2017.

The facility failed to maintain an effective training program for staff on abuse, neglect, exploitation, and misappropriation of resident property.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 201.18(b)(1) Management

28 Pa Code 201.18(b)(2) Management

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












 Plan of Correction - To be completed: 04/28/2020

1.E10 has been terminated from employment and R78's checkbook has been removed from the facility by the family.
2. All similar residents with checkbooks in their possession will be encouraged to use locked bedside table. Families will be encouraged not to leave checkbooks in LTC rooms.
3. Facility will ensure all staff will be re-educated on abuse and neglect with the element of misappropriation of property.
4. auditing of education will be performed by administrator and will be conducted weekly x3months. Audits will be reported to QAPI team x3 months or until substantial compliance.

201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:


Based on staff interviews; review of facility policy and infection control committee attendance records, it was determined that the facility did not comply with the requirements of Act 52 of 2007: Medical Care Availability and Reduction of Error (MCARE) Act.

Findings include:

Review of Act 52 of 2007: Medical Care Availability and Reduction of Error (MCARE) Act. Section 1303.403. Infection Control Plan states that a health care facility should develop and implement an internal infections plan that should be established for the purpose of improving the health and safety of residents and health care workers and should include a multidisciplinary committee including a representative from each of the following, if applicable to the specific health care facility:

(i) Medical staff
(ii) Administration representatives
(iii) Laboratory personnel
(iv) Nursing staff
(v) Pharmacy staff
(vi) Physical plant personnel
(vii) Patient safety officer
(viii) Members from the infection control team, which could include an epidemiologist
(ix) The Community, except that these representatives may not be an agent, employee or contractor of the health care facility

Review of the facility policy title "Quality Assessment and Performance Improvement, Infection Control" (revised October 22, 2019) states that it is the policy of the facility and its affiliates that the community will maintain a safe, sanitary and comfortable environment to help prevent and manage transmission of diseases and infections.

Review of the committee meeting attendance records and interview with the Director of Nursing on February 25, 2020 at approximately 10:45 a.m., revealed that in infection control meetings held on December 11, 2019 and January 20, 2020,the following personnel were not in attendance:
December 11, 2019 - Community person
January 20, 2020- Community person

The facility did not comply with the requirements of Act 52 of 2007: Medical Care Availability and Reduction of Error (MCARE) Act.





 Plan of Correction - To be completed: 04/28/2020

1. Community member not present at monthly infectious disease meeting.
2. Community member will be in attendance for all future infectious disease meetings.
3. Infectious disease nurse will ensure community member is in attendance
4. Infectious disease will audit for attendance x3 months and will report to QAPI committee x3 months or until substantial compliance.


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