Nursing Investigation Results -

Pennsylvania Department of Health
SILVER LAKE CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SILVER LAKE CENTER
Inspection Results For:

There are  125 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SILVER LAKE CENTER - 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 January 15, 2020, it was determined that Silver Lake Center, 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:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
483.10(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, review of facility documentation, review of facility policy and procedure and interviews with residents and staff, it was determined that the facility failed to maintain comfortable water temperatures for residents on one of four nursing units (post acute unit).

Findings include:

A review of the undated facility policy, "Test and log hot water temperatures - Sunday", indicated that water temperatures will be tested to ensure patient room water temperatures do not exceed 110 degrees Fahrenheit, and to check rooms at the end of each wing on a rotating basis, and to let the water run for three minutes before taking the reading.

Interview with Resident R6, who resides in Room 10, on January 13, 2020 at approximately 2:00 p.m., revealed that the water in the shower is cold. The resident reported that it may start out luke-warm but turns cold. He also indicated that when he put the thermometer under the running water it was reading 76 degrees. The resident further stated that he cannot tolerate a cold shower and feels bad for the other residents like his roommate who is older has trouble staying warm without a cold shower.

Observations of the water temperatures in resident rooms taken on January 14, 2020 at approximately 10 a.m. in the presence of Employee E3, Maintenance Director and the Nursing Home Administrator (NHA), using the facility thermometer, revealed the following shower temperatures: Room 10 - 83.6 degrees; Room 25 - 83.6 degrees. During the observation of the shower temperatures the NHA indicated the temperature as being luke-warm and not what he was getting during his audits.

Interview with Employee E3, in the presence of the NHA, on January 14, 2020 at approximately 10:15 a.m. confirmed that the boiler for the post-acute unit (rooms 1- 29) was not functioning properly. Observation of the boiler for the post-acute unit conducted on January 14, 2020, at approximately 10:30 a.m. revealed that the boiler, located in the front of the building, was not operating and that the facility had called a plumber to come in to repair the boiler.

Further interview with Employee E 3 on January 14, 2020, at approximately 1:25 p.m. revealed that the plumber had come and was working on the boiler and that it would need parts, but that it was working. During a follow-up observation of the shower temperatures at approximately 1:30 p.m. in Room 25 the reading was 93.1 degrees after the water had run for a few minutes.

Interview with the NHA on January 14, 2020, at approximately 2:15 p.m. confirmed that the boiler was working intermittently and that the plumber had ordered a new mixing valve which would be installed as soon as it was available. He further stated that the facility was monitoring water temperatures hourly on the post-acute unit and that the nursing staff was in-serviced on using showers on the other units until the boiler was repaired.

A review of shower temperature logs, back to September 2, 2019, revealed that the recorded shower temperatures were between 100 and 110 degrees until January 14, 2020 when the 94.5 degrees was recorded for room 10.

The facility failed to maintain comfortable water temperatures for residents on one of four nursing units.

42 CFR 483.10 Resident Rights
Previously cited 12/06/2018

28 Pa. Code 201.29(j) Resident rights
Previously cited 11/20/19, 12/6/18

28 Pa. Code 205.37(e) Equipment for bathrooms








 Plan of Correction - To be completed: 02/17/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

Resident R6 interviewed and reported water in shower room is warm during shower. Water in shower room temperature is 108.6. Room 10 water temperature is 109.2. Rm 25 water temperature is 108.1. Boiler repaired by plumber on 1/14/2020. Mixing valve repaired on1/29/2020 . Hourly water temps obtained until 1/29/2020 and findings included 108.9 degree Fahrenheit.
Maintenance Director will obtain water temperatures in Post Acute random resident shower rooms and unit shower rooms.
Nursing Home Administrator will in-service facility Maintenance Director on ensuring resident water temperatures range remains between 100-110 degrees.
Maintenance Director will obtain water temps in Post-Acute Unit 5 random rooms 5x a week for four (4) weeks, weekly x 4 weeks then monthly x three (3) months, and as needed. IDT will interview 5 random residents/week for 4 weeks, then monthly x three (3) months, and as needed. Audit findings will be reported at monthly QA and A for further review and recommendations.


483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 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 the clinical record and interviews with staff, it was determined that the facility failed to ensure that one of 36 residents review was free from abuse. (Resident R78)

Findings include:

Review of the clinical record for Resident R78 revealed diagnoses that included, but were not limited to, vascular dementia (a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain), bipolar disorder (serious mental illness characterized by extreme mood swings), anxiety disorder (characterized by excessive, uncontrollable and often irrational worry about events or activities, dysphagia (dysphagia-difficulty in swallowing) and restlessness and agitation.

Review of Resident R78's current person-centered care plan and the resident's interdisciplinary notes from January 2019 through January 2020 revealed that the resident exhibited a number of behaviors, which included, refusing care and treatment, combative behaviors towards staff, wandering (random or repetitive movement or the ability to move from one place to another. It can be goal-directed such as an individual searching for something such as an exit, or it can be non-goal directed or aimless) disrobing and grabbing items on the nursing carts on the units.

Review of Resident R78's interdisciplinary notes dated August 11, 2019 at approximately 9:30 p.m. revealed an allegation of abuse that Employee E7, nursing assistant, had reported she witnessed while the resident was receiving care from another nursing assistant (Employee E8). Employee E7 reported that she was asked by Employee E8 to help provide care to Resident 78 while being changed. Employee E7 indicated that Employee E8 "got frustrated and smacked the resident on the head."

Review of the investigation regarding the above allegations revealed that Resident R78 was not alert or oriented to name, person or place and that he could not be interviewed due to his cognitive status.

Review of the interview that Employee E8 provided to the charge nurse after Employee E7 reported the incident to her revealed that Employee E8 reported that hitting the resident on the head was "a reaction" as the resident kept trying to get up.

Further review of the investigation revealed that during the resident's skin assessment following the allegation on August 11, 2019, "a right upper arm bruise" was documented and its appearance was described as "discoloration bruise, redness and blue." In addition, "Right arm (upper) scratches" were also found during the skin assessment completed on the above referenced date.

Interview with the Director of Nursing (DON) on January 15, 2020 at approximately 1:00 p.m. confirmed that the allegation of abuse that was substantiated.

The facility failed to ensure that one resident was free from abuse.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/20/19, 12/6/18

28 Pa. Code 201.18(b)(1) Management
Previously cited 12/6/18

28 Pa. Code 201.29(j) Resident rights
Previously cited 11/2019, 12/6/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 7/18/19, 12/6/18











 Plan of Correction - To be completed: 02/17/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

R78 remains free from abuse and was seen by charge nurse. Employee E8 was terminated on 8/15/2019.
Unit Managers/designee will perform skin sweeps on residents with impaired cognition to ensure residents remain free from abuse. Unit Managers/designee will review any skin impairments in last 7 days to ensure residents have remained free from abuse.
Staff Development Coordinator/designee will in-service all staff on facility Abuse Policy including Elder Justice Act.
DON/designee will audit incidents of skin impairment in clinical meeting to ensure residents remain free from abuse. Unit Managers/designee will review skin assessments in clinical meeting of residents with impaired cognition to ensure residents remain free from abuse. Unit Managers/designee will interview random staff 5 X week to ensure abused policy being followed (any witnessed abuse is reported). Audit findings will be reported at monthly QA and A for further review and recommendations.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

The facility failed ensure that residents received proper grooming and personal hygiene for three of 36 residents reviewed (Resident R17, R76 and R156).

Findings include:

Review of the clinical record for Resident R17 revealed diagnoses including, but not limited to, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), hypertension (hypertension-high blood pressure), difficulty walking and lack of coordination. Review of Resident R17's Quarterly Minimum Data Set Assessment (MDS-an assessment of a resident care needs) dated October 15, 2019, revealed that the resident required extensive assistance with dressing and personal hygiene and that Resident R17 was cognitively impaired.

Observation of the second-floor nursing unit on January 12, 2020 at approximately 11:00 a.m. revealed a strong urine odor detected in the hallway on which Resident R17 resided. The odor started in the middle of the hall way, and the presence of the odor became stronger the closer that one got to Resident R17, who was sitting at the end of the hall way. Further observation of Resident R17, at that time, revealed that the resident was not shaven and the hair on the resident's head was not properly groomed (cut, combed, or brushed).

Review of facility documentation revealed that the last time Resident R17 had a hair cut was on December 4, 2019, approximately 31 days prior to the observation.

Observation of the second-floor nursing unit on January 14, 2019 at approximately 11:30 a.m. revealed that the above referenced urine odor was again detected. The odor became stronger the closer one got to Resident R17, who again was observed sitting at the end of the hall way. Continued observation of Resident R17 revealed that, at the time of the observation, he was unshaved and appeared disheveled.

Review of the clinical record for Resident R76 revealed diagnoses including, but not limited to, cerebrovascular disease (a stroke), muscle weakness, difficulty walking; alcohol dependence and dysphagia (difficulty swallowing). Review of Resident R76's Annual Minimum Data Set Assessment dated November 15, 2019, revealed that Resident R76 required extensive assistance for personal hygiene which included, combing hair, shaving and brushing teeth.
and that the resident was severely cognitively impaired.

Observation of the second-floor nursing unit on January 12, 2020 at approximately 11:00 a.m. revealed that Resident R76 was observed outside his room with overgrown hair that was in the shape of a bush. Further observation of Resident R76 revealed that he had not been shaved in quite some time.

Review of the documentation provided by the facility revealed that the last time Resident R76 had a hair cut was March 27, 2019, over nine months prior to the observation.

Review of the clinical record for Resident R156 revealed diagnoses including, but not limited to, dementia ( a group of symptoms that affects memory, thinking and interferes with daily life) and anxiety (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Resident R156's Admission Minimum Data Set dated December 30, 2019, revealed that Resident R156 required extensive assistance with personal hygiene, including, combing his hair and brushing his teeth. Additionally, the Annual Minimum Data Set dated December 30, 2019, revealed that the resident was moderately cognitively impaired.

Observation on January 13, 2020 at approximately 10:28 a.m. revealed that Resident R156 was observed with nails that were dirty and hair that was uncombed. Review of information provided by the facility revealed that the last time the resident saw the hair dresser was on September 10, 2019 for a shampoo and hair cut, approximatley four months prior to the observation.

Interview with Employee E9, Clinical Reimbursement Director, on January 15, 2019 at approximately 1:07 p.m. revealed that the hair dresser /barber comes three times a week, and that residents receive services from the hair dresser/barber once every 6 weeks, and as needed. Employee E9 also stated that the nursing assistants should be combing the women's hair and that residents should receive nail care and shaving on their shower days.

The facility failed to ensure that three residents received proper grooming and personal hygiene.

28 Pa. Code: 201.18(b)(1) Management
Previously cited 12/6/18

28 Pa. Code: 201.29(j) Resident rights
Previiously cited 11/20/19, 12/6/18

28 Pa. Code 211.10(d) Resident care policies
Previoulsy cited 12/6/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 12/6/18
28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 12/6/18















 Plan of Correction - To be completed: 02/17/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

R17, R76, and R56 have received proper grooming and personal hygiene.
Unit Managers/designee will review residents shower record to ensure all residents have been properly groomed and received personal hygiene x last 14 days.
Staff Development Coordinator/designee will in-service all nursing staff on F0677

Unit Managers/designee will review resident shower records in clinical meeting.IDT will observe residents to ensure they have received proper grooming and personal hygiene 5 x week for 4 weeks, then weekly x 4 then monthly. Social Service Director/designee will provide hairdresser with schedule twice weekly for residents to receive services and audit for compliance. Audit findings will be reported at monthly QA and A for further review and recommendations.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on observation, staff interviews and a review of clinical records, it was determined that the facility failed to follow physician's orders for one of 36 resident reviewed (Resident R58).

Findings include:

A review of resident R58's clinical record revealed that the resident was admitted to the facility on January 15, 2016, with diagnoses, including but not limited to, bi-polar disorder (a disorder associated with episodes of mood swing ranging from depressive lows to manic highs) and stroke (damage to the brain from interruption of its blood supply.)

A review of the resident's medication management assessment (a visit from the nurse practioner for psychiatric care) dated September 5, 2019, revealed a recommendation to start the medication Hydroxyzine (an antihistamine used to treat anxiety) 25 milligrams one pill one time a day by mouth. The medication was started on September 9, 2019.

Further review of the resident medication management assessment dated October 4, 2019, revealed recommendations from the nurse practioner to increase Abilify (antipsychotic-used to treat bipolar disorder) back to 10 milligrams daily and to discontinue Hydroxyzine. A review of the MAR (Medication Administration Record) for January 2020, revealed that the resident has still been receiving Hydroxyzine 25 milligrams one time a day by mouth since September 9, 2019. Additionally, the resident has been receiving Abilify seven milligrams one time a day by mouth since June 24, 2019. A review of a new physician's order dated January 7, 2020, revealed to give Abilify 5 milligrams at bedtime one time a day by mouth for two weeks then discontinue.

Futher review of medication management assessment dated November 8, 2019, revealed that the nurse practioner documented under medication recommendation that "medication recommendations not followed, refer to primary care physician." No other evidence available for review that the recommendation were acted upon or reviewed by the physician.

Interview with the Employee E4, a nurse, on January 15, 2020, at 11:00 a.m. confirmed that the resident is still on Hydroxyzine 25 milligrams one time a day by mouth and the Abilify is five milligrams at bedtime one pill by mouth.

The facility failed to ensure that physician's orders were followed for Resident R58.

42 CFR 483.25 Quality of Care
Previously cited 12/16/2018

28 Pa. Code 211. 12 (d)(1) Nursing services
Previously cited 7/18/19, 12/6/18

28 Pa. Code 211. 12 (d)(5) Nursing services
Previously cited 7/18/19, 12/6/18
















 Plan of Correction - To be completed: 02/17/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

R68 and medications were reviewed by Md on 2/5/2020 with recommendations followed per Md orders. Med Options consulted to evaluate resident on 11/08/2019.
DON/designee will review Medication Management Assessments (Med Options consults) to ensure physician orders followed x last 30 days.
Staff Development Coordinator/designee will in-service licensed nurses on facility Physician Notification Policy.
DON/designee will review recommendations including Medication Management Assessments in clinical meeting to ensure physician orders followed. Recommendations will be audited weekly x 4 weeks, then monthly to ensure physician orders followed. Audit findings will be reported at monthly QA and A for further review and recommendations.


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on observation, review of facility policy and review of clinical records, it was determined that the facility failed to ensure that one of 54 residents on the second floor was provided with adequate supervision during medication administration (Resident R163).

Findings include:

Review of facility policy, "Medication Administration General Guidelines," dated 12/12, revealed that medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. The policy also stated that the resident is always observed after administration to ensure that the dose was completely ingested.

Further review of the policy revealed that residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations.

Review of the clinical record for Resident R163 revealed diagnoses including, but not limited to, catatonic schizophrenia (a form of schizophrenia characterized by extreme withdrawal usually with immobility and mutism), schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations, delusions, and mood disorder symptoms) and hypertension (high blood pressure).

Review of Resident R163's physican orders dated January 2020 revealed a physician's order for Lactulose Solution (drug used to treat or prevent complications of liver disease) give 45 milliliters by mouth two times a day for encephalopathy (abnormal condition of the brain). Review of Resident R156's quarterly Minimum Data Set (MDS-an assessment of a resident's need) dated January 2, 2020 revealed that the resident was mildly cognitively impaired.

Observation of the 2nd floor nursing unit on January 14, 2020 at approximately 11:00 a.m. revealed Resident R163 eating a cup of oatmeal. Further observation at this time, revealed the presence of two small plastic cups on the resident's dresser. A liquid was observed inside each cup. Interview with Resident R163, at the time of the observation, revealed that the two small plastic cups belonged to her and the resident further indicated "... that's my medication she bought in here. I have to take those after I finish eating."

Interview with Employee E6, Licensed Practical Nurse, at the time of the observation, revealed that she had provided the resident with the two small plastic cups that were filled with liquid medication. Further interview with Employee E6 revealed that the contents inside the cups was the resident's Lactulose medication. Employee E6 stated, "I thought she took it, and then said to the resident, "Oh, you didn't take that?" The resident replied "no."

Review of the resident's physician orders for Resident R163 revealed no order for the self-administration of medications. Interview with the Director of Nursing (DON) on January 15, 2020 at approximately 3:45 p.m. confirmed that the resident did not have a physician's order to self-administer her medication.

The facility failed to provide adequate supervision to Resident 163 during medication administration.

42 CFR 483.25 Quality of Care
Previously cited 12/06/2018

28 Pa. Code 211.14(a) Responsibility of licensee
Previously cited 11/20/19, 12/6/18

28 Pa. Code 201.18(b)(1) Management
Previously cited 12/6/18

28 Pa. Code 211.10(d) Resident care policies
Previously cited 12/6/18

28 Pa Code 211.12(d)(1) Nursing services
Previously cited 7/18/19, 12/6/18










 Plan of Correction - To be completed: 02/17/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

R163 assessed and no changes noted from meds left at bedside. Resident had lactulose level drawn on 1/15 and result WNL. E6 educated on providing adequate supervision during medication administration.
Unit Manager/designee will perform rounds 5 x week to ensure random resident environment is free of accident hazards by ensuring medications meds administered under adequate supervision.
Staff Development Coordinator/designee will in-service licensed nurses on facility Medication Administration General Guidelines Policy.
Unit Manager/Designee will audit resident rooms weekly x 4 then monthly x 3 to ensure resident environment is free of accident hazards by ensuring medications never left at resident's bedside unattended. Staff Development Coordinator/designee will perform Medication Pass Observation Competencies with random licensed nurses to audit for adequate supervision provided during medication administration 5 x week for 4 weeks, then weekly x 4 weeks then monthly. Audit findings will be reported at monthly QA and A for further review and recommendations.

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 observation, review of facility policy, review of clinical records and interviews with staff, it was determined that the facility failed to properly monitor a peripherally inserted central catheter line (PICC) for one of three residents reviewed with PICC lines. (Resident R220).

Findings include:

A review of the facility policy, " Vascular Access Devices- PICC Catheter", dated August 8, 2016, revealed that the catheter tip is threaded into a vein and the ideal location of the tip of the catheter is at the atrial cava junction (a section of the heart). Consideration: measure the external length of the PICC catheter at insertion and measure when clinically indicated if catheter dislodgement is suspected. Compare to measurement obtained at insertion.

A review of Resident R220's clinical record revealed that the resident was admitted to the facility on January 6, 2020, with diagnoses including, but not limited to, lung cancer and respiratory failure (difficulty breathing).

A review of physician's orders dated January 11, 2020, revealed an order to change the intravenous PICC line dressing every 7 days and as needed for soiling and dislodgement during evening shift every seven days.
Further review of physician's orders for Resident R220 dated January 2020, revealed no order to measure the length of the external catheter.

Interview with Employee E5, licensed nursing staff, on January 15, 2020, at 12:30 p.m. confirmed that the external length of the catheter was only measured on insertion. When asked how would the facility know if the PICC line catheter had moved (come out or migrated), Employee E5, stated she would inquire.

The facility failed to ensure that Resident R220's PICC line was properly monitored.

28 Pa. Code 211.12 (d)(1) Nursing services.
Previously cited 7/18/19, 12/6/18








 Plan of Correction - To be completed: 02/17/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

R20 was discharged to home on 1/24/20 unable to address order.
Unit Manager/designee will review orders of residents with PICC line to ensure proper monitoring of PICC line including weekly measurements of external catheters.
Staff Development Coordinator/designee will in-service licensed nurses on facility Vascular Access Device PICC Catheter Policy.
Unit Manager/designee will review orders for all residents with PICC line catheters upon admission in clinical meeting to ensure orders for external catheter length measured weekly. Unit Manager/designee will audit residents with PICC line catheters weekly x 4 then monthly x 4 month to ensure proper monitoring of PICC line catheter including weekly measurements of external catheter length. Audit findings will be reported at monthly QA and A for further review and recommendations.

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on a review of clinical records and staff interview, it was determined that the facilit failed to ensure that one of one resident review on dialysis received dialysis services.

Findings include;

A review of Resident R158's clinical record revealed that the resident was admitted to the facility on July 22, 2019, with a diagnosis including, but not limited to, dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood, in people whose kidneys are not functioning properly) and diabetes (a group of disease that result in too much sugar in the blood).

Review of physician's orders dated November 12, 2019, revealed that that the resident went to dialysis on Tuesday, Thursday and Saturdays.

Interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on January 14, 2020, at 2:30 p.m. revealed that they were unaware that the resident had not gone to dialysis on Tuesday January 14, 2020.

An additional interview with the NHA and DON on January 15, 2020, at 10:00 a.m. confirmed that the 11:00 p.m. to 7:00 a.m. shift nurse did not inform the next shift or the physician that the resident did not want to go to dialysis on January 14, 2020.

The facility failed to ensure that physician's orders were followed for dialysis and did not inform staff or the physician that the resident did not receive dialysis treatment as scheduled.


42 CFR 483.25 Quality of Care
Previously cited 12/16/2018

28 Pa. Code 211. 12 (d)(1) Nursing services
Previously cited 7/18/19, 12/6/18

28 Pa. Code 211. 12 (d)(5) Nursing services
Previously cited 7/18/19, 12/6/18



 Plan of Correction - To be completed: 02/17/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

R58 physician notified of resident dialysis refusal on 1/14/20 and was rescheduled for 1/15/20.
Unit Manager/designee will review residents receiving dialysis to ensure physician orders followed and that physician notified if dialysis treatment not received x last 14 days.
Staff Development Coordinator/designee will in-service all licensed nurses on facility Dialysis Management Policy.
Unit Manager will review 24- hour report in clinical meeting and will audit residents receiving dialysis to ensure physician orders followed and if not Md notified timely 3 times week for 4 weeks, then weekly x 4 then monthly x 2 months and after as needed. Audit findings will be reported at monthly QA and A for further review and recommendations.

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 documentation, it was determined that the facility failed to ensure that a dementia training program was developed for facility staff for

Findings include:

Review of the January 2020 physician's orders for Resident R78 revealed diagnoses that included, but not limited to, vascular dementia ( disease assiciated with problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain); bipolar disorder (a serious mental illness characterized by extreme mood swings); anxiety disorder (disorder characterized by excessive, uncontrollable and often irrational worry about events or activities; dysphagia (difficulty in swallowing); restlessness and agitation, and difficulty in walking.

Review of the resident's person-centered care plan provided and interdisciplinary notes from January 2019 through January 2020 revealed that resident exhibited a number of behaviors, which included, refusing care and treatment, combative behaviors towards staff, wandering (a random or repetitive movement or the ability to move from one place to another, disrobing, grabbing items on the nursing carts on the units, poor appetite, and spitting on the floor.

Review of Resident R78's interdisciplinary notes dated August 11, 2019 at approximately 9:30 p.m. revealed an allegation of abuse involving the resident, that a nursing assistant Employee E7 reported that she witnessed while the resident was receiving care from another nursing assistant (Employee E8).

Review of the investigation regarding the above allegations revealed that the resident was not alert or oriented to name, person or place and that he could not be interviewed due to his cognitive status.

Review of the interview that Employee E8 provided to the charge nurse after Employee E7 reported the incident to her revealed that Employee E8 reported that hitting the resident on the head was "a reaction" as the resident kept trying to get up.

Employee E7 reported that she was asked by Employee E8 to help provide care to Resident R78. Employee E7 stated that the resident was trying to stand up while being changed and that Employee E8 "got frustrated and smacked the resident on the head."

Review of nursing assistant Employee E7's personnel record including training records did not include any training on dementia management.

During a discussion with the Director of Nursing on January 15, 2020 it was confirmed by the Director of Nursing that dementia management training provided to nursing staff could not be produced.

The facility failed to ensure that a training program on dementia management was developed for staff.

28 Pa Code:


















 Plan of Correction - To be completed: 02/17/2020

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

E7 is no longer employed in the facility.
Staff Development Coordinator/designee will review employee personnel records for Dementia Training program.
DON/designee will in-service Staff Development Coordinator on Dementia Training program.
Staff Development Coordinator/designee will audit new hires employee personnel records weekly each month x 4 to ensure Dementia Program in-service received. Audit findings will be reported at monthly QA and A for further review and recommendations.


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