Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT GETTYSBURG, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT GETTYSBURG, THE
Inspection Results For:
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GARDENS AT GETTYSBURG, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on findings of an abbreviated complaint survey in response to one complaint completed on January 3, 2020, at the Gardens at Gettysburg, it was identified that the facility was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

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 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and staff interview it was determined that the facility failed to maintain a safe, clean and home-like environment for 15 of 48 resident rooms (four resident room floors on the 100 hallway, two resident room floors on the 200 hallway, seven resident room floors and two resident bathrooms on the 300 hallway, and two resident room floors on the 400 hallway).

Findings include:

Observations in Resident 1's room December 30, 2019, at approximately 10:19 AM revealed that there was crushed orange crumbs on the floor in front of the window at the bottom of the bed, there was dry cold cereal and one napkin on the floor near Resident 1's bed, and a brown film was noted on the floor with notable foot prints just inside the doorway to Resident 1's room.

Observation in Resident 3's room on December 30, 2019, at approximately 10:31 AM revealed black specks on the floor in front of the closet. Additional observation at 11:25 AM with the Nursing Home Administrator and the Director of Housekeeping revealed that the black specks were bird seed.

An interview with the Director of Housekeeping (HK) on December 30, 2019 at approximately 11:20 AM revealed that resident room floors are cleaned daily with a micro-fiber cloth. It was also revealed that during the week there are three housekeepers and one floor tech scheduled. Each housekeeper is assigned one hallway and the 100 hallway is split between the three housekeepers. The floor tech is responsible for cleaning the hallway floors and the nursing stations. On the weekends there are two housekeepers scheduled and they each are responsible for 2 hallways each.

During a tour of the resident rooms there were concerns pertaining to cleanliness of the floors and two toilets that contained a dried brown substance on/near the toilet seat on the 300 and 400 hallways
on December 30, 2019, at approximately 11:20 AM that lasted until approximately 11:50 AM, with the Nursing Home Administrator and the Director of Housekeeping (HK), it was revealed that the two toilets on the 300 hallway that contained a dried brown substance on the seat should have been cleaned, and that when a floor requires additional cleaning staff should alert housekeeping and/or complete an initial cleaning if necessary.

During a second tour of 2 rooms on the 300 hallway and 2 rooms on the 400 hallway with the Director of Housekeeping (HK) on December 30, 2019, at approximately 2:00 PM it was revealed that the floors were free from debris and the brown film was removed, however the two toilets on the 300 hallway still contained a dried brown substance on/near the toilet seat.

28 Pa. Code 207.2(a) Administration responsibility

Plan of Correction - To be completed: 02/06/2020

How the facility will correct the deficiency as it relates to the individual.
The identified areas were cleaned the same day.

How facility will act to protect residents in similar situations?
A whole-house audit will be completed by the Director of Housekeeping to identify other floors and toilets needing cleaning.

Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Housekeeping staff will be re-educated on floor care and toilet cleaning.

How the facility plans to monitor its performance to make sure that solutions are permanent; i.e., what quality assurance programs will be established?

Director of Housekeeping/designee will audit three rooms per hall weekly x four weeks and then three rooms per hall monthly x two to ensure the problem does not recur.

Results of audits will be reported monthly at the QAPI Committee to review compliance and make possible changes to the system.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision:

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(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

§483.25(a)(1) In making appointments, and

§483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Observations:

Based on review of facility policy, observations, clinical record review and interviews it was determined that the facility failed to ensure each resident receives proper assistive devices to maintain hearing abilities for two of 3 residents reviewed (Residents 1, and 2).

Findings include:

Review of the facility policy Care of Hearing Impaired Resident, revised February 2018, revealed "staff will assist residents with care and maintenance of hearing devices."

Review of Resident 1's clinical record revealed diagnoses that included: Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movement), schizoaffective disorder bipolar type (a mental health condition alternating periods of elation and depression), depression (feelings of severe despondency and dejection).

Review of Resident 1's Quarterly Minimum Data Set (MDS- periodic assessment of resident needs), dated December 11, 2019, revealed that Resident 1's hearing is adequate, and has hearing aids.

Observation on December 30, 2019, at approximately 12:47 PM revealed Resident 1 in common area at the end of the 100 unit without wearing his hearing aids.

During an interview with the LPN 1, on December 30, 2019, at approximately 12:47 PM it was revealed that Resident 1 is very hard of hearing but does not have hearing aids.

Review of Resident 1's care plan (a written plan of care that included focus areas, goals and interventions) and focus sheet (individualized guidelines to care for each resident) revealed a focus area for communication impaired due to impaired hearing with a history of breaking hearing aids with a revision date of December 9, 2019; and interventions to speak at appropriate volume. and to use simple and direct communication. The aforementioned care plan or focus sheet didn't include the utilization of, or assistance with hearing aids.

During an interview with the Assistant Director of Nursing on December 30, 2019, at approximately 1:33 PM it was revealed that Resident 1 does have hearing aids and has had hearing aids a little over a month. She stated that according to Resident 1, he usually asks the routine dayshift LPN for them in the morning; however that staff member has been on medical leave for the past month. Per the Assistant Director of Nursing, Resident 1 was provided his hearing aids and the care plan and focus sheet were updated. The Assistant Director of Nursing also revealed the expectation is for staff to offer resident 1 his hearing aids.

During an interview with the Director of Nursing on December 30, 2019, at approximately 1:45 PM it was revealed that Resident 1's hearing aids should have been documented on the focus sheet and they weren't. It was also revealed that staff located Resident 1's hearing aids in the medication cart, and that staff should have offered Resident 1 his hearing aids after AM care.

Review of Resident 2's clinical record revealed diagnoses that included: depression (feelings of severe despondency and dejection), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), anxiety (a feeling of worry, nervousness, or unease), and aphasia (loss of the ability to understand or express speech).

Review of Resident 2's clinical record revealed a physician's order to ensure hearing aids are in place and functioning properly every 2 hours while awake, with a start date of November 30, 2018, and hearing aids are to be place each AM by the nurse, ensure batteries are working and installed properly with a start date of December 1, 2018. Further review of Resident 2's clinical record revealed the use of hearing aids on the care plan and focus card.

Observation of Resident 2 on December 30, 2019, at approximately 11:00 AM in the dining room during an activity, revealed Resident 2's hearing aids were not in.

During an interview with Nursing Assistant 1, Resident 2's hearing aids are stored in the medication cart when resident is in bed or refuses to wear them. Nursing Assistant 1 was not aware if Resident 2 was offered her hearing aids prior to attending the activity in the dining room. Resident 2's hearing aids were located in the medication cart and donned with resident acceptance.

During an interview with the Director of Nursing on December 30, 2019, at approximately 2:00 PM it was revealed that Resident 2 refuses to wear her hearing aids at times.

29 Pa code 211.12(d)(5) Nursing Services

Plan of Correction - To be completed: 02/06/2020

How the facility will correct the deficiency as it relates to the individual.
Hearing aides were given to and accepted by identified residents.

How facility will act to protect residents in similar situations?
An audit was completed to identify other residents with hearing aides.

Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Nursing staff were educated by the DON/designee on use and documentation of hearing aides.

How the facility plans to monitor its performance to make sure that solutions are permanent; i.e., what quality assurance programs will be established?
Audits will be completed weekly times 4 and monthly times 2 by the unit charge nurse to verify residents hearing aides are in place and functioning.

Results of audits will be reported monthly at the QAPI Committee to review compliance and make possible changes to the system.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§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 review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure one of 3 residents reviewed were free of unnecessary psychotropic medications (Resident 2 ).

Findings include:

Review of the facility policy, Antipsychotic Medication Use, revised December 2016, revealed "residents will not receive PRN (Pro Re Nata, as needed) doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record."

Review of Resident 2's clinical record revealed diagnoses that included: depression (feelings of severe despondency and dejection), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), anxiety (a feeling of worry, nervousness, or unease), and aphasia (loss of the ability to understand or express speech).

Review of Resident 2's clinical record revealed a physician's order for as needed Ativan 0.5mg (milligrams, a unit of measure) every 6 hours as needed for anxiety/depression, with a start date of November 28, 2019.

Review of Resident 2's December 2019, Medication Administration Record (MAR, a record of medications that were administered) revealed Resident 2 had received one dose of the aforementioned medication on the following dates in December 2019: 1st, 2nd, 3rd 4th 5th, two doses on the 7th, two doses on the 8th, 10th, 11th, 14, 15th, 16th, two doses on the 20th, 21st, 23rd, and 29th.

Further review of Resident 2's clinical record failed to reveal behaviors or non-pharmacological interventions to minimize behaviors on the following dates in December 2019: 3rd, 4th, 5th and the 11th.

28 Pa Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 02/06/2020

1. How facility will correct the deficiency as relates to individual.

The nursing staff that failed to document behaviors and/or non-pharmacological interventions identified in Resident 2's record have been educated on the documentation requirements prior to the administration of Resident 2's PRN medication.

2. How facility will act to protect residents in similar situations
The DON/designee will complete a whole house audit of the Medication Administration Records and identify residents with orders for PRN psychotropic medications to ensure they have proper documentation for behavior and non-pharmacologic interventions prior to medication.

3. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Licensed nursing staff were educated by the DON/designee on the documentation requirements prior to the administration of PRN medication.

4. How the facility plans to monitor its performance to make sure that solutions are permanent. ; i.e. what quality assurance programs will be established?
DON/designee will audit administered psychotropic PRN's for appropriate behaviors and non-pharm documentation weekly times four and monthly times three to monitor performance and make sure the solutions are permanent.

Results of the audit will be reported monthly to the QAPI Committee by the DON/designee to track compliance and/or modification to the system.

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