Nursing Investigation Results -

Pennsylvania Department of Health
SUSQUEHANNA HEALTH SKILLED NURSING & REHABILITATION CENTER
Patient Care Inspection Results

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SUSQUEHANNA HEALTH SKILLED NURSING & REHABILITATION CENTER
Inspection Results For:

There are  67 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.
SUSQUEHANNA HEALTH SKILLED NURSING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a Complaint Investigation on September 13, 2019, it was determined that Susquehanna Health Skilled Nursing and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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.
483.25 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 clinical record review and staff interview, it was determined that the facility failed to provide the highest practical care regarding physician ordered treatments for three of six residents reviewed (Residents 66, 83, and 89).

Finding include:

Clinical record review for Resident 66 revealed the resident had a treatment order initiated on May 2, 2019, to cleanse her right lower abdominal fold with soap and water, pat dry, and apply a thin layer of Desitin Rapid Relief (a cream used to prevent and heal skin discomfort), every shift in the morning and evening. There was no evidence this was completed as ordered on August 20 or 21, 2019 evening shift or September 1 or 4, 2019, morning shift. A treatment order dated August 17, 2019, also indicated the resident was to have Desitin Rapid Relief applied to the resident's labia and peri-area every shift in the morning and evening for erythema (redness of the skin). There is no evidence this was completed for the resident on the evening shift of August 21, 2019, or the morning shift of August 24, September 1 and 4, 2019.

A treatment order for Resident 66 dated September 5, 2019, indicated the resident was to have Miconazole ointment (used to treat skin infections) applied every morning and evening shift for seven days due to yeast. There was no evidence to indicate the treatment was completed for the morning shift of September 6, 2019.

There was no documentation identified to indicate a reason Resident 66's treatments were not completed as noted above.

Clinical record review for Resident 83 revealed the resident was to receive a treatment ordered on July 17, 2019 to cleanse her left heel pressure injury with normal saline, apply a nickel thick layer of Santyl (an ointment used in the healing of skin ulcers) gauze, three rolls of cast padding, then one roll of Kerlix (bandage roll), and tape, to be changed daily on the morning shift. There was no evidence the treatment was completed on August 11, 2019. This treatment was noted as discontinued on August 14, 2019.

Resident 83 received a treatment change order to her left heel pressure injury on August 14, 2019, which indicated the resident would now have the area cleansed with normal saline, Santyl, then Exufiber (a wound dressing), covered with gauze, then three rolls of cast padding and one roll of Kerlix, to be changed daily on the morning shift. There was no evidence to indicate the treatment was completed as ordered on August 14 or August 25, 2019.

Although the resident was ordered a treatment change to her left heel pressure injury on August 14, 2019, there was no evidence to indicate either the old treatment as noted above, or the new treatment was completed on August 14, 2019.

There was no documentation identified as to why Resident 83 did not receive the treatments as ordered above.

Clinical record review for Resident 89 revealed the physician ordered a treatment on July 25, 2019, to cleanse the left lateral lower leg pressure injury with normal saline, pat dry, and apply Allevyn foam (wound dressing) to be changed daily. There was no evidence to indicate the treatment was completed on August 5, 9, or 13, 2019.

Resident 89 was also ordered a treatment on July 17, 2019, to cleanse the pressure injury on her left heel with normal saline, apply Cavilon (skin protectant) to the peri wound, apply Dakin's strength solution (used to treat and prevent skin and tissue infections) to a 4x4 gauze, wring out well then lightly pack in the 12 o'clock position and apply to the rest to the wound, apply a 4x4 dry gauze, and then apply three rolls of cast padding and one roll of Kerlix to be changed twice a day in morning and evening shift. There was no evidence this treatment was completed on August 5, 9, 13, or 25, 2019, morning shift. Resident 89 received a new order on August 27, 2019 to change the treatment to the left heel pressure injury to once daily on the morning shift. There was no evidence to indicate the treatment was completed on August 28, 2019.

Another treatment order dated July 17, 2019 for Resident 89 indicated the resident was to have a skin tear on her left forearm cleansed with normal saline, patted dry, and Allevyn foam applied daily. There was no evidence to indicate the treatment was completed on August 6, 12, or 21, 2019.

Resident 89 also had an order dated August 27, 2019 to cleanse her left foot 5th metatarsal vascular ulcer with normal saline, soak a 2x2 gauze with Dakin's solution, wring out and apply to the wound, then apply Cavilon to the peri wound and pat dry and apply Allevyn foam, to be changed daily on the morning shift. There was no evidence to indicate this treatment was completed on August 4 or 5, 2019.

There was no evidence of any documentation to indicate why Resident 89's treatments were not completed as noted above.

The surveyor reviewed the above findings for Residents 66, 83, and 89 during an interview with the Nursing Home Administrator and the Director of Nursing on September 13, 2019, at 3:00 PM.

28 Pa. Code 211.10(a)(c) Resident care policies

28 Pa. Code 211.10(d) Resident care policies
Previously cited 4/12/19

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 4/12/19


 Plan of Correction - To be completed: 10/22/2019

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

1. Wound nurse assessed residents 66, 83, and 89 to ensure proper treatments are in place.

2. LPNs will show exception report to Charge RN at the end of each shift to ensure all treatments were signed for.

3. Education to licensed staff regarding thorough documentation of treatment record.

4. DON or designee will monitor exception reports for RN check off daily x 3 months with results reported at QAPI.

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 clinical record review and staff and resident interview, it was determined that the facility failed to ensure the availability and administration of physician ordered medications for three of six residents reviewed (Residents 66, 87, and 116).

Findings include:

Review of Resident 66's clinical record revealed a physician's order dated January 22, 2019, for the nursing staff to administer Acetaminophen (pain reliever), 500 mg (milligrams) tablet twice daily for pain. Review of Resident 66's Medication Administration Record (MAR, a form used to document the administration of medications) dated August 2019, revealed that the nursing staff did not administer Resident 66's Acetaminophen on the evening of August 30, 2019, and noted the medication as 'held." A nurse's note dated August 30, 2019, at 4:31 PM noted that Resident 66's Acetaminophen 500 mg was held due to waiting on the pharmacy.

Further review revealed Resident 66 had an order dated January 22, 2019, for the nursing staff to administer Levetiracetam (a medication used to control seizures), 500 mg tablet twice a day. Review of Resident 66's MAR dated September 2019, revealed the nursing staff documented the morning dose of the Levetiracetam 500 mg on September 3, 2019, as "held." A nurse's note dated September 3, 2019, at 1:59 PM noted the Levetiracetam 500 mg tablet was held because it was not being available.

Clinical record review for Resident 66 also revealed the resident received a physician's order on September 2, 2019, for Macrobid (antibiotic) 100 mg, to be administered by nursing staff twice a day for seven days (last day to be September 8, 2019) for a urinary tract infection. Review of Resident 66's MAR for September 2019, revealed the resident was not administered the Macrobid on the evening of September 3, or the morning of September 4, 2019. A nurse's note dated September 4, 2019 at 9:53 PM noted the resident's physician was made aware of the missed doses of Macrobid, and new orders were received on September 4, 2019, for the resident to be administered the Macrobid 100 mg twice a day for seven days to be completed on September 11, 2019, (three days later than the original completion date due to the missed doses).

Clinical record review for Resident 87 revealed a physician's order dated January 21, 2019, for the nursing staff to administer Pepcid (an acid reducer) 20 mg tablet twice daily, Namenda XR (a medication used to treat dementia) 14 mg capsule daily, and an order dated August 2, 2019, for the nursing staff to administer Escitalopram oxalate (a medication used to treat depression and anxiety) 5 mg, tablet daily for depression. A review of Resident 87's MAR dated September 2019, revealed the resident's morning dose of Pepcid, daily dose of Namenda, and daily dose of Escitalopram Oxalate, was noted as "held" on September 4, 2019. A nurse's note dated September 4, 2019 at 1:36 PM noted the resident's Pepcid, 20 mg tablet, Namenda ER 14 mg capsule, and the Escitalopram Oxalate was held because it was not available.

Clinical record review for Resident 116 revealed the following physician's orders:

January 22, 2019, K-Dur (a potassium supplement) 20 milliequivalents (MEq) twice daily
Roxanol (a medication used to treat moderate to severe pain ) 20 mg/ml (milliliter) solution at a dose of 0.25 ml at bedtime
August 30, 2019, for Levothyroxine Sodium (a medication used to treat thyroid conditions) 150 mcg (micrograms) to be administered daily

A review of Resident 116's MAR dated September 2019, did not reveal any evidence that the resident's K-Dur was administered on the evening of September 3, 2019, that her Roxanol was administered on September 16, 2019, or that the Levothyroxine was administered on September 3, 2019.

There was no evidence of any documentation indicating why Resident 116 was not administered the medications as noted above.

The surveyor reviewed the above findings for Residents 66, 87, and 116, during an interview with the Nursing Home Administrator and the Director of Nursing on September 13, 2019, at 3:00 PM.

28 Pa. Code 211.9(k) Pharmacy services

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 4/12/19

28 Pa. Code 211.12(c) Nursing services


 Plan of Correction - To be completed: 10/22/2019

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

1. Residents 66, 87 and 116 have medications as ordered.

2. House audit to assure all ordered medications are available and accessible.


3. Staff education of pharmacy policy regarding appropriate steps to acquire ordered medications. LPNs will show exception report to Charge RN at the end of each shift to ensure availability of medications and to report any medications not given due to unavailable.

4. DON or designee will audit weekly to ensure availability of medications x 3 months with results reported to QAPI.

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 review of select facility policies, facility documents, clinical record review, and staff interview, it was determined that the facility failed to assess and implement appropriate interventions to prevent falls for two of three residents reviewed for falls (Residents 84 and 116).

Findings include:

Review of the current facility policy entitled "Fall Prevention and Management," revealed the licensed nurse will obtain vital signs for all falls (witnessed and unwitnessed) and neurological checks will be initiated if there is an unwitnessed event or known head injury every 15 minutes for four times, every 30 minutes for four times, every one hour for two times, every four hours for the remainder of the first 24 hours after the fall, and then every eight hours for the remainder of 72 hours.

Clinical record review for Resident 84 revealed the resident had an unwitnessed fall on August 6, 2019, at 4:10 PM in which the resident slipped onto the floor getting out of bed.

Review of facility documentation for Resident 84 revealed a "Neurological Monitoring Flowsheet," was initiated on August 6, 2019, at 4:20 PM for the resident due to the unwitnessed fall noted above. There was no evidence to indicate the neurological checks were completed on the resident for the second one-hour check, the third and fourth every four hours check, or every eight hours for the remainder of the 72 hours after the resident's fall.

Further clinical record review for Resident 84 revealed a follow up note to the fall dated August 7, 2019, at 2:18 PM indicating a therapy evaluation/screen would be implemented to prevent future falls. There was no evidence to indicate a therapy evaluation/screen was completed on the resident until August 14, 2019, (eight days after the fall). A therapy note dated August 14, 2019, indicated a rehab screen was completed as the resident had increased falls and unsteady gait.

Resident 84 was noted to have a fall again on August 17, 2019 at 3:50 PM, and August 23, 2019, at 10:55 AM.

A review of Resident 84's "Neurological Monitoring Flowsheet," initiated after the resident's unwitnessed fall on August 23, 2019, at 10:55 AM revealed no evidence the resident's neurological checks were completed for the first half hour check, the third half hour check, the first one hour check, fourth or fifth four hour check, or every eight hours for the remainder of the 72 hours after the resident's fall.

Resident 84 continued to fall again on August 31, 2019, 5:30PM, and September 4, 2019, at 8:45 AM.

In a follow up nurse's note on September 4, 2019, regarding the resident's fall, it was noted the resident's blood pressure would be monitored for three days after the fall. There was no evidence to indicate the resident's blood pressure was checked the three days after the fall.

Clinical record review for Resident 116 revealed the resident had an unwitnessed fall on August 15, 2019, at 5:58 AM in which she slipped from her bed.

Review of a "Neurological Monitoring Flowsheet," initiated on August 15, 2019, at 6:15 AM for Resident 116, due to her unwitnessed fall, revealed no evidence that the resident's neurological checks were completed for the second and third four-hour check, or for the first four every eight-hour checks.

A follow up note to Resident 116's fall dated August 15, 2019, at 9:22 AM noted the resident was to receive a therapy evaluation/screen as a plan of action to prevent further falls. Further clinical record review revealed the therapy screen was not completed until August 21, 2019, six days after the resident's fall. The resident sustained another fall on August 31, 2019, at 2:40 AM in which it was noted the resident again slipped out of bed.

The surveyor reviewed the above findings for Resident 84 and 116 during an interview with the Nursing Home Administrator and the Director of Nursing on September 13, 2019, at 3:00 PM.

483.25(d)(1)(2) Free of Accident Hazards
Previously cited 4/12/19

28 Pa. Code 201.18(b)(e)(1) Management
Previously cited 4/12/19

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 4/12/19


 Plan of Correction - To be completed: 10/22/2019

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements.

1. Residents 84 and 116 had therapy evaluation completed near time of falls and both were placed on therapy caseload. Residents 84 and 116 neuro assessments are within normal limits. Resident 84 received an order to check ortho BPs for 3 days.

2. House audit of falls in the last 30 days with therapy as intervention will be reviewed to assure therapy screen completed. House audit of falls with neuro checks required in the last 30 days will be reviewed to assure neuro eval was completed and if not, neurological status will be assessed by RN with abnormal findings reported to provider. House audit of falls with orthostatic BPs ordered as fall intervention in the last 30 days will be reviewed to assure completion, if not done order for orthostatic BPs will be obtained and completed with abnormal findings reported to provider.

3. Staff education regarding neuro checks policy and fall interventions. Therapy screens will be completed after every fall within 3 days. Restorative LPN or designee will ensure all fall interventions have been implemented and completed.

4. Restorative LPN or designee will audit daily to ensure fall interventions are completed x 3 months with results reported at QAPI.


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