Pennsylvania Department of Health
MASONIC VILLAGE AT LAFAYETTE HILL
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MASONIC VILLAGE AT LAFAYETTE HILL - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on August 1, 2024, it was determined that Masonic Village at Lafayette Hill, 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:

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of facility policy, observations, and interviews with staff, it was determined that the facility failed to maintain proper infection control practices to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents reviewed. (Resident R1)

Findings Include:

Review of the facility policy titled, "Infection Transmission Prevention and Interventions" undated states "The facility has established and will maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections."

iii. Droplet precautions
1.These precautions protect staff, visitors, and other residents from droplets that are expelled during coughing, sneezing, or talking.
2.Masks are to be worn when working in close proximity to the resident.
3.Specific guidelines may be needed during the transport and placement of residents. The environmental management of equipment, etc. should be used according to each category's requirement.

Review of facility training for "Droplet Precautions", "Hand Hygiene-Why it Matters", "Respiratory Illness Refresher/Guidance" and "Tool Kit for Respiratory Pathogens" trainings completed with staff during the month of July 2024 revealed only licensed nurses and nurse aides were trained and signed off on being trained.

Interview held with the Nursing Home Administrator Employee E1 and the Director of Nursing Employee E2 at 9:20 a.m. to obtain access to clinical records and facility information. At this time the signage in the lobby regarding an Upper Respiratory Infection outbreak was discussed. Employee E1 and Employee E2 stated that during the month of July 2024 there was an outbreak of the HIB (Haemophilus Influenzae Disease) virus. Review of reportable documentation submitted to the Department of Health from July 17, 2024 revealed "Starting on July 5, 2024 some of the healthcare center residents started showing signs of respiratory illness. Infection control policies and procedures were implemented and remain ongoing. Residents were placed into isolation, testing completed per CDC guidelines. PCR sent to lab. Per our previous reports, 3 cases over the time since July 5 were positive for COVID however all other testing was coming back negative. Over the course of this time since 7/5, 32 residents have presented with respiratory illness and testing continued to result negative including testing for Legionella." "On July 16, 2024, the DON received a call from public health department to report a positive swab they obtained from CHH on a resident that lives in our retirement living section. The swab was positive in the hospital for Haemophilis Influenzae."

Review of Resident R1's clinical record revealed the resident was admitted to the facility on March 31, 2023 with diagnoses of Acute Embolism, Acute Respiratory Failure with Hypoxia, Essential Hypertension, Dysphagia, Chronic Pain, Hearing loss, Lack of Coordination, Osteoporosis, Cognitive Communication deficit, Abnormalities of Gait, Urinary Incontinence, and a contracture of the left knee.

Resident R1 was put on isolation and on droplet precautions on July 31, 2024 for wheezing and possibility of infection. During observations on the unit signage stating "Before entering this room, please see the nurse, thank you" and PPE (personal protective equipment) was observed outside of the resident R1's room. During observation outside of the resident's room, two staff were observed going into the room without putting on appropriate PPE.

Observation of the second-floor unit revealed a licensed nurse, Employee E5 went into resident R1's room after putting on PPE including a mask, face shield, and gloves at 10:08 a.m. At 10:09 a.m. a contracted phlebotomist worker went into Resident R1's room with mask on without putting on additional PPE including gloves and a face shield. A minute later the phlebotomist came out of the resident's room and started to look in the drawers for PPE. The licensed nurse Employee E5 then came out of the room and asked the phlebotomist if she could not find the appropriate PPE. Employee E4 stated that she could not find any face shields in the drawers and license nurse Employee E5 stated that she would retrieve some.

Interview held with the phlebotomist revealed that she was not aware precautions were needed as she was just here to obtain the resident's blood samples. The phlebotomist was asked if she was obtaining samples for any other residents in the building today and she stated, "no". The phlebotomist was asked if she was aware Resident R1 was on droplet precautions, and she stated "no". Interview held with licensed nurse Employee E5 who confirmed that Resident R1 was on isolation and droplet precautions which required staff to wear a mask, face shield, and gloves when entering the resident's room. The phlebotomist on August 1, 2024 at 10:12 a.m. put on a face shield and gloves and went back into Resident R1's room. After obtaining a blood sample, the phlebotomist left Resident R1's room, took off her gloves at the PPE station outside of the room and placed the gloves into her sweatshirt pocket. The phlebotomist then put on new gloves and went back into the resident's room. At 10:16 a.m. the phlebotomist left the resident's room without gloves but still wearing a mask and a face shield. The phlebotomist took off the face shield, hung it around her wrist and walked off the unit with it.

At 10:19 a.m. a nurse practitioner, Employee E3 knocked on the door and went into Resident R1's room without putting on any PPE. Employee E3 had no mask, no face shield, and no gloves on. Employee E3 came out of Resident R1's room at 10:25 a.m. Employee E3 was asked how come she went into the room without PPE and nurse practitioner Employee E3 stated, "I'm sorry, I was not aware, I was only aware that the resident was having nausea."

Interview held with the Director of Nursing Employee E1 at 12:10 p.m. and confirmed that all staff going into any resident room with droplet precautions should wear PPE into the room and the worn PPE should be discarded prior to leaving the resident's room.

The facility was unable to provide evidence that nurse practitioner Employee E3 and phlemobotomist were made aware of Resident R1's droplet precaution status prior to them having contact with the resident on August 1, 2024.

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

Plan of Correction - To be completed: 09/10/2024

Resident R1 swab results were obtained on 8/2/24 and negative. She was removed from isolation and no further sign or symptoms of infection were noted.

Education of the lab and nurse practitioner were completed in regard to infection control and droplet precautions. Including proper PPE requirements.

Annual staff trainings are sent to our contractors (sent January 2024) which include education on infection control and prevention.

As of 8/1/24 all contracted employees must check in with a supervisor prior to resident contact/visits to ensure they are aware of any special needs. Staff was educated on this procedure. Contracted employees are being made aware as they visit and being sent letters to remind of the process.

Audits will be performed by DON or designee weekly x 2 months, then monthly x3 and as needed in isolation rooms to ensure staff is compliant with PPE requirements. All findings will be reviewed in QAPI.

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