Nursing Investigation Results -

Pennsylvania Department of Health
MEADOWS NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MEADOWS NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  76 surveys for this facility. Please select a date to view the survey results.

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MEADOWS NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on May 24, 2022, it was determined that Meadows Nursing and Rehabilitation Nursing 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:


483.12(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 select facility policy, investigative reports, information submitted by the facility and clinical records, and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from physical abuse, which caused multiple lacerations to one resident (Resident 38) and minor injury to one resident (Resident 51) and neglected to provide necessary care as planned to avoid physical harm to one resident (Residents 68) resulting in minor injury, out of six sampled residents.

Findings include:

A review of the facility policy entitled "investigation of allegations of abuse, neglect or the misappropriation of resident property", last reviewed by the facility January 5, 2022, revealed that residents have the right to privacy, dignity, and confidentiality for all aspects of care and services. Physical abuse includes but is not limited to hitting, slapping, pinching, kicking and shoving. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm.

A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on April 15, 2022, with diagnoses to include dementia with behavioral disturbance (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), gastro-esophageal reflux disease (GERD) and anxiety.

A review of Resident CR1's Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 21, 2022, revealed that the resident was severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status - a tool to assess cognitive function).

A review of Resident 38's clinical record revealed admission to the facility on March 1, 2022, with diagnoses, which included congestive heart failure, gastro-esophageal reflux disease (GERD), diabetes, peripheral vascular disease (PVD - a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel), acute and chronic respiratory failure, left and right below the knee amputation (BKA), and muscle weakness.

A review of Resident 38's Significant change MDS Assessment dated April 6, 2022, revealed that the resident was cognitively intact with a BIMS score of 14.

Nursing documentation in Resident CR1's clinical record dated, April 15, 2022, at 8:48 PM, revealed that Resident CR1 had demonstrated "extreme behaviors this PM." Nursing noted that the resident had kicked and punched the nurse and knocked nurse to floor. The resident was packing belongings, exhibiting paranoid behavior and was "very combative wander-hall looking for family to pick him up." He was making claims he had "double brain surgery." Nursing noted "Support offered, calmly, walking with resident. Responsible party (RP) and MD aware."

A nursing note in Resident CR1's clinical record dated April 17, 2022, at 10:10 PM, indicated that a "thumping sound" was heard and a man's voice yelling out. Resident CR1 was found lying on his left side with upper body against shower room door. "When questioned what happened, resident stated, I'll sue your %*%es off." "RP made aware and expressed concern about resident's increasing cognitive and behavioral issues. MD aware of incident and RP concern including resident receiving 2 milligrams (mg) of straight Ativan (a medication which can be used to treat anxiety) and still very agitated. Will address in the morning."

A nursing note entry dated April 18, 2022, at 6:28 AM, in Resident CR1's clinical record indicated that MD visit (physiatry) was in with no new orders (NNO). RP, MD made aware.

Resident CR1's clinical record revealed a nursing note entry dated, April 18, 2022, at 4:00 PM, which indicated "resident being very combative and abusive at this time. Stating he had to "take a sh*t." When approaching resident to wheel down to bathroom resident then jumped onto feet and punched nurse in the face, he then grabbed onto nurses both wrists and began shaking nurse and twisting arms stating, "I'm going to break them and you." Approached by second nurse and scheduler at this time to unbind resident's hands from nurse and he then let go and punched second nurse in the chest. He then grabbed, ripped and broke her necklace stating, "I'm going to choke you and kill you too". Resident was then sat back down into wheelchair and left alone in hallway outside of nurse's station to diffuse situation. Safe at this time with no employee or resident within arms - reach."

Resident CR1's clinical record revealed a nursing entry dated April 18, 2022, at 4:25 PM, indicated resident was seated outside the nurses station attempting to self- transfer. When nurse approached to assure his safety while standing, he punched nurse in face and grabbed her shirt and begun shaking nurse back and forth. A second nurse then approached the situation to remove resident's hands from other nurse, and the resident then punched the second nurse in face. A Nurse was able to seat the resident in a wheelchair. RP and physician aware, new orders were obtained to transfer resident to local hospital ER for evaluation.

A nursing note dated April 19, 2022, at 1:02 AM, in Resident CR1's clinical record indicated that Resident CR1 returned from hospital ER at this time. ER stated "no behaviors while there, however, did document "patient has a history of dementia and behaviors which were appreciated multiple times throughout his recent hospital stay! No behaviors at present, however, to be anticipated secondary to recent activity and history, monitor."

A review of Resident CR1's clinical record dated, April 20, 2022, at 5:41 AM, indicated resident was verbally aggressive toward staff stating, "Get out of my room and shut the door." When explaining that the door needs to be cracked in order to hear safety alarms, resident began yelling out and cursing at staff again stating, "what do you think i'm stupid."

A review of Resident CR1's clinical record revealed a nursing note dated April 21, 2022, at 6:07 AM, which was indicated as a late entry, noting "Dr in in am and examined resident with no order change."

Nursing noted on April 21, 2022, at 5:58 PM, in Resident CR1's record that "new orders received to discontinue (D/C) Ativan 2 mg by mouth (PO) at hour of sleep (HS). Change to Ativan 1 mg by po at 4 PM and HS. RP aware."

Nursing notes in Resident CR1's clinical record dated April 26, 2022, at 12:47 PM, indicated that the nurse practitioner was in and examined the resident on April 25, 2022, with no new recommendations at this time. The CRNP noted to continue with current medications.

According to a review of Resident CR1's clinical record on April 30, 2022, at 9:16 AM, a nurse intervened when Resident CR1 was stabbing Resident 38 with a metal fork and butter knife. Nursing noted that Resident CR1 was redirected from Resident 38, while securing utensils from him. Staff alerted, 911 called, Resident CR1 secured with blanket wrapped around him until police arrived. Resident CR1 repeatedly screamed out "welcome to the murder scene, it's a blood bath, who's next?"

Nursing noted that on April 30, 2022, at 9:45 AM, Resident CR1 was transferred to the local hospital ER for a psych evaluation and treatment with a police escort. RP and MD made aware.

A nursing entry in Resident CR1's clinical record dated, May 2, 2022, at 2:06 PM, indicated that the resident was not returning to the facility.

A review of Resident 38's clinical record dated, April 30, 2022, at 9:15 AM, indicated that nursing heard Resident 38 yelling out from her room. Staff went into Resident 38's room and saw Resident CR1 stabbing Resident 38 with fork and butter knife. Redirected resident (Resident CR1) away, alerted staff and secured utensils. Attended to Resident 38's wounds with pressure. 911 called, on scene, treating.

A review of Resident 38's clinical record dated, April 30, 2022, at 9:16 AM, indicated that Resident 38 was sent via 911 emergency transfer out to local hospital ER for evaluation and treatment. RP called, MD made aware.

A further review of Resident 38's clinical record revealed nursing documentation dated April 30, 2022, at 5:55 PM, which indicated "resident returned from hospital ER at this time, accompanied by ambulance staff. Made comfortable in bed, changed out of clothes into gown, comforting words and touches offered from staff. Vital signs (VS) obtained, within normal limits (WNL). Food/drink provided by brother/sister-in-law, who are at bedside at this time. Dressing to left forearm laceration and hematoma, laceration to left axilla, laceration to left elbow, laceration to left hand, laceration to left neck and lower left face; 19 stitches total."

A review of Resident 38's hospital documentation entitled "Emergency Department Discharge Instructions", dated April 30, 2022, indicated that Resident 38 was "assaulted at home sustaining lacerations to her left axilla (armpit), left elbow, left hand, left forearm and neck."

A review of information dated April 30, 2022, submitted by the facility and facility investigation report, dated April 30, 2022, reported that Resident CR1 had physically assaulted Resident 38, attacking her, and stabbing her with a knife and fork.

Interview with Resident 38, on May 24, 2022, at approximately 2:29 PM, revealed that the resident recalled the incident with Resident CR1. She stated that she was asleep and felt something and awoke to Resident CR1, standing over her with a knife and fork, stabbing her.

The facility failed to ensure that Resident 38 was free from physical abuse, perpetrated by Resident CR1.

An interview with the Nursing Home Administrator (NHA) on May 24, 2022, at approximately 2:07 PM, confirmed the facility failed to ensure that Resident 38 was free from physical abuse perpetrated by Resident CR1.

A review of Resident 51's clinical record revealed that the resident was most recently admitted to the facility on July 27, 2021, with diagnoses to include Protein-calorie malnutrition, compression fracture of lumbar (lower back) vertebra (back bone), dysphagia (difficulty swallowing), and ambulatory dysfunction.

A continued review of Resident 51's quarterly MDS Assessment dated November 1, 2021, revealed the resident was severely cognitively impaired with a BIMS score of 5, (a score of 0-7 equates to being severely cognitively impaired).

A review of Resident 49's clinical record revealed that the resident was admitted to the facility on April 16, 2021, with diagnoses to include dementia with behavioral disturbance (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), anxiety, psychosis (when people lose some contact with reality), peripheral vascular disease (PVD - a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel), and seizures.

A review of Resident 49's quarterly MDS Assessment dated December 16, 2021, revealed that the resident was severely cognitively impaired with a BIMS score of 4, (a score of 0-7 equates to being severely cognitively impaired).

Nursing notes dated January 6, 2022, at 10:29 PM, indicated Resident 51 was heard yelling out for help. Upon arrival, staff observed Resident 49 quickly rolling away in her wheelchair. Resident 51 was holding her arm and stated that Resident 49 had grabbed her arm and pinched and twisted the skin. A small, crescent-shaped skin tear, measuring 1.0 cm x less then .01 cm in size was observed. No active bleeding. The skin tear was cleansed, covered with an absorbent dressing. Residents separated, and put on 15-minute safety checks. RP and MD aware.

A further review of Resident 51's clinical record, progress notes dated January 14, 2022, at 1:32 PM, indicated Resident 51 skin tear to right anterior forearm resolved. Skin intact and fleshtone. New order noted to discontinue (D/C) treatment. Call placed to RP to make aware of same.

A review of facility provided incident investigation, physical, investigation forms, and facility provided documentation indicated on January 6, 2022, at 10:29 PM, noted the incident as described above during which Resident 49 had grabbed and twisted Resident 51's arm and caused a skin tear to her right forearm.

The facility failed to ensure that Resident 51 was free from physical abuse, perpetrated by Resident 49.

An interview with the Nursing Home Administrator (NHA) on May 24, 2022, at approximately 2:07 PM, confirmed the facility failed to ensure that Resident 51 was free from physical abuse perpetrated by Resident 49.

A review of Resident 69's clinical record revealed that the resident was admitted to the facility on May 18, 2022, with diagnoses to include fracture of the left femur (long bone in the leg), left artificial hip joint, chronic obstructive pulmonary disease (COPD), diabetes, protein-calorie malnutrition, and anxiety.

A review of Resident 69's Admission MDS Assessment dated May 21, 2022, revealed the resident was cognitively intact with a BIMS score of 14 (a score of 13-15 equates to being Cognitively Intact).

A review of current Resident 69's care plan (a tool - instructions used to guide care) dated May 17, 2022, indicated that the resident was to be transferred by assist of 2 staff members with a rolling walker (rw).

A nursing note in Resident 69's clinical record dated, May 19, 2022, at 6:45 PM, revealed that Resident 69 had sustained a skin tear to the left lower extremity, outer shin. The skin appears split, top layer laying flat, approximately 1 centimeter (cm) opening, less then 0.1 cm depth, sanguineous (leakage of fresh blood from an open wound) fluid seeping. No complaints of pain, indicating she believes it was bumped on the chair. Area cleansed with antiseptic spray, measured and steri strips applied. RP and Physician made aware. Resident resting quietly in no distress.

A review of facility provided incident investigation, skin, investigation forms, and provided documentation indicated on May 19, 2022, at approximately 7:30 PM, Employee 5 (Certified Nursing Assistant - CNA employed by a staffing agency), was in the process of transferring Resident 69, by herself, from the resident's wheelchair into her bed. During the transfer, Resident 69 sustained a skin tear on her left lower leg (front) measuring 5.0 centimeter (cm) x 1.0 cm x 0.1 cm.

Review of Employee 5 (agency CNA), witness statement dated May 19, 2022, indicated that Resident 69 had requested to go to bed, and Employee 5 requested help from fellow staff members, but they were in the process of assisting other residents. According to Employee 5's statement Resident 69 "was eager to go to bed, so \ hugged her and pivoted her to the bed and believes during this stand and pivot transfer, the side of the wheelchair leg rest."

The facility failed to provide Resident 69 with the necessary care and services to prevent injury and physical harm by failing to provide sufficient staff assistance and use proper technique during a transfer as care planned for the resident.

An interview with the NHA on May 24, 2022, at approximately 2:07 PM, confirmed that Employee 5 neglected to provide necessary staff assistance and appropriate technique as care planned and required by the resident resulting in minor injury to Resident 69.


483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(a)(c)(d) Resident Rights

28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services










 Plan of Correction - To be completed: 07/12/2022

1. Resident CR1 is no longer in facility
Resident 38 and Resident 51are free from physical abuse
Resident 69 is receiving the necessary care and services to prevent injury and is being transferred according to Physician Order and being provided appropriate staff assistance to prevent accident and injury.
Resident 49 plan of care has been reviewed by Nurse Practitioner for behavioral interventions.

2. Current Residents with a diagnosis of Dementia with behavioral disturbances will have their care plan updated with individualized interventions to ensure safety of residents in the facility.

Current Residents requiring assistance of two staff for transfers have been reviewed to ensure appropriate staff assistance and proper technique provided.

3. ADON/Designee shall provide reeducation to nursing personnel on the importance of reviewing resident Kardex prior to transferring resident and the importance of adhering to the plan of care to obtain appropriate staff assistance and using proper technique during a transfer as care planned.

Nursing personnel shall be re-educated on Facility Abuse Protocol.

4. Charge nurse/designee will audit level of assistance being provided to residents by staff to ensure that it is completed according to physician order and plan of care. IDT/Designee will complete audits with healthcare personnel on Facility Abuse Protocol and Procedures

5. Results of audits will be reported to QA Committee for review and recommendations.

6. Corrective Action Date July 12, 2022

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training: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.
483.95(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 review of the facility's abuse prevention policy and training records of agency/contracted staff and staff interviews, it was determined that the facility failed to ensure all agency staff working in the facility are oriented to the facility and educated/trained on the facility specific abuse prohibition policy and procedures including Employee 5.

Findings include:

A review of the facility policy entitled "investigation of allegations of abuse, neglect or the misappropriation of resident property", last reviewed by the facility January 5, 2022, revealed that residents have the right to privacy, dignity, and confidentiality for all aspects of care and services. Physical abuse includes but is not limited to hitting, slapping, pinching, kicking and shoving. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm. Training, the facility has implemented a program of educational in-services to assist employees in recognizing abuse, dealing with resident behavior, dementia management and dealing with burnout, which may contribute to an environment where abuse may occur. Employees/Volunteers during orientation and prior to resident contact and at least yearly thereafter, the Abuse Policy & Procedures will be viewed. "Agency" staff will receive education on the facilities Abuse Policy and Procedures.

A review of facility provided incident investigation, skin, investigation forms, and facility provided documentation indicated on May 19, 2022, at approximately 7:30 PM, Employee 5 (Certified Nursing Assistant - CNA employed by a staffing agency), was in the process of transferring Resident 69, by herself, from the resident's wheelchair into her bed. During the transfer, sustained a skin tear on her left lower leg (front) measuring 5.0 centimeter (cm) x 1.0 cm x 0.1 cm. Upon facility investigation, it was discovered that resident 69's care plan (a tool - instructions used to guide care) indicated the resident was to be transferred by assist of 2 staff members with a rolling walker (rw).

Review of Employee 5 (agency CNA), witness statement dated May 19, 2022, indicated Resident 69 had requested to go to bed. Employee 5 requested help from fellow staff members, but they were in the process of assisting other residents. According to Employee 5, Resident 69 was eager to go to bed, so Employee 5 (agency CNA) hugged her and pivoted her to the bed. and Employee 5 believes during this stand and pivot transfer, Resident 5 hit the side of the wheelchair leg rest.

At the time of the survey ending May 24, 2022, there was no documented evidence that Employee 5 (agency CNA), had been provided facility specific orientation, trainings including abuse/neglect, and competencies, prior to the above stated incident on May 19, 2022.

Interview with the Nursing Home Administrator (NHA) on May 24, 2022, at approximately 2:07 PM, confirmed the facility was unable to provide documented evidence that Employee 5, agency contracted employee, was trained on the facility specific orientation and abuse training prior to the above stated incident on May 19, 2022.



28 Pa Code 201.18 (e)(1) Management

28 Pa. Code 201.29(a)(c) Resident rights

28 Pa. Code 201.19 Personnel policies and procedures

28 Pa. Code 201.20(b) Staff development






 Plan of Correction - To be completed: 07/12/2022

1. Agency staff working in facility acknowledge and receive education on Act 13, Types of Abuse and Elder Justice Act.

2. Agency Staff shall be educated on Facility Abuse Prohibition Protocol and Procedures and receive orientation to the facility, which includes an orientation to facility and the importance of following resident plan of care via the Kardex for transfers.

3. RN Charge Nurse/Designee will complete audits with agency personnel on Facility Abuse Protocol and Procedures.

4.Results of Audits will be discussed at QA for comment and review

5. Corrective Action Date July 12, 2022

483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on a review of clinical records and facility provided documentation and staff interview, it was determined that the facility failed to consistently implement the individualized plan developed to address a resident's dementia-related behavioral symptoms for one out of six residents reviewed (Resident CR1).

Findings include:

A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on April 15, 2022, with diagnoses to include dementia with behavioral disturbance (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), gastro-esophageal reflux disease (GERD) and anxiety.

A review of Resident CR1's Admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 21, 2022, revealed that the resident was severely cognitively impaired with a BIMS score of 7 (Brief Interview for Mental Status (BIMS section of the MDS which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 0-7 equates to being Severely Cognitively Impaired).

Nursing noted on April 15, 2022, at 8:48 PM, that Resident CR1 demonstrated "extreme behaviors this pm", kicked, and punched the nurse and knocked nurse to floor. Packing belonging exhibiting paranoid behavior and "very combative" wander-hall looking for family to pick him up. He was making claims he had "double brain surgery". Support offered, calmly, walking with resident. Responsible party (RP) and MD aware. "

Nursing noted on April 17, 2022, at 10:10 PM, that a "thumping sound" was heard and a man's voice yelling out. Resident CR1 was found lying on his left side with upper body against shower room door. "When questioned what happened, resident stated, I'll sue your %*%es off". RP made aware and expressed concern about resident's increasing cognitive and behavioral issues. MD aware of incident and RP concern including resident receiving 2 milligrams (mg) of straight Ativan (a medication which can be used to treat anxiety) and still very agitated. Will address in the morning."

A review of Resident CR1's clinical record dated, April 18, 2022, at 6:28 AM, indicated that MD visit (physiatry) was in with no new orders (NNO). RP, MD made aware.

Nursing noted on April 18, 2022, at 4:00 PM, that Resident CR1 was being "very combative and abusive at this time. Stating he had to "take a sh*t". When approaching resident to wheel down to bathroom resident then jumped onto feet and punched nurse in the face, he then grabbed onto nurses both wrists and began shaking nurse and twisting arms stating, "I'm going to break them and you." Approached by second nurse and scheduler at this time to unbind resident's hands from nurse and he then let go and punched second nurse in the chest. He then grabbed, ripped and broke her necklace stating, "I'm going to choke you and kill you too". Resident was then sat back down into wheelchair and left alone in hallway outside of nurse's station to diffuse situation. Safe at this time with no employee or resident within arms - reach."

Nursing noted on April 18, 2022, at 4:25 PM, that Resident CR1 was seated outside nurses station attempting to self- transfer. When nurse approached to assure his safety while standing, he punched nurse in face and grabbed her shirt and begun shaking nurse back and forth. A second nurse then approached situation to remove residents hands from other nurse and he then punched second nurse in face. Nurse was able to sit resident in wheelchair. RP and physician aware, new orders obtained to transfer resident to local hospital ER for evaluation.

Progress notes dated April 19, 2022, at 1:02 AM, indicated that resident returned from hospital ER at this time. ER stated no behaviors while there however did document "patient has a history of dementia and behaviors which were appreciated multiple times throughout his recent hospital stay!" No behaviors at present however to be anticipated secondary to recent activity and history, monitor."

Nursing noted on April 20, 2022, at 5:41 AM, that Resident CR1 was verbally aggressive toward staff stating, "Get out of my room and shut the door." When explaining that the door needs to be cracked in order to hear safety alarms, resident began yelling out and cursing at staff again stating, " what do you think i'm stupid."

A late entry was noted April 21, 2022, at 6:07 AM, that "Dr in in AM and examined resident with no order change."

Progress notes dated April 21, 2022, at 5:58 PM, indicated that new orders were received to discontinue (D/C) Ativan 2 mg by mouth (po) at hour of sleep (HS). Change to Ativan 1 mg by po at 4 PM and HS. RP aware.

Progress notes dated April 26, 2022, at 12:47 PM, indicated that the nurse practitioner was in and examined the resident on April 25, 2022, with no new recommendations at this time. Continue with current medications.

Nursing noted on April 30, 2022, at 9:16 AM, that the nurse intervened, Resident CR1 was stabbing Resident 38 with a metal fork and butter knife. Resident CR1 was redirected from Resident 38, while securing utensils from him. Staff alerted, 911 called, resident CR1 secured with blanket wrapped around him until police arrived. Resident CR1 repeatedly screamed out, "welcome to the murder scene, it's a blood bath, who's next?"

A review of Resident CR1's care plan initially dated April 18, 2022, and revised May 24, 2022, revealed that Resident CR1 was a "new resident, and is involved with therapy. Wears glasses, and has current/past interests include: TV (News programs, CNBC and WVIA), music -loves music (40's and Brenda Lee), reading (newspaper), traveled (All over the country and Europe), loved attending Broadway Shows and Opera in NY, pets (dogs and cats), outdoors and religious activities - Catholic. Has in room TV."

A review of Activities "Documentation Survey Report v2" for April 2022, indicated that from April 15, 2022, through April 30, 2022, Resident CR1 had minimal attendance at organized group activities and was not provided individualized activities programming or diversional activities.

Interview with Employee 1 (Activity Director) on May 24, 2022, at approximately 11:50 AM, confirmed that the activity log entitled "Documentation Survey Report v2" for April 2022 was accurate and that "99" indicated the resident was not available, "98" indicated that the resident refused, and "97" indicated not applicable. Employee 1 stated that the facility staff was not able to provide activities to Resident CR1, with known a dementia diagnosis with behavioral disturbances. She stated that the staff were working on a activity box, but the resident had been discharged from the facility prior to its completion. She confirmed that she was unable to provide any documented evidence and or additional information that the facility had provided the individualized person-centered activities planned in an attempt to address and divert the resident's dementia-related behavioral symptoms.

The facility failed to demonstrate the consistent implementation of the individualized person-centered plan developed to address, modify and/or manage this resident's dementia-related behaviors.

An interview with the Nursing Home Administrator (NHA) on May 24, 2022, at approximately 2:07 PM, confirmed the facility was unable to provide evidence of implementation of an individualized person-centered plan to address Resident CR1's dementia-related behaviors.

Refer F600


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

28 Pa Code 211.11(d) Resident care plan






 Plan of Correction - To be completed: 07/12/2022

1. Resident CR1 has been discharged from facility
Resident 49's behavioral plan of care has been reviewed by IDT and Nurse Practitioner to include specific behaviors exhibited and person-centered interventions for staff to implement for dementia-related behavioral symptoms.

2. Current residents exhibiting dementia-related behaviors have been reviewed by IDT Team for individualized person-centered activities to address and divert the resident's with dementia-related behavioral symptoms. Interventions to reduce the behavioral symptoms, shall be based on a review of the resident's preferences, social/past life history, customary routines and interests in an effort to manage the symptoms.
Residents exhibiting dementia related behavioral symptoms will be reviewed by IDT at Clinical Meeting to address and/or manage the resident's behaviors.

3. Facility staff have been re-educated on offering individualized person-centered interventions and activities for residents exhibiting dementia-related behaviors.

4. IDT Team/Designee will audit behavioral care plans for the development and implementation of individualized person-centered activities and interventions to address dementia-related behaviors.

5. Results of audits will be discussed at QA for comment and review

7. Corrective Action Date July 12, 2022

483.80(i)(1)-(3)(i)-(x) REQUIREMENT COVID-19 Vaccination of Facility Staff:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.80(i)
COVID-19 Vaccination of facility staff. The facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine.

483.80(i)(1) Regardless of clinical responsibility or resident contact, the policies and procedures must apply to the following facility staff, who provide any care, treatment, or other services for the facility and/or its residents:
(i) Facility employees;
(ii) Licensed practitioners;
(iii) Students, trainees, and volunteers; and
(iv) Individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement.

483.80(i)(2) The policies and procedures of this section do not apply to the following facility staff:
(i) Staff who exclusively provide telehealth or telemedicine services outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section; and
(ii) Staff who provide support services for the facility that are performed exclusively outside of the facility setting and who do not have any direct contact with residents and other staff specified in paragraph (i)(1) of this section.

483.80(i)(3) The policies and procedures must include, at a minimum, the following components:
(i) A process for ensuring all staff specified in paragraph (i)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the facility and/or its residents;
(iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19;
(iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (i)(1) of this section;
(v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC;
(vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law;
(vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the facility has granted, an exemption from the staff COVID-19 vaccination requirements;
(viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains:
(A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and
(B) A statement by the authenticating practitioner recommending that the staff member be exempted from the facility's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications;
(ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and
(x) Contingency plans for staff who are not fully vaccinated for COVID-19.

Effective 60 Days After Publication:
483.80(i)(3)(ii) A process for ensuring that all staff specified in paragraph (i)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations;
Observations:

Based on a review of the DEPARTMENT OF HEALTH & HUMAN SERVICES QSO 22-07-ALL memo dated December 28, 2021, and select facility policy, observations and staff interviews, it was determined that the facility failed to fully develop and or follow the policy for COVID-19 vaccination for staff.

Findings include:

A review of a DEPARTMENT OF HEALTH & HUMAN SERVICES, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group dated December 28, 2021, QSO 22-07-ALL memo stated that:

Within 60 days after the issuance of this memorandum 4, if the facility demonstrates that:

Policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or patient or resident contact are vaccinated for COVID-19; and 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple-dose vaccine series), or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is compliant under the rule; or Less than 100% of all staff have received at least one dose of a single-dose vaccine, or all doses of a multiple-dose vaccine series, or have been granted a qualifying exemption, or identified as having a temporary delay as recommended by the CDC, the facility is noncompliant.

A review of the facility's "COVID-19 Vaccine Immunization Requirements for Residents and Staff Protocol", dated May 11, 2021, and "COVID - 19 Vaccine Protocol Employees", last revised by the facility on February 15, 2022, revealed the following:

Procedure:

4. The infection Preventionist or designee, will educate all employees who are not fully vaccinated (i.e.., employee received one dose of a two-dose series or less than 2 weeks since the last dose of a primary COVID 19 vaccine and employees with a valid exemption) of additional precautions and measures to mitigate the transmission and spread of COVID 19 for all staff that are not fully vaccinated:

A.Personal Protective Equipment
B.Transmission-Based Precautions
C.Hand Hygiene
D.Physical Distancing
E.Screening
G.Testing per facility COVID 19 testing policy and procedure
H.Use of a NIOSH -approved N95 or equivalent or higher - level respirator for source control, regardless of whether they are providing direct care to or otherwise interacting with patients.

There was no documented evidence, at the time of the review during the survey of May 24, 2022, that the policy indicated above (COVID - 19 Vaccine Protocol Employees) included specific procedures or protocol to define the specific Personal Protective Equipment that is to be worn, when it is required and/or where within the facility it is required.

In addition, there was no documented evidence, at the time of the review, on May 24, 2022, that the policies above included procedures for defining the necessary dates for the required COVID vaccination.

Interview on May 24, 2022, at approximately 12:49 PM, with Employee 2, Licensed Practical Nurse (LPN), on the First Floor, revealed that she was returning from lunch. She stated that she was unvaccinated and granted a non-medical exemption. She was observed during this interview to be wearing only surgical mask, which was confirmed by Employee 2.

Interview on May 24, 2022, at approximately 12:45 PM, with Employee 3, LPN, on the First Floor, indicated he was returning from lunch. He stated that he was unvaccinated and was granted a non-medical exemption. He was observed during this interview to be wearing a surgical mask, which was confirmed by Employee 3.

An additional observation on May 24, 2022, at approximately 2:30 PM, of Employee 3, LPN, on the First Floor, were observed conversing with another staff member. Employee 3 was wearing a surgical mask during his conversation with the other staff member.

Interview on May 24, 2022, at approximately 1:46 PM, with Employee 4, Registered Nurse (RN), Infection Preventionist (IP), revealed that all employees who are not fully vaccinated are required to wear an N95 mask in the entire facility (all floors), for source control at all times, regardless of whether they are providing direct care to, or interacting with patients, as stated in the facility policy.

At the time of the survey ending May 24, 2022, the facility did not have a positive outbreak over the previous four weeks of COVID-19 among residents.

Review of National Healthcare Safety Network (NHSN) date for week ending May 8, 2022, revealed that the facility had 91.5% of staff fully vaccinated.

Review of the facility provided, employee vaccination status - matrix, at the time survey ending May 24, 2022, revealed that 159 staff were fully vaccinated, with 0 partially vaccinated, 17 religious exemptions, 2 medical exemption, and 1 temporary delay/medical, totaling 100% staff vaccination rate.

Interview with the NHA on May 24, 2022, at approximately 2:07 PM, confirmed that the facility's policy regarding COVID-19 vaccinations lacked specific mitigation procedures and deadlines for vaccination. In addition, she confirmed that all staff are expected to follow all mitigation procedures set forth by the facility, and that the facility failed to follow the mitigation efforts to wear an N95 mask as unvaccinated staff were observed wearing only surgical masks.



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

28 Pa. Code 201.14 (a) Responsibility of Licensee

28 Pa. Code 201.18(b)(1)(d)(e)(1) Management




 Plan of Correction - To be completed: 07/12/2022

1. Facility COVID-19 Vaccine Protocol has been revised to include specific Personal Protective Equipment that is required for employees who are unvaccinated when within the facility and the necessary dates for the required vaccinations.

2. Employees who are not fully vaccinated or have an exemption are wearing the proper PPE (Personal Protective Equipment) which includes a N95 mask for source control, regardless of whether or not they are providing direct care to or otherwise interacting with a resident.

3. HCP who are not fully vaccinated or who have an exemption on file have been re-educated on the mitigation procedures to prevent the spread of the virus.

4. IDT Team/ Designee will monitor staff compliance for appropriate wearing of N95 mask while in facility.

5. Results of audit will be discussed at QA for comment and review

6. Corrective Action Date July 12, 2022


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