Nursing Investigation Results -

Pennsylvania Department of Health
NUGENT CONVALESCENT HOME
Patient Care Inspection Results

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NUGENT CONVALESCENT HOME
Inspection Results For:

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NUGENT CONVALESCENT HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on September 27, 2019, it was determined that Nugent Convalescent Home, 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:


483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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.
483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:


Based on review of clinical records and staff interview, it was determined that the facility failed to assure physician orders and resident's wishes regarding life-sustaining treatments were consistent for one of 25 residents reviewed (Resident R83).

Findings include:

Resident R83's clinical record revealed an admission date of 5/6/19, with diagnoses that included diabetes (metabolic disorder resulting in high blood sugar), high blood pressure, and peripheral vascular disease (narrowing of the arteries resulting in decreased blood flow).

Resident R83's admission orders completed 5/6/19, and signed by the physician on 5/10/19, included an order for "DNR" (do not resuscitate). An advanced directive signed by Resident R83 on 5/6/19, directed his/her attending physician to perform cardiac resuscitation (procedure to revive the heart).

There was no evidence to indicate that Resident R83 had revised or changed his/her wishes related to life sustaining treatment since signing the advanced directive on 5/6/19.

During an interview on 9/26/19, at 11:08 a.m. Registered Nurse Employee E1 confirmed that Resident R83's physician orders for a DNR was not consistent with Resident R83's advanced directive directing his/her physician to perform cardiac resuscitation.

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

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(c) Resident care policies








 Plan of Correction - To be completed: 11/13/2019

1.) Immediately following this observation, R83 was interviewed and his current advanced directive wishes were made current.
2.) A review of all current charts and new admissions are being conducted to ensure an appropriate physician order and advanced directive form are in place. This will be noted by a Progress Note in the chart.
3.) A new policy will be developed along with education and in-service training for all Registered Nurses, Licensed Practical Nurses, the Social Services Director, and the Admission Coordinator. The Social Services Director or designee will verify that Advanced Directive status are correct upon admission.
4.) Advanced Directives will now be included in our Quality Assurance program monthly. Residents will be interviewed quarterly during care plan conferences by the Social Services Director ensuring their wishes remain current.

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 observations, review of clinical records and facility policy and staff interview, it was determined that the facility failed to utilize appropriate hand hygiene practices during a dressing change for one of seven residents (Resident R88).

Findings include:

The facility policy entitled "Dressing Change, Clean," dated 6/30/19, indicated that during a dressing change, after cleansing the wound with the ordered solution, gloves are to be removed, hands washed or sanitized, and clean gloves applied before placing medication on the wound.

Resident R88's clinical record revealed an admission date of 3/01/16, with diagnoses that included Alzheimer's disease, history of a fractured hip, diabetes and dysphagia (difficulty swallowing). The clinical record also included a current physician order, dated 9/06/19, to cleanse Resident R88's sacral (base of the spine) ulcer with normal saline (salt) solution, pat dry and apply silver alginate (an absorbent, anti-microbial dressing) to the wound bed and a foam dressing, daily and as needed for soiling.

Observation of wound care on 9/25/19, at 10:43 a.m. revealed that Licensed Practical Nurse (LPN) Employee E6 proceeded with gloved hands to remove Resident R88's soiled dressing and cleansed the wound with normal saline. LPN Employee E6 then changed gloves without the benefit of performing hand hygiene and then applied a silver alginate dressing soaked in normal saline to the wound bed.

During an interview on 9/25/19, at 10:55 a.m. LPN Employee E2 confirmed that he/she did not perform hand hygiene when changing gloves following cleansing of the wound and before applying the clean silver alginate dressing.


28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
Previously cited 7/20/2018













 Plan of Correction - To be completed: 11/13/2019

1.) R88 was not harmed in any way. This dressing change and Hand Hygiene Policy was immediately reviewed by the Director of Nursing and E6. Return demonstration was then performed as evidence of E6's understanding.
2.) To prevent any further deficiencies, the Director of Nursing and Wound Care Registered Nurse performed Hand Hygiene competencies on both Licensed Practical and Registered Nurses. In addition, several dressing change procedures were observed on two separate shifts.
3.) Education will be on-going until all staff have completed a Hand Hygiene Competency with either the Director of Nursing, or the Wound Care Nurse. Monthly in-services will also include Hand Hygiene education for the next 6 months.
4.) The Wound Care Registered Nurse will monitor three dressing change procedures each week for 4 weeks. Then, once a week, bi-weekly for 6 months. Audits will be reviewed during our monthly Quality Assurance meeting.


483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
483.70(o) Hospice services.
483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in 418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at 483.24.
Observations:


Based on observation, review of clinical records and a hospice contract and staff interviews, it was determined that the facility failed to coordinate hospice services regarding oxygen use for one of 21 residents (Resident R75).

Findings include:

The "Hospice Care Services Agreement" revealed "all physican orders communicated to the Facility on behalf of Hospice in connection with a plan of care shall be in writing and signed by the applicable attending physician or Hospice Physician ..."

Resident R75's clinical record revealed an admission date of 4/18/18, with diagnoses that included chronic obstructive pulmonary disease (constriction of the airways making it difficult to breathe)., pacemaker, and stomach and heart problems. The Significant Change Minimum Data Set (periodic review of resident care needs), dated 6/11/19, revealed that Resident R75 was started on hospice services (care focusing on pain, symptoms, emotion and spiritual needs).

Observation on 9/24/19, at 10:34 a.m. revealed Resident R75 with oxygen supplied through a nasal cannula (tubing to the nose supplying oxygen), running at seven liters of oxygen.

The Hospice "Physician's Plan of Care" orders relating to oxygen, originally dated 7/19/19, revealed Resident R75 could have one to five liters of oxygen via nasal cannula as needed for shortness of breath/end of life care if oxygen saturation was less than 90 percent and 6-10 liters via simple face mask or device of choice as needed for shortness of breath/end of life care if oxygen saturation is less than 90 percent.

The facility Primary Care Physician's (PCP) orders dated 9/01/19, revealed an order for oxygen at three liters via nasal cannula as needed. There was no order signed by the facility PCP to reflect the hospice orders were followed for Resident R75's oxygen usage were being .

Observation on 9/26/19, at 9:16. a.m. revealed Resident R75 with a nasal cannula on and receiving oxygen at seven liters. During an interview on 9/26/19, at the time of the observation Registered Nurse Employee E7 confirmed that the oxygen was set at seven liters through a nasal cannula and also confirmed that the hospice oxygen orders did not get transcribed onto the facility's PCP orders for coordination of care.

During an interview on 9/26/19, at 11:02 a.m. the Director of Nursing confirmed that the hospice orders did not get entered for the facility PCP recapitulation to assure that the hospice orders were followed for Resident R75.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 7/20/18

28 Pa. Code 211.12.(d)(1)(3)(5) Nursing services
Previously cited 7/20/18










 Plan of Correction - To be completed: 11/13/2019

1. R75 was not harmed in the deficient act of this facility. This practice was immediately corrected by clarifying physician orders, and ensuring these orders were subsequently reconciled for accuracy.
2. A review was conducted of the 6 current Hospice designated patients ensuring the physician orders were reconciled and correct.
3. The Director of Nursing and/or designee will conduct an in-service with all Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants in conjunction with Hospice contract staff related to the clinical management of residents going forward.
4. An audit performed by the Director of Nursing and/or designee of this review process will be conducted as follows:
All current Hospice designated residents will be audited for reconciliation and accuracy of all orders x 60 days. Results will be reviewed on a monthly basis at the facility's QA meeting.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on observations, review of facility policy and clinical records and staff interviews, it was determined that the facility failed to implement appropriate treatment and therapy services for one of two residents (Resident R64).

Findings include:

Resident R64's clinical record revealed an admission date of 3/11/19, with diagnoses that included Lewy body Dementia (loss of mental function due to protein build up in the brain), urinary retention, back pain and a history of falls. The clinical record identified a current restorative nursing care program for active assisted range of motion (AAROM - independent movement of joints performed with some staff assistance) to Resident R64's upper extremities and a discontinued transfer restorative nursing care program (provided from 4/23/19, through 9/11/19).

The facility policy entitled Rehabilitative (Restorative) Nursing Care (therapy services not requiring the use of a professional therapist) dated 6/30/19, indicated that the facility had an active rehabilitative nursing program; that nursing staff are trained in the process; that the service is performed daily; and that documentation including refusal of the service should be documented in the clinical record.

A physical therapy recommendation, dated 7/17/19, and signed by the Resident R64's physician on 7/22/19, requested a consult to a local orthotic (brace, splint) company to obtain bilateral PRAFO's (Pressure Reducing Ankle and Foot Orthotic - a device that is worn on the calf and foot similar to a boot, used for ankle and foot alignment and pressure relief) to facilitate contracture management. A current physician order, originally dated 8/09/19, indicated that Resident R64 was to have bilateral PRAFO boots on at all times while in bed on every shift to address ankle contractures. The clinical record included a second therapy recommendation dated 8/19/19, for passive range of motion (PROM - assisted movement of joints to maintain or improve flexibility) to the lower extremities including knee flexion (bending), for 30 second holds, for five repetitions. Resident R64's restorative therapy records indicated that from 7/22/19, through 9/22/19, Resident R64 received AAROM therapy (documented in minutes) on 5 of 66 days, and transfer therapy (documented in minutes) on 2 of 51 days and no documentation of refusals on given days. The clinical record lacked evidence that Resident R64's physician ordered PRAFO boots and the therapy recommended PROM program to the lower legs was provided on any day.

Observation on 9/24/19, at 10:31 a.m. revealed Resident R64 lying in bed without shoes or socks, with feet plantar-flexed (pointed in a downward position rather than upward) and rigid (unable to move/flex when asked).

During an interview on 9/25/19, at 1:26 p.m. Resident R64's responsible party indicated that Resident R64 had a number of back surgeries in the past resulting in leg pain and impacting his/her ability to walk; that both feet were "contracted" upon admission, one worse than the other; and that there had been little improvement following therapy.

Observation on 9/25/19, at 3:00 p.m. revealed Physical Therapist (PT) Employee E2 assessing and conducting range of motion to Resident R64's lower extremities. Resident R64's lower legs were extended straight on the wheelchair's leg rests with the feet plantar-flexed. PT Employee E2 indicated that Resident R64 was being reassessed by therapy due to inconsistent use of PRAFO's and to evaluate for other devices or treatments to the lower legs.

During an interview on 9/26/19, at 2:27 p.m. Restorative LPN Employee E4 confirmed that Resident R64 frequently refused restorative therapies but based on documentation, it could not be clarified the days of refusals, he/she was not aware of the order for Resident R64's PRAFO boots and therefore did not implement a restorative program for their use. LPN Employee E4 also confirmed that the therapy recommendation for a PROM program to Resident 64's lower extremities was received by the restorative nursing department but had not yet been instituted (38 days later).

During an interview on 9/27/19, at 8:45 a.m. Rehabilitation Director Employee E5, confirmed that Resident R64 was currently receiving therapy services and that following a previous round of therapy PRAFO boots were ordered on 8/09/19, and a PROM program to the lower legs on 8/19/19, both programs were to be instituted by the restorative nursing department.

During an interview on 9/27/19, at 11:44 a.m., the Director of Nursing confirmed there was no evidence in the clinical record to support that either the PRAFO boots or PROM to Resident R64's lower extremities had been implemented per physician order or therapy recommendation.

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

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

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 7/20/18











 Plan of Correction - To be completed: 11/13/2019

1.) The immediate corrective action for R64 included on-going Physical Therapy to determine if splinting devices will continue to be used and instructions for the Nursing and Restorative staff developed. Currently, Prafo Boots continue to be in trial. Upon discharge of Physical Therapy, the Therapy Manager will educate the Restorative Manager on what splint is to be used and on the associated wear schedule.
2.) All current residents with splinting devices are under review to ensure collaboration between the Therapy Department and Nursing Department has been met and that all information is accurate and understood. A new "Therapy to Restorative Communication Form" has been introduced to communicate new orders, trialing, changes in condition, and other pertinent information about the resident.
3.) Restorative and Nursing staff will be educated on the correct way to document resident refusals on the Restorative flow chart and on entering information in the Medication Administration Record and Treatment Administration Record by the Director of Nursing and Restorative Manager.
4.) An audit, in conjunction with Therapy, will be performed of 5 residents currently receiving Restorative Therapy Services and any newly admitted residents to these services will be audited each day x 60 days. This information will also be discussed at our monthly Quality Assurance Meeting.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on review of clinical records and facility policies and staff interview, it was determined that the facility failed to update/revise care plans to reflect individualized interventions utilized for resident behaviors for one of 21 residents (Resident R52).

Findings include:

The "Care Plans, Comprehensive Person-Centered" policy dated 6/30/19, revealed "identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the end point of an interdisciplinary process."

The "Resident Face Sheet" revealed that Resident R52 was admitted to the facility on 2/09/17, with diagnoses that included Alzheimer's disease, psychotic disorder with hallucinations, restlessness and agitation, anxiety and depression.

Nursing notes revealed the following behaviors:
9/07/19 - facing wall, yelling at person, however noone present in the room
9/16/19 - refusing care, yelling at people not present, refusing treatments, and spitting out food into hand
9/17/19 - screaming, arguing with persons not present
9/21/19 - seeing water on the wall, refusing medications

The behavior care plan lacked support of what individualized interventions the staff would utilize to address the behaviors that Resident R52 displayed.

During an interview on 9/27/19, at 10:52 a.m. the Director of Nursing confirmed that Resident R52's care plans did not have individualized interventions for staff to utilize to address Resident R52's behaviors displayed.


28 Pa. Code 211.11(d) Resident care plan.

28 Pa. Code 211.12.(d)(1)(3)(5) Nursing services
Previously cited 7/20/18










 Plan of Correction - To be completed: 11/13/2019

1.) R52 was not harmed by this deficient practice and the progress notes and care plan for R52 were reviewed and updated. The specific interventions added for R52's behaviors included, One to one with a Licensed Practical Nurse, Activity Staff, or Social Worker, Gospel Music, Classical movies (such as Gone with the Wind), move to a new environment, repositioning, and Applesauce or Pudding.

2.) All residents receiving Psychotropic Medication, and residents that show any behaviors will be reviewed. The Registered Nurse Assessment Coordinator will ensure that all behaviors have effective resident specific interventions with a checklist. Also, the Registered and Licensed Practical Nurses will be educated by the Director of Nursing on how to document in the progress notes any new or adverse behavior, the intervention used, and if it was effective.

3.) The Director of Nursing and Social Services Director will monitor all resident progress notes with a computer-generated report, specifically looking for behaviors, changes, and if interventions were attempted. This will occur once every 24 hours (72 hours on Monday) These will then be conveyed to the Registered Nurse Assessment Coordinator who will ensure all interventions have been entered into the Plan of Care, and that they are appropriate, and audit 10 random care plans per month. The Inter-Departmental Team will continue to discuss new interventions during each plan of care conference quarterly, and as needed.

4.) All gathered information will be added to the monthly Quality Assurance program to ensure this process remains sustainable going forward.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:


Based on review of clinical records and facility policy and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) for two of six residents transferred out of the facility to the hospital (Residents R92 and R83).

Findings include:

Resident R92's clinical record revealed an admission date of 5/28/19, with diagnoses that included respiratory failure and chronic obstructive pulmonary disease (obstructed airflow in the lungs). The clinical record revealed that Resident R92 was transferred from the facility to the hospital on 6/02/19, and returned on 6/05/19. There was no evidence that Resident R92 and/or their representative was provided a written notice of the facility bed-hold policy.

During an interview on 9/27/19, at 12:33 p.m. the Director of Nursing (DON) confirmed that there was no evidence that a copy of the bed-hold policy was given to Resident R92 or their representative upon or within twenty-four hours of transfer to the hospital.

Resident R83's clinical record revealed an admission date of 5/6/19, with diagnoses that included diabetes (metabolic disorder resulting in high blood sugar), high blood pressure, and peripheral vascular disease (narrowing of the arteries resulting in decreased blood flow). The clinical record revealed that Resident R83 was transferred from the facility to the hospital on 8/29/19, and returned on 9/7/19. There was no evidence that Resident R83 and/or their representative was provided a written notice of the facility bed-hold policy.

During an interview on 9/27/19, at 12:22 p.m. the DON confirmed that there was no evidence that a copy of the bed-hold policy was given to Resident R83 or their representative upon or within twenty-four hours of transfer to the hospital.

483.15(d) Previously cited 7/20/18

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 7/20/18

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

28 Pa. Code 201.29(a) Resident rights



 Plan of Correction - To be completed: 11/13/2019

1.) Neither R-83 or R-92 were negatively affected or harmed by this deficient practice.

2.) Moving forward, a new policy has been put in place ensuring no other residents are affected.

3.) This facility will now, at the time of transfer, ensure a Bed Hold notice is given to the resident/responsible party. A Progress Note will be entered into the chart. A new policy has been created and education is being provided to all Registered Nurses, Licensed Practical Nurses, the Admission Coordinator, and the Social Service Director.

4.) This new process will be audited by the Director of Nursing/designee for all transfers daily x 30 days, 5 transfers per week x 4 weeks, 5 transfers every two weeks x one month, and 5 transfers per month x 2 months. We will include audit findings in our monthly Quality Assurance program.


483.20(g) REQUIREMENT Accuracy of Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of the Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that the MDS assessment accurately reflected the status for one of 21 residents reviewed (Resident R20).

Findings include:

Resident R20's clinical record revealed an admission date of 10/18/17, with diagnoses that included dementia (a group of symptoms that affect the memory and thinking), high blood pressure, and diabetes.

Clinical record documentation revealed a physician order for and staff signage on the treatment record indicating usage of oxygen at three liters per minute by way of nasal cannula during the fourteen-day look-back period for Resident R20. The MDS's with Assessment Reference Dates of 7/15/19 and 8/6/19, did not indicate the usage of oxygen while a resident in the facility.

During an interview on 9/26/19, at 1:07 p.m. Registered Nurse Assessment Coordinator confirmed that the 7/15/19 and 8/56/19, MDS's were both coded incorrectly regarding the usage of oxygen.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 7/20/18

28 Pa. Code 211.5(f) Clinical Records







 Plan of Correction - To be completed: 11/13/2019

I hereby acknowledge the CMS 2567-A, issued to NUGENT CONVALESCENT HOME for the survey ending 09/27/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on review of clinical records and facility policies and staff interviews, it was determined that the facility failed to provide the resident and resident representatives with a written summary of the baseline care plan for two of 21 residents (Residents R62 and R89).

The "Care Plans- Baseline" policy, dated 6/30/19, revealed that "to assure that the residents immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the residents admission...and the resident and their representative will be provided a summary of the baseline care plan ..."

Resident R62's clinical record revealed an admission date of 5/23/19. The clinical record lacked evidence that a summary of Resident R62's baseline care plan was provided to his/her representative.

Resident R89's clinical record revealed an admission date of 11/12/18. The clinical record lacked evidence that a summary of Resident R89's baseline care plan was provided to his/her representative.

During an interview on 9/26/19, at 12:05 p.m., the DON confirmed that the clinical record lacked evidence that a summary of the baseline care plan was provided to Residents R62 and R89's representatives.

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

28 Pa. Code 211.10(a) Resident care policies

28 Pa. Code 211.11(e)Resident care plan

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 7/20/18

 Plan of Correction - To be completed: 11/13/2019

I hereby acknowledge the CMS 2567-A, issued to NUGENT CONVALESCENT HOME for the survey ending 09/27/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:

Based on review of facility infection control records and staff interviews, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1) a.

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:

(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

During review the facility's Infection Control Program documentation on 9/27/19, at 11:45 a.m., it was determined that there was no documented evidence that all the above mandatory members were part of the facility's infection control committee.

During an interview at the time of the review, the Director of Nursing confirmed the lack of evidence of the infection control meeting members attendance.




 Plan of Correction - To be completed: 11/13/2019

1. An immediate Infection Control meeting was planned with all committee meeting members invited including the Medical Director, Community, Pharmaceutical and laboratory representatives.
2. The DON/Designee will verify that the attendees of the Infection Control Committee will now log their attendance on separate forms designated for "Infection Control Committee Meeting", separate from "Quality Assurance" or other meetings.
3. The Director of Nursing and/or designee plans on monitoring its performance to make sure that solutions are sustained via documenting evidence of minutes and attendee signatures once per month. DON/Designee will ensure ALL members of the multidisciplinary committee attends at least once quarterly.
4. The verification for the above stated Plan of Correction will be reviewed at all monthly Quality Assurance committee meetings.

201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:

Based on review of personnel records and staff interviews, it was determined that the facility failed to include in their files information regarding employee job descriptions for five of five personnel records reviewed.

Findings include:

The personnel records reviewed for five newly hired employees, that included two registered nurses, an activity aide, a dietary employee and a nurse aide, failed to include evidence that job descriptions were reviewed and/or provided to the employees.

During an interview on 9/27/19, at 2:20 p.m. the Nursing Home Administrator confirmed the lack of job description information for the five newly hired employees.








 Plan of Correction - To be completed: 11/13/2019

All current employees have been provided with a copy of their job description. The description was reviewed with the employee and their respective boss (Dept Manager, DON, NHA, etc.) Subsequently, all did agree to sign it, affirming their understanding of the specific role for which they were hired. These job descriptions were then copied and placed into their own personal employee file as evidence.

An audit will be conducted by the NHA and/or designee, once per month, for the next 6 months, to assure on-going compliance has been demonstrated for all current employees as well as new employees. The audit will be performed by generating a current list of all employees within this facility and then reconciled to their personal file. These audit findings will be monitored through our Quality Assurance process, ensuring all remains sustainable.


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