Nursing Investigation Results -

Pennsylvania Department of Health
OHESSON MANOR
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
OHESSON MANOR
Inspection Results For:

There are  74 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
OHESSON MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on April 2, 2021, it was determined that Ohesson Manor was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(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 clinical record review, observation, and staff interview, it was determined that the facility failed to implement a restorative nursing program to prevent further decrease in range of motion for one of two residents reviewed for range of motion concerns (Resident 47).

Findings include:

Resident 47 was admitted to the facility on January 29, 2021, with a primary diagnosis of Multiple Sclerosis (a condition that can affect the brain and spinal cord, causing a wide range of potential symptoms, including with vision, arm/leg movement, sensation, or balance).

Observation of Resident 47 on March 30, 2021, at 12:15 PM revealed the resident was lying in bed in a fetal position with positioning aids and supports of the joints.

Clinical record review of the occupational therapy discharge summary for Resident 47 from January 29 through February 12, 2021, revealed the resident has contractures (abnormal shortening of muscle tissue, which can lead to permanent disability, pain, and inability to move a joint) of the upper extremities (arms/hands) and is primarily bed bound. On discharge from occupational therapy services, a RNP (restorative nursing program, a program designed to improve or maintain the functional ability of residents) for PROM (passive range of motion, exercises performed by nursing staff to the resident to keep the joints moveable) was recommended. Training to the nursing staff on PROM was provided. The goal for the RNP was to facilitate tone (muscle tone is what allows muscles to move) in the upper extremities, to preserve skin integrity, and promote contracture management. The prognosis to maintain the resident's current level of functioning was excellent with consistent staff support of the RNP.

Clinical record review of the physical therapy discharge summary for Resident 47 from January 29 through February 12, 2021, revealed the resident has contractures of the lower extremities (hips/legs). Recommendations included a RNP for PROM of both lower extremities to decrease the risk for fixed joint deformity (inability to move a joint) and to promote improved hygiene. The nursing staff was educated on the PROM. The resident's prognosis was listed as good with consistent staff follow through.

There was no documented evidence for Resident 47 that a RNP for PROM was performed.

During an interview with the Director of Nursing on April 2, 2021, at 12:45 PM it was confirmed that the facility was unable to provide documentation that the PROM for Resident 47 was provided.

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


 Plan of Correction - To be completed: 05/11/2021

1. Resident 47 plan of care reviewed and updated to include plan for PROM per therapy recommendations
2. Director of Nursing or Designee will complete audits on residents who require ROM's programs to ensure program has been implemented and plan of care being managed per recommendations.
3. Director of Nursing or designee will re-educate all licensed and direct care staff on Restorative maintenance programs for contracture management and providing highest level of care for residents.
4. Director of Nursing/Designee will conduct weekly random audits for 3 months to ensure therapy recommendations have been implemented and plan of care updated to ensure resident's needs are being met.
Results of auditing will be reviewed monthly at Quality Assurance/Performance Improvement Committee monthly for 3 months for further review and recommendations.

483.25(n)(1)-(4) REQUIREMENT Bedrails:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure the completion of all required elements for side rail use for 9 of 12 residents reviewed for accident hazards (Residents 6, 19, 31, 39, 58, 62, 63, 73, and 80).

Findings include:

The facility policy entitled, "Bed Rail - Enabler Guideline," last reviewed without changes on November 13, 2020, indicated that it is the policy of the facility to limit the use of bed rails and similar devices unless the benefit outweighs the risks. Rails/enablers of any type will be applied with prior assessment as to the appropriateness of the use and device selected. Assessment is completed to identify potential benefits from utilizing bed rail/enablers and minimize risk. If bed rails/enablers are considered, an assessment is completed before the use, with ongoing reassessments (at least quarterly). Care plan interventions are implemented when bed rails/enablers are utilized and reviewed at least quarterly. Compliance monitoring includes that residents with bed rails/enablers have appropriate assessments completed and that there is evidence that risks and benefits were explained to the resident/resident's representatives. Documentation includes the consent for the use of the enabler/side rails form and the side rail/enabler assessment.

Observation of Resident 6's room on March 31, 2021, at 8:52 AM revealed that she was in bed and there was a one-half side rail (a bar to assist with positioning/mobility/transfer in bed) on the left side of her bed.

Observation of Resident 6's room on April 2, 2021, at 11:15 AM revealed that she was in bed and there were bilateral one-half side rails on her bed.

There was no documentation available indicating that the facility assessed Resident 6's bed to determine if there was a risk of side rail entrapment.

Observation of Resident 19's room on March 31, 2021, at 8:57 AM revealed that she was asleep in bed and there were bilateral one-half side rails on her bed.

There was no documentation available indicating that the facility assessed Resident 19's bed to determine if there was a risk of side rail entrapment.

Clinical record review for Resident 80 revealed a physician's order dated March 29, 2021, indicating that he was to utilize a right one-half side rail to assist with bed mobility.

Observation of Resident 80 on April 2, 2021, at 11:10 AM revealed that the right one-half side rail was on his bed.

There was no documentation available indicating that the facility assessed Resident 80's bed to determine if there was a risk of side rail entrapment. There was no informed consent for the use of the one-half side rail, nor was there documentation that the facility reviewed the potential risks and benefits of the use of the one-half side rail with either the resident or the resident's responsible party.

The surveyor reviewed the above information for Residents 6, 19, and 80 during an interview with the Director of Nursing (DON) on April 2, 2021, at 11:45 AM.

Observation on March 30, 2021, at 11:46 AM revealed Resident 17's right side of her bed was up against the wall with her left quarter side rail in the elevated position.

Observation of Resident 31's room on March 31, 2021, at 10:06 AM revealed her bed was equipped with bilateral side rails at the head of her bed.

Clinical record review for Resident 31 revealed an "Enabler Rail Evaluation" (not signed or dated) that indicated Resident 31 indicated "No" to the question "Does the resident want the enabler rail(s) raised?" A handwritten notation by the unknown writer instructed, "Please install bilateral half rails."

Resident 31's clinical record did not include evidence that the facility assessed Resident 31's risks for entrapment with the use of the bilateral half rails.

An active plan of care developed by the facility to address Resident 31's need for assistance with bed mobility and transfers revealed that Resident 31 would utilize half rail(s) for bed mobility and transfers. Interventions included in the plan of care instructed staff to assess the half rail(s) utilization upon admission, quarterly, and as needed.

Interview with the Nursing Home Administrator on April 1, 2021, at 12:16 PM, revealed that the facility could not provide evidence of an entrapment risk assessment for the use of side rails for Resident 31.

Observation of Resident 62 on March 30, 2021, at 1:23 PM revealed her bed was equipped with bilateral side rails at the head of her bed.

Clinical record review for Resident 62 revealed no evidence of an entrapment risk assessment for Resident 62's side rail use.

An undated physical therapy assessment indicated that staff assessed only a left-sided upper half rail as an intervention provided to Resident 62.

A Consent for Use of Enablers/Side Rails dated June 21, 2019, revealed that the left upper one-half rail was recommended at all times when Resident 62 was in bed; however, Resident 62 neither consented nor refused the recommendation with her signature on June 21, 2019.

The surveyor reviewed the above findings for Resident 62 during an interview with the Nursing Home Administrator and the Director of Nursing on March 31, 2021, at 2:00 PM.

A Consent for Use of Bed Rails to Enable Movement form provided by the facility on April 1, 2021 (dated March 31, 2021, following the surveyor's questioning) indicated that Resident 62 did not consent to the use of enabler bars.

Observation of Resident 63's room on March 30, 2021, at 3:41 PM revealed her bed was equipped with bilateral side rails at the head of her bed.

Clinical record review for Resident 63 revealed an undated occupational therapy evaluation that the intervention appropriate for Resident 63 was a right sided one-half rail. Resident 63's clinical record did not include a "Consent for Use of Bed Rails to Enable Movement."

A current plan of care developed by the facility on February 13, 2020, to address Resident 63's needed assistance with bed mobility and transfers included the intervention that Resident 63 would utilize half rail(s) for bed mobility and transfers. The plan of care did not incorporate the occupational therapy evaluation that only one half rail was appropriate for the right side of her bed.

Interview with the Nursing Home Administrator and Director of Nursing on April 1, 2021, at 1:45 PM confirmed the above findings for Resident 63.

Observation of Resident 58 on April 2, 2021, at 8:30 AM revealed the resident was in bed with bilateral half side rails present near the head of the bed.

Clinical record review for Resident 58 revealed an incomplete Enabler Bar Evaluation dated November 2, 2020, and the physician orders for March 2021, did not include an order for side rails.

Observation of Resident 39 on April 2, 2021, at 8:40 AM revealed the resident was in bed with bilateral half side rails present near the head of the bed.

There was no documentation available indicating that the facility assessed Residents 39 and 58 for side rail use including assessment of the risk of side rail entrapment, ensuring bed dimensions are appropriate for the resident size and weight, review of the potential risks and benefits of side rails with either the resident or the resident's responsible party, or obtained informed consent.

During an interview with the Nursing Home Administrator on April 2, 2021, at 9:00 AM it was confirmed that there was no documented evidence for side rail use for Residents 39 and 58.

Observation of Resident 73 on March 31, 2021, at 9:10 AM revealed that she was in bed, which was equipped with bilateral side rails at the head of her bed.

Clinical record review for Resident 73 revealed a physician's order dated February 26, 2021, that instructed staff to utilize bilateral enabler bars on Resident 73's bed.

The surveyor requested evidence that the facility obtained Resident 73's consent and evaluated the entrapment risks for the use of the observed enabler bars during an interview with the Nursing Home Administrator and Director of Nursing on March 31, 2021, at 2:00 PM.

Interview with the Nursing Home Administrator and the Director of Nursing on April 1, 2021, at 1:45 PM confirmed that the facility could not provide evidence of an assessment of Resident 73's entrapment risks from the use of bilateral enabler bars prior to their installation. The facility could not provide evidence that staff reviewed the risks and benefits of the enabler bars with either Resident 73 or her representative or obtained informed consent prior to their installation.

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


 Plan of Correction - To be completed: 05/11/2021

1. Residents 6,19,31,39,58,62,63,73,and 80 will be re-evaluated to ensure that bed rails are still appropriate. If it is determined that bed rails are appropriate, staff will complete a risk assessment, review the risks and benefits with the resident or responsible person, obtain consent and evaluate the bed, mattress, bed rail system. If bed rails are not appropriate they will be removed.

2. Other residents with bed rails in place will be re-evaluated and managed as in #1.

3. Nursing and Maintenance staff will be re-educated regarding all required elements for bed rails use, including; Risk assessment, Review of risks and benefits with resident or responsible person, Consent, Ensuring that the bed's dimensions are appropriate for the resident's size and weight, and Manufacturer's recommendations and specifications for installing and maintaining bed rails.

4. DON or Designee will audit residents with side rails in place to ensure all required elements are in place upon admission and with a change in the bed or bed rail system. Results of Audits will be reviewed at facility QAPI meeting monthly for three months for further review and recommendations.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide required notification to a resident whose payment coverage changed for one of three residents reviewed (Resident 39).

Findings include:

A review of the form "Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123," (a notice that informs the recipient when care received from the skilled nursing facility is ending; and how to contact a Quality Improvement Organization (QIO) to appeal) revealed instructions that a Medicare provider must ensure that the notice is delivered at least two calendar days before Medicare covered services end. The provider must ensure that the beneficiary or their representative signs and dates the NOMNC to demonstrate that the beneficiary or their representative received the notice and understands the termination of services can be disputed. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. Confirm the telephone contact by written notice mailed on that same date.

A review of the "Form Instructions Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055" revealed that the SNF enters a good faith estimate of the cost of the corresponding care that may not be covered by Medicare. The beneficiary selects an option box to indicate a desire to continue to receive the care or not to continue to receive the care and if there is a desire to have the bill submitted to Medicare for consideration. The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice.

Clinical record review for Resident 39 revealed admission activity information that indicated Resident 39 received Medicare payment for services from December 2 through 21, 2020. Resident 39 began private payment for services beginning December 22, 2020.

A review of a CMS-10123 indicated that the facility completed a telephone communication on December 18, 2020 (Friday) with Resident 39's brother regarding his last covered day for services on December 21, 2020 (Monday); however, the stamped postmark on the certified mail receipt for the notice to Resident 39's brother was December 21, 2020 (indicating that the facility failed to mail the notice on the same date as the documented telephone conversation as required).

The facility had no evidence that staff provided a CMS-10055 notice to Resident 39 or his responsible party when his services were no longer covered by Medicare.

The surveyor reviewed the above findings for Resident 39 during an interview with the Nursing Home Administrator and Director of Nursing on April 1, 2021, at 1:45 PM.

Interview with the Director of Nursing on April 1, 2021, at 2:55 PM confirmed that the facility had no evidence that the facility provided the CMS-10055 notice to either Resident 39 or his responsible party.

28 Pa. Code 201.18(b)(2)(e)(1) Management

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 05/11/2021

1. There is no way to correct the date the notice was mailed. The responsible party of Resident 39 will receive a CMS-10055 notice with explanation that it was not provided at the time his services were no longer covered by Medicare.
2. Residents whose services were covered by Medicare in the past 90 days will be reviewed to ensure they have received the required notification that services were no longer covered by Medicare.
3. Training will be provided to staff responsible for notification of the end of Medicare coverage that includes; the time frame for mailing the notice of non-coverage and the forms required to notify residents and responsible parties of the end of Medicare coverage.
4. Administrator or designee will audit the dates notices are mailed and the documents provided to Medicare beneficiaries whose services are no longer covered by Medicare. Audit findings will be reviewed by the Quality Assurance/ Performance Improvement Committee monthly for three months for further review and recommendations.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure medication storage security for one of three medication storage rooms (400/500 medication storage room).

Findings include:

The facility policy entitled, "Storage of Medications," last reviewed without changes on November 13, 2020, revealed that the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments. Only persons authorized to prepare and administer medications have access to locked medications. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, etc.) containing drugs and biologicals are locked when not in use.

Observation of the 400/500 nursing unit medication storage room on April 2, 2021, at 11:37 AM revealed Employee 2, registered nurse supervisor, pushed an unlocked door to enter the medication storage room; the door was not securely locked. Employee 2 stated that the door is known to malfunction if staff do not pull the door completely shut, the locking mechanism will not engage, and the door does not lock. Observation inside the medication storage room revealed numerous prescription medications openly visible on the counter and in a storage box on the floor (Employee 2 stated these were medications of residents who were discharged or medications that have been discontinued).

Observation of medications available for resident use within the 400/500 medication storage room revealed two 16-ounce bottles of liquid Acetaminophen (Tylenol, over-the-counter pain medication) with a label indicating that the medication expired on January 21, 2021. Employee 2 stated that nursing staff are to pull expired medications from the stock available for resident use; however, she confirmed that this was not done for the liquid Acetaminophen.

During the continued observation of the 400/500 medication storage room on April 2, 2021, at 11:53 AM, Employee 1, assistant director of nursing, entered the area and confirmed that she was aware that the medication storage room door had an issue with not catching the lock and allowing the door to not fully shut behind staff leaving the area.

The surveyor reviewed the medication storage concerns during an interview with the Director of Nursing on April 2, 2021, at 12:00 PM.

28 Pa. Code 207.2(a) Administrator's responsibility

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


 Plan of Correction - To be completed: 05/11/2021

1. The door locking mechanism was repaired on 4/2/21. The medications stored in the medication room were reviewed to ensure no expired medications were available for resident use.
2. The remaining medication storage areas were inspected to ensure the door locked properly and that there were no expired medications available for resident use.
3. Door locking mechanisms have been added to routine maintenance rounds. Nursing staff will be educated about the proper procedure for reporting improper door locking and the facility policy "Storage Of Medications".
4. DON or Designee will audit medication storage areas to ensure proper door locking and there are no expired medications available for resident use. Audit findings will be reviewed by the Quality Assurance/ Performance Improvement Committee monthly for three months for further review and recommendations.
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident's medication regime was free from potentially unnecessary medications for one of five residents selected for medication regimen review (Resident 62)

Findings include:

The facility policy entitled, "Psychotropic Medication Use," last reviewed without changes on November 13, 2020, indicated that the facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other applicable law relating to the use of psychopharmacologic medications including gradual dose reductions. PRN (as needed) orders for psychotropic drugs should be limited to 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Clinical record review for Resident 62 revealed a physician's order dated February 2, 2021, for staff to administer the antianxiety medication, Lorazepam, 1.5 mg (milligrams) daily. Resident 62's physician orders dated February 2, 2021, also included instructions for staff to administer additional Lorazepam 0.5 mg as needed (PRN) every 24 hours (once a day). The PRN Lorazepam order did not indicate the duration for the PRN order.

Review of Resident 62's eMAR (electronic medication administration record, system the facility utilizes to document the administration of medication) dated February and March 2021 revealed no evidence that staff administered any doses of the PRN Lorazepam 0.5 mg to Resident 62.

A consultant pharmacist review dated February 19, 2021, informed the physician that upon Resident 62's recent readmission to the facility, the medication reconciliation process revealed discrepancies on the readmission orders that included that prior to leaving the facility Resident 62's Lorazepam medication was administered only as needed (not as a routine dose); however, upon readmission, the Lorazepam was ordered as a routine dose with the availability of additional dosing as needed. The consultant pharmacist did not inform the physician that Resident 62 failed to utilize any of the as needed Lorazepam available to her since her readmission to the facility.

The physician's response to the consultant pharmacist's concern was that the medication review was completed with the provider and the resident upon return from hospital; and that the current orders are what was agreed upon.

The physician's response did not indicate that the physician reviewed Resident 62's failure to use the PRN dose of the Lorazepam medication. The physician's response did not include a rationale to continue the PRN dose of Lorazepam beyond 14 days post her readmission (as she reflected no use of the medication since her readmission).

Interview with the Nursing Home Administrator and the Director of Nursing on March 31, 2021, at 3:05 PM confirmed that the PRN order for Resident 62's Lorazepam has been active beyond 14 days without documentation by the prescribing practitioner of the rationale for continuing a PRN antianxiety medication that has not been utilized by the resident.

483.45(c)(3)(e)(1)-(5) Free From Unnecessary Psychotropic Medications/PRN Use
Previously cited deficiency 9/6/19

28 Pa. Code 211.2(a) Physician services

28 Pa. Code 211.9(k) Pharmacy services

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


 Plan of Correction - To be completed: 05/11/2021

1. Resident 62 Medication Regimen has been reviewed by physician and PRN Ativan has been addressed by MD to comply with psychopharmacological dosage guidelines per CMS.
2. Director of Nursing/ Designee will complete audit on residents receiving PRN Ativan to ensure that orders comply with CMS guidelines and are not ordered for greater than 14 day time frame.
3. Director of Nursing/ Designee will re-educate all licensed staff on facility policy for "Psychotropic Medications", including the CMS guidelines for psychopharmacological dosage guidelines.
4. Director of Nursing/ Designee will conduct random weekly audits for three Months of PRN psychotropic medication use to ensure that medications prescribed comply with guidelines and are not ordered greater than 14 day time frame.
Results of Audits will be reviewed at facility QAPI meeting monthly for three months for further review and recommendations.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of three residents reviewed (Resident 64).

Findings include:

Review of the facility policy entitled "Oxygen Therapy," last reviewed without changes on November 13, 2020, revealed that oxygen will be administered per the physician's order.

Clinical record review for Resident 64 revealed that there was a current physician order for staff to administer oxygen continuously via nasal cannula (NC, a device used to deliver supplemental oxygen through the nose) at 2 liters per minute (LPM) with humidification.

Observation on March 30, 2021, at 12:59 PM, March 31, 2021, at 9:00 AM, and April 2, 2021, at 11:11 AM revealed that Resident 64's oxygen was on via NC and set at 2 LPM as ordered. There was no humidifier cannister on Resident 64's oxygen administration.

The facility did not administer or document Resident 64's oxygen humidification correctly per the physician's order and facility policy.

The surveyor reviewed the above information for Resident 64 during an interview with the Director of Nursing on April 2, 2021, at 11:45 AM.

483.25(i) Respiratory/tracheostomy Care and Suctioning
Previously cited 11/6/19 and 9/6/19

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

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


 Plan of Correction - To be completed: 05/11/2021

1. Resident 64 physician order for oxygen administration clarified with MD and plan of care updated to reflect changes.
2. Director of Nursing/Designee will review residents with oxygen orders to ensure residents orders are being followed per physician's orders.
3. Director of Nursing or Designee will re-educate licensed staff on "Oxygen Therapy" Policy including ensuring that Physicians orders are being followed for oxygen administration.
4. Director of Nursing/Designee will conduct weekly random audits for three months of residents with Oxygen Administration orders to ensure physician's orders are being followed per resident's plan of care. Audit findings will be reviewed to the facility Quality Assurance/Performance Improvement Committee monthly for three months for further review and recommendations.

483.25(b)(2)(i)(ii) REQUIREMENT Foot Care: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(b)(2) Foot care.
To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must:
(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and
(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.
Observations:

Based on review of select facility policies and procedures, observation, and resident and staff interview, it was determined that the facility failed to provide proper toenail care for one of three residents reviewed for activities of daily living (Resident 73).

Findings include:

The facility policy entitled, "Medical/Dental Care Selection," last reviewed without changes on November 13, 2020, revealed that the resident has a right to select medical (which includes podiatrists) and dental care providers. The purpose of the policy is to maintain a quality of life that supports a right to independent choices and decision-making. Implementation of the policy included that upon admission to the facility, a list of current facility approved ancillary services is reviewed with the resident and/or health care agent/surrogate. In the event the resident or the agent/surrogate does not choose an ancillary service, they will be required to make private arrangements with the ancillary service of their choice.

In an interview with Resident 73 on March 31, 2021, at 8:45 AM, Resident 73 asked the surveyor to have someone arrange to have her toenails cut. Observation of Resident 73 on March 31, 2021, at 8:45 AM, with the assistance of Employee 5 (nurse aide), revealed that the toenails of both her feet were thick, long, and with jagged edges.

Clinical record review for Resident 73 revealed that her diagnoses list included cellulitis (bacterial skin infection) of both her lower extremities and the need for assistance with personal care.

An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 4, 2021, assessed Resident 73 as requiring extensive physical assistance from two staff for personal hygiene; and diagnoses that included a need for assistance with personal care.

The surveyor requested evidence of the facility's provision of podiatry care for Resident 73 since her admission to the facility on February 25, 2021, during an interview with the Nursing Home Administrator and Director of Nursing on March 31, 2021, at 2:00 PM.

A consent provided by the facility on April 1, 2021 (following the surveyor's questioning) revealed that the facility obtained Resident 73's son's consent for podiatry services on April 1, 2021. The facility could not provide evidence that facility staff reviewed the list of ancillary service providers with Resident 73 or her son upon her admission as per the facility policy.

The facility was unable to provide evidence that staff identified the condition of Resident 73's toenails before the surveyor's questioning; or obtained podiatry services to treat her thickened, long toenails.

Interview with the Director of Nursing on April 1, 2021, at 11:45 AM confirmed that the consultant podiatrist has provided services in the facility since Resident 73's admission on February 25, 2021; however, she was not referred for services. The interview indicated that the facility would now submit her on the list for consultant podiatrist services following the surveyor's questioning.

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


 Plan of Correction - To be completed: 05/11/2021


1. Resident 73 no longer resides at facility
2. Director of Nursing or Designee will conduct an audit on any resident requiring assistance with ADL's to ensure that proper toenail care has been provided or services are being provided routinely to ensure that needs are being met.
3. Director of Nursing or Designee will re-educate licensed staff and direct care staff on facility policy "Medical/Dental Care Selection". Including the need to ensure residents needs are being met and maintained by providing assistance with ADL's or with the offering of outside providers for ancillary services.
4. Director of Nursing or designee will conduct random weekly audits of residents requiring assistance with ADLS including nail care and that services continue to be offered as needed to ensure residents needs continue to be met.
5. Results of monitoring will be reviewed at Quality Assurance Process Improvement Committee meeting monthly for 3 months for further review and recommendations.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of select facility policies and procedures, clinical record review, and staff and resident interview, it was determined that the facility failed to provide the highest practicable care regarding hospice services coordination for one of two residents reviewed for hospice services (Resident 73) and for a positioning device for one of two residents reviewed for limited range of motion (Resident 49).

Findings include:

The facility policy entitled, "Hospice Program," last reviewed without changes on November 13, 2020, revealed that the hospice provider in contract with the facility is held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility. In general, it is the responsibility of hospice to manage the resident's care as it relates to the terminal illness and related conditions including determining the appropriate hospice plan of care and providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms. In general, it is the responsibility of the facility to 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. These include administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care. The facility staff collaborate with the hospice representatives and coordinate the facility staff participation in the hospice care planning process. The facility obtains information from hospice that includes the most recent hospice plan of care specific to the resident and the hospice medication information specific to each resident. The coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility (including the responsible provider and the discipline assigned to the specific task) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The coordinated plan of care will reflect the resident's goals and wishes and will be revised and updated as necessary to reflect the resident's current status.

The policy implementation steps included a section for the designation of the facility's staff's name and title of the person who coordinates the care provided by the facility and hospice staff; however, this section was blank.

Interview with Resident 73 on March 31, 2021, at 9:10 AM revealed that she believed that she started receiving hospice services about three weeks ago; however, she did not know if she had been seen by hospice staff or how frequently they visit her in the facility.

Clinical record review for Resident 73 revealed a physician's order dated March 16, 2021, instructing staff to arrange for a hospice provider consult.

The plans of care contained in Resident 73's available medical record failed to include the integration of hospice services (e.g. disciplines providing services to Resident 73 (e.g. social services, nursing, nurse aide, and/or clergy), frequency of those services, or medication and/or supplies provided by the consulting hospice provider, etc.).

The surveyor requested information regarding the coordinated plan of care between the consulting hospice provider and the facility during an interview with the Nursing Home Administrator and the Director of Nursing March 31, 2021, at 1:45 PM, and April 1, 2021, at 2:00 PM. The interview indicated that the consulting hospice provider maintains a binder at the nurse's station containing the coordinated plan of care.

Review of the binder maintained for Resident 73 revealed instructions for staff to call for medication refills and additional medical supplies; however, the information available did not indicate what supplies or medications the consulting hospice service provided. The binder index indicated that the "Interdisciplinary Group Plan of Care" could be found within the binder; however, the binder did not include this information.

An interview with the Nursing Home Administrator and the Director of Nursing on April 2, 2021, at 9:59 AM revealed that the consulting hospice provider did not supply the interdisciplinary plan of care up to this point; and that the Nursing Home Administrator contacted them yesterday regarding this omission. The interview confirmed that, to this point, the facility has not received this plan of care although documentation indicated that the skilled nurse made three visits to Resident 73. The facility was unable to provide the plan of care that would specify the frequency of skilled nursing visits and what supplies/medications the consulting hospice service supplied through Resident 73's hospice benefit.

Observation of Resident 49 on March 30, 2021, at 12:09 PM and again on March 31, 2021, at 10:15 AM revealed she was sitting in a wheelchair with a sling in place on her right arm.

An occupational therapy noted dated March 9, 2021, indicated that Resident 49 may benefit from a sling for her right upper extremity to stabilize her arm while seated in her wheelchair to prevent further injury.

Review of Resident 49's clinical record revealed no documented evidence to indicate the facility obtained a physician's order for the use of the sling. There was also no documented evidence in Resident 49's care plan to indicate the need for a right arm sling.

Interview with the Director of Nursing on April 2, 2021, at 10:21 AM confirmed that there was no current physician's order for Resident 49's use of the right arm sling, that it was not care planned, and that Resident 49's physician was not made aware of the recommendation from therapy for the use of the sling.

483.25 Quality Of Care
Previously cited deficiency 9/6/19

28 Pa. Code 211.11(d) Resident care plan

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


 Plan of Correction - To be completed: 05/11/2021

1. Resident 73 and Resident 49 no longer reside at the facility.
2. Social Service director will conduct audits on all current hospice residents to ensure that plan of care is integrated with hospice services. Director of Nursing/Designee will conduct audits on all residents that have Slings/Braces/adaptive equipment in place to ensure adaptive equipment is included in resident's plan of care and physician orders are in place.
3. Director of Nursing/designee will provide education to direct care givers and licensed staff regarding "Hospice Program" policy, and the need for integration of hospice service within residents plan of care. Executive Director will contact Hospice agencies and provide education regarding need to timely provide plan of care and work with facility to ensure hospice services are integrated into residents plan of care. Director of Nursing/designee will provide education to licensed staff and direct care givers that all braces/splints and adaptive equipment will be part of residents plan of care and physician orders need obtained.
4. Social Service Director will conduct random audits weekly of hospice residents plan of care to ensure that hospice services are integrated into residents plan of care weekly for three months. Director of nursing/designee will conduct random audits on use of braces/splints or adaptive equipment weekly for three months to ensure plan of care is updated and appropriate documentation in place. Audit findings will be reported to the facility Quality Assurance/Performance Improvement Committee monthly for three months for further review and recommendations.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on review of select facility policies, clinical record review, observation, and staff and family interview, it was determined that the facility failed to maintain adequate hygiene for one of three residents reviewed (Resident 19).

Findings include:

Review of the facility policy entitled "Activities of Daily Living," last reviewed without changes on November 13, 2020, revealed that residents who are unable to carry out activities of daily living (ADLs) will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .

Clinical record review for Resident 19 revealed that the facility identified that it was somewhat important to choose between receiving a shower or a tub bath. Review of Resident 19's most recent quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated January 13, 2021, revealed that Resident 19 needed extensive assistance by two staff members for personal hygiene, including combing hair and washing her face and hands, and was totally dependent on two staff members to be bathed and/or showered.

Interview with Resident 19's responsible party on March 31, 2021, at 9:39 AM revealed that during her virtual family visits with Resident 19 she observed her hair being long, dirty, and stringy and her fingernails with dirt and debris underneath them.

Observation of Resident 19 on March 31, 2021, at 9:54 AM confirmed that Resident 19 was in bed sleeping. Her hair was long, dirty, stringy and that there was debris underneath her fingernails.

Review of facility documentation revealed that the facility last showered Resident 19 on March 26, 2021, five days before the above noted observation.

Interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on March 31, 2021, at 2:00 PM acknowledged the above findings with Resident 19's appearance. The NHA indicated that the beautician had been on hold due to the Covid 19 outbreak but had returned in February 2021 to provide services to the residents. Resident 19 had not been seen by the beautician since their return for a haircut.

483.24(a)(2) ADL Care Provided for Dependent Residents
Previously cited 9/16/19

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


 Plan of Correction - To be completed: 05/11/2021


1. Resident 19 has received beautician services and continues to be offered shower weekly, nails have been cleaned and clipped on shower days.
2. Interdisciplinary team will complete audit on all dependent residents to ensure resident's needs are being met and residents maintain clean well-groomed appearance per plan of care.
3. Director of Nursing/Designee will provide re-education to direct care staff and licensed staff on "Activities of Daily Living" policy and providing needed to care to ensure that residents maintain a clean well groom appearance.
4. Interdisciplinary team will complete random audits weekly for three months to ensure that residents needs continue to be met and cleanliness is maintained per resident's plan of care.
Audit findings will be reviewed by the Quality Assurance/ Performance Improvement Committee monthly for three months for further review and recommendations.


483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on observation, resident and staff interview, and clinical record review, it was determined that the facility failed to ensure a dependent resident received treatment and services to use hearing aids for one of one resident reviewed for hearing concerns (Resident 13).

Findings include:

Observation of Resident 13 on March 31, 2021, at 10:10 A, revealed he was wearing a hearing aid in his left ear; however, Resident 13 could not hear any question asked by the surveyor and did not appropriately respond to any question asked.

Clinical record review for Resident 13 revealed his diagnoses list included bilateral hearing loss.

An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated January 3, 2021, assessed Resident 13 as having minimal difficulty in some environments (e.g. when person speaks softly or setting is noisy) while a hearing aid or other hearing appliance used; and that Resident 13 required the extensive physical assistance of one staff for dressing and hygiene. The Care Area Assessment Summary noted that the communication care area triggered, and that staff would proceed to the development of a plan of care.

A plan of care developed by the facility to address Resident 13's cognitive status noted that Resident 13 had a cognitive decline related to age and decreased hearing. This plan of care made no mention of the use of hearing aids. A plan of care developed by the facility to address Resident 13's communication deficits noted that Resident 13 was able to usually understand others and instructed staff to clean Resident 13's hearing aid(s), check the batteries, and insert hearing aid(s) before breakfast. The plans of care available did not note if Resident 13 wore one or bilateral hearing aids or in which ear Resident 13 wore a hearing aid.

Review of Resident 13's physician orders revealed no directives for staff to utilize a hearing aid for his care.

Nursing documentation dated January 24, 2021, at 6:42 PM noted that Resident 13 complained of an inability to hear out of his left ear. Upon exam, staff noted that his ear canal was packed with wax.

A physician communication form dated January 24, 2021, informed the physician that Resident 13's ears were packed with wax; and the physician provided an order on January 26, 2021, for staff to utilize Debrox (over-the-counter ear drops that foam on contact and soften/loosen earwax for easiest removal with gentle warm water irrigation) twice daily for four days and to obtain a consult with audiology if the Debrox was ineffective.

Nursing documentation dated January 26, 2021, at 11:54 AM revealed that staff acknowledged the physician's order for the Debrox treatment, that Resident 13's appointment with audiology was scheduled, and that Resident 13's brother-in-law was informed of the battery size for Resident 13's hearing aid.

Interview with the Nursing Home Administrator and Director of Nursing on March 31, 2021, at 2:00 PM, and the Director of Nursing on April 1, 2021, at 11:30 AM indicated that the facility provides hearing aid batteries; and were unaware that staff attempted to have Resident 13's responsible party provide the hearing aid batteries.

Nursing documentation dated January 29, 2021, at 2:23 PM revealed that Resident 13 was out of the facility for his scheduled appointment with audiology and that upon his return staff were made aware that the findings of his appointment were that the battery in his hearing aid was dead and that audiology requested no further follow up.

Review of the consulting audiology provider Report of Consultation dated January 29, 2021, revealed one sentence of findings noting, "Battery in aid was dead."

Nursing documentation dated March 17, 2021, at 12:14 PM again noted that staff notified Resident 13's responsible party that he needed hearing aid batteries; and that Resident 13's responsible party would bring some into the facility within the next few days.

Interview with the Nursing Home Administrator and the Director of Nursing on April 1, 2021, at 1:45 PM again reiterated that the facility has and provides Resident 13's hearing aid batteries and the facility provided no rationale for staff contacting Resident 13's responsible party for this supply. The interview confirmed that staff sent Resident 13 to his audiology appointment with a dead battery in his hearing aid.

28 Pa. Code 211.11(d) Resident care plan

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


 Plan of Correction - To be completed: 05/11/2021

1. Resident 13 went to follow up appointment on January 29, 2021 where hearing aid battery replaced and hearing aid was cleaned at audiology appointment. Resident continues to utilize hearing aid in left ear. Resident's plan of care has been updated to include use of left hearing aid.
2. Director of Nursing or designee will audit residents utilizing assistive hearing devices to ensure Hearing devices are included in plan of care to meet resident's needs, along with orders for routine battery checks.
3. Director of Nursing or Designee will provide re-education to all direct care staff and licensed staff regarding use of assistive hearing devices and routinely checking the functioning of hearing devices.
4. Director of Nursing or designee will conduct random audits weekly for three months with residents with assistive hearing devices in place to ensure needs are being met and plan of care reflects use of devices.
Audit findings will be reviewed to the facility Quality Assurance /Performance Improvement Committee monthly for three months for any further review and recommendations.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
483.12 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 clinical record review, review of select facility policies and procedures, review of facility documentation, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin to rule out abuse and/or neglect for one of one resident reviewed (Resident 49).

Findings include:

The policy entitled "Abuse/Neglect/Mistreatment of Residents/Misappropriation of Resident Property," last reviewed without changes on November 13, 2020, defines neglect as the failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Example of neglect could be a failure to note and report a significant change in condition resulting in delay of treatment. The facility is to report an allegation of neglect to the Pennsylvania Department of Health within 24 hours, notify the area agency on aging, and complete a Provider Bulletin 22 (PB-22, a form submitted to the state Department of Health, which includes the investigation into abuse) within five working days of the allegation or incident).

The policy further indicates that all resident injuries of unknown origin will be reported immediately and that a "Resident Incident Investigation Report" will be completed. Interview with the Director of Nursing on April 2, 2021, at 12:45 PM confirmed that a facility's investigation into injuries of unknown origin include obtaining staff statements from the previous three shifts.

Review of a therapy discharge summary dated November 25, 2020, indicated that Resident 49's transfer status can be completed with the assist of one caregiver. Review of Resident 49's current care plan also indicated that staff are to transfer her with one assist, a rolling walker, and a gait belt.

Nursing documentation dated March 4, 2021, at 6:03 AM revealed that nursing staff identified a bruise to Resident 49's right chest and axilla (armpit). Resident 49 appeared to be having pain and was guarding with movement.

Review of the facility's investigation into the bruising dated March 4, 2021, indicated that Resident 49's right chest and axilla bruise measured 8.4 cm (centimeters) long by 5.2 cm wide. The investigation described the bruise as dark purple in color, firm to touch, and that Resident 49 appears to exhibit pain when the bruise is touched. There was no documented evidence included in the investigation on how the facility ruled out the potential for abuse and/or neglect, or that the facility obtained any witness statements from staff from the previous three shifts regarding the bruise.

Interview with the Director of Nursing on April 2, 2021, at 11:02 AM revealed that when staff are completing yearly competencies on using lifts for residents, they are verbally educated that if a resident requires more assistance with transfers or requires the use of a lift, they are to notify therapy of the residents change in condition so that they can be assessed to determine the safest device to use for the transfer of the resident.

An occupational therapy evaluation dated March 5, 2021 through April 3, 2021 indicates that Resident 49 experienced a decline in transfers and that staff had been using a stand-up lift. Occupation therapy noted that they were not recommending the use of the stand-up lift due to Resident 49's hand contractures and safety.

Review of the facility investigation into Resident 49's dislocation revealed a staff statement dated March 8, 2021, indicating that Employee 4, nurse aide, had been using a stand up lift (a lift that helps secure a person upright using a sling that wraps underneath the arms while being lifted) on Resident 49 for about two months. Employee 4's statement indicated that she failed to notify therapy regarding Resident 49's need for a change in transfer status.

Interview with the Administrator and Direction of Nursing on April 1, 2021, at 1:45 PM confirmed that the facility did not complete a PB-22 for submission to the state Department of Health regarding Employee 4 not following Resident 49's plan of care for transfers, and violating facility policy regarding transfer status in place for the safety of the residents.

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

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

28 Pa. Code 201.29(a) Resident rights

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


 Plan of Correction - To be completed: 05/11/2021

1. Resident 49 no longer resides at facility. Investigation completed and education has been provided to nursing assistant regarding reporting to supervisor when down grading residents transfer status so therapy screen can be placed. During time- frame of injury, transfer status was followed per residents plan of care of 1 assit.
2. Director of Nursing or Designee will review all injuries of unknown for last 30 days to ensure residents plan of care followed and investigation complete to rule out abuse and neglect.
3. Director of Nursing or Designee will re-educate direct care and licensed staff on "Abuse/Neglect/Mistreatment of Residents/ Misappropriation of Residents Property", including following residents plan of care and reporting of abuse and neglect.
4. Director of Nursing or Designee will audit injuries of unknown origin to ensure plan of care followed and abuse and neglect ruled out Bi-weekly for three months. Audit findings will be reported to facility Quality Assurance/Performance Improvement Committee monthly for three months for further review and recommendations.

483.10(g)(5)(i)(ii) REQUIREMENT Required Postings: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.
483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.
Observations:

Based on observation and staff interview, it was determined that the facility failed to display pertinent documents in an area accessible to residents and resident representatives on three of three nursing units.

Findings include:

During an observation on March 31, 2021, at 12:15 PM with Employee 3, social worker, it was revealed that a display of the required statement that the resident may file a complaint with the State Survey Agency, the State licensure office, and Medicaid Fraud Control Unit, and their phone numbers and addresses (mailing and email) could not be located on any resident area.

During an interview with the Nursing Home Administrator on March 31, 2021, at 3:15 PM it was confirmed that the required postings were not displayed.

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

28 Pa. Code 201.18(a)(b)(3)(e)(1) Management



 Plan of Correction - To be completed: 05/11/2021

1. Required postings will be displayed in areas accessible to residents on each nursing unit.
2. Required postings will be displayed in areas accessible to residents on each nursing unit.
3. The process for displaying required postings has been revised to ensure required postings are displayed in areas accessible to residents in each nursing unit.
4. Administrator or designee will include a visual check of required postings during routine rounds. Audit findings will be reviewed by the Quality Assurance/ Performance Improvement Committee monthly for three months for further review and recommendations.


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