Nursing Investigation Results -

Pennsylvania Department of Health
VILLAGE AT PENN STATE, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
VILLAGE AT PENN STATE, THE
Inspection Results For:

There are  28 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.
VILLAGE AT PENN STATE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on January 24, 2020, it was determined that The Village at Penn State 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(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
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 the highest practicable pain management for two of three residents reviewed for pain concerns (Residents 20 and 28).

Findings include:

The facility policy entitled, "Pain Assessment and Management," last reviewed without changes on December 3, 2019, revealed that the facility will ensure that the residents receive the appropriate care and treatment for relieving pain so that quality of life and the resident's psycho-social needs are addressed as they progress through all stages of life including but not limited to the care of the dying resident. Staff will document on the pain management flow sheet for PRN (as needed) pain medication.

Review of the facility's Pain Management Flowsheet revealed that staff utilize four pain intensity scales. The Wong-Baker FACES Pain Rating Scale, which staff utilize the resident's facial expression to help identify the extent of their pain, with a smile being no pain and crying being the worst pain experienced. The Pain Rating Scale, which staff utilize to determine no pain, mild pain, moderate pain, severe pain, very serve pain, and worst pain experienced. The Numeric Pain Scale, which staff ask residents to rate their pain along a zero to 10 scale, with zero being no pain, five being moderate pain, and 10 being the worst possible pain. The PAINAD (Pain Assessment in Advanced Dementia) scale, which staff identify how/what a resident's breathing, negative vocalizations, facial expression, body language, and consolability are on a zero to two-point scale with the higher the total of all five areas meaning a higher pain level for the resident.

Clinical record review of Resident 28 revealed the resident has a current physician's order for Tylenol (a medication used to treat mild pain) 325 mg (milligrams), two tablets by mouth every four hours as needed for mild pain. Resident 28 also had a current order for Roxanol (morphine sulfate, a medication used to treat moderate to severe pain), 20 mg/ml, (milligrams per milliliter), 0.5 ml (10 mg), under tongue every 30 minutes as needed for pain or dyspnea. There was no evidence of any pain rating parameters to indicate at what pain rating the facility was to administer the Roxanol.

Further clinical record review for Resident 28 revealed an interdisciplinary note dated January 3, 2020 at 1:30 PM, which noted "resident pain much better, but still has a little bit." Another note dated January 4, 2020, at 4:45 AM noted the resident complained of neck pain and back pain and "offered and given Roxanol per physician's order."

Review of Resident 28's MARs (medication administration record, a form to document medication administration) for January 2020 revealed the resident was administered Roxanol on January 4, 2020 at 4:40 AM. Review of the resident's pain management flow sheet for January 2020, did not reveal any assessment of Resident 28's pain rating prior to administering the Roxanol, or any alternative treatment.

The surveyor reviewed the above findings for Resident 28 during an interview with the Nursing Home Administrator and the Director of Nursing on January 23, 2020, at 2:15 PM.

Clinical record review for Resident 20 revealed current physician's orders for the following pain medications:

Tylenol 325 mg two tablets by mouth (PO) every four hours PRN for pain, max 3 grams per 24 hours
Tramadol 50 mg one tablet PO every four hours PRN moderate pain
Roxanol (medication used for severe pain) 20 mg/ml use 0.5 ml (10 mg) under the tongue every one-hour PRN pain

There was no documentation differentiating the pain level in which staff are to administer Tylenol or Roxanol to Resident 20.

Review of Resident 20's MARs, Roxanol and Tramadol Controlled Substance Proof-of-Use Records, and Pain Management Flowsheets for November and December 2019 and January 2020 revealed that staff administered roxanol on the following dates:

November 4, 2019, at 10:00 AM
November 16, 2019, at 2:00 PM
January 16, 2020, at 2:00 PM

Review of Resident 20's MARs, Roxanol and Tramadol Controlled Substance Proof-of-Use Records, and Pain Management Flowsheets for November and December 2019 and January 2020 revealed that staff administered tramadol on the following dates:

November 29, 2019, at 3:30 AM
December 25, 2019, at 5:00 PM

There was no documentation of Resident 20's pain level and/or the effectiveness of either medication for any of the administrations.

On the following dates, staff administered roxanol for a pain level of 8:

December 10, 2019, at 7:00 AM
December 15, 2019, at 5:00 PM
January 13, 2020, at 9:00 AM
January 14, 2020, at 10:45 AM
January 17, 2020, at 3:00 PM

On the following date, staff administered roxanol for a pain level of 7:

January 21, 2020, at 4:00 PM

On the following dates, staff administered tramadol for a pain level of 8:

December 12, 2019, at 4:00 PM
December 21, 2019, at 4:00 PM

On the following dates, staff administered tramadol for a pain level of 7:

January 3, 2020, at 12:00 PM
January 6, 2020, at 5:30 PM
January 15, 2020, at 4:00 PM

Staff are overlapping pain medications for the same pain level as there were no pain level parameters determined for the Roxanol.

The surveyor reviewed the above findings for Resident 20 during an interview with the Nursing Home Administrator and Director of Nursing on January 22, 2020, at 2:15 PM.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited January 25, 2019

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


 Plan of Correction - To be completed: 03/24/2020

1. Resident 28- Clarification orders were obtained on 01/23/2020: Tylenol PRN was discontinued; Roxanol 20mg/ml PO/SL give every 30 minutes as needed for moderate to severe pain or dyspnea. The missing assessments of pain levels are not able to be corrected.
Resident 20- clarification orders were obtained on 01/23/2020 for pain medication regimen; Tylenol 325mg- take 2 tabs (650mg) PO every 4 hours as needed for mild pain. Ultram 50mg PO every 4 hours as needed for moderate pain. Roxanol 10mg PO/SL as needed for pain not relieved by Ultram or for shortness of breath/resp. distress. The missing assessments pain levels are not able to be corrected.
2. Chart audits were completed for all 33 residents in house on 01/23/2020. Clarification orders for pain medication management were obtained for 3 residents.

3. Licensed Staff will be in-serviced on the pain management policy.

4. The Director of Nursing or designee will audit pain medication orders of newly admitted residents and as needed for new/changed orders for 1 year. Audits of pain management flow sheets for all residents receiving PRN pain medications will be completed weekly for 4 weeks, monthly for 3 months, quarterly for 2 quarters to ensure documentation and follow up of resident's pain level and the effectiveness of the pain medication administered.
Results of audits will be presented at community QAPI meetings. Processes will be revised as indicated.


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 assess for the risk of side rail entrapment, review the risk and benefits of side rail utilization with the resident or resident representative, and receive consent for the use of side rails for six of seven residents reviewed (Residents 2, 4, 5, 12, 23, and 29).

Findings include:

The facility policy entitled "Side Rail Use," last reviewed without changes in December 3, 2019, indicated that the facility would provide education to the resident and/or resident representative on the use of side rails and/or use of alternative measures. Staff will obtain an informed consent.

Clinical record review for Resident 23 revealed that there was not an informed consent for the use of side rails.

Observation of Resident 23 on January 21, 2020 at 9:32 AM and 10:59 AM and January 23, 2020, at 9:35 AM revealed that she was in bed and had bilateral side rails in the raised position.

The surveyor reviewed the above information for Resident 23 during an interview with the Nursing Home Administrator (NHA) on January 23, 2020, at 9:05 AM. The NHA confirmed that the facility did not obtain a resident or responsible party consent for the use of side rails.

Observation of Resident 4's bed on January 21, 2020 at 2:14 PM revealed the left side against the wall and enabler bars were raised on both sides of the bed.

There was no evidence to indicate Resident 4 and his responsible party were educated on the risks of entrapment with the use of the enabler bars, signed consent, or that the entrapment zones were assessed prior to the utilization of the enabler bars on Resident 4's bed.

An observation of Resident 5's bed on January 21, 2020, at 10:58 AM revealed enabler bars up on both sides of the resident's bed.

Clinical record review for Resident 5 revealed a bed rail/assist bar evaluation last completed on January 15, 2020. The evaluation indicated Resident 5 utilized the enabler bars for positioning and support and to promote independence with bed mobility.

There was no evidence to indicate Resident 5 and/or his responsible party were educated on the risks of entrapment with the use of the enabler bars, signed consent, or that the entrapment zones were assessed prior to the utilization of the enabler bars on Resident 5's bed.

Observation of Resident 2 on January 22, 2020, at 10:00 AM revealed she was in bed with bilateral quarter side rails up.

Clinical record review for Resident 2 revealed a side rail evaluation last completed on January 3, 2020. The evaluation indicated Resident 2 utilized the quarter side rails as an enabler to promote independence.

There was no evidence to indicate Resident 2's responsible party was educated on the risks of entrapment with the use of the side rails, signed a consent for use of the side rails, or that the entrapment zones were assessed prior to the utilization of the side rails on Resident 2's bed.

Observation of Resident 12 on January 22, 2020, at 9:15 AM revealed she was in bed with bilateral quarter side rails up.

Clinical record review for Resident 12 revealed a bed rail/assist bar evaluation last completed on November 5, 2019. The evaluation indicated that Resident 12 utilized the quarter side rails as an enabler to promote independence and that she requested to have the side rails.

There was no evidence to indicate Resident 12 and/or her responsible party were educated on the risks of entrapment with the use of the side rails, signed a consent for use of the side rails, or that the entrapment zones were assessed prior to the utilization of the side rails on Resident 12's bed.

Observation of Resident 29's bed on January 21, 2020, at 9:20 AM revealed bilateral quarter side rails were in the raised position. The quarter side rail housed Resident 29's television controls and bed controls.

Clinical record review for Resident 29 revealed a bed rail/assist bar evaluation last completed on September 20, 2019. The evaluation indicated that Resident 29 utilized the assist bar as an enabler to promote independence.

There was no evidence to indicate Resident 29's responsible party was educated on the risks of entrapment with the use of the side rails, signed a consent for use of the side rails, or that the entrapment zones were assessed prior to the utilization of the side rails on Resident 29's bed.

The surveyor reviewed the above findings for Residents 4, 5, 2, 12, and 29 during an interview with the Nursing Home Administrator and the Director of Nursing on January 23, 2020, at 2:15 PM

28 Pa. Code 211.12 (d)(5) Nursing services
Previously cited 1/25/19


 Plan of Correction - To be completed: 03/24/2020

1. Entrapment zones on the beds of residents 2,4,5,12,23, and 29 have been measured to assess for the risk of side rail entrapment.
The risks and benefits of side rail utilization will be reviewed with residents 2,4,5,12,23, and 29 (or the residents' representatives) and consent will be requested.
2. Entrapment zones on the beds of other residents with side rails in use have been measured to assess for the risk of side rail entrapment.
The risks and benefits of side rail utilization will be reviewed with residents (or the residents' representatives) who have side rails in use and consent will be requested.
3. The policy "Side Rail Use" will be reviewed and revised to ensure needed components are included. Nursing staff will be educated regarding the possible risks and benefits of side rail utilization and the policy "Side Rail Use", as well as the need to measure entrapment zones when changing the bed, mattress, bedrail system. Maintenance staff will be educated regarding the need to perform periodic measurements of entrapment zones on beds with side rails in use.
4. The nursing home administrator or designee will perform monthly audits of residents with side rails in use to ensure the entrapment zones have been measured to assess the risk of side rail entrapment, the risks and benefits have been reviewed with the resident or responsible party and consent has been received. Audit results will be presented at community QAPI meetings. Processes will be revised as indicated by the audit results.




483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on review of select facility policies, observation, and staff interview, it was determined that the facility failed to provide adequate housekeeping services to ensure a clean, safe, and orderly environment on one of two nursing units (First Floor Nursing Unit, Resident 20).

Findings include:

Review of the facility policy entitled "Housekeeping Services," last reviewed on December 3, 2019, without changes, revealed that the facility will promote a sanitary environment.

Observation of Resident 20's room on the following dates and times revealed that it smelled strongly of urine:

January 21, 2020, at 10:37 AM and 11:01 AM
January 23, 2020, at 9:37 AM and 10:00 AM

The surveyor reviewed the above information during an interview with the Director of Nursing on January 23, 2020, at 10:00 AM.

28 Pa. Code 201.18(b)(3) Management

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


 Plan of Correction - To be completed: 03/24/2020

1. On 1/24/2020 a urine sample was obtained for Resident 20 due to malodorous urine. The culture was positive and an antibiotic was started on 1/27/2020. Due to the culture results, the physician prescribed a maintenance dose of Methenamine. Foley catheter changes have been reviewed and increased to twice a month. Resident 20's recliner and carpet were cleaned and will continue to be cleaned at least twice monthly. The type of deodorizer used in the room has been changed. There is no urine odor in the room at this time.
2. A walk thru has been done to identify other rooms with a persistent urine odor. No other rooms have been identified.
3. Nursing and other staff who work in the skilled nursing units will be educated regarding steps to take when a persistent urine odor is noticed. Housekeeping staff will be educated about techniques and equipment available to address persistent odors.
4. The nursing home administrator or designee will walk thru rooms weekly for four weeks, biweekly for four weeks, and then monthly to identify rooms with persistent odors. Results of walk thrus and interventions will be presented at community QAPI meetings. Processes will be revised as indicated by audit findings.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on review of select facility policies, observation, and staff interview, it was determined that the facility failed to provide an environment free from the potential spread of infection regarding resident bedpans and basins for one of one resident reviewed (Resident 20).

Findings include:

Review of the facility policy entitled "Cleaning of Bedpans, Commodes, and Urinals," last reviewed without changes on December 3, 2019, revealed that personal care items must be kept separate from bedpans and urinals.

Observation of Resident 20's room on the following dates and times revealed that her bedpan and basin were sitting on top of one another either under the sink or under the shower bench in the resident's shower. Neither the bedpan nor the basin were bagged or covered to prevent the potential for infection and/or cross-contamination.

January 21, 2020, at 9:35 AM and 12:52 PM
January 22, 2020, at 9:23 AM and 12:15 PM
January 23, 2020, at 9:38 AM

Observation and concurrent interview on January 23, 2020, at 10:00 AM with the Director of Nursing confirmed and acknowledged the above findings.

28 Pa. Code 211.10(d) Resident care policies
Previously cited 1/25/19

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 1/25/19

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


 Plan of Correction - To be completed: 03/24/2020

1. On 01/23/2020 the bed pan and basin were removed from resident 20's bathroom and discarded.
2. A walk thru has been done to identify other rooms with bedpans and personal items stored together. No other rooms have been identified.
3. Licensed Staff, Certified Nursing Assistants and Housekeeping staff will be educated on Policy 1.11 Cleaning of Bedpans, Commodes, and Urinals; including the need to keep personal care items separate from bedpans and urinals.
4. The Director of Nursing or designee will walk thru rooms weekly for four weeks, biweekly for four weeks, and then monthly to identify rooms with bedpans and personal items stored together. Results of walk thrus will be presented at community QAPI meetings. Processes will be revised as indicated by findings of walkthrus.

201.22(j) LICENSURE Prevention, control and surveillance of TB.:State only Deficiency.
(j) New employes shall have the 2-step intradermal skin test before beginning employment unless there is documentation of a previous positive skin reaction. Test results shall be made available prior to assumption of job responsibilities. CDC guidelines shall be followed with regard to repeat periodic testing of all employes.
Observations:

Based on a review of personnel files of recently hired employees and staff interview, it was determined that the facility failed to utilize the one-step intradermal tuberculin skin test for initial testing for two of five employees reviewed (Employees 1 and 2).

Findings include:

The facility hired Employee 1, nurse aide, on September 19, 2019. The facility did not administer a tuberculin test (a screening test for tuberculosis) to the employee prior to her hire.

Review of Employee 1's personnel file revealed she had received a two-step intradermal tuberculin test from another employer with results on February 11 and 25, 2019. There was no evidence that the facility completed a tuberculin test before the employee was hired in the facility on September 19.

The facility hired Employee 2, licensed practical nurse, on October 22, 2019. The facility did not administer a tuberculin test to the employee prior to her hire.

Review of Employee 2's personnel file revealed she had received a two-step intradermal tuberculin test from another employer with results on April 25, and May 6, 2019. There was no evidence that the facility completed a tuberculin test before the employee was hired in the facility on October 22, 2019.

The Centers for Disease Control and Prevention requires that if there is a previous documented negative tuberculosis test result less than 12 months prior for new employment a single tuberculosis skin test is needed for baseline testing.

In an interview with the Nursing Home Administrator on January 24, 2020, at 11:15 AM she indicated that Employee 1 and 2 did not have a single tuberculosis skin test prior to her hire at the facility.

The facility failed to complete the tuberculosis screening prior to new employment as required by the Centers for Disease Control and Prevention.


 Plan of Correction - To be completed: 03/24/2020

1. Employee 1 received a one step intradermal tuberculin skin test on 1/24/2020.
Employee 2 is a per diem staff member and will receive a one step intradermal tuberculin skin test prior to next scheduled shift.
2. Employees hired since February 1, 2019 have been reviewed to identify employees who should have received a one-step intradermal tuberculin skin test at time of hire. Employees who were identified as needing the test but not receiving it will receive the test.
3. Human resources staff are being educated to ensure compliance with the regulation and CDC guidelines.
4. Tuberculin Skin Tests of new hires will be reviewed by the infection control nurse to ensure proper testing.

Human resources staff will track hire dates and Tuberculin Skin Testing dates of new hires to ensure proper testing. Tracking results will be reported monthly at community QAPI meetings.


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