Nursing Investigation Results -

Pennsylvania Department of Health
WILLOWS OF PRESBYTERIAN SENIORCARE
Patient Care Inspection Results

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WILLOWS OF PRESBYTERIAN SENIORCARE
Inspection Results For:

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WILLOWS OF PRESBYTERIAN SENIORCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and an Abbreviated Survey in response to a complaint completed on September 27, 2019, it was determined that the Willows of Presbyterian Senior Care was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:
Based on facility document and clinical record review, observations and staff interviews it was determined that the facility failed to provide an environment that promotes dignity for two of six residents (Resident R105 and R385).

Findings include:

The facility "Resident Resource Guide" provided to residents on admission indicated that the resident shall be treated with consideration, respect and full recognition of dignity, including privacy in treatment and care for his/her personal needs.

A review of the Admission Sheet indicated that Resident R105 was admitted to the facility on 8/9/19, with diagnoses that included left eye blindness, depression and falls.

A review of the Admission Sheet indicated that Resident R385 was admitted to the facility on 9/14/19, with diagnoses that included falls and orthostatic hypotension (low blood pressure when changing positions).

During an observation on 9/24/19, at 10:30 a.m. it was revealed that Resident R105's briefs were stored on a counter near the resident bed in full view of visitors or any person entering the room.

During an interview on 9/24/19, at 10:30 a.m. Registered Nurse Employee E3 confirmed that storing resident briefs in view of staff and visitors was not dignified.

During an observation on 9/24/19, at 1:17 p.m. it was revealed that Resident R385's briefs were stored on a counter near the resident bed in full view of visitors or any person entering the room.

During an observation on 9/27/19, at 11:45 a.m. it was revealed that Resident R385's briefs remained on a counter near the resident bed in full view of visitors or any person entering the room.

During an interview on 9/27/19, at 11:45 a.m. Registered Nurse Employee E4 confirmed that Resident R385's briefs were left in view of visitors and staff and that the facility failed to provide a dignified environment.

28 Pa. Code: 201.29(j) Resident rights.


 Plan of Correction - To be completed: 11/18/2019

The facility submits this plan of correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long term care. This plan of correction should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements.

R105 and R385 briefs were removed from counter near resident's bed and placed in bedside stand.
All residents have the potential to be affected by the deficient practice. A whole house audit will be performed to assure that the resident's environment promotes dignity. This included all resident briefs were stored out of full view of any visitor or any person entering the room. Briefs found to be in full view were placed in the resident's bed side stand.
The Director of Nursing or designee will educate all nursing staff on the "Resident Resource Guide" and the importance of providing an environment that promotes dignity.
The Director of Nursing or designee will conduct audits of the resident rooms for proper storage of briefs. These audits will occur 5 days a week for two weeks, then 3 days a week for two weeks, and then once a day for 2 weeks. Random audits will occur until substantial compliance occurs. Any deficient practices will be corrected immediately during the audit. The results of these audits will be shared with the Administrator and reviewed with the Quality Assurance Performance Improvement Committee.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to report an incident of alleged neglect as required to the State Agency for one of five residents (Resident R81).

Findings include:

A review of the clinical record indicated that Resident R81 was admitted to the facility on 11/30/17, with diagnoses that included stroke, and high blood pressure.

A review of the quarterly minimum data set resident assessment (MDS) dated 8/5/19, indicated the diagnoses remain current and Resident R81 transfers with extensive assist of two persons for toileting.

A review of Resident R 81's physician order dated 8/23/19, indicated transfer with Sara Lift (mechanical lift) using extensive assist of two persons.

A review of a nurse progress note dated 9/12/19, indicated a staff member transferred Resident R81 to the toilet without following the resident's transfer with Sara Lift and assist of two persons, and the resident fell.

There was no evidence that the facility reported the incident of alleged neglect to the State Agency as required.

During an interview on 9/27/19, at 11:35 a.m. the Director of Nursing confirmed above findings and the facility failed to report an incident of alleged neglect as required to the State Agency for Resident R81.

28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee.
28 Pa. Code: 201.18(e)(1) Management
28 Pa. Code: 201.20(b) Staff development.


 Plan of Correction - To be completed: 11/18/2019

R 81 was not affected by the deficient practice of not reporting an incident
Nursing staff will be educated on the importance of reporting incidents that occurred immediately to Facility Management so an investigation can occur and a report can be submitted to the proper State Agency. A review of incidents/accidents tracking tool will be conducted
An in-service education program will be conducted by the Director of Nursing Services and the Administrator with all direct care staff and management team addressing circumstances that require State Agency reporting. This education will include appropriate time frames.
The Director of Nursing Services or designee will conduct a random audit of incidents/accidents forms to ensure that incidents and injuries are identified properly and are investigated and reported to the appropriate State Agency timely. These audits will occur 5 days a week for two weeks, then 3 days a week for two weeks, and then once a day for 2 weeks. Random audits will occur until substantial compliance occurs. Any deficient practices will be corrected immediately during the audit.
The results of these audits will be shared with the Administrator and reviewed by the Quality Assurance Performance Improvement Committee

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 facility policy and clinical record review, and staff interviews, it was determined that the facility failed to provide assistance with eating for one of nine residents (Resident R83).

Findings include:

A review of the facility policy "Skilled Nursing - Feeding Guidelines" dated June 2019, indicated residents who require assistance to consume their meal will have a seated assistant.

A review of the clinical record revealed Resident R83 was admitted to the facility on 12/11/14, with diagnoses that included Parkinson's (a progressive disease of the nervous system) and dysphagia (difficulty swallowing food).

A review of the Quarterly Minimum Data Set (MDS - periodic assessment of care needs) dated 8/6/19, indicated the above diagnoses remain current, Resident R83 is sometimes understood or understands, has impaired cognition and requires extensive assist of one person with meals.

During an observation on 9/23/19, of the lunch meal on the Second Floor West wing nursing unit, Resident R83 received the meal tray at 12:00 p.m. During an observation at 12:30 p.m., Resident R83 was observed trying to eat the meal by using her left hand to pick at various food items. No staff arrived to assist Resident R83.

During an interview on 9/23/19, at 12:30 p.m. Hospitality Aide (HA) Employee E5 revealed "I told them she needs help." HA Employee E5 confirmed no staff assisted Resident R83.

During an interview on 9/24/19, at 3:00 p.m. the Director of Nursing confirmed the above findings and the facility failed to provide assistance with eating for Resident R83.

28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(5) Nursing services.


 Plan of Correction - To be completed: 11/18/2019

Assistance with feeding was provided to R83 on 9/23/19. The Director of Nursing Services did a review of R83 chart and consulted the Dietician, OT and Speech Therapy to rescreen resident for adaptive devices.
The facility has determined that all residents that need assistance to eat have the potential to be affected. A whole house audit will be conducted to identify all residents needing assistance during meal time.
An in-service education program will be conducted by the Director of Nursing Services or designee with direct care staff addressing the facility policy "Skilled Nursing Feeding Guidelines". This education will include the importance to assist residents with meals.
Nurse Management or designees will review and monitor residents who require meal assistance.
The Director of Nursing Services or designee will conduct direct observations audits of residents who require meal assistance. These audits will occur 5 days a week for two weeks, then 3 days a week for two weeks, and then once a day for 2 weeks. Random audits will occur until substantial compliance occurs
Any deficient practices will be corrected immediately during the audit and observation.
The results of these audits and observations will be shared with the Administrator and reviewed by the Quality Assurance Performance Improvement Committee.

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 the manufacturer guide, clinical record review and staff interview, it was determined that the facility failed to provide care to the insertion site of a peripherally inserted central catheter (PICC line- a line inserted in the arm that advances toward the heart and is used to supply antibiotics or fluids) for one of 9 residents (Resident R166).

Findings include:

The manufacturer guide for the PICC line indicated site care should be done on a regular basis as ordered by your doctor. You may need to change the dressing daily, three times a week or weekly or if it becomes loose or soiled. Observe the insertion site for redness or drainage (signs of infection) and measure the external length of the catheter to ensure it has not gotten longer or shorter.

The physician orders dated 8/9/19, indicated Resident R166 was admitted to the facility on 8/9/19, with diagnoses that included an abscess of the right ankle and foot. The orders indicated to maintain the PICC line with normal saline (NSS) intravenous (IV) flushes as needed and before and after each medication and blood draw. The order did not indicate when to provide care to the insertion site.

The plan of care "Dehydration and Fluid Maintenance" dated 8/14/19, through 9/24/19, indicated Resident R166 needed IV (PICC line) dressing changes per facility policy and as needed.

A review of the IV (PICC Line) Consultant Service form dated 8/30/19, indicated Resident R166 was administered cath-flow (an activator to unclog a PICC line) and indicated the PICC line dressing was changed.

A review of the clinical record on 9/26/19, at 2:42 p.m. did not include documentation that care or dressing changes were provided to Resident R166's PICC line from 8/14/19, to 8/29/19, or from 8/31/19, until 9/19/19.

During an interview on 9/26/19, at 2:42 p.m. Registered Nurse Employee E4 confirmed the facility failed to obtain orders for PICC line care and failed to make certain that Resident R166's PICC line dressing changes were completed.

28 Pa. code: 201.14(a) Responsibility of licensee.

28 Pa. code: 201.18(b)(1) Management.

28 Pa. code: 211.10(a) Resident care policies.

28 Pa. code: 201.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 11/18/2019

R166 was not affected by the deficient practice of not having an order for PICC line care, and was discharged home from the facility without any adverse effects.
The facility has determined all residents with IV Intravenous catheters lines have the potential to be affected. A whole house audit for all residents with IV Intravenous catheters will be completed to ensure all have orders for the care of the catheter insertion site. Orders will be obtained for those residents found not to have insertion site care orders.
The Director of Nursing or designee will conduct an in-service education program for Nursing staff on obtaining orders for the care of Intravenous catheters The Director of nursing or designee will perform audits of residents with Intravenous catheters to assure care has been completed as ordered.
The Director of Nursing or designee will conduct audits for the care of the residents with Intravenous catheters to assure orders include the care of insertion site. These audits will occur 5 days a week for two weeks, then 3 days a week for two weeks, and then once a day for 2 weeks. Random audits will occur until substantial compliance occurs.
Any deficient practices will be corrected immediately during the audit. The results of these audits will be shared with the Administrator and reviewed with the Quality Assurance Performance Improvement Committee.


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 facility policy and clinical record review and staff interview, it was determined that the facility failed to limit PRN (as needed) anti-psychotic drug use for one of 8 residents (Residents R44).

Findings include:

A review of the facility policy "Medication, Treatment, Orders" dated June 2019, indicated that all orders for medications must include: the name and strength of the drug, the number of doses, a start and stop date and/or specific duration of therapy, dosage and frequency of administration and the route of administration.

A review of the clinical record revealed that Resident R44 was admitted to the facility on 10/2/18, and Minimum Data Set (MDS-periodic assessment of care needs) dated 7/11/19, included diagnoses of high blood pressure, dementia with behavioral disturbance, depression, anxiety disorder and insomnia.

A review of the clinical record revealed Resident R44's physician orders for as needed Ativan (an antianxiety medication) as follows:
On 5/16/19, Ativan 0.5 mg every day as needed.
On 6/25/19, Ativan 0.5 mg orally twice a day as needed for anxiety.
On 7/19/19, Ativan 0.5 mg every day as needed for anxiety.
On 9/25/19, Ativan 0.25 mg orally twice a day as needed for anxiety.

During an interview on 9/26/19, at 2:00 p.m. Registered Nurse Employee E7 confirmed that the facility failed to indicate a stop date for Resident R44's PRN Ativan as required.

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


 Plan of Correction - To be completed: 11/18/2019

R44-was not affected by this deficient practice. She was reviewed on 3/29 at the psychotropic interdisciplinary meeting.
The facility has determined all residents have the potential to be affected. The Physician will be involved to review for continued use of this medication. Charts of residents receiving PRN psychotropic medications will be reviewed to ensure they have the proper stop date and documentation. Residents that are found to have orders that are out of compliance lacking a stop date will have their attending Physician notified and a new order will be obtained that includes a stop date.
The DON or designee will educate staff on the facility policy "Medication Treatment Order" and the need for a 14 day stop date on PRN psychotropic medications.
The Director of Nursing Services or designee, will audit charts of residents that are ordered PRN psychotropic medications to assure orders include a 14 day stop date. for compliance with 14 day limit, 5 times a week for 2 weeks, 3 times a week for 2 weeks, weekly for 2 weeks. Random chart audits will occur until substantial compliance is achieved.
The results of the Audit will be shared with the Administrator, Medical Director and at the Quality Assurance Performance Improvement Committee meeting.


211.9(j) LICENSURE Pharmacy services.:State only Deficiency.
(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.
Observations:
Based on clinical closed record review and staff interview, it was determined that the Facillity failed to document the method of disposition and quantity of drugs disposed for two of three closed records (Resident CR133 and CR183).

A review of the Physician Discharge Summary indicated that Resident CR133 was admitted to the facility on 8/24/19, with diagnoses of cerebral vascular accident and aphasia (difficulty with talking).

A review of the physician order dated 8/24/19, indicated Resident CR133 received the following medications: Aspirin, Atorvastatin (cholesterol lowering medication), Coreg (for blood pressure) Pepcid (for gastric reflux) and Breo-Ellipta (for chronic lung disease).

A review of the physician order dated 8/26/19, indicated to give Resident CR133 Plavix (to prevent blood clots).

A review of the closed clinical record on 9/26/19, revealed documentation did not include the final disposition of Resident CR133's medications.

A review of the Physician Discharge Summary indicated that Resident CR183 was admitted to the facility on 7/23/19, with diagnoses of congestive heart failure, cerebral vascular disease (stroke) and dementia and that Resident CR183 ceased to breath (died) on 8/6/19.

A review of the physician order dated 7/23/19, indicated Resident CR183 received the following medications: Lexapro (for depression), and Trazodone (for depression).

A review of the physician order dated 7/24/19, indicated Resident CR183 received Lasix (an antidiuretic-reduces fluid).

A review of the closed clinical record on 9/26/19, revealed documentation did not include the final disposition of resident CR183's medications.

During an interview on 9/26/19, at 10:55 a.m. Registered Nurse Employee E8 confirmed the facility failed to document the disposition of medications for Resident CR133 and CR183.


 Plan of Correction - To be completed: 11/18/2019

CR133 and CR 183 were not affected by the deficient practice
All residents have the potential to be affected by the deficient practice. Residents that were discharged will have their closed medical record audited to assure the disposition of medications form was filled out and completed.
A whole house audit will be performed to assure that a disposition of medication form is completed during the discharge process.
The Director of Nursing or designee will educate all nursing staff to the disposition of medication policy. The Director Medical Records or designee will review residents closed medical record to ensure each chart has a disposition of medication record completed upon discharge.
The Director of Medical Records or designee will conduct audits of the resident charts upon discharge to assure a disposition of medication form has been completed. These audits will occur on all discharges for two weeks, then random audits will occur until substantial compliance occurs.
The results of these audits will be shared with the Administrator and reviewed by the Quality Assurance Performance Improvement Committee


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