Nursing Investigation Results -

Pennsylvania Department of Health
PAUL'S RUN
Patient Care Inspection Results

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PAUL'S RUN
Inspection Results For:

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PAUL'S RUN - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure and Civil Rights Compliance Survey completed on January 29, 2020 it was determined that Pauls' Run 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:


483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments: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.
483.20(f) Automated data processing requirement-
483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.
Observations:

Based on review of clinical records and staff interviews, it was determined that the facility failed to transmit a Minimum Data Set (MDS-federally-mandated assessments of a resident's abilities and care needs) to the required electronic system of the Centers for Medicare and Medicaid Services (CMS) Quality Improvement and Evaluation System Assessment Submission (QIES) and Processing System, within 14 days of completion as required for one of 28 residents reviewed (Residents R2)

Findings include:

Review of clinical record for Resident R2 revealed that the resident was admitted to the facility on August 17, 2019.

Review of clinical record revealed that the facility completed a quarterly Minimum Data Set (MDS- assessment of resident care needs) assessment for Resident R2 on November 20, 2019 as required by the CMS.

Review of clinical record for Resident R2 revealed that the quarterly MDS assessment dated November 20, 2019 was not transmitted to CMS, Quality Improvement and Evaluation System, within 14 days of completion.

Interview with the Registered Nurse Assessment Coordinator, Employee E5, on January 29, 2020, at approximately 11:00 a.m. confirmed that the MDS for Resident R2 dated November 20, 2019 was not submitted to CMS in a timely manner.


28 Pa. Code 211.5(f) Clinical records.
Previously cited 2/19/19.




 Plan of Correction - To be completed: 02/13/2020

RNACs were reeducated re: transmission time frames using the RAI manual on 2/3/2020

MDS' for resident R2 were transmitted on date discovered (1/29/2020)

Lead RNAC will monitor reports weekly for 100% accuracy/compliance and will report findings at monthly QA meetings


483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on the review of clinical records and staff interviews, it was determined that the facility failed to complete comprehensive assessments that accurately reflected the resident status for one of 28 residents reviewed (Residents R20).

Findings include:

Review of clinical record for Resident R20 revealed that the resident started receiving hospice services (end of life care to support resident and family) on August 16, 2019.

Review of Resident 20's Minimum Data Set (MDS - periodic assessment of resident needs) dated August 23, 2019 revealed that the facility completed a significant change in status assessment. Review of the Section 'O' (Special Treatments and Programs) of the MDS assessment revealed that hospice services were not been provided.

Review of a quarterly MDS for Resident 20's, dated November 20, 2019 revealed that the hospice services were not provided.

Interview with the Assistant Director of Nursing, Employee E3, on January 28, 2020 at approximately 1:00 p.m. stated, Resident R20 was on hospice services since August 16, 2019.

Interview with Registered Nurse Assessment Coordinator (RNAC), Employee E5, on January 28, 2020 at approximately 1:00 p.m. confirmed that Resident R20's MDS dated August 23, 2019 and November 20, 2019 did not accurately reflected resident's hospice services.

The facility failed to complete comprehensive assessments that accurately reflected Resident 20's hospice status.

28 Pa. Code 211.5(f) Clinical records
Previously cited 2/19/19.






 Plan of Correction - To be completed: 02/03/2020

MDS' were modified and retransmitted on 1/28/2020

Lead RNAC will monitor all hospice residents MDS' before transmission to ensure accuracy. (Hospice list is updated weekly by Social Services) . Findings to be reported at monthly QA meetings

Education: accurate coding and transmission of MDS was completed on 2/3/2020 for the MDS coordinators/RNACs
483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on observations, interviews with a resident and staff and review of clinical records, it was determined that the facility failed to develop a care plan for incontinence, and interventions associated with the risks of skin breakdown for one resident, failed to implement the intervention to prevent blistering for one resident, and failed to formulate a care plan for one resident with an indwelling urinary catheter for three out of 28 records reviewed (Resident R11, R54 and R266).

Findings include:

Review of facility policy titled, "Care Plan" dated November 28, 2019, revealed that a care plan be developed by a Registered Nurse and the Interdisciplinary Team for each resident. The policy further stated that the care plan will identify interventions that are appropriate for the resident with the date the care plan was initiated.

Review of Resident R11 care plan revealed a diagnosis of Dementia (progressive degenerative disease of the brain), difficulty with short-and long-term memory loss, confusion and needed extensive assistance with daily living.

Review of facility documentation dated November 20, 2019 revealed while the nursing assistant was giving Resident R11 a shower. The nursing assistant observed redness on two areas of the left lower inner thigh measuring, 2.0 x 2.0 centimeters (cm). Also noted was an intact fluid filled blister measuring 2.0 x 1.5 cm and a 3.0 x 2.0 cm reddened area with a 0.5 x 0.5 cm open blister on the resident's right medical calf. On November 20, 2019 the facility implemented a new intervention to Resident R11 's care plan to include placing a pillow between the resident's legs while in bed to prevent further blistering.

Review of the facility documentation dated January 12, 2020 revealed an observation by a nursing assistant of another fluid filled blister on Resident R11's left inner knee measuring 4.0 cm x 1.5 cm. The facility implemented to continue with the plan of care.

Observations conducted on January 29, 2020 at 12:25 p.m. with nursing assistant, Employee E6, of Resident R11, revealed that the resident was sleeping in bed without a pillow placed between her legs. When nursing assistant was asked about the intervention of a pillow between the resident's legs, the nursing assistant was not aware that Resident R11 was to have a pillow between her legs while sleeping.

Review of Resident R54's nursing progress note, dated October 30, 2019 stated a nursing assistant saw four blisters on the right groin area measuring 1.0 x 1.0 cm., .5 x .5 cm, .4 x .4 cm and 1. X .2 cm. The same day, the Certified Registered Nurse Practitioner noted that Resident R54 had large fluid filled blisters in the right groin area, "patient wears briefs and has a large heavy abdomen that hangs over thighs. No complain of pain just uncomfortable."

Further review of Resident R54's care plan stated she was continent and did not wear briefs. Interview with the Supervisor, Register Nurse (RN), Employee E7 on January 27, 2020 at 11:47 a.m. stated, "Blisters were on her brief line." (the RN pointed to her upper inner thigh) "We thought the brief was rubbing against the skin. We went up a size, it helped, and it healed and now it's gone". Employee E7 indicated that the resident had periods of incontinence and wore proptection (an adult brief).

During an interview and observation of Resident R54's groin area, with Licensed Registered Nurse Employee E8, on January 27, 2020 at 12:00 p.m. the resident indicated she had discomfort with the briefs and felt much better once they changed the size.

The facility failed to develop a comprehensive care plan related to incontinence care for Resident R54.

Review of Resident R266's clinical record revealed the resident was admitted to the facility on January 9, 2020 with diagnoses including, end stage renal disease (when the gradual loss of kidney function reaches an advanced state), osteomyelitis (an infection of the bone) and diabetes (a disease that affects the way the body processes blood sugar (glucose)).

Review of January 2020 physician's orders revealed an order for indwelling urinary catheter as follows: "Foley catheter 16 French/10CC balloon ..." for a diagnosis of retention of urine. A review of Resident R266's current care plan revealed that there was no comprehensive person-centered care plan developed regarding the use of an indwelling urinary catheter.

An interview with licensed nursing's staff, Employee E1, on January 28 at 2:00 p.m. confirmed that Resident R266 did not have a comprehensive care plan developed regarding the use of a urinary catheter.

The facility failed to develop comprehensive person-centered care plans related to the use of a urinary catheter for Resident R266.


42 CFR 483.21(b)(1), Develop/Implement Comprehensive Care Plan

28 Pa. Code 211.5(f) Clinical records
Previously cited 02/19/2019

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

28 Pa. Code 211.12 (d)(1) Nursing services
Previously cited 02/19/2019

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


28 Pa. Code 211.12 (d)(5) Nursing services
Previously cited 02/19/2019










 Plan of Correction - To be completed: 02/13/2020

Residents , R11, R54 and R266, care plans were updated at time of discovery.

Staff were educated to review and update the Plan of Care at each order change and/or change in condition of resident. (1/30 thru 2/4/2020 to capture all staff)

Nursing Administration reviewed all care plans for accuracy and individualized plan of care ( completed on 2/3/2020

DON will evaluate and monitor > 20% of care plans monthly for completeness, accuracy and any specialized services. Findings will be reported at monthly QA meetings.

483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:


Based on observation, review of clinical records and interviews with staff, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous (IV-tube inserted into a vein) lines, for one of 28 residents reviewed (Resident R266)

Findings include:

Review of Resident R266's clinical record revealed the resident was admitted to the facility on January 9, 2020 with diagnoses including endocarditis (infection of the inner lining of the heart chambers and heart valves), osteomyelitis (an infection of the bone) and diabetes (a disease that affects the way the body processes blood sugar (glucose)).

Observation of Resident R266 on January 28, 2020 at 12:20 p.m. revealed that the resident had a peripherally inserted central catheter (PICC) line to the resident's right upper extremity.

Review of Resident R266's physician orders revealed an order to measure external catheter length every 5 days with dressing changes and measure upper arm in centimeters above insertion site every 5 days with dressing changes.

Further review of Resident R266's clinical record revealed no documented evidence the resident's right upper extremity's arm circumference or the resident's external PICC line at the insertion site were measured and the measurements documented.

Interview with licensed nursing staff, Employee E1, on January 27, 2020 at 11:59 a.m. confirmed there were no measurements documented in the resident's clinical record.

The facility failed to ensure that measurements were obtained of the resident's right upper extremity's arm circumference and the resident's external PICC line as ordered by the physician.

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 02/19/2019

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 02/19/2019



 Plan of Correction - To be completed: 02/13/2020

Orders for PICC line measurements including length of PICC and circumference of arm were modified for clarification by creating 2 separate entries to ensure that measurements are accurate at time of dressing changes(1/30/2020)

All licensed nurses were educated and competency completed (1/30 thru 2/2/2020)

All residents with PICCs are identified at time of admission or insertion of PICC to ensure that physician orders for PICC are followed.

A QA audit initiated to capture all components of PICC orders and measurements for all residents with PICC lines. DON will report findings monthly with goal of 100% compliance

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

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

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

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

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

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

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


Based on observations, staff interviews and a review of the facility policies, it was determined that the facility did not ensure implementation of appropriate infection control measures related to precautions for two of 28 residents reviewed (Resident R220, and Resident R16).

Finding include:

Review of the facility's policy titled, "Reverse Isolation" date revised 2019, indicated that the cart is placed outside of the resident's room with instructions: "Stop" "Please see the nurse before entering."

Review of Resident R220's clinical record revealed that the resident was admitted to the facility on January 20, 2020 with diagnoses including malignant neoplasm of stomach (stomach cancer), diabetes (a disease that affects the way the body processes blood sugar (glucose)) and pancreatitis (inflammation of the pancreas). Further review revealed that the resident was placed on neutropenic precautions (precautions to take when the body may not be able to fight infection), every shift, January 22, 2020 due to low wbc count (a count of white blood cells that means a body may not be able to properly fight infection).

Observations conducted on January 23, 2020 at approximately 10:15a.m. revealed no signage on the resident's door or cart alerting the staff and visitors to the precautions.

Interview with licensed nursing staff, Employee E1, on January 23, 2020 at 10:20 a.m. confirmed that there was no sign posted outside Resident R220's room.

Review of Resident R16's clinical record revealed that the resident was admitted to the facility on October 30, 2019 with diagnoses including end stage renal disease (gradual loss of kidney function that has reached an advanced state), diabetes (a disease that affects the way the body processes blood sugar (glucose)) and Alzheimer ' s Disease (a progressive disease that destroys memory and other mental functions). Further review of the clinical record revealed that the resident was placed on contact precautions (precautions used for infections, diseases, or germs that are spread by touching the patient or items in the room), all shifts, on January 17, 2020.

Observations conducted on January 23, 2020 at approximately 10:21a.m. revealed no signage on the resident's door or cart alerting the staff and visitors to the precautions.

Interview with licensed nursing staff, Employee E1, on January 23, 2020 at 10:22 a.m. confirmed that there was no sign posted outside the room.

The facility failed to implement infection control measures related to precautions for Resident R220 and Resident R16.


28 Pa. Code 201.18(b)(1)(3) Management
Previously cited 02/19/2019

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

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 02/19/2019

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

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 02/19/2019







 Plan of Correction - To be completed: 02/03/2020

The Infection Preventionist educated staff to place "Stop" and "Please see the nurse before entering the room" signs when a resident is placed in isolation precautions. (1/30/2020)

Staff were educated on isolation precautions on 1/30/2020

The nursing supervisors will check isolation carts every shift for correct sign placement on cart and at entrance to room. Check isolation signs task was added to the 24-hour report sheet for q shift monitoring. The DON or designee will review the report sheets for compliance daily.

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