Nursing Investigation Results -

Pennsylvania Department of Health
PRESBYTERIAN HOMES OF THE PRESBYTERY OF HUNTINGDON
Patient Care Inspection Results

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PRESBYTERIAN HOMES OF THE PRESBYTERY OF HUNTINGDON
Inspection Results For:

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PRESBYTERIAN HOMES OF THE PRESBYTERY OF HUNTINGDON - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on March 12, 2020, it was determined that Presbyterian Homes of the Presbytery of Hollidaysburg was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:


Based on review of policies, Pennsylvania laws and personnel records, as well as observations and staff interviews, it was determined that the facility failed to implement its abuse prevention policies by failing to ensure that Pennsylvania State Police background checks were completed for ten of ten privately hired agency companions (Companions 1-10).

Findings include:

The facility's abuse policy, dated January 10, 2020, revealed that residents were not to be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Criminal background checks were required for each new employee prior to the first day of employment.

Chapter 5, Section 502(a)(1) of Pennsylvania Act 169, dated December 18, 1996, indicated that a criminal history report was to be obtained from the State Police for all applicants, and Section 501 defined "State Police" as The Pennsylvania State Police. Section 506 indicated that the facility could employ applicants on a provisional basis for a single period not to exceed 30 days if the applicant has applied for the Pennsylvania State Police criminal history record and the applicant provides a copy of the request form.

Observations on March 9, 2020, at 11:50 a.m. revealed that Resident 1 had a private companion with her. An interview with the Director of Nursing on March 9, 2020, at 2:30 p.m. revealed that Resident 1's spouse hired an agency to provide companionship for his wife each day. A total of ten agency companions had been scheduled to sit with Resident 1 since February 1, 2020. There was no documented evidence that the facility conducted criminal background checks on the companions prior to their first day in the facility.

Interview with the Nursing Home Administrator on March 11, 2020, at 3:30 p.m. confirmed that there were no criminal background checks completed for Companions 1-10 prior to working in the facility.

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



 Plan of Correction - To be completed: 04/03/2020

1. Resident 1 had no ill effects as a result of the failure to run criminal background checks. Criminal background checks were obtained from the agency on 3/11/2020.
2. Current residents with private duty companions will be audited to ensure that criminal background checks are in place.
3. Letter will be sent from the Nursing Home Administrator to agency that provided private duty companions that they are not to send their staff to the facility until the facility receives the appropriate background checks. When the facility is notified of family request for private companion, the Nursing Home Administrator will contact the agency and require a copy of the criminal background check prior to the companion beginning services with the resident. The Nursing Home Administrator (or designee) will be responsible for this. Members of the Interdisciplinary Team (including Nursing Home Administrator) will be educated to ensure that they understand to inform residents/families wishing to initiate private duty companions that criminal background checks must be completed and received by the facility prior to initiating services.
4. An audit of residents with private duty companions will be completed weekly for four weeks, and then monthly for two months by the Nursing Home Administrator or designee to ensure that criminal background checks are in place for private duty companions. Audit results will be reviewed by the Quality Assurance Process Improvement committee for review.

483.25(h) REQUIREMENT Parenteral/IV Fluids: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(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 review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed according to facility policy for one of 29 residents reviewed (Resident 35).

Findings include:

The facility's policy regarding peripherally inserted central catheters (PICC line - a catheter that is placed in a peripheral vein for long-term administration of fluids and/or medication), dated January 10, 2020, indicated that when infusing intermittent drugs or antibiotics, the procedure was to flush the catheter with normal saline solution (sterile salt and water solution), administer the medication, then flush afterward with normal saline. The policy did not include the amount of normal saline solution to use for flushing the catheter.

Physician's orders for Resident 35, dated January 31, 2020, included an order for the resident to receive 1 gram of Vancomycin (an antibiotic) into 250 milliters (ml) of normal saline solution and infuse every 12 hours over 60 minutes through March 2, 2020. The resident's care plan, dated January 27, 2020, included that the resident had a PICC line and the line was to be flushed before and after the administration of an antibiotic.

Resident 35's Medication Administration Record (MAR) for February 2020 revealed that staff administered Vancomycin at 6:01 a.m. and 6:01 p.m. on February 1 to 29, 2020. However, there was no documented evidence that staff flushed Resident 35's PICC line with normal saline solution before and after the administration of Vancomycin on these days.

Interview with the Director of Nursing on March 5, 2020, at 6:22 p.m. confirmed that there was no documented evidence that Resident 35's PICC line was flushed before and after the administration of Vancomycin.

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




 Plan of Correction - To be completed: 04/03/2020

1. Resident 35 was discharge to home on 3/3/2020 with no ill effects.
2. Current residents with orders for Intravenous(IV) Medications will be audited to ensure that proper flush orders are documented.
3. Licensed Nursing staff will be educated regarding the need for appropriate flush orders for residents receiving IV medications. New licensed staff will receive this education during orientation. If or when agency staff it utilized the will be educated on this prior to working in the facility. Flushes will be documented by licensed staff in the electronic medical record.
4. An audit of 3 residents receiving IV medications will be reviewed weekly for four weeks and the monthly for 2 months to ensure that appropriate flush orders are being documented. Audit results will be reviewed by the Quality Assurance Process Improvement Committee.

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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 29 residents reviewed (Residents 8, 32).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that if the assessment was the first assessment since the most recent admission/entry or reentry, then Section A0310E was to be coded one (1) - Yes. Section J1700, the resident's fall history on admission/entry or re-entry, was to be completed if Section A0310E was coded one (1) - Yes. If the resident had a fall any time in the last month prior to admission/entry or reentry, then Section J1700A was to be coded one (1) - Yes. If the resident had a fracture related to a fall in the six months prior to admission/entry or re-entry, then Section J1700C was to be coded one - (1) Yes.

An investigation report for Resident 8, dated February 21, 2020, at 4:45 p.m. revealed that the resident fell in her bathroom when attempting to transfer herself from her wheelchair to the toilet. The resident's left foot and ankle were deformed and positioned almost sideways under the toilet. The resident was transferred to the hospital and had a fractured left ankle.

A quarterly MDS assessment for Resident 8, dated March 2, 2020, revealed that Section A0310E was incorrectly coded zero (0) - No, indicating that this was not the resident's first MDS assessment since being readmitted. By coding Section A0310E as zero (0), the computerized MDS software did not allow Sections J1700A and J1700C to be completed to reflect that the resident had a fall and fracture in the past 30 days.

Interview with Registered Nurse Assessment Coordinator 11 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 12, 2020, at 5:33 p.m. confirmed that Resident 8's fall and fracture on February 21, 2020, was not captured on the quarterly MDS assessment of March 2, 2020, and should have been.


The RAI User's Manual, dated October 2019, revealed that Section H0600 (Bowel Patterns), was to be coded with a zero (0) - No or one (1) - Yes, depending on if the resident showed signs of constipation during the seven-day look back period. The definition of constipation was if the resident had two or fewer bowel movements during the 7-day look-back period, or if for most bowel movements the stool was hard and difficult to pass (no matter what the frequency of bowel movements was).

A comprehensive annual MDS assessment for Resident 32, dated January 20, 2020, revealed that Section H0600 was coded with a zero (0), indicating that the resident showed no signs of constipation during the seven-day look back period (January 13-19, 2020). However, the resident's bowel records for January 13-29, 2020, revealed that she had only two documented bowel movements during the 7-day look back period.

Interview with RNAC 11 on March 12, 2020, at 11:23 a.m. confirmed that Resident 32 had only two bowel movements during the MDS look-back period. She indicated that she coded Section H0600 as a zero (0) because she interpreted the RAI Manual instructions to mean that as long as the bowel movements were not hard or difficult to pass that constipation should not be coded, regardless of the frequency.

28 Pa. Code 211.5(f) Clinical records.



 Plan of Correction - To be completed: 04/03/2020

1. Resident 8 and Resident 32 had no ill effects as a result of the incorrect coding in their assessments. Minimum Data Set (MDS) for Resident 8 and Resident 32 were modified to reflect the correct information.
2. An audit of current residents with an MDS completed in the past 30 days will be completed to ensure accuracy of A0310E and H0600. If incorrect, a modification of the MDS will be completed.
3. The Registered Nurse Assessment Coordinator (RNAC) and Licensed Nursing Coordinator (LNC) have been educated on the Resident Assessment Instrument Manual (RAI manual) definitions of A0310E and H0600 for proper completion of the MDS.
4. An audit of five resident MDS will be completed weekly for four weeks and then monthly for two months to ensure accuracy of section A0310E and H0600. Audit results will be reviewed by the Quality Assurance Process Improvement Committee.

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 clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of one of 29 residents reviewed (Resident 8).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated March 2, 2020, revealed that the resident received an anticoagulant medication (a medication that thins the blood to prevent clots). Physician's orders, dated February 29, 2020, included orders for the resident to receive 0.4 milliters (ml) of enoxaparin (an anticoagulant medication) subcutaneously (injected beneath the skin) every 24 hours for 21 days, and the resident's Medication Administration Records (MAR's) for March 2020 revealed that the resident received enoxaparin on March 1 through 11, 2020.

There was no documented evidence that a care plan was developed to address Resident 8's specific and individualized care needs related to receiving an anticoagulant medication.

Interview with the Director of Nursing on March 12, 2020, at 3:31 p.m. confirmed that an individualized care plan and interventions were not developed related to Resident 8 receiving anticoagulant medication.

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

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



 Plan of Correction - To be completed: 04/03/2020

1. Resident 8 care plan was updated to include anticoagulant medication.
2. An audit of current residents who are receiving anticoagulant medications will be completed to ensure that care plans are in place for those medications.
3. Licensed Nursing Staff and Registered Nurse Assessment Coordinators will be educated regarding the need for the completion of a care plan for residents receiving anticoagulant medications. The interdisciplinary care plan team ensures that care plans are current and address current needs during regularly required reviews.
4. An audit of five residents receiving anticoagulant medications will be completed weekly for four weeks and then monthly for two months. Audit results will be reviewed by the Quality Assurance Process Improvement Committee.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of the Pennsylvania Nursing Practice Act and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse completed an assessment of a resident following a change in condition for one of 29 residents reviewed (Resident 36).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated February 3, 2020, revealed that the resident had severely impaired cognition, required limited assistance with walking, used a wheelchair, had a history of falls, and had a diagnosis of dementia.

Nursing notes, dated December 28, 2019, at 9:54 p.m. revealed that Resident 36 continued to be more lethargic, was up and ate dinner, and continued to sleep most of the evening. She was not wandering around per her baseline normal. There was no documented evidence that a registered nurse assessed Resident 36 when she was noted to be lethargic.

An investigation report, dated December 29, 2019, at 12:15 p.m. revealed that Resident 36 was getting up from the dining room table and fell to the floor. She had an abrasion to her forehead and a skin tear to the bridge of her nose. A nursing note dated December 29, 2019, at 12:57 p.m. revealed that the resident slept in, was tired, and was unsteady per the nurse aide. She was placed in a wheelchair for dining and was taken to the dining room and fell out of her wheelchair, causing an injury to her face and right arm. There was no documented evidence that a registered nurse assessed Resident 36 when she was unsteady.

Interview with the Director of Nursing on March 12, 2020, at 6:52 p.m. confirmed that there was no documented evidence of a registered nurse assessment of Resident 36 when she was lethargic and unsteady, and confirmed that the nurse aide should not have put the resident in her wheelchair and taken her to the dining room without a registered nurse assessing her on December 29, 2020.

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



 Plan of Correction - To be completed: 04/03/2020

1. Resident 36 face and arm has healed and has not had any additional falls since the 12/29/2019 fall.
2. Current residents with falls in the past 15 days will be reviewed to determine if there was a change in condition prior to the fall that was not assessed by a Registered Nurse.
3. Nursing staff will be educated that a resident with any change in condition such as lethargy or unsteady gait will need to have a Registered Nurse assessment. New licensed nursing staff will be educated on this during orientation. If or when agency is used, they will be educated on this prior to starting at the facility. The Director of Nursing (or designee) reviews the 24 hour report each day for any changes in condition to ensure that a Registered Nurse assessment took place.
4. An audit of five residents who have had a fall will be completed weekly for four weeks and then monthly for 2 months to determine if there was a change in condition prior to the fall that was not assessed by a Registered Nurse. Audit results will be reviewed by the Quality Assurance Process 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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by failing to follow physician's orders for bowel medications for one of 29 residents reviewed (Resident 32).

Findings include:

The facility's bowel management program, dated January 10, 2020, indicated that if the resident did not have a bowel movement per their normal routine, staff were to follow the specific physician-ordered bowel protocol for the resident.

Physician's orders for Resident 32, dated July 3, 2019, included orders for staff to administer 30 milliliters (ml's) of Milk of Magnesia (MOM - an oral laxative) once daily as needed if there was no bowel movement by the third day (to be administered on day four), and a Dulcolax suppository (a laxative inserted rectally) if there was no bowel movement every fifth day if the MOM was ineffective.

Resident 32's bowel movement records for September and October 2019 revealed that the resident did not have a bowel movement from September 28 through October 6, 2019 (nine days). The resident's Medication Administration Records (MAR's) for October 2019 revealed that staff administered a dose of MOM on October 1, 2019, at 1:22 p.m., and again on October 1, 2019, at 9:19 p.m.

Interview with the Director of Nursing on March 12, 2020, at 2:21 p.m. confirmed that staff should not have administered two doses of MOM in eight hours to Resident 32 on October 1, 2019.

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



 Plan of Correction - To be completed: 04/03/2020

1. Resident 32 has had no ill effects from not receiving the bowel medications per physician orders.
2. Current residents' bowel records and Medication Administration Record will be audited for the past 5 days to ensure that physician ordered medications were given correctly.
3. Licensed Nursing staff will be educated how to review the bowel records and administer bowel medications per the physician orders. New licensed staff will be education on this during orientation. If or when licensed agency staff are utilized they will be educated on this prior to working at the facility.
4. An audit of five residents will be completed weekly for four weeks and then monthly for 2 months to determine if bowel medications were administered correctly per the physician order. Audit results will be reviewed by the Quality Assurance Process Improvement Committee.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on review of policies, clinical records, and the facility's investigation documents, as well as staff interviews, it was determined that the facility failed to provide adequate supervision, monitoring, and/or assistance devices to prevent accidents for two of 29 residents reviewed (Residents 1, 48).

Findings include:

The facility's policy regarding falls, dated January 10, 2020, indicated that each resident was to be provided with an appropriate assessment and interventions to prevent falls and to minimize complications if a fall would occur. The facility was to ensure the resident environment remained as free of accident hazards as possible.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 5, 2019, revealed that the resident was severely cognitively impaired, required the assistance of two staff for bed mobility and transferring from one position to another, had balance problems, and had diagnoses that included dementia (causes issues with thinking and/or memory). Resident 1's care plan, dated December 3, 2018, indicated that she was at high risk for falls due to a history of stroke, confusion and a lack of safety awareness, and she required assistance with all transfers. Staff were to anticipate her needs, assist with activities of daily living as needed, provide constant safety reminders, and slipper socks at all times.

An incident/accident investigation report, dated November 27, 2019, revealed that at 8:30 a.m. the hospice caregiver (staff from an agency that provides end-of-life care) was providing morning care to Resident 1, sat her up on the side of her bed, and she slid off the bed onto the floor. The resident received a laceration above the right eye, a skin tear on her right shin, and a raised area above her right eye.

A statement from Nurse Aide 14, dated November 27, 2019, revealed that she sat Resident 1 up on the side of the bed and when she sat her up, the resident yelled and slid out of bed, hitting the floor on her right side. A nursing note, dated November 28, 2019, at 2:43 p.m. revealed that Nurse Aide 14 sat Resident 1 up after dressing her and she began to lean. Nurse Aide 14 reported that she tried to stop the fall but Resident 1 fell to the floor.

Interview with the Director of Nursing on March 12, 2020, at 2:15 p.m. confirmed that Resident 1 required two staff for bed mobility and Nurse Aide 14 should not have sat her up on the side of the bed by herself.


A quarterly MDS assessment for Resident 48, dated February 13, 2020, indicated that the resident had clear speech, was able to be understood, was usually able to understand others, was severely cognitively impaired, required supervision for mobility about the nursing unit, and had diagnoses that inclued Alzheimer's disease (a type of dementia that caused memory loss and impairs daily life).

A behavior care plan for Resident 48, dated July 9, 2018, identified that Resident 48 had a history of exit seeking and wandering, and the Interdisciplinary Team (IDT) was to review the resident's behavior plan quarterly and as needed for changes in these behaviors. Physician's orders dated July 20, 2019, included behavior monitoring orders to document behaviors and any antianxiety medication side effects every shift.

Information submitted by the facility, dated October 4, 2019, revealed that on October 3, 2019, at 6:50 p.m. Resident 48 exited in her wheelchair through the fire doors at the end of the main corridor to the second floor nursing unit and was found on the landing between the two flights of steps with her wheelchair on top of her. The resident was transported to the emergency room where diagnostic studies revealed a collapsed spinal vertebra (bone of the spinal column) that may or may not have been preexisting. The resident returned to the facility on October 4, 2019, at 2:05 a.m. A skin assessment revealed that the resident had one hematoma (collection of blood under the skin), 13 bruises, two staples to the back of her head, a laceration to the left knee, and four skin tears including one above the right eye that was glued with (medical) adhesive. The facility initiated behavior logs for 72 hours (staff were to document any behaviors - attempts to go out exits) and the IDT was to assess these behaviors and care plan for additional interventions. The information also indicated that one staff member would be monitoring the resident's behaviors for 72 hours beginning October 4, 2019, and that as of October 7, 2019, there were no behaviors noted due to the resident being in bed.

Resident 48's care plan was updated in October 2019 to include interventions such as providing a coloring book for enjoyment, providing a snack when she wanders, offering a baby doll or soft animal to hold, redirecting to a pleasurable activity when exit seeking, and implementing a 72-hour behavior log as needed to document if the resident was going toward the doors.

A "Task Administration Record Report" for Resident 48, for July 2019 through March 12, 2020, revealed that staff documented that the resident had "No Behaviors" for all three shifts every day.

Review of IDT notes revealed that as of October 24, 2019, Resident 48 had not been wandering since her fall, but had been more able to move her wheelchair since feeling better. A nursing note dated October 26, 2019, revealed that the resident was exit seeking after lunch but was effectively redirected. A nursing note dated November 8, 2019, at 2:06 p.m. revealed that Resident 48 was observed "pushing down on the door handle" and was easily redirected. A note dated November 15, 2019, at 1:51 p.m. revealed that the resident was exit seeking through the door by the Assistant Director of Nursing's office and the licensed practical nurse redirected her to come back and eat lunch, noting that the alarm was sounding at the time of the incident and the resident holds the bar down until the door opens, then she holds the door open and self-propels through. IDT notes dated December 20, 2019, indicated that staff noted that wandering had declined, and a note dated January 3, 2020, indicated that though the resident had no documentation of wandering in the past week, the resident still wanders at times. An IDT note dated January 10, 2020, indicated that the resident still continued to wander at times and staff attempted to redirect her with one-to-one conversation, holding a baby doll, sitting in the dining room with other residents, and activities, again noting that no wandering behaviors were documented in the past week. An IDT note dated January 31, 2020, revealed that the resident continued to trigger for behaviors due to wandering at times, becoming restless, and stating she needs to find her husband or kids. The resident's daughter stated that even when she is visiting, the resident wanders away from her. Staff try many diversional activities; however, the resident has a very short attention span and usually only stays engaged for a few minutes, and even with one-to-one does not engage well. An IDT note dated February 21, 2020, revealed that staff noted that the resident had less wandering behaviors, and a February 28, 2020, IDT note indicated that there was no wandering in the past week. The most recent recent IDT note, dated March 8, 2020, revealed that the resident continued to roam up and down the hallway and into other residents' rooms since the last review, and hospice staff (end-of-life services) were now visiting in the early evenings, which tended to be the time she wandered more.

Interview with Nurse Aide 15 on March 12, 2020, at 1:26 p.m. confirmed that Resident 48 still wanders to the exit doors but she has only observed this once in a great while. The nurse aide indicated that there was no place for nurse aides to document wandering or exit seeking behaviors in the resident's chart, and that wandering behaviors were to be passed on to the licensed practical nurse in charge that shift.

Interview with Nurse Aide 16 on March 12, 2020, at 1:43 p.m. revealed that she had to redirect Resident 48 away from the exit doors approximately eight to ten weeks ago. The nurse aide indicated that there was no place for nurse aides to document wandering or exit seeking behaviors in the resident's chart, and that wandering behaviors were to be passed on to the licensed practical nurse.

Interview with Nurse Aide 13 on March 12, 2020, at 2:35 p.m. revealed that he was very familiar with Resident 48 and was routinely assigned to her care. He confirmed that the resident continued to wander to the exit doors by the stairwell and he had to redirect her away from the exits a couple of times a week. The nurse aide indicated that there was no place for nurse aides to document wandering or exit seeking in the resident's chart, and that wandering behaviors were to be passed on to the licensed practical nurse.

Interview with Nurse Aide 17 on March 12, 2020, at 2:45 p.m. revealed that he has had to redirect Resident 48 from the stairwell two to three times since being assigned to the second floor.

Interview with Licensed Practical Nurse 18 on March 10, 2020, at 1:00 p.m. revealed that behavior monitoring/tracking records were kept in a binder in the nursing station, and each resident who was being monitored for behaviors was to have their own record. The licensed practical nurses were to record the behaviors on the individual resident's record. He confirmed that Resident 48 did not have any current behavior monitoring/tracking record in the binder and he was not aware of any recent behaviors or exit seeking by Resident 48.

Interview with Licensed Practical Nurse 19 on March 12, 2020, at 3:30 p.m. revealed that staff have not reported any wandering or exit seeking behaviors by Resident 48 to him.

Interviews with the Nursing Home Administrator and the Director of Nursing on March 12, 2020, at 12:47 p.m. confirmed that the "Task Administration Record Report" for Resident 48 for July 2019 through March 12, 2020, revealed that staff documented "No Behaviors" on all three shifts every day from July 2019 through and including March 20, 2020, and that there was only sporadic documentation of exit seeking behaviors in the resident's IDT and nursing notes. They believed that their current interventions were effective in preventing exit seeking for Resident 48. They confirmed that nurse aides were to report attempts at exit seeking to the licensed practical nurse in charge, and they were not aware of any of the above attempts at exit seeking that were described by the nurse aides, and these occurrences should have been communicated and documented for the IDT to review.


The facility's policy regarding transferring a resident, dated January 10, 2020, revealed that foot rests were to be used whenever the resident did not self-propel the wheelchair.

A quarterly MDS assessment for Resident 48, dated February 13, 2020, indicated that the resident was severely cognitively impaired and required supervision for mobility about the nursing unit.

Observations on March 9, 2020, at 3:02 p.m. revealed that Hospice Nurse Aide 12 pushed Resident 48 in her wheelchair from in front of the restroom door, past the nursing station and dining area, and down the next hall to the resident's room. During this transport, there were no foot rests in place on the wheelchair, and the resident's feet were in contact with the floor, gliding across the floor, as she was being pushed. When Hospice Nurse Aide 12 turned the corner and started down the hall to the resident's room, Nurse Aide 13 called out to Hospice Nurse Aide 12, "She needs foot rests, she needs foot rests." Nurse Aide 13 got up from the desk and met Hospice Nurse Aide 12 at Resident 48's doorway and told her again that the resident needed to have foot rests in place on her wheelchair while being pushed. Hospice Nurse Aide 12 then went into the resident's room, opened her closet doors, and looked for the foot rests, which were in a bag attached to the back of the resident's wheelchair.

Interview with Nurse Aide 13 on March 12, 2020, at 3:05 p.m. confirmed that Hospice Nurse Aide 12 should have had foot rests in place on Resident 48's wheelchair when pushing her.

Interview with the Director of Nursing on March 10, 2020, at 4:12 p.m. confirmed that staff were to use foot rests when pushing residents in wheelchairs.

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




 Plan of Correction - To be completed: 04/07/2020

1. Resident 1 has had no additional falls since the 11/27/2019 fall. Resident 48 Behavior Monitoring Task has been added to specify wandering. Resident 48 had no ill effects as a result of not having the foot rests on the wheelchair.
2. Current residents with falls in the past 15 days will be reviewed to determine if the care plan was followed. Current residents with wandering behaviors will have the Behavior Monitoring Task updated. Current residents will be reviewed to identify any residents not having foot rests utilized appropriately.
3. Hospice nurse aides will be educated regarding resident care plan, amount of assistance needed for tasks that they perform, and foot rest use policy. Staff will be educated on the use of footrests as well as where to find the proper transfer and bed mobility status. Licensed Nursing staff will be educated regarding the importance of proper documentation in the Behavior Monitoring Task. New licensed staff will be educated on these topics during their orientation. If or when licensed agency staff are utilized they will be educated on this prior to working at the facility.
4. An audit of five residents will be completed weekly for four weeks and then monthly for 2 months to determine if Behavior Monitoring Tasks were documented correctly. An audit will be completed of 3 of Hospice Nurse Aid visits per week for 4 weeks and then for 2 months to ensure that care is being provided based on resident care plan and leg rest use policy. Audit results will be reviewed by the Quality Assurance Process Improvement Committee.


483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for two of 29 residents reviewed (Residents 1, 110).

Findings include:

The facility's policy regarding medication administration, dated January 10, 2020, indicated that medications were to be administered as prescribed, in accordance with good nursing principles and practices, and only by persons legally authorized to do so.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs)for Resident 1, dated February 28, 2020, revealed that the resident was severely cognitively impaired, required extensive assistance from staff for toileting, and was always incontinent of bowel and bladder.

Physician's orders for Resident 1, dated September 1, 2016, and May 28, 2018, included orders for the resident to receive 30 milliliters (ml) of Milk of Magnesia (an oral laxative) as needed for constipation if the resident did not have a bowel movement in three days, one Bisacodyl suppository (a laxative inserted rectally) as needed for constipation on day five without a bowel movement, and one Fleets enema (liquid inserted rectally to stimulate a bowel movement) as needed for constipation on day six without a bowel movement.

Resident 1's bowel movement records revealed that she did not have a bowel movement from December 14 through 19, 2019, (six days) and the resident's nursing notes and Medication Administration Records (MAR's) for December 2019 revealed that staff administered 30 ml's of Milk of Magnesia on December 17, 2019, at 1:30 p.m. and a Bisacodyl suppository on December 18 at 1:55 p.m., without any results. There was no documented evidence that a Fleets enema was administered on December 19, 2019 (the sixth day without a bowel movement) as ordered by the physician.

Interview with the Director of Nursing on March 12, 2020, at 12:58 p.m. confirmed that Resident 1's physician's orders for bowel medications were not followed and they should have been.


Physician's orders for Resident 110, dated March 3, 2020, included an order for the resident to receive Novolog insulin (used to lower blood sugar levels) prior to meals according to a sliding scale (the amount of insulin given depends on the result of a fingerstick blood sugar test). The sliding scale included giving 1 unit of Novolog for blood sugar levels between 226-275 milligrams per deciliter (mg/dL), 2 units of Novolog for blood sugar levels between 276-325 mg/dL, 3 units of Novolog for blood sugar levels between 326-375 mg/dL, and 4 units of Novolog for blood sugar levels greater than 375 mg/dL.

Resident 110's MAR's for March 2020 revealed that on March 4, 2020, prior to the meal the resident's blood sugar level was 280 mg/dL and 4 units of Novolog was administered instead of 2 units as ordered.

Interview with the Director of Nursing on March 12, 2020, at 12:58 p.m. confirmed that Resident 110's physician's order for sliding scale insulin coverage was not followed.

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





 Plan of Correction - To be completed: 04/03/2020

1. Resident 1 had no ill effects from not being administered the fleets enema and had a bowel movement on 12/21/2019. Resident 110 had no ill effects from being administered 4 units of insulin.
2. Current residents' bowel records and Medication Administration Record will be audited for the past 5 days to ensure that physician ordered medications were given correctly. Current residents receiving sliding scale insulin for the last 5 days will have their records audited to ensure they received the appropriate dose of insulin.
3. Licensed Nursing staff will be educated how to review the bowel records and administer bowel medications per the physician orders. Licensed nursing staff will also be educated on following the physician's orders for administering insulin. New licensed staff will be educated on this during orientation. If or when agency staff is utilized they will be educated on this prior to working in the facility.
4. An audit of five residents will be completed weekly for four weeks and then monthly for 2 months to determine if bowel medications were administered correctly per the physician order. An audit of five residents will be completed weekly for four weeks and then monthly for 2 months to determine if insulin was administered correctly per the physician order. Licensed staff will receive a follow up competency test to ensure that they have retained and understand the process for bowel protocol administration. They will receive this test monthly in coordination with the monthly audits. Audit results will be reviewed by the Quality Assurance Process Improvement Committee.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for one of 39 residents reviewed (Resident 110).

Findings include:

A nursing note, dated March 5, 2020, at 11:45 p.m. revealed that Resident 110 had audible wheezing; decreased breath sounds; a harsh, congested non-productive cough; a temperature of 101.8 degrees Fahrenheit; and his color was pale. On March 6, 2020, at 12:15 a.m. the physician was notified and orders were received for a chest x-ray, a flu swab (test for influenza), and nebulizer treatments.

A laboratory report, dated March 6, 2020, revealed that the resident tested positive for influenza A virus, the physician was notified, and droplet precautions (special infection control procedures) were ordered.

However, there was no documented evidence that the physcian's order to implement droplet precautions was entered into Resident 110's electronic medical record until March 9, 2020.

Interview with the Director of Nursing on March 11, 2020, at 4:03 p.m. confirmed that staff did not enter the physician's order for droplet precautions into the electronic medical record until March 9, 2020.

28 Pa. Code 211.5(f) Clinical records.


 Plan of Correction - To be completed: 04/03/2020

1. Resident 110 had no ill effects from the physician order for droplet precautions not being documented in the electronic record timely.
2. Current residents' orders for droplet precautions will be audited for the last 5 days to ensure that the physician's order was entered into the electronic record timely.
3. Licensed nursing staff will be educated on entering droplet precautions into the electronic medical record timely. New licensed staff will be educated on this during orientation. If or when agency staff is utilized they will be educated on this prior to working in the facility.
4. An audit of five residents will be completed weekly for four weeks and the monthly for two months to ensure that residents with physician's orders for droplet precautions are entered into the electronic medical record timely. Audit results will be reviewed by the Quality Assurance Process Improvement Committee.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ensure that corrective plans to improve and/or correct quality deficiencies effectively addressed recurring deficiencies and ensured that the facility maintained compliance with nursing home regulations.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending March 14 and September 3, 2019, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending March 12, 2020, identified repeated deficiencies related to professional standards of practice and failure to be free from significant medication errors.

The facility's plan of correction for a deficiency regarding meeting professional standards of quality, cited during the survey ending September 3, 2019, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding following professional standards of quality.

The facility's plan of correction for a deficiency regarding failure to be free from significant medication errors, cited during the survey ending March 14, 2019, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F760, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding residents being free from significant medication errors.

Refer to F658, F760.

28 Pa. Code 201.14(a) Responsibility of licensee.

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


 Plan of Correction - To be completed: 04/03/2020

1. No residents were harmed by this practice
2. Process Improvement plans have been reviewed and / or implemented for areas noted to be repeat deficiencies.
3. Nursing Administration and Health Care Administration will be re-educated by the Executive Director on the Quality Assurance Process Improvement Policy to assure Plans of Corrections are followed.
4. Audits will be conducted on the Quality Assurance process to assure the facility is monitoring and reviewing the Plan of Correction to assure compliance of deficient practices. Random audits will be completed as assigned Quarterly for 3 quarters by having Quality Assurance Members gather proof/information to present during Quality Assurance meeting to show compliance of Deficient practices. Results of audit will be reviewed quarterly during Quality Assurance Process Improvement Meeting for recommendations


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