Pennsylvania Department of Health
PASSAVANT RET & HEALTH CTR
Patient Care Inspection Results

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PASSAVANT RET & HEALTH CTR
Inspection Results For:

There are  67 surveys for this facility. Please select a date to view the survey results.

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PASSAVANT RET & HEALTH CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey completed on March 28, 2024, it was determined that Passavant Retirement and Health Center, was not in compliance with the 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 related to the health portion of the survey process.


 Plan of Correction:


483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on facility policy, clinical record review, and interview, the facility failed to have a physician's order, and a care plan, for the use of an indwelling catheter (a tube placed in the bladder to drain urine), for one of four residents (Resident R193), and failed to ensure that appropriate treatment and services were provided for two of four residents (Resident R67 and R73) with an indwelling urinary catheter.

Findings include:

Review of facility policy "Catheter Care; Urinary" dated 1/23/24, indicated to review the resident's care plan to assess for any special needs of the resident. It is suggested to change catheters and drainage bags based on clinical indications, and a physician's order.Review of the Centers for Disease Control guidance "Guidelines for Prevention of Catheter-Associated Urinary Tract Infections" updated 6/6/19, indicated to keep the collecting bag below the level of the bladder at all times.

Review of the clinical record indicated Resident R67 was admitted to the facility on 6/7/22.

Review of Resident R67's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/13/24, indicated diagnoses of high blood pressure, Benign Prostatic Hyperplasia (BPH - age-associated prostate gland enlargement that can cause urination difficulty), and obstructive uropathy (a condition in which flow of urine is blocked).
Review of a physician order dated 3/17/24, indicated to change Resident R67's suprapubic (enters the body through an incision in the abdomen) catheter on the first day of every month, 18 French catheter size.

During an observation on 3/25/24, at 9:56 a.m., Resident R67 was in bed with his urinary drainage bag uncovered and laying on his bed.

During an interview on 3/25/24, at 10:26 a.m., Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R67's privacy cover was not being utilized for his urinary drainage bag.

Review of the clinical record indicated Resident R73 was admitted to the facility on 8/17/22.

Review of Resident R73's MDS dated 3/22/24, indicated diagnoses of high blood pressure, obstructive uropathy, and retention of urine.

During an observation on 3/25/24, at 10:16 a.m., Resident R73 was in bed with his urinary drainage bag uncovered and attached to the bed frame at head of the bed above the level of the bladder.

During an interview on 3/25/24, at 10:26 a.m., LPN Employee E1 confirmed Resident R73's privacy cover was not being utilized and that his urinary drainage bag was above the level of the bladder.

Review of a physician's order dated 10/7/22, indicated continuous suprapubic catheter.

Review of a physician's order dated 10/7/22, indicated once every month, change the catheter drainage bag. The bag/tubing is to be dated and initialed.

During an interview on 3/28/24, at 11:42 a.m. Director of Nursing 1 (DON 1) confirmed that the physician order failed to indicate a catheter size for Resident R73.

Review of the admission record indicated Resident R193 was admitted to the facility on 3/19/24, with the diagnoses of brain cancer (a cancerous mass or growth of abnormal cells in the brain), anxiety disorder, and neuromuscular bladder dysfunction (the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem).

Review of progress note dated 3/22/24, at 1:52 p.m., indicated hospice nurse here today. Foley catheter changed and hematuria (blood in the urine) was noted in the tubing at lunch.

Review of Resident R193's physician orders on 3/28/24, at 11:20 a.m., failed to include an order for use of the indwelling urinary catheter.

Review of Resident R193's care plan on 3/28/24, at 11:21 a.m., failed to include a care plan for use of the indwelling urinary catheter.

Observation of Resident R193 on 3/28/24, at 11:28 a.m., indicated resident lying in bed with a foley catheter connected to a drainage bag.

Interview on 3/28/24, at 11:29 a.m., Registered Nurse (RN) Employee E6 confirmed the foley catheter was in use.

Interview on 3/28/24, at 11:40 a.m., DON 2 confirmed that the facility failed to have a physician's order, and a care plan, for the use of an indwelling catheter, for one of four residents (Resident R193).During an interview on 3/28/24, at 11:42 a.m. DON 1 confirmed that the facility failed to ensure that appropriate treatment and services were provided for two of four residents (Resident R67 and R73) with an indwelling urinary catheter.
28 Pa. Code 201.14(a) Responsibility of licensee.

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

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

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


 Plan of Correction - To be completed: 04/22/2024

The seven residents with indwelling catheters were immediately checked for Physician orders, Treatment orders, Care Plans, urine collection bags below the level of the bladder, Physician orders for changing of catheters and drainage bags, and dignity bags to the urine collection bags. Charge Nurses and CNA's will be re-educated on Policies "Catheter Care; Urinary" "Guidelines for Prevention of Catheter-Associated Urinary Tract Infections" by the Clinical Nurse Educator or designee for all residents with indwelling catheters. The residents with indwelling catheters will be monitored weekly by the DON's/RN Clinical Nurse Manager/Clinical Coordinator for Physician orders of the indwelling catheters, Treatment orders, Care Plans, urine collection bags below the level of the bladder, Physician orders for changing catheters and drainage bags, and dignity bags to the urine collection bags. This will be monitored for three months or until substantial compliance is achieved.
483.25(n)(1)-(4) REQUIREMENT Bedrails:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

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

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

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

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

Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for five of five residents (Residents R6, R14, R31, R32, and R34).

Findings include:

Review of Title 42 Code of Federal Regulations (CFR) - Bed Rails states that the facility must assess the resident for risk of entrapment from bed rails prior to installation. Additionally, there should be evidence in the resident's records that the facility performed ongoing assessments to assure that the bed rail is used to meet the resident's needs and that there is an ongoing evaluation of risks associated with bed rail usage.

Review of facility policy "Mobility Bars/Bedrails" dated 1/23/24, indicated before a resident is fitted with mobility bars or bed rails, an interdisciplinary team must determine the presence of a specific medical symptom that would require the use of a bed rail and how that use would treat the medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his or her highest practicable level of physical and psychological wellbeing. On-going monitoring through the quarterly and/or with significant change assessment process will be used for evaluation of the reduction of restrictive devices in order to maintain the highest level of independence and safety.

Review of the clinical record indicated that Resident R6 was admitted to the facility on 12/22/23.

Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/18/24, indicated diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), overactive bladder (a problem with bladder function that causes the sudden need to urinate), and spinal stenosis (the space inside the bones of the spine get too small).

Review of Resident R6s physician order dated 1/20/24, indicated mobility bars continuously.

Review of Resident R6's care plan on 3/27/24, at 10:00 a.m., indicated bilateral (both sides) mobility bars for bed mobility.

Review of Resident R6's clinical record on 3/27/24, at 10:00 a.m., failed to reveal an ongoing assessment of the mobility bars.

Observation on 3/27/24, at 1:35 p.m., indicated Resident R6's bed with two mobility bars.

Interview on 3/27/24, at 1:36 p.m., Nurse Aide (NA) Employee E9 confirmed Resident R6 had two mobility bars on the bed.

Review of the clinical record indicated that Resident R14 was admitted to the facility on 5/26/19.

Review of Resident R14's MDS dated 3/12/24, indicated diagnoses of high blood pressure, heart failure (heart doesn't pump blood as well as it should), and coronary artery disease (narrow arteries decreasing blood flow to heart).

Review of Resident R14's physician order dated 2/27/24, indicated left side mobility bar for bed mobility.

Review of Resident R14's care plan on 3/27/24, at 10:05 a.m., indicated left mobility bar for bed mobility.

Review of Resident R14's clinical record on 3/27/24, at 10:05 a.m., failed to reveal an ongoing assessment of the mobility bars.

Observation on 3/27/24, at 1:36 p.m., indicated Resident R14's bed with one mobility bar on the left side of the bed.

Interview on 3/27/24, at 1:36 p.m., NA Employee E9 confirmed Resident R14 had one mobility bar on the left side of the bed.

Review of the clinical record indicated that Resident R31 was admitted to the facility on 4/17/23.

Review of Resident R31's MDS dated 1/26/24, indicated diagnoses Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions), anxiety, and depression.

Review of Resident R31's physician order dated 2/23/24, indicated bilateral mobility bars to aide in mobility.

Review of Resident R31's care plan on 3/27/24, at 10:08 a.m., indicated bilateral mobility bars to aide in mobility.

Review of Resident R31's clinical record on 3/27/24, at 10:08 a.m., failed to reveal an ongoing assessment of the mobility bars.

Observation on 3/27/24, at 1:35 p.m., indicated Resident R31's bed with two mobility bars.

Review of the clinical record indicated Resident R32 was admitted to the facility on 4/5/22.

Review of Resident R32's MDS dated 2/9/24, indicated diagnoses of history of falling, anemia (too little iron in the body causing fatigue), and dementia (a group of symptoms that affects memory and thinking, and interferes with daily life). Review of Section G: Functional Status, Question GG0170 indicated Resident R32 required substantial assistance with the helper doing more than half of the effort to complete bed mobility.

Review of a physician order dated 8/17/22, indicated resident to use bilateral mobility bars to increase safety/independence with bed transfers and bed mobility.

Review of Resident R32's clinical record failed to reveal a current assessment for the continuation of mobility bar usage.

An observation on 3/25/24, at 9:44 a.m., revealed mobility bars on both sides of Resident R32's bed.

During an interview on 3/27/24, at 1:39 p.m., Registered Nurse (RN) Employee E2 confirmed Resident R32 had bilateral mobility bars applied to his bed.

Review of the clinical record indicated Resident R34 was admitted to the facility on 3/8/21.

Review of Resident R34's MDS dated 3/5/24, indicated diagnoses of high blood pressure, history of falling, and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Review of Section G: Functional Status, Question GG0170 indicated Resident R34 required substantial assistance with the helper doing more than half of the effort to complete bed mobility.

Review of a physician's order dated 7/15/21, indicated to apply mobility bars x 2 for assist with bed mobility.

Review of Resident R34's clinical record failed to reveal a current assessment for the continuation of mobility bar usage.

An observation on 3/25/23, at 9:38 a.m., revealed mobility bars on both sides of Resident R34's bed.

During an interview on 3/27/24, at 1:35 p.m., Nurse Aide (NA) Employee E3 confirmed Resident R34 had bilateral mobility bars applied to her bed.

During an interview on 3/27/24, at 1:08 p.m., Director of Nursing 1 (DON 1) confirmed that quarterly mobility bar assessments are not completed.

During an interview on 3/27/24, at 1:40 p.m., DON 1 confirmed that the facility failed to conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for five of five residents (Residents R6, R14, R31, R32, and R34).

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

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

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


 Plan of Correction - To be completed: 04/22/2024

. Cited residents are being evaluated by O.T. department for benefits and risks of mobility/enabler bars usage. Nurse Educator or designee will educate Charge Nurses on the newly updated process of the quarterly assessment that is generated by the MDS schedule to include adding an O.T. Evaluation for assessment for the risks and benefits of mobility/enabler bar usage. Residents on admission will continued to be evaluated by O.T. for the risks and benefits of mobility/enabler bar usage prior to installation. The Rehab. Director will educate her O.T. team on the new process of evaluating the mobility/enabler bar usage. Rehab. Department will evaluate 12 residents weekly for continuation of mobility/enabler bar usage for three months or until substantial compliance is achieved.
483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:

Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of resident's medical information on one of six nursing households (second floor Tionesta household).

Findings include:

Review of the facility policy "Use of Laptops or other portable computers", last reviewed on 1/23/24, indicated that resident information should be kept confidential. The computer screen should be turned so that only the resident or resident's family can see the screen. Keep the lid partially closed if resident data is displayed and information is not actively being documented. No resident data should be displayed if information is not actively being documented.

Review of facility policy "Medication Administration-General Guidelines", last reviewed on 1/23/24, indicate privacy is always maintained for all resident information by closing computer screen when not in use.

During an observation on 3/26/24, at 11:58 a.m., the medication cart/portable computer unit outside of room 231 Tionesta household was left unattended with the computer screen open with identifiable information so any passerby could see resident personal and confidential information.

During an observation on 3/26/24, at 12:10 p.m., the medication cart/portable computer unit outside of room 227 Tionesta household was left unattended with the computer screen open with identifiable information so any passerby could see resident personal and confidential information.

During an interview on 3/26/24, at 12:17 p.m., Licensed Practical Nurse Employee E7 confirmed the computer screen was open and that the facility failed to maintain resident identifiable personal and medical information in a confidential manner on one of six nursing households (second floor Tionesta household).

28 Pa. code: 211.5(b) Clinical records.

28 Pa. Code: 201.29(i) Resident Rights

28 Pa. Code: 211.12(d)(3) Nursing Services


 Plan of Correction - To be completed: 04/22/2024

The Nursing staff were immediately instructed to review policies on "Lap top or other Portable Computers" and "Maintaining Respect and Dignity of the Resident". The Confidentiality of the resident's medical information will be maintained by the Charge Nurse covering the computer screen so that no resident's identifiable data is displayed. Nurses will be re-educated by the Clinical Nurse Educator and or designee. Weekly monitoring of the confidentiality of resident's personal medical data will be completed by the DON's/RN Clinical Nurse Manager/Clinical Coordinator. Each week six resident's medical information will be kept private by the DON's/RN Clinical Nurse Manager/Clinical Coordinator observing the Charge Nurse's Medication Administration on each Nursing Household to ensure computers screens are kept covered. This will be monitored for three months or until substantial compliance is achieved
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 facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to ensure that residents received neurological assessment after an incident involving a fall for two of five residents (Resident R9 and Resident R69).

Findings include:

Review of facility policy "Falls - Resident Treatment Of" dated 1/23/24, indicated a fall will refer to an incident when a resident drops to the floor suddenly or if a resident moves from one plane to another. Incidents that are considered a fall are when a resident is slowly and gently lowered to the floor, or when a resident slowly and purposefully lies or sits on the floor. If the resident is on the floor and the incident was unobserved, staff is to presume that it was a fall and proceed accordingly. When there is doubt, an incident should be considered a fall.

Review of facility policy "Neurological Assessment - Using the Flowsheet" dated 1/23/24, indicated that a Neurological Review Flowsheet will be initiated in the electronic medical record (EMR) or as a paper form and completed for all residents who have sustained head trauma, either from a fall or an act in which the resident is struck on the head. This EMR electronic assessment form or paper form will be completed every 15 minutes for one hour, every two hours for the next six hours, then every shift for 48 hours.

Review of the clinical record indicated Resident R9 was admitted to the facility on 2/12/21.

Review of Resident R9's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/26/24, indicated diagnoses of high blood pressure, hemiplegia (paralysis on one side of the body), and history of falling.

Review of Resident R9's clinical records dated 9/19/23, indicated he had a fall on 9/19/23, after sliding out of a mechanical lift in the shower and being lowered to the floor by a staff member. The clinical records indicate that Resident R9 sustained two lacerations (a jagged or torn wound to the skin) to the right side of his head, a laceration to the right side of his neck, and an abrasion (a superficial wearing of the skin) to his right shoulder. Neurological checks were initiated.

Review of Resident R9's "Neurological Review Flow Sheet" dated 9/19/23 and 9/20/23, indicated only nine neurological checks were completed out of 15 opportunities.

During an interview on 3/27/24, at 10:05 a.m., Director of Nursing 1 (DON1) stated, "Some of the neurological checks may have been completed on paper, we do hybrid charting."

During an interview on 3/27/24, at 10:08 a.m., DON1 was unable to locate any additional neurological checks in Resident R9's clinical record.

During an interview on 3/27/24, at 11:23 a.m., DON1 confirmed that Resident R9's neurological checks were not completed per facility policy.

Review of the clinical record indicated Resident R69 was admitted to the facility on 4/4/22.
Review of Resident R69's MDS dated 1/18/24, indicated diagnoses of high blood pressure, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions).

Review of Resident R69's clinical records dated 2/6/24, indicated Resident R69 was observed with an abrasion on her forehead and an abrasion on her nose. Resident R69 was unable to clearly state what caused the abrasions due to a language barrier. Neurological checks were initiated due to a presumed fall.

Review of Resident R69's "Neurological Review Flow Sheet" dated 2/6/24, and 2/7/24, indicated only 11 neurological checks were completed out of 15 opportunities.

During an interview on 3/28/24, at 9:49 a.m., Licensed Practical Nurse (LPN) Employee E5 confirmed she was unable to locate additional neurological checks in Resident R69's clinical record.

During an interview on 3/28/24, at 9:50 a.m., LPN Employee E5 confirmed that the facility failed to ensure that neurological assessments were completed for Resident R69 as required per facility policy.

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

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

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

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


 Plan of Correction - To be completed: 04/22/2024

The Neurological Assessment Using the Flowsheet will be completed for all residents who sustain or are suspected of head trauma. The Charge Nurses will be re-educated by the Clinical Nurse Educator or designee on the Neurological Assessment Using the Flowsheet. Monitoring will be completed on all residents who sustained or are suspected of head trauma by the DON's/RN Clinical Nurse Manager/Clinical Coordinator for completion for three months or until substantial compliance is achieved.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on facility policy review, resident observations and interviews, clinical record review and staff interviews, it was determined that the facility failed to make certain a physician order for use of and cleaning of a Bi-PAP/CPAP machine (machines used to make breathing easier) and failed to develop a plan of care for one of three residents (Resident R58).

Findings include:

Review of the policy "Respiratory Care Documentation" dated 1/23/24, indicated nurses will be responsible for completing the eTAR (electronic treatment administration record), for any resident who has physician orders CPAP, Bi-PAP therapy.

Review of the policy "Respiratory Care Equipment Changes" dated 12/12/23, indicated CPAP/BIPAP maintenance included the following: mask cleaning, headgear (helps secure the mask around the nose, mouth, or both to prevent pressure leaks during sleep) cleaning, tubing cleaning, humidifier chamber cleaning, filter cleaning, and replacement of worn-out components.

Review of the admission record indicated Resident R58 admitted to the facility on 12/12/23.

Review of Resident R58's Minimum Data Set (MDS- a periodic assessment of care needs) dated 3/12/24, indicated the diagnoses of obstructive sleep apnea (OSA -intermittent airflow blockage during sleep), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and high blood pressure.

Review of Resident R58's physician orders on 3/28/24, at 9:00 a.m., failed to include an order for BiPAP/CPAP therapy.

Review of Resident R58's care plan on 3/28/24, at 9:01 a.m., failed to include a plan of care for the use of BiPAP/CPAP therapy.

Review of Resident R58's progress notes dated 2/18/24, 12:34 p.m., indicated the resident resting in bed this morning with CPAP on until about 9:00 a.m. when he woke up.

Observation on 3/25/24, at 10:10 a.m., revealed a BiPAP/CPAP machine in Resident R58's room.

Interview on 3/25/24, at 10:10 a.m., Resident R58 indicated they wear it at night for breathing.

Interview on 3/28/24, at 9:56 a.m., the Director of Nursing DON2 confirmed the facility failed to make certain a physician order for use of, and cleaning of a Bi-PAP/CPAP machine, and failed to develop a plan of care for one of three residents (Resident R58).

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

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


 Plan of Correction - To be completed: 04/22/2024

The four residents with C-pap/Bi-pap were immediately checked by the Charge Nurse for Physician orders for use of and cleaning of a C-pap/Bi-pap machine, and Care Plan in place. Residents with C-pap/Bi-pap machine will have Physician orders, Treatment for C-pap/Bi-pap maintenance and care plan. Charge Nurses will be re-educated by the Clinical Nurse Educator or designee on the policies "Respiratory Care Equipment Changes" and "Respiratory Care Documentation on eMAR or eTAR" Residents with C-pap/Bi-pap will be monitored weekly by the DON's/RN Clinical Nurse Manager/Clinical Coordinator for three months or until substantial compliance is achieved.
483.25(m) REQUIREMENT Trauma Informed 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(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:

Based on review of facility policy, resident record review, and staff interviews, it was determined to facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for one of one residents (Resident R69).

Findings include:

Review of facility policy "Trauma-Informed Care" dated 1/23/24, indicated the facility will provide culturally competent, trauma-informed care across all disciplines to mitigate potential triggers for nursing residents who have experienced past or present trauma.

Review of the clinical record indicated Resident R69 was admitted to the facility on 4/4/22.
Review of Resident R69's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/18/24, indicated diagnoses of high blood pressure, Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions).

Review of Resident R69's care plan on 3/28/24, did not include a plan of care developed with goals and interventions related to post-traumatic stress disorder.

During an interview on 3/28/24, at 9:26 a.m., Social Worker Employee E3 stated, "I'm not sure why she has a PTSD diagnosis, I think it might be from an experience with her daughter, the allegation is that her daughter hit her. She is care planned for mood and behaviors, I thought it would be redundant to care plan her for PTSD."

During an interview on 3/28/24, at 9:26 a.m., Social Worker Employee E3 confirmed that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization.

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

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


 Plan of Correction - To be completed: 04/22/2024

The Trauma Informed Care plan was immediately implemented for resident with a diagnosis of PTSD by the Social Worker. On admission residents that have a diagnosis of PTSD or is a trauma survivor will have a Trauma Informed Care Plan initiated. The Social Workers were re-educated about implementing a Trauma informed Care plan when the resident comes in with a diagnosis of PTSD regardless of how the resident scores on the Life events PTSD Assessment. The Social Workers on admission and quarterly will monitor residents for the diagnosis of PTSD to assure a Trauma Informed Care Plan is implemented. Residents who have a diagnosis of PTSD on admission. The Social workers will monitor new admissions for PTSD diagnosis for three months or until substantial compliance is achieved.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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

Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly secure a medication drawer on four occasions in one of six households (Tionesta household).

Findings include:

Review of facility policy "Medication Administration-General Guidelines", last reviewed 1/23/24, indicate during administration of medications, the medication cart /portable computer unit is kept closed and locked when out of sight of the medication nurse.

During an observation on 3/26/24, 11:58 a.m., outside room 231 the portable computer unit medication drawer was left open, unattended, and out of site of the medication nurse.

During an observation on 3/26/24, 12:10 p.m., outside room 227 the portable computer unit medication drawer was left open, unattended, and out of site of the medication nurse.

During an interview on 3/26/24, at 12:17 p.m., Licensed Practical Nurse (LPN) Employee E7 confirmed the above findings.

During an observation on 3/27/24, 8:40 a.m., outside room 229 the portable computer unit medication drawer was left open, unattended, and out of site of the medication nurse.

During an observation on 3/27/24, 8:57 a.m., outside room 218 the portable computer unit medication drawer was left open and unattended and out of site of the medication nurse.

During an interview on 3/27/24, 9:14 a.m., Licensed Practical Nurse (LPN) Employee E8 confirmed the above observation. During this interview, LPN Employee E8 acknowledged that "Since I've been here, I know we lock the cabinets, I honestly don't know the policy concerning the drawer, I'm sure we are supposed to close/lock in between the residents".

During an interview 3/27/24, 9:15 a.m., Clinical Nurse Manager stated, "We don't usually close the drawer when in site, if leaving the area would shut and lock, I will call the Director of Nursing (DON) and ask".

During an interview 3/27/24, 9:25 a.m., Director of Nursing (DON2) stated, "the medication drawer on the portable computer units is to be shut and locked, the computer screen is to be closed " and confirmed that the facility failed to secure a medication drawer in one of six households.

28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1) Pharmacy services.

28 Pa. Code:211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 04/22/2024

Charge Nurse E7 and E8 were immediately re-educated by the RN Clinical Nurse Manager to secure and lock portable computer cart drawer when unattended or out of sight. Charge Nurses will be re-educated by the Clinical Nurse Educator or designee on the facility policy "Medication Administration-General Guidelines". The DON's/RN Clinical Nurse Manager/Clinical Coordinator will monitor six Charge Nurses every week for three months or until substantial compliance is achieved.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to implement measures to prevent the potential for cross contamination during finger stick blood sugar monitoring for one of two residents (Resident R301) and failed to complete hand hygiene after a finger stick blood sampling on one of two residents (Resident R299)

Findings include:

Review of facility policy Hand Hygiene/Handwashing" last reviewed on 1/23/24, indicate it is the policy of Passavant Community that all staff will follow the principles of good hand hygiene. Appropriate times to use hand hygiene include but are not limited to the following:
- Before and after performing a task that includes hand washing in the procedure. For example, before and after performing a task that includes any invasive procedure, finger stick blood sampling, inserting urinary catheters, caring for vascular catheters, and changing dressing.

Review of facility policy "Diabetes-Glucometer" last reviewed 1/23/24, indicate after completion of finger stick dispose of lancet, gloves and used strip in designated container, wash hands. Wipe glucometer off with a germicidal wipe.

Review of Sani-cloth germicidal wipe instructions indicate unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two minutes, let air dry.

During an observation of a medication pass on 3/26/24, at 11:58 a.m., Licensed Practical Nurse (LPN) Employee E7 obtained a finger stick blood sampling glucose reading from Resident R301, after cleaning the blood glucose monitor with a Sani-cloth wipe, Employee E7 placed the glucometer directly back into a black case, not allowing the glucometer to remain wet for a full two minutes and air dry.

During an observation of a medication pass on 3/26/24, at 12:10 p.m. LPN Employee E7 obtained a finger stick blood sampling glucose reading from Resident R299, informed resident of reading and the required insulin per physician orders. Employee LPN E7 did not complete hand hygiene after completion of finger stick blood sampling prior to preparation of the insulin pen and insulin administration.

During an interview on 3/26/27, at 12:17 p.m. LPN Employee E7 confirmed not allowing drying time after cleansing/sanitizing the glucometer after use for Resident R301, and did not complete hand hygiene after completion of finger stick blood sampling glucometer check for Resident R299 prior to preparation of the insulin pen and insulin administration.


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

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


 Plan of Correction - To be completed: 04/22/2024

Charge Nurse E7 was immediately re-educated by RN Clinical Nurse Manager on policies "Hand Hygiene/Handwashing" and "Diabetes-Glucometer" Charge Nurses will be re-educated by Clinical Nurse Educator or designee on policies "Hand Hygiene/Handwashing" and "Diabetes-Glucometer" and monitored for Hand Hygiene before and after glucometer usage, and Proper hand hygiene and proper cleaning/disinfecting of glucometers with germicidal agent per policy. Six Charge Nurses will be monitored every week for three months or until substantial compliance is achieved.


211.12(f.1)(4) LICENSURE Nursing services. :State only Deficiency.
(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.
Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 40 residents on the night shift on 1 of 21 days (2/23/24).

Findings include:

Review of facility census data indicated that on 2/23/24, the facility census was 98, which required 2.45 licensed practical nurses (LPN's) during the night shift.

Review of the nursing time schedules revealed 2.0 LPNs provided care on the night shift 2/23/24. No additional excess higher-level staff were available to compensate this deficiency.

During an interview on 3/28/24, at 9:15 a.m., Nursing Home Administrator confirmed that the facility administrative staff failed to provide a minimum of one licensed practical nurse (LPN) per 40 residents on the night shift on 1 of 21 days (2/23/24).



 Plan of Correction - To be completed: 04/22/2024


Re-education was given to the Staffing Coordinator by the Executive Director so that a minimum of one LPN per 40 residents will be on the night shift. The Staffing Coordinator will monitor daily staffing patterns on nights and report to QAPI for 3 months or until substantial compliance is achieved.
Passavant Community on an ongoing basis checks wages of LPN/RN to stay competitive. The night shift has an increase incentive to work the 11-7 shift. Lutheranseniorlife Corporate Recruiter is constantly searches for talent. Passavant has partnered with South College of Cranberry's LPN school to be an educational site for their geriatric rotation. The Directors of Nursing speak to graduating LPN schools about work opportunities at Passavant.


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