Nursing Investigation Results -

Pennsylvania Department of Health
PATRIOT, A CHOICE COMMUNITY THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PATRIOT, A CHOICE COMMUNITY THE
Inspection Results For:

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PATRIOT, A CHOICE COMMUNITY THE - 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 18, 2021, it was determined that The Patriot, A Choice Community 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:


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
483.21(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 provide services in accordance with professional standards of quality, by failing to ensure that physician's orders were clarified for one of 30 residents reviewed (Resident 39).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, and was responsible for assessing human responses and plans, implementing nursing care, and analyzing/comparing data with the norm in determining care needs.

A comprehensive annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care need) for Resident 39, dated February 6, 2021, revealed that the resident had diagnoses that included heart disease and high blood pressure. Physician's orders dated February 14, 2020, included an order for the resident to receive 5 milligrams (mg) of lisinopril (treats high blood pressure and heart failure) daily for a systolic blood pressure (the top number of a blood pressure reading) that was less than 100 millimeters of mercury (mmHg) or a heart rate of less than 60 beats per minute.

Observations during medication administration for Resident 39 on March 15, 2021, at 11:30 a.m. revealed that Licensed Practical Nurse 9 administered 5 mg of lisinopril to Resident 39 without first taking her blood pressure or heart rate.

Interview with Licensed Practical Nurse 9 on March 15, 2021, at 11:31 a.m. revealed that the physician's order for Resident 39's lisinopril was to give it for a systolic blood pressure that was less than 100 mmHg and a heart rate less than 60 beats per minute, which seemed incorrect, as normally lisinopril was to be held (not given) for a systolic blood pressure less than 100 or a heart rate less than 60. A follow-up interview with Licensed Practical Nurse 9 on March 15, 2021, at 2:27 p.m. revealed that she had confused the greater than (>) and less than (<) symbols and transcribed the order incorrectly. She confirmed that the order should have read to hold the lisinopril for a systolic blood pressure less than 100 or a heart rate less than 60.

Interview with the Director Nursing on March 15, 2021, at 4:17 p.m. confirmed that the parameters given for Resident 39's lisinopril (to give it for a systolic blood pressure less than 100 and a heart rate less than 60) were interpreted and transcribed incorrectly. She confirmed that the resident's Medication Administration Records (MAR's) for February 2020 through March 2021 incorrectly indicated that the resident was to receive 5 mgs of lisinopril for a systolic blood pressure less than 100 and a heart rate less then 60, when they should have been to hold the lisinopril for a systolic blood pressure less than 100 or a heart rate less than 60.

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




 Plan of Correction - To be completed: 05/07/2021

Patriot Annual Survey Plan of Correction
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because The Patriot, A Choice Community agrees with the allegations and citations listed on the statement of deficiencies. The Patriot, A Choice Community maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as The Patriot, A Choice Community's written credible allegation of compliance.
By submitting this plan of correction, The Patriot, A Choice Community does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and The Patriot, A Choice Community reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

1.R39 physician order for Lisinopril has been clarified with the attending physician and updated. R39 has not displayed adverse effects. Licensed Nurse received education on hold parameters and writing out physician order instructions rather than using symbols.

2.Residents receiving medications with hold parameters were reviewed to validate the orders were clear and correct.

3.Newly hired, current, and agency licensed nursing staff will be educated on completing vital signs prior to administering medications with hold parameters, writing out administration instructions, and to refrain from using symbols when transcribing physician orders. The Director of Nursing/Designee will monitor transcription of physician orders to validate the instructions are clear, without symbols and hold parameters are followed daily x 2 weeks, weekly x 2 weeks and monthly x 4.

4.Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation.


483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on review of policies and Resident Council meeting minutes, as well as observations and interviews with residents and staff, it was determined that hot foods were not served at proper and palatable temperatures.

Findings include:

The facility's policy regarding food temperatures, dated January 27, 2021, indicated that the temperatures of hot foods were to be maintained at 170 to 180 degrees Farenheit (F) on the steam table and served at 135 degrees F or above.

Resident Council meeting minutes, dated December 2020, and January and February 2021, revealed that the residents verbalized concerns regarding hot foods being served cold.

Interviews with Residents 23, 24 and 44 on March 15, 2021, at 9:00 a.m. revealed that the residents resided on the South hall and they stated that hot foods were not always served hot, and they preferred that hot foods be served hot. Resident 23 commented that the food was terrible and it was cold. Resident 24 stated that the coffee was cold, and Resident 44 stated that the soup and entrees were often served cold.

A test tray completed on the South hall during the lunch meal on March 15, 2021, revealed that meal trays left the kitchen at 11:40 p.m., arrived on the South hall at 12:01 p.m., and the test tray was tasted at 12:31 p.m., after the last resident was served and eating. The temperature of the chicken leg was 113.9 degrees F, the sweet potato was 128 degrees F, the broccoli/cauliflower/carrot medley was 116 degrees F, the tomato soup was 124 degrees F, and the coffee was 136 degrees F. The items were lukewarm to taste and a green, mechanically altered food item was lukewarm and not palatable.

Interview with the Dietary Manager on March 15, 2021, at 12:36 p.m. revealed that food temperatures were taken in the kitchen prior to placing items onto individual trays and sending them up to the units. She confirmed that the temperatures of hot foods should have been at least 135 degrees F when served to residents.

Interview with the Nursing Home Administrator on March 16, 2021, at 3:16 p.m. revealed that he reviews the Resident Council meeting minutes and he should have updated the Dietary Manager regarding the residents' continuing concern with food temperatures.




 Plan of Correction - To be completed: 05/07/2021

1. Staff present in the facility were verbally re-educated regarding the importance of timely tray preparation and delivery to ensure palatable food temperatures. Future test trays completed post education reveal appropriate food temperatures with meals delivered.

2. Current dietary and nursing staff will be re-educated on the tray preparation and meal cart delivery schedule with expectation of prompt food tray preparation, timely meal tray delivery to each unit, and prompt individual delivery from the meal cart to the resident(s).

3. The Dietary Manager/Designee will complete a test tray and resident satisfaction questionnaire on food palatability, spanning all units, all meals and different days of the week. Audits will occur daily, Monday-Friday x 2 weeks, weekly x 2 weeks and monthly x 2 months.

Food palatability and temperature will be reviewed and discussed at the monthly resident council meeting to solicit resident feedback. Any concerns will be recorded through the We Care process (grievance process) for further investigation and follow up.

4. Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation

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


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for four of 30 residents reviewed (Residents 12, 39, 49, 54).

Findings include:

The facility's policy regarding medication administration, dated January 27, 2021, indicated that the licensed nurse should review and note the physician's medication order, and ensure the medication is administered within the parameters identified by the drug manufacturer (such as monitoring blood pressure) and the ordering physician.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated March 5, 2021, revealed that the resident had diagnoses that included hypertension (high blood pressure), coronary artery disease (narrowing or blockage of the arteries), and heart failure. Physician's orders, dated October 10, 2018, included orders for the resident to receive 25 milligrams (mg) of metoprolol (medication to lower blood pressure) twice daily, and to hold the medication if the systolic blood pressure (the top number of a blood pressure reading) was less than 100 millimeters of mercury (mmHg). The resident's Medication Administration Records (MAR's) for March 2020 through March 2021 revealed that nurses administered metoprolol to the resident without obtaining the resident's blood pressure prior to administering the evening dose.


A comprehensive annual MDS assessment for Resident 39, dated February 6, 2021, revealed that the resident had diagnoses that included heart disease and hypertension. Physician's orders, dated February 14, 2020, included an order for the resident to receive 5 mg of lisinopril (treats heart disease and high blood pressure) daily for a systolic blood pressure less than 100 mmHg, or a heart rate less than 60 beats per minute. The resident's MAR's for February 14, 2020, through March 15, 2021, revealed that staff administered 5 mg of lisinopril to the resident daily without first obtaining the resident's blood pressure and heart rate.


A quarterly MDS assessment for Resident 49, dated February 15, 2021, revealed that the resident had diagnoses that included high blood pressure. Physician's orders, dated December 12, 2019, included orders for the resident to receive 20 mg of lisinopril twice daily, and to hold the medication if the systolic blood pressure was less than 100 mmHg. The resident's MAR's for July 2020 through March 16, 2021, revealed that staff administered lisinopril to the resident twice daily, at 7:30 a.m. and 7:30 p.m., without first obtaining the resident's blood pressure, except for August 27, 2020, at 6:28 a.m.; November 29, 2020, at 6:22 p.m.; February 3, 2021, at 6:43 a.m; and February 4, 2021, at 6:48 a.m.


A quarterly MDS assessment for Resident 54, dated February 19, 2021, revealed that the resident had diagnoses that included high blood pressure. Physician's orders, dated February 14, 2020, included orders for the resident to receive 25 mg of atenolol (medication to lower blood pressure) daily, and to hold the medication if the systolic blood pressure was less than 100 mmHg. The resident's MAR's for March 2020 through March 16, 2021, revealed that staff administered atenolol to the resident daily at 3:30 p.m. without first obtaining the resident's blood pressure or heart rate.

Interview with the Director of Nursing on March 17, 2021, at 3:54 p.m. confirmed that there was no documented evidence that the nurses who administered cardiac medications to Residents 12, 39, 49 and 54 obtained and documented the residents' blood pressures and/or heart rates prior to administering the medications.

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



 Plan of Correction - To be completed: 05/07/2021

1. Medication Error reports will be completed for Residents 12,39,49,54. Noted residents remain free from adverse effects.

2. Documentation of blood pressure and pulse will be audited for all current residents receiving medications with hold parameters.

3. Newly hired, current, and agency Licensed nursing staff will be educated on entering, completing, and recording vital signs (blood pressure, pulse, heart rate) per ordered hold parameters, prior to administering medications.

4. The Director of Nursing/Designee will monitor documentation of vital signs for medications with hold parameters daily on Monday-Friday x 2 weeks, weekly x 2 weeks and monthly x 4.

5. Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation.


483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:


Based on review of nurse aides' hire dates and personnel files, as well as staff interviews, it was determined that the facility failed to complete annual nurse aide performance evaluations for six out of 28 nurse aides reviewed (Nurse Aides 1-6).

Findings include:

A list of current nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations were due to be completed from January 1 through December 31, 2020, for Nurse Aides 1-6.

The personnel files for Nurse Aides 1-6 revealed no documented evidence that performance evaluations were completed during 2020.

Interview with the Assistant Director of Nursing on March 18, 2021, at 2:40 p.m. confirmed that there was no documented evidence that annual performance evaluations were completed in 2020 for Nurse Aides 1-6. Interview with the Director of Nursing on March 18, 2021, at 3:16 p.m. confirmed that annual performance evaluations should have been completed in 2020 for Nurse Aides 1-6; however, there was no documented evidence that they were completed as required.

28 Pa. Code 201.20(a) Staff development.



 Plan of Correction - To be completed: 05/07/2021

1. Performance reviews for nurse aides 1,2,3,4,5,6 are scheduled for completion by 4/30/2021.


2. Current nurse aide personnel files will be reviewed for current performance evaluations within the past year. Outstanding evaluations will be assigned for completion.

3. The Human Resources Director/Designee will monitor and track the nurse aide evaluations that are due to validate that the evaluations are initiated and completed in a timely fashion.

4. The Nursing Home Administrator/Designee will audit personnel files of nurse aides due for performance evaluations to validate the evaluation was completed timely. Audit will be completed monthly x 3 months.

5. Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation.



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 observations and 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 and the facility's policies for one of 30 residents reviewed (Resident 3).

Findings include:

The facility's policy regarding accidents/incidents, dated Januray 21, 2021, indicated that regardless of how minor an accident or incident may be, including injuries of unknown source, it must be reported to the department supervisor.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated March 1, 2021, revealed that the resident was cognitively intact, required extensive assistance or was dependent with daily care tasks, and received anticoagulant medication (commonly known as blood thinners). Physician's orders, dated November 20, 2020, included orders for the resident to receive showers on Monday and Thursdays, and that licensed staff were to ensure weekly skin evaluations were completed and report skin issues to the registered nurse. Physician's orders dated March 4, 2021, included an order for the resident to receive Coumadin (blood thinning medication) daily related to atrial fibrillation (quivering heat beat). The resident's care plan regarding anticoagulant therapy, initiated on September 8, 2020, revealed an intervention of daily skin inspections with abnormalities reported to the nurse.

Resident 3's skin assessments revealed that his skin was documented as "unremarkable" on March 1, March 8 and March 15, 2021.

Observations on March 15, 2021, at 9:44 a.m. revealed that Resident 3 had multiple red and/or purple bruises on both forearms. Interview with the resident at that time revealed that he did not know how the bruises occurred.

There was no documented evidence that the observed bruises were identified and reported to the nurse.

Interview with Nurse Aide 7 on March 17, 2021, at 3:33 p.m. revealed that she provided care to Resident 3 for approximately two weeks and thought that the bruises on his forearms were previously identified.

Interview with the Director of Nursing on March 18, 2021, at 10:25 a.m. confirmed that the bruises of Resident 3's forearms should have been reported to the nurse.

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



 Plan of Correction - To be completed: 05/07/2021

1. A skin assessment and report for the bruising was completed on R3. The forearm bruises are resolving, without complication.

2. Skin inspections will be completed on all residents receiving anti-coagulation medications for any skin concerns. Identified concerns will be evaluated and recorded in the medical record.

3. Newly hired, current, and agency nursing staff will be educated on completion of skin inspection, reporting and documenting skin concerns in the medical record.

4. The Director of Nursing/Designee will audit skin inspections on 5 random residents weekly x 2 weeks then monthly x 2 months to validate accuracy of skin assessments. The Interdisciplinary team will review skin concerns daily, Monday- Friday.

5. Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation.


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 clinical records and accident investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for two of 30 residents reviewed (Residents 36, 44).

Findings include:

A comprehensive significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated November 11, 2020, indicated that the resident was cognitively impaired, required extensive assistance with transfers, and had a recent history of falls. The resident's care plan, dated September 19, 2020, indicated that the resident was to transfer with the assistance of one staff member and a front-wheeled walker.

A fall investigation report for Resident 36, dated December 2, 2020, revealed that Nurse Aide 10 heard Resident 36's personal alarm (alarm attached to the resident that alerts staff when the resident attempts to get up) sounding and entered the room to find the resident sitting on the side of the bed in an attempt to go to the restroom. Nurse Aide 10 assisted the resident to lay back down in her bed and left to get another staff member to help transfer the resident and walk her to the restroom, as she thought the resident required two staff for transfers and walking. Upon returning to the resident's room with another staff, the resident was found on the floor in front of the bathroom door. The investigation concluded that Nurse Aide 10 was not aware that Resident 36's transfer status was currently the assistance of one staff with a wheeled walker, because the program that the nurse aides used was not updated and still indicated that the resident required two staff for transfers.

Interview with the Director of Nursing on March 17, 2021, at 3:11 p.m. confirmed that Nurse Aide 10 was not provided with accurate information regarding Resident 36's transfer status, and would have been able to stay with the resident and transfer her to the restroom herself if the program had been updated.


A comprehensive significant change MDS assessment for Resident 44, dated November 16, 2020, indicated that the resident was alert and oriented, required extensive assistance with transfers, did not have a recent history of falls, and had diagnoses that included heart disease, kidney disease, and arthritis. The resident's care plan, dated October 8, 2019, indicated that she was to transfer with the assistance of one staff member and a front-wheeled walker.

A fall investigation report for Resident 44, dated December 15, 2020, revealed that Nurse Aide 11 was assisting the resident to transfer from her recliner chair to her wheelchair when the resident's legs buckled and the nurse aide lowered the resident to the floor. The investigation concluded that Nurse Aide 11 did not use a walker when assisting the resident to transfer, in accordance with the resident's care plan.

Interview with the Director of Nursing on March 18, 2021, at 5:05 p.m. confirmed that Nurse Aide 11 did not use a walker when she transferred Resident 44 on December 15, 2020, and she should have.

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



 Plan of Correction - To be completed: 05/07/2021

1. Nurse aide task list was updated for R36 to reflect current transfer status. Nurse Aide 11 was educated on R44's plan of care for transfer status.

2. Resident transfer status will be reviewed in the clinical software and plan of care for current residents to validate that resident transfer status is current and visible to relevant nursing staff.

3. Nursing staff (Registered Nurse, Licensed Practical Nurse, Certified Nurse Aides, and waiver Aide staff) will be re-educated on following the plan of care and tasks to be completed in our clinical software. Therapy staff and licensed nursing staff will be re-educated on the procedure and protocol for properly entering resident transfer status into clinical software so it is visible to nursing staff.

4. The Director of Nursing/Designee will review changes in resident transfer status to validate the clinical software and plan of care are updated and communicated daily on Monday-Friday x 2 weeks, weekly x 2 weeks and monthly x 2 months. The Director of Nursing/Designee will observe 5 random resident transfers to validate the plan of care and tasks are completed as directed, weekly x 2 weeks and monthly x 2 months.

5. Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation.

483.25(h) REQUIREMENT Parenteral/IV Fluids:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:


Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that implanted venous ports were flushed according to the facility's protocol for one of 30 residents reviewed (Resident 45).

Findings include:

The facility's protocol regarding flushing implanted venous port devices (a surgically implanted device just beneath the skin, which allows easy access to a vein and that can be used for an extended period of time to deliver fluids and/or medications), dated January 27, 2021, revealed that the port was to be flushed to maintain patency (open/unobstructed).

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated February 25, 2021, revealed that the resident was alert and oriented, required extensive staff assistance for daily care tasks, and had diagnoses that included multiple sclerosis (disease that attacks the central nervous system). A nursing note dated February 15, 2021, at 6:53 p.m. revealed that the nurse removed the needle from Resident 45's implanted venous port. Physician's orders, dated February 17, 2021, included orders for the resident's (venous) port to be flushed monthly with 10 cubic centimeters (cc) of normal saline solution (an injectable mixture of salt and water) starting on March 14, 2021.

The resident's Medication Administration Records (MAR's) for February 2021 revealed that the resident's implanted venous port was last flushed with 10 cc's of normal saline solution during the day shift on February 15, 2021. MAR's for March 2021 revealed no documented evidence that the implanted venous port was flushed at any time between March 1 and 18, 2021.

Interview with Resident 45 on March 18, 2021, at 5:50 p.m. confirmed that she currently had an implantable venous port in the right upper chest area, which could be visualized under the skin.

Interview with the Director of Nursing on March 18, 2021, at 6:12 p.m. confirmed that there was no documented evidence that Resident 45's implanted venous port was flushed starting on March 14, 2021, as ordered by the physician and it should have been.

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




 Plan of Correction - To be completed: 05/07/2021

1. R45's implanted venous port was flushed successfully on 03/19/2021, without complications. A schedule to flush the port monthly was re-established in the clinical software to automatically populate when the flush is due to be completed.

2. Residents with implanted ports receiving parenteral therapy were reviewed to validate that routine flushes are scheduled for completion per physician orders.

3. Newly hired, current, and agency Licensed staff (Registered Nurse/Licensed Practical Nurse) will be educated on required components of correctly entering intravenous orders, including scheduling reoccurring flushes to auto populate when due.

4. The Director of Nursing/Designee will monitor physician orders for parenteral therapy to validate that required components are ordered. The Director of Nursing/Designee will audit residents receiving parenteral therapy to validate flushes are completed per physician orders. Audits will be completed Monday-Friday x 2 weeks, weekly x 2 weeks and monthly x 2 months.

5. Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation.


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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice and the resident's person-centered care plan for one of 30 residents reviewed (Resident 50).

Findings include:

An admission comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 50, dated February 15, 2021, revealed that the resident was severely cognitively impaired, required extensive assistance with daily care tasks, had diagnoses that included atrial fibrillation (quivering or irregular heartbeat), and required supplemental oxygen. Physician's orders, dated February 8, 2021, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute by nasal cannula (tubes that deliver oxygen into the nostrils). The resident's care plan, initiated on February 9, 2021, included that the resident received oxygen therapy, needed the oxygen set-up (tubing and cannula) to be changed weekly in accordance with the facility's policy.

Observations on March 15, 2021, at 10:15 a.m. and March 17, 2021, at 3:09 p.m. revealed that the tubing being used by the resident was dated March 7, 2021, and humidification bottle was dated March 8, 2021.

Interview with Licensed Practical Nurse 8 on March 17, 2021, at 3:25 p.m. confirmed that Resident 50's oxygen set-up was dated March 7 and 8, 2021. The nurse indicated that the oxygen set-up was usually replaced every Sunday night.

Interview with the Director of Nursing on March 17, 2021, at 3:58 p.m. confirmed that Resident 50's oxygen set-up should have been replaced weekly on March 14, 2021, according to the facility's policy.

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




 Plan of Correction - To be completed: 05/07/2021

1. The Oxygen tubing and humidification bottle for R50 was changed with date noted.

2. Current residents with physician orders for oxygen will be reviewed to validate that the oxygen tubing and humidification bottle have been changed within the past 7 days.

3. Newly employed, current, and agency Licensed nursing staff (Registered Nurse/Licensed Practical Nurse) will be re-educated on the facility policy and procedure for changing oxygen set up and dating the tubing and humidification bottle when changed.

4. Central Supply/Designee will audit residents receiving oxygen therapy for timely set up changes weekly x 4, then monthly x 2.

5. Facility staff completing tubing and humidification bottle changes will be provided a current list of residents with equipment by Central Supply/Designee to ensure changes occur.

6. Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation.



483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
483.70(o) Hospice services.
483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in 418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at 483.24.
Observations:


Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for two of 30 residents reviewed (Residents 7, 56).

Findings include:

The facility's policy regarding hospice (end-of-life) services, dated January 21, 2021, revealed that for a resident to qualify for the hospice benefit under Medicare there must be a certification of terminal illness, and the facility was responsible for communication with the hospice provider and documention to ensure that the needs of the resident were met twenty-four hours a day.

Physician's orders and a care plan for Resident 7, dated November 26, 2020, revealed that the resident was to receive a hospice evaluation and treatment. A comprehensive, significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated December 4, 2020, indicated that the resident was severely cognitively impaired, had diagnoses that included Parkinson's disease (a disease that affects the brain and movement) and COVID-19, and received hospice services during the assessment period.

There was no documented evidence that information about hospice visits/services provided from November 26, 2020, to March 16, 2021, were a part of the resident's clinical record.

Interview with the Nursing Home Administrator on March 17, 2021, at 4:20 p.m. confirmed that hospice notes were to be kept in a binder or scanned into the resident's electronic record, and there were no hospice notes that were currently part of Resident 7's records.


Physician's orders for Resident 56, dated March 1, 2021, included an order for a hospice consultation. A comprehensive, significant change MDS assessment, dated March 9, 2021, indicated that the resident was severely cognitively impaired, and received hospice services during the assessment period.

There was no documented evidence that a physician's certification of terminal illness was obtained and was part of Resident 56's clinical record.

Interview with the Director of Nursing on March 18, 2021, at 10:47 a.m. confirmed that there was no documented evidence that a physician's certification of terminal illness was obtained and on record for Resident 56.

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



 Plan of Correction - To be completed: 05/07/2021

1. Hospice documentation for services provided from November 26,2020 through March 16, 2021 were filed in R7's medical record.
The physician's certification of terminal illness was filed in the R56's medical record.

2. Records of current hospice residents will be reviewed to validate documentation of hospice visits/services provided and physician certification of terminal illness are present and current.

3. The Interdisciplinary team will be re-educated on the responsibilities outlined in the regulatory requirements, including but not limited to: hospice collaboration, communication and documentation requirements.

4. Hospice documentation will be uploaded to the electronic medical record. Medical Records/Designee will be responsible to receive and upload documentation in the resident electronic record.

5. Social Service/Designee will monitor 20% of hospice resident records to validate hospice documentation is current and physician certification of terminal illness is present, weekly x 4 weeks, the monthly x 3 months.

6. Audit results will be reported and reviewed by the Quality Assurance Process Improvement Committee monthly x 3, for further review and recommendation.


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