Nursing Investigation Results -

Pennsylvania Department of Health
ROCHESTER MANOR
Patient Care Inspection Results

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ROCHESTER MANOR
Inspection Results For:

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ROCHESTER MANOR - 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 an Abbreviated Survey in response to a complaint completed on February 6, 2020, it was determined that Rochester Manor 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:


483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on review of clinical record review, resident and staff interview, it was determined that the facility failed to ensure residents received necessary assistance with bathing for ten of 33 residents (Resident R6, R14, R18,R26,R28,R50, R59, R63, R88, and R200).

Findings include:

Interview with Residents during Resident Group meeting on 2/4/20, at 2:45 p.m. all residents were in agreement that showers are not completed as agreed upon between facility staff and residents. Resident R50 stated that when they ask for a shower they are told there is not enough staff, and Residents can go days without showers. Resident R59 stated they have not had a shower for three weeks. Resident R18 stated they have not had a shower for days and missed doing things out side of their room. Residents were in an agreement that the facility told them they get specific shower days and they were not able to get showers on those days.

Review of Resident R6's plan of care indicated two showers were to be given during the day shift on Monday and Thursday's.

Review of Resident R6's shower log's from 1/8/20 through 1/30/20 revealed no showers were given and the Resident received bed baths only.

Review of Resident R14's plan of care indicated two showers were to be given during the day shift on Monday and Thursday's.

Review of Resident R14's shower log from 1/8/20 through 2/5/20 revealed three showers were given to the Resident.

Review of Resident R26's plan of care indicated two showers were to be given during the day shift on Tuesday and Saturday.

Review of Resident R26's shower log from 1/8/20 through 2/5/20 revealed no showers were and the Resident received bed baths.

Review of Resident R18's plan of care indicated two showers were to be given on Sunday and Thursday during the evening shift.

Review of Resident R18's shower log from 1/13/20 through 2/5/20 revealed no showers were given.

Review of Resident R28's plan of care indicated two showers were to be given on Wednesday and Sunday daylight shift.

Review of Resident R28's shower log from 1/8/20 through 2/5/20 revealed no showers were given.

Review of Resident R50's plan of care indicated two showers were to be given on Monday and Thursday on the daylight shift.

Review of Resident R50's shower log from 1/8/20 through 2/6/20 revealed two showers were given to the Resident.

Review of Resident R63's plan of care indicated two showers were to be given on Monday and Thursdays during the daylight shift.

Review of Resident R63's shower log from 1/24/20 through 2/6/20 revealed no showers were given.

Review of Resident R59's plan of care indicated two showers were to be given on Wednesday and Sunday during the daylight shift.

Review of Resident R59's shower log from 1/8/20 through 2/6/20 revealed two showers were given during the daylight shift.

Review of Resident R200's plan of care indicated two showers were to be given on during the week (no specific date).

Review of Resident R200's shower log from 1/8/20 through 2/6/20 revealed no showers were given.

Review of Resident R88's plan of care indicated two showers were to be given on Wednesdays and Saturdays on the daylight shift.

Review of Resident R88 shower log from 1/8/20 through 2/6/20 revealed no showers were given.

During an interview on 2/6/20, at 2:49 p.m. Director of Nursing (DON) confirmed that showers were not given and the facility failed to assist residents with bathing needs for ten residents.

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

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

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



 Plan of Correction - To be completed: 04/06/2020

1. Resident R6, R14, R18, R26, R28, R50, R59, R63, R88, and R200 will be interviewed by DON or designee to determine if needs have been met. Resident R6, R14, R18, R26, R28, R50, R59, R63, R88, and R200 will be offered their bathing of choice and will be interviewed for preferences, with bathing preferences care planned.

2. A whole house audit will be conducted to ensure bathing preferences are being met, bathing is completed per resident preferences, and updated care plans and bathing schedules as appropriate.

3. Education of nursing department will be conducted by center Director of Nursing or designee regarding bathing preferences.

4. Audits of bathing sheets for facility residents will be conducted by DON or designee weekly x 4 weeks and monthly x 3 months.

5. Results of audits with recommendations for changes will be submitted to QAPI committee.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 and clinical record review, observations and staff interviews, it was determined that the facility failed to use proper infection control technique which created the potential of cross-contamination during a dressing change for one of one resident reviewed (Resident R10).

Findings include:

Review of Resident R10's clinical record revealed that Resident R10 was admitted on 11/4/19 with diagnoses of major depressive disorder and pressure ulcer.

During an observation of a dressing change on 2/4/20 at 1:40 p.m., the following was observed:

Registered Nurse (RN) Employee E7 performed hand washing in Resident R10's bathroom sink. Licensed Practical Nurse (LPN) Employee E8 performed a two second hand wash. Gloves were applied at bedside. Resident R10 was uncovered, was turned toward LPN Employee E8, brief removed. RN Employee E7 placed used brief in biohazard bag, removed gloves, failed to use hand sanitizer and donned gloves. RN Employee E7 sanitized overbed table and created clean field, doffed gloves, failed to use hand sanitizer, donned gloves. RN Employee E7 removed old dressing, removed gloves, performed hand washing in sink. RN Employee E7 donned gloves at bedside, cleaned and swabbed wound, took skin prep from clean field, doffed gloves. RN Employee E7 donned gloves without hand sanitizer, packed wound, returned to clean field for scissors, back to wound, cut packing, picked up topical dressing and applied to wound, doffed gloves. RN Employee E7 then took sharpie from pocket and placed on clean field, cleansed sharpie with alcohol wipe, donned gloves, applied dressing on Resident R10's buttocks, doffed gloves. RN Employee E7 donned gloves without hand sanitizer, took brief from drawer and applied brief and rolled Resident R10 onto back. LPN Employee E8 removed gloves, turned off light, lowered bed, then pulled up Resident R10's pants, washed hands. RN Employee E7 donned gloves, cleaned up supplies, tied up biohazard bag, doffed gloves, hand sanitizer used, all other supplies gathered and placed in dressing change bag. RN Employee E7 took biohazard bag to bathroom, sat on floor while donning gloves from bathroom, took biohazard bag to biohazard room, opening two doors with gloved hands to dispose of bag, doffed gloves. RN Employee E7 washed hands in soiled utility room, returned to Resident R10's room to pick up supplies and tray, took to clean utility room, verbalized completion of dressing change. RN Employee E7 failed to sanitize over-bed table.

During an interview on 2/4/20 at 2:45 p.m., RN Employee E7 confirmed that proper infection control procedures were not maintained during the dressing change and created the potential for cross contamination.

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

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

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

28 Pa. Code: 201.20(c) Staff development.

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

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




























 Plan of Correction - To be completed: 04/06/2020

1. Cited resident had no negative outcome.

2. Licensed Nurses will be educated on infection control procedures as it relates to wound dressing changes by center Director of Nursing or designee.

3. Each licensed nurse will be audited for proper infection control techniques during dressing changes.

4. Audits will be conducted by Director of Nursing or designee to ensure proper infection control procedures are utilized during dressing changes weekly x 4 weeks then monthly x 3 months.

5. Results of audits with recommendations for changes will be submitted to QAPI committee
483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:
Based on review of facility policy, observations and staff interview, it was determined that the facility failed to maintain resident dignity during a dressing change for one of one resident (Resident R10).

Findings include:

Review of the "Resident Rights" policy dated 10/24/19, indicated that each resident has the right to be treated with respect and dignity.

During an observation on 2/4/20, from 1:40 p.m. through 2:14 p.m. Registered Nurse (RN) Employee E7 performed dressing changes to the coccyx (tailbone area) of Resident R10 and the following was observed:

RN Employee E7 entered Resident R10's room without knocking and asking for permission to enter. RN Employee E7 applied the dressing on Resident R10's coccyx and wrote his/her initials and date on the dressing after it was applied to Resident R10's coccyx. RN Employee E7 then left Resident R10's room and returned to room and failed to knock and ask for permission to enter.

During an interview on 2/4/20, at 2:49 p.m. RN Employee E7 confirmed that Resident R10's dignity was not maintained during the dressing change.

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

28 Pa. Code: 211.10(a)(b) Resident care policies.

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

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


 Plan of Correction - To be completed: 04/06/2020

1. Cited resident had no negative outcome.

2. Other residents who receive dressing changes will be interviewed by Social Services to determined if privacy has been provided during treatment provision.

3. Licensed Nurses will be educated on dressing change procedures as it relates to dignity by center Director of Nursing or designee.

4. Audits will be conducted by Director of Nursing or designee to ensure proper dignified procedures are utilized during dressing changes as per nurse observation weekly x 4 weeks then monthly x 3 months.

5. Results of audits with recommendations for changes will be submitted to QAPI committee
483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on review of facility policy, resident council meeting minutes, and resident and staff interviews, it was determined that the facility failed to demonstrate a response to grievances from resident council for eight of eight months (April, May, June, July, August, September, October, November and December 2019).

Findings include:

The facility grievance policy dated 10/24/19, indicated that residents and family members may voice grievances to the facility or other agency/entity that hears grievances without discrimination or reprisal and without fear.

A review of resident council meeting minutes for April, May ,June, July , August , September,October, November, and December indicated the following concerns:

4/2/19: "call bells are not always answered in a timely manner especially overnight, staff on their cell phones, showers not given"
4/22/19: "consistent staffing with nursing and aides, residents reminding staff to give showers"
5/28/19: "aides not always available at night and have not been introducing themselves, residents not receiving showers, call bell not being answered in a timely manner in the evenings/nights, rooms not being cleaned thoroughly"
6/18/19: "rooms not being cleaned thoroughly, residents not receiving showers"
7/24/19: "rooms not being cleaned thoroughly"
8/13/19: "residents feel that call bells are not being answered in a timely manner in the evening and night, too much noise at night"
9/24/19: "change sheets more often, blinds in rooms need cleaned, clean under bed, dresser/shelves/end tables are not being cleaned,snacks not being offered"
10/29/19: "aides not coming in timely manner after call bell is rung, aides not using beepers, staff changing shifts are to loud and disrupting the residents, beds are not being being made everyday, residents are not getting their showers on scheduled days, floors are not being swept and mopped"
11/26/19: "aides do not answer resident in timely manner in restroom, aides don't answer the call bells, rooms are not being cleaned often enough"
12/30/19: "curtains not being cleaned and privacy"

During a resident group on 2/4/20, at 2:30 p.m. Residents R300, R301, R302, R303, R304, R305, R306, R308 and R309 indicated that these items are still on-going concerns for the group and they are discussed at resident council and continue to be a problem.

During an interview on 2/6/20, at 1:44 p.m. Activity Director Employee E12 confirmed that residents have on-going concerns regarding call bells not being answered timely, residents not getting showered, too much noise at night, rooms not being cleaned, snacks not being offered, clean sheets on beds, and not having consistent staff and the facility is not not using concern forms to follow up on residents concerns from resident council and that the facility failed to demonstrate a response to the the residents concerns.

28 Pa. Code 201.18(e)(4)Management.




 Plan of Correction - To be completed: 04/06/2020

1. Cited concerns are being addressed through center grievance process.

2. Resident concerns expressed during resident council will be addressed through the center grievance process to include grievance forms and responses in writing by appropriate department head. Department heads will be educated by NHA on this new process for resident council responses.

3. Audits to ensure proper responses and utilization of resident council grievance forms NHA or designee weekly x 4 weeks and monthly x 3 months.

4. Results of audits with recommendations for changes will be submitted to QAPI committee.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:
Based on observations, facility documentation and staff interview it was determined that the facility failed to maintain a homelike environment for two of 33 residents (Resident R6 and R66).

Findings include:

During observations on 2/3/20, the following was observed:
10:15 a.m.: Resident R6 was in bed sleeping in a hospital gown with a strong smell of urine in resdient room.
10:15 a.m.: Resident R66 was in bed awake wearing a hospital gown with a catheter bag on the side of the bed and a strong smell of urine in the room.
11:08 a.m. Resident R6 and Resident R66 both awake wearing hospital gown with strong smell of urine in resident room
1:40 p.m. Resident R6 in hospital gown awake, strong smell of urine in resident room

During a review of facility documenation on 2/3/20, at 11:34 a.m. ADL (Activities of Daily Living - documenation showing when residents have received assistance with care) indicated that Resident R6 had yet to receive care for morning care.

During an interview on 2/5/20, at 5;05 p.m. Unit Manager Registered Nurse (RN) Employee E5, confirmed that Resident R6 and R66 were in bed throughout 2/3/20, in bed wearing hospital gowns and a strong smell of urine was noted and the facility failed to maintain a homelike environment.


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



 Plan of Correction - To be completed: 04/06/2020

1. Cited residents will be interviewed to determine if needs have been met. Cited residents will be offered AM care at a time they prefer and clothing of their choice, and will be interviewed for preferences, with preferences care planned.
2. A whole house audit will be conducted to ensure AM care time and clothing preferences are being met, with updated care plans as appropriate.
3. Education of nursing department will be conducted by center Director of Nursing or designee regarding AM care time and clothing preferences.
4. Audits of AM care and clothing preferences will be conducted by DON or designee weekly x 4 weeks and monthly x 3 months.
5. Results of audits with recommendations for changes will be submitted to QAPI committee.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:
Based on review of facility policy, observation, clinical record review, and staff interview it was determined the the facility failed to identify the placement of beds against the wall as a restraint and failed to obtain justification for safe use of the bed against the wall for two of two residents reviewed (Resident R144 and R90).

Findings include:

Review of "Resident Right" policy dated 10/24/19, indicated that residents have the right to a safe, clean. comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

A review of the clinical record indicated Resident R144 was admitted ot the facility on 1/20/20, with alzheimer's disease with late onset (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration's of the brain- a group of thinking and social symptoms that interferes with daily functioning).

During an observation on 2/5/20, at 5:14 p.m. Resident R144 was asleep in bed and the bed (left side) was pushed flush against the wall.

A review of the care plans revealed Resident R144 was a potential for falls due to weakness/debility, and poor safety awareness/cognitive loss. No care plan or assessment was included in the clinical record for Resident R144 for safety with a bed against the wall.

During an interview on 2/6/20, at 12:02 p.m. Director of Nursing confirmed that the facility failed to identify the placemnt of beds against a wall as a restraint and failed to obtain justification for safe use of the beds against the wall for Resident R144.

Review of Resident R90's clinical record revealed that resident was admitted to the facility on 1/18/20, with diagnosis that included irregular heart beat, weakness, heart failure, high blood pressure, anxiety, respiratory failure, back pain, depression and difficulty walking.

Review of the care plan dated 1/14/20, revealed Resident R90 was at risk for falls due to weakness/debility, tremors and a history of falls. No care plan or assessment was included in the clinical record for Resident R90 for safety with a bed against the wall.

During an interview on 2/6/20, at 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to identify the placemnt of beds against a wall as a restraint and failed to obtain justification for safe use of the beds against the wall for Resident R90.

28 Pa. Code:211.8(a)(d)(e)Use of restraints.

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

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


 Plan of Correction - To be completed: 04/06/2020

1. Residents R90 and R144 were assessed and care planned for beds against the wall at time of survey.
2. A whole house audit will be conducted to determine if other resident beds are against the wall, with updated assessments and care plans as appropriate or beds moved away from the wall if not appropriate.
3. Education of nursing department will be conducted by center Director of Nursing or designee regarding beds against the wall as a possible restraint.
4. Audits of beds will be conducted by DON or designee weekly x 4 weeks and monthly x 3 months.
5. Results of audits with recommendations for changes will be submitted to QAPI committee.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on review of clinical records, and staff and resident interviews, it was determined that the facility failed to follow physician orders for one of two residents reviewed (Resident R30).

Findings include:

The Admission Record indicated that Resident R30 was admitted to the facility on 11/3/17, with diagnoses of Diabetes (a condition in which the pancreas does not produce enough of the hormone insulin), and heart disease.

During an interview on 2/3/20 at 11:14 a.m., Resident R30 stated he wanted to walk again but needed diabetic shoes. He stated he is losing strength lying in bed every day. He was waiting for molds of his feet to be made. A provider representative was in 12/2019, and made a tracing of his feet and there was no follow up.

Clinical record review of physician orders dated 8/15/18, indicated an order for diabetic shoes.

Review of the care plan dated 5/13/19, listed the goal as diabetic shoes and the intervention of an orthotic's company to evaluate Resident R30 for diabetic shoes.

The clinical record indicated no follow up for Resident R30's diabetic shoe molding after the tracings were made.

During an interview on 2/4/20, at 12:22 p.m., the Director of Rehabilitation Employee E6, confirmed that no one had notified any other provider.

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) Resident care policies.

28 Pa. Code 211.11(a)(b)(c) Resident Care Plan.






















 Plan of Correction - To be completed: 04/06/2020

1. Resident R30 received the diabetic shoes.

2. A whole house audit will be conducted to determine if other resident have not received specialty devices per physician order.

3. Education of nursing department will be conducted by center Director of Nursing or designee regarding receiving supplies per physician order.

4. Audits of supply orders will be conducted by DON or designee weekly x 4 weeks and monthly x 3 months.

5. Results of audits with recommendations for changes will be submitted to QAPI committee.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:
Based on review of clinical records and staff interviews, it was determined that the facility failed to identify and address nutrition concerns for one of five residents (Resident R294).

Findings include:

The clinical record indicated that Resident R294 was admitted on 1/30/20, with a diagnosis of diabetes (insufficient insulin produced by the pancreas). A physician's order dated 1/30/20, indicated Resident R294 was prescribed a Controlled Carbohydrate Diet.

During an interview on 2/3/20, at 10:00 AM, Resident R294 indicated he was receiving meals with high amounts carbohydrate and his blood sugars were in the 300 range before lunch, had trouble chewing meat, and had no visit from the dietitian up to this time.

During an interview on 2/3/20, at 11:45 a.m., Dietitian Employee E11, confirmed that she did not meet with Resident R294.

During an interview on 2/4/20 at 10:14 a.m., Resident R294 stated he did not receive an appropriate meal for dinner. Dietary was called and sent another inappropriate meal then was called a second time before an appropriate dinner meal was sent.

During an interview on 2/6/20 at 1:28 p.m., the Director of Nursing confirmed that the facility failed to identify and address nutrition concerns for Resident R294.

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

28 Pa. Code: 211.6(e) Dietary services.

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

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






























 Plan of Correction - To be completed: 04/06/2020

1. Cited resident is no longer at facility.
2. A whole house audit will be conducted to ensure dietary concerns are being addressed through the center grievance process; ensure that residents are seen upon admission by RD; verify that physician ordered diets are being provided.
3. Audits of resident satisfaction with meals will be conducted by RD or designee weekly x 4 weeks and monthly x 3 months.
5. Results of audits with recommendations for changes will be submitted to QAPI committee.

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 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.
483.35(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 facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for four of five nurse aides reviewed (Employee E1, E2, E3, and E4).

Finding include:

Review of Nurse Aide (NA) Employees Employee E1, E2, E3, E4's education records with hire date greater than 12 months revealed the following:

NA Employee E1 had a hire date of 8/19/14, with 4.25 hours in-service education between 8/19/18, and 8/19/19.
NA Employee E2 had a hire date of 6/16/11, with 7.75 hours in-service education between 6/16/18, and 6/16/19.
NA Employee E3 had a hire date of 7/27/17, with 8.00 hours in-service education between 7/27/18, and 7/27/19.
NA Employee E4 had a hire date of 11/11/10, with 5.00 hours in-service education between 11/11/18, and 11/11/19.

During an interview on 2/4/20, at 1:56 p.m. the Director of Nursing confirmed that the facility failed to provide the required 12 hours annual in-service education within 12 months of their hire date anniversary for NA Employees E1, E2, E3, and E4.

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

28 Pa. Code: 201.20(c) Staff Development.






 Plan of Correction - To be completed: 04/06/2020

1. Employees E1, E2, E3, and E4 will receive the remainder of their 12 hours of in-service education from DON or designee.
2. An audit of CNA education will be conducted by HRD or designee.
3. An education plan will be put in place by DON or designee to be conducted on a monthly basis to ensure CNAs receive their 12 hours of in-service education.
4. An ongoing audit will be completed by HRD or designee to ensure CNAs are receiving education according to the plan weekly x4 weeks then monthly x3 months.
5. Results of audits with recommendations for changes will be submitted to QAPI committee

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