Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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ROSEMONT CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey in response to two complaints completed on February 18, 2020, it was determined that Rosemont Center 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 as its relates to the Health portion of the survey process.

 Plan of Correction:

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.

Based on review of clinical records, observation, review of facility policies, and resident and staff interviews, it was determined that the facility failed to ensure that the appropriate measures were put in place for to prevent the potential spread of infection of MRSA for two of three residents reviewed. (Residents R1 and R2)

Findings include:

Review of the facility's policy entitled "Infection Prevention and Control Program" dated May, 2017, which indicated that it is the policy of the facility to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable enviornment to prevent the development and transmission of communicable diseases and infections.

Review of facility's policy entitled "Infection Control" dated January, 2019, indicated that under topic of "Conditions Requiring Contact Precautions" that residents with MRSA ( Methicillin Resistant Staph Aureus) were listed as requiring contact precautions. The policy further indicated residents with similar infections may be roomed together as long as there are no contraindications.

Review of the clinical record of Resident R1 revealed that the resident was admitted October 16,2018, and readmitted August 29, 2019, with a diagnosis of MRSA in his sputum (mixture of saliva and mucus coughed up from the respiratory tract). Observations conducted on February 18, 2020 at 9:40 a.m. revealed that licensed nursing staff, Employee E1 was providing care to Resident R1. Employee E1 wearing a mask and gloves during care. Employee E1 was interviewed at the time of the observation and reported that the resident had MRSA in his sputum.

Review of Resident R2 (the roommate of Resident R1) clinical record revealed that the resident was admitted to the facility January 15, 2020, with the diagnoses including but not limited to Diabetes (the inability to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), and wounds to the right and left lower abdomen, and fungal dermatitis (red itchy swollen skin with small blisters) related morbid obesity.

Interview with Resident R2 on February 18, 2020, at 2:30 p.m. revealed that the resident was concerned that he was in the same room with Resident R1, because he had a infection and that he was a sick man. The resident was aware that his roommate had MRSA in his sputum. He kept the curtain closed to avoid being exposed, that he wanted to be sure he was not going to get sick. Review of an undated written statement from Resident R2 to the facility revealed " I [Resident R2], have some concern regarding my roommate and any infections that might harm myself. My roommate states that he has MRSA and I want to make sure that he doesn't get me infected. I just want to make sure I's safe in this room. Please let me know!!'

Interview with the Director of Nursing on February 18, 2020, 10:00 a.m., revealed that she instituted the contact isolation precautions of using gloves and a mask for care related to the diagnosis of a MRSA infection of the sputum. The most recent sputum culture January 2, 2020, confirmed that Resident R1, continued with MRSA of the sputum and that there was a heavy growth of Methicillin resistant organism, and that contact precautions are indicated.

The facility failed to provide a safe enviornment to prevent the transmission of MRSA and as indicated in the facility policy by placing Resident R1 with a diagnosis of MRSA in the same room with Resident R2 who did not have a MRSA or similar infection diagnosis and did have open abdominal wounds.

28 Pa. Code 211.109(d) Resident care policies.
Previously cited 5/24/19

28 Pa. Code 211.12(d)(5) Nusing services
Previously cited 6/29/18 &, 5/24/19

 Plan of Correction - To be completed: 04/18/2020

R2 was moved to a different room. The facility believed it was following the physician order of droplet precautions, as outlined in its droplet precaution policy and Centers for Disease Control guidelines for long term care facilities. R2 was not harmed. The physician discontinued the order for droplet precautions, as R1 has been treated for MRSA with antibiotic therapy.

All residents may be at risk for facility acquired infections without proper precautions in place. At this time, no other residents have been diagnosed with MRSA in the sputum.

Staff will be educated on droplet precautions and resident placement, using guidelines from the Centers for Disease Control.

Placement of any resident will be monitored, to ensure a resident is not being put at potential risk for contracting MRSA of the sputum. The administrator or designee will be responsible for conducting this audit, which will be done with each new admission, for a period of three months. Results of the monitoring will be taken to the quality assurance committee for follow up and recommendations.

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