Nursing Investigation Results -

Pennsylvania Department of Health
MARKLEY REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MARKLEY REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:
There are 63 surveys for this facility. Please select a date to view the survey results.

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MARKLEY REHABILITATION AND HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health on Novemeber 19, 2021 and completed on December 6, 2021. It was determined the Markley Rehabilitation and Healthcare Center was not in compliance with 42 CFR 483.73 related to E-0024(b)(6)

Plan of Correction:

Initial comments:

Based on the findings of a COVID-19 Focused Infection Control Survey and two Abbreviated Complaint Surveys, completed on December 6, 2021 at Markley Rehabilitation and Healthcare Center, it was determined that Markley Rehabilitation and Healthcare Center was not in compliance with 42CFR Part 483, Subpart B Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensing Regulations as they relate to the Health portion of the survey process and has not implemented the CMS and Center for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

Plan of Correction:

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 the review of clinical records and interviews with staff, it was determined that the facility failed to ensure physician's orders related to a dermatologist consultation for one of 24 residents reviewed (Resident R1 and R2).

Findings include:

Review of the resident's interdisciplinary notes indicated that Resident R1 was admitted into the facility on May 14, 2021.

Review of the resident's Quarterly Minimum Data Set Assessment (MDS-an assessment of resident care needs) dated August 16, 2021, indicated that the resident was alert and oriented.

During an interview with Resident R1 on November 22, 2021 at approximately 11:00 a.m. Resident R1 reported that she requested to see the nurse practitioner due to what she described as "cysts" that were near her vagina area. Resident R1 also reported that the cysts were painful.

Review of a nurse practitioner clinical note dated August 27, 2021 indicated that Resident R1 was seen by the nurse practitioner for "follow up chronic pain."

Review of the August 27, 2021 clinical note also documented, "Patient requesting dermatology consult for hx (history) of suppurative hidradenitis (a long-term skin condition characterized by painful bumps under the skin that usually occurs in the armpits, groin, buttocks or breasts), patient reports she has an active lesion which has required lancing in the past. Patient irritable but cooperative."

During a conference call with Employee E3 (Nurse Practitioner) on November 22, 2021 at approximately 3:31 p.m. Employee E3 reported that she had a visit with Resident R1 on August 27, 2021. Employee E3 stated that after speaking with Resident R1 regarding her concerns, she wrote a consultation for the resident to be seen by the dermatologist due to the resident's concern that she had cysts near her groin area during the visit. Employee E3 reported that the resident did not allow her to examine the area during the visit that she expressed concern.

Review of the physician orders for November 2021 indicated a physician's order dated August 27, 2021 for a consultation with a dermatologist, "dermatology consult eval &treat Dx: hx of hidradenitis suppurativa."

Review of the resident's clinical record did not show evidence that an appointment was made for the physician's order related to the dermatology consultation that was ordered on August 27, 2021.

During a discussion with the Nursing Home Administrator and the Regional Nurse on November 22, 2021 at approximately 4:15 p.m. it was reported that there was no documentation showing evidence that Resident R1 was seen by the dermatologist, as ordered.

28 Pa. Code 211.5(f) Clinical records

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

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

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

Plan of Correction - To be completed: 12/27/2021

This plan of correction constitutes the facility's written allegation for the deficiencies cited. The submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the department's inspection report.

1. R# 1 had a skin assessment completed on 11/22/21 and did not require any intervention or physician notification at the time of the assessment. Skin unremarkable. A dermatology consult was completed on 11/29/21.
2. Current residents orders will be reviewed to determine if any dermatology consult that have been ordered have not been completed. Follow up will occur based on the findings of this review.
3. Licensed nurses and Social Services will be educated by the Director of Nursing / designee on the facility policy for follow up / communication when a dermatology consult has been ordered.
4. Physician orders will be audited during the clinical meeting by the Director of Nursing / designee to ensure dermatology consults that have been ordered are scheduled for completion. Audits will be conducted weekly for 4 weeks and then monthly for 2 months. Findings of the audits will be submitted to the monthly QAPI committee for review.
5. DOC 12/27/2021

483.50(a)(1)(i) REQUIREMENT Laboratory Services:

§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to obtained laboratory services as ordered by the physician for one of 24 clinical records reviewed. (Resident R2)

Findings obtained:

Review of Resident R2's clinical record revealed the resident was admitted on September 15, 2021 diagnosed with Diabetes Mellitus (body cannot produce insulin) hypertensive (high blood pressure), abnormal gait and mobility and needed assistance with personal care.

Review of Resident R2's October 28, 2021 Admissions MDS indicated that the resident was alert and oriented and was continent of bowel and bladder.

Review of Resident R2's interdisciplinary notes dated November 12, 2021 indicated the resident complained of frequency and burning with urination and appeared cloudy with odor. A physician's order was obtained for a STAT(immediate) Urinalysis and culture and sensitivity test (a urine culture can detect bacteria; a culture tells what type of bacteria and susceptibility tells what antibiotic is used to treat the infection), a Complete Blood Count with differential (looks for infections/illnesses in your blood) Thyroid-Stimulating Hormone (to test the thyroid function) and a Basic Metabolic Panel (provides information about sugar (glucose), calcium levels, kidney function and fluid balance).

Further review of the nursing progress notes did not reveal complaints of urinary pain and discomfort until Resident R2 was found on the floor, confused on November 15, 2021. The progress note stated the resident's urine was "foul smelling" and the resident complained about "Burning and frequency with urination." The same note indicated the resident's vital signs were "Hypertensive" documentated at 208/101 (normal blood pressure is 120/80), the heart rate was 101 (high), the temperature was 99.9 degrees, with complaints of nausea and was sent 911 to the hospital.

Review of Resident R2's hospital records stated, "Patient has clear evidence of UTI (Urinary tract infection) and was given intravenous ceftriaxone (an antibiotic)."

Further review of the November 12, 2021 STAT Urinalysis revealed the culture and sensitivity results were not found. Interview with the Director of Nursing on November 19, 2021 at 3:22 p.m. confirmed the culture and sensitivity test were not completed as ordered.

28 Pa. Code 211.5(f) Clinical records

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

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

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

Plan of Correction - To be completed: 12/27/2021

1. R# 2 had a culture and sensitivity completed at the hospital on 12/2/2021
2. An audit will be completed by the Director of Nursing / designee of the past 2 weeks of physician orders to ensure that orders for a urine with culture and sensitivity have had both completed. Follow up will occur based on the audits.
3. Licensed Nurses will be educated on follow up for obtaining urine cultures and sensitivity including completion of the laboratory requisition forms by the director of nursing / designee.
4. The Director of Nursing / designee will audit orders for urines with culture and sensitivity during the clinical meeting to ensure both have been completed. The audits will be conducted weekly for 4 weeks and then monthly for 2 months. Findings of the audits will be submitted to the monthly QAPI committee for review.
5. DOC 12/27/2021

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

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

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

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

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

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

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

Observations:

document the administration of a medications and treatments ordered by the physician for 15 of 24 resident records reviewed (Resident R1, R2, R4, R5, R7, R9, R10, R11, R12, R13, R15, R16, R17, R18 and R19).

Findings include:

Review of the Electronic Medication Administration Record (EMAR) on November 8, 2021 during the 3 p.m. to 11:00 p.m. shift for Resident R1, R2, R4, R5, R7, R9, R10, R11, R12, R13, R15, R16, R17, R18 and R19 revealed that medications were not documented as administered by Registered Nurse (RN) Employee E15.

Facility documentation revealed a letter dated November 20, 2021 signed by the RN stating that on November 8, 2021 during the 3-11 shift, "All meds and care were completed and given."

The Director of Nursing on November 20, 2021 at 3:00 p.m. confirmed the RN administered the medications as ordered but failed to document that they were administered.

28 Pa. Code 211.5(f) Clinical records

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

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

Plan of Correction - To be completed: 12/27/2021

1. Statement obtained by Employee # 15 that she did administer the ordered medications including controlled substances which were signed for.
2. Capable residents were interviewed on unit 2C. All denied any concerns related to not receiving medications.
3. Licensed Nurses will be educated by the Director of Nursing / designee on medication administration including documentation of medication administered.
4. Audits of medication administration documentation will be completed by the Director of Nursing / designee at the clinical meeting to ensure completion. The audits will be conducted weekly for 4 weeks and then monthly for 2 months. Findings of the audits will be submitted to the monthly QAPI committee for review.
5. DOC 12/27/2021

483.80(b)(1)-(4)(c) REQUIREMENT Infection Preventionist Qualifications/Role:

§483.80(b) Infection preventionist
The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP. The IP must:

§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;

§483.80(b)(2) Be qualified by education, training, experience or certification;

§483.80(b)(3) Work at least part-time at the facility; and

§483.80(b)(4) Have completed specialized training in infection prevention and control.

§483.80 (c) IP participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of the facility's policies, as well as staff interviews, it was determined that the facility failed to ensure that the designated Infection Preventionist completed specialized training in infection prevention and control.

Findings include:

Review of the facility's policy titled, "Infection Preventionist" not dated, stated, "The Infection Preventionist (IP - an expert on practical methods of preventing and controlling the spread of infectious diseases) is responsible for coordinating the implementation and updating of our established infection prevention and control policies and practices. It further stated, "The IP shall keep abreast of changes in infection prevention and control guidelines and regulations to ensure our facility's protocols remain current and aid in preventing and controlling the spread of infections.

Interview with the Director of Nursing (DON) on November 19, 2021 at 1:39 p.m. revealed that the facility's previous Infection Preventionist/DON resigned and following her departure, the Director of Nursing assumed the duties of the IP. The DON confirmed that she had not completed the required IP specialized training and education course and was not certified.

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

28 Pa. Code 211.10(d) Resident care policies

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

Plan of Correction - To be completed: 12/27/2021

1. All residents had the potential to be affected.
2. The Assistant Director of Nursing and facility designated IP completed her certification on 11/26/2021
3. The Director of Nursing will be educated to ensure the designated IP has completed their certification prior to the assignment of that role.
4. The NHA / designee will audit for any staff changes that would require a change in the IP and ensure that the person assigned has their certification. Audits will be conducted weekly x 4 then monthly x 2. Findings of the audits will be submitted to the monthly QAPI
5. DOC 12/27/2021

§ 211.12(i) LICENSURE Nursing services.:

(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.

Observations:

Based on a review of nursing staffing schedules and staff interviews, it was determined that the facility failed to comply with the State minimum requirement of nursing care hours.

Findings include:

A review of the facility's nursing staffing schedules dated November 1, 2021, through November 18, 2021 revealed that one of the eighteen days reviewed were below 2.7 hours of direct resident care, the State minimum requirement. Nursing staffing schedules dated November 6, 2021, revealed direct resident care hours of 2.33.

An interview with the Administrator on December 6, 2021, at 11:04 a.m., verified the nursing staff and their hours worked on November 6, 2021 and confirmed the nursing care hours were below the State minimum requirements.

Plan of Correction - To be completed: 12/27/2021

1. All residents had the potential to be affected.
2. The facility will review the scheduling process & make any changes as needed to ensure required PPD is met.
3. The scheduler and nursing supervisors will be educated by the Director of Nursing / designee on ensuring that the PPD is at the required hours and communicating call outs that may result in a decrease in the PPD.
4. The NHA / scheduler and designees will have staffing meetings and complete audits to ensure the facility is meeting the required PPD. The audits will be conducted weekly times 4 weeks and then monthly for 2 months. Findings of the audits will be submitted to the monthly QAPI committee for review.
5. DOC 12/27/2021

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