Nursing Investigation Results -

Pennsylvania Department of Health
RIVERSTREET MANOR
Patient Care Inspection Results

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

There are  101 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
RIVERSTREET MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on November 19, 2021, it was determined that Riverstreet 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:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:


Based on a review of clinical records and select incident reports, observations and staff interviews it was determined that the facility failed to timely review and revise measures to promote healing and prevent worsening of a pressure sore for one of seven residents reviewed (Resident 77).

Findings:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of Resident 77's clinical record revealed admission to the facility on June 23, 2020, with diagnoses to include diabetes, iron deficiency, low back pain and multiple sclerosis (unpredictable disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body).

A review of the Resident 77's A quarterly Minimum Data Set (MDS) assessment dated May 2, 2021, (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident had a BIMS (brief interview mental screening tool) score of 14, which indicated that the resident was cognitively intact, required extensive assistance with bed mobility, transfer, dressing, toilet use, eating, limited assistance with personal hygiene, and was identified as being at risk for developing pressure areas. The resident had functional limitation in range of motion in his upper and lower extremity, with impairment on both sides.

A review of Resident 77's care plan and interventions/tasks (a tool used by staff to direct the care needed for the specific resident) indicated that interventions were in place to prevent pressure sore development that included the use of a moisture barrier to buttocks and perineal area every shift and as needed (PRN), pressure reducing cushion on chair, pressure reducing device while in bed, turning and repositioning, house lotion to all extremities and torso twice daily with AM and PM care, and to keep heels elevated off bed with pillow.

Review of Resident 77's Braden Scale Assessment (a standardized, evidence -based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) dated June 14, 2021, revealed that the resident scored a 14 (total score of 13-14 indicates the resident was at MODERATE RISK). Facility was unable to provide a prior Braden Scale Assessment from the time period requested from February 2021 to June 2021, which identifed the resident's risk score.

Nursing noted on June 14, 2021, that the resident was found to have new pressure area to right buttock measuring 1.5 cm x 1.2 cm x 0.1 cm; granulating tissue noted to wound bed, scant serous drainage noted to brief. Wound edges defined with some noted maceration to surrounding skin. Call was placed to Dr. aware of new area and new order received, call placed to resident's daughter and responsible party (RP) who is aware and agreeable to interventions and new orders.

A review of a facility provided incident report dated June 14, 2021 at 8:31 PM revealed that the resident had developed a Stage II pressure sore to the right buttocks, described as 1.5 cm x 1.2 x 0.1 cm (L-Length, W-Width, D - Depth, cm - centimeter - (a unit of length). The area has granulation tissue (new connective tissue) in the wound bed, with scant drainage.

The resident's family, dietary, therapy and physician were made aware with new orders obtained - cleanse right buttock wound with normal saline solution (NSS), pat dry and apply Dermasyn and cover with a Comfort Foam Boarder Dressing daily.

A review of a facility provided "Skin Integrity Report", revealed that on June 14, 2021, a stage 2, pressure ulcer was identified on Resident 77's right buttocks and measured 1.5 cm (L) X 1.2 cm (W) X 0.1 cm (D) (L-Length, W-Width, D - Depth, cm - centimeter - (a unit of length). The wound appearance is granulation, has serous drainage, the wounds surrounding tissue is macerated tissue (white, wrinkly, and soggy), without odor.

The TAR for the month of July 2021, revealed physician orders cleanse right buttock wound with normal saline solution (NSS), pat dry and apply Calcium Alginate and cover with a boarder gauze, change every evening shift, every day, which wa discontinued on July 6, 2021

A review of the "Skin Integrity Report", indicated that on July 6, and 13, 2021, the right buttock pressure sore was resolved.

On July 19, 2021, physician orders were noted for Collagenase Ointment, apply to left buttock topically every evening shift for wound care cleanse Stage 2 to left buttock with normal saline, pat to dry, apply santyl, cover with bordered dressing, which was discontinued on July 27, 2021.

A further review of the "Skin Integrity Report", indicated on July 20, 2021, the right buttock pressure sore reopened and was a Stage II pressure sore measuring 3.0 cm (L) X 2.5 cm (W) X 0.1 cm (D). The wound appearance was 100 % epithelial tissue (thin, continuous, protective layer of compactly packed cells), has serous drainage, the wounds surrounding tissue is macerated, without odor.

On July 27, 2021, physician orders to cleanse Stage II to left buttock with wound cleanser, pat to dry, apply hydrogel, cover with bordered dressing every evening shift.

A review of a "Skin Integrity Report", dated August 10, 2021, indicated that the right buttock pressure sore increased in size and measured 3.5 cm (L) X 4.0 cm (W) X 0.1 cm (D). The wound appearance was 30% slough (a white or yellow covering on the base of the wound), 60 % granular, and 10 % sk, no drainage, the wounds surrounding tissue is healthy, without odor.

A further review of a "Skin Integrity Report", dated August 31, 2021, indicated the right buttock pressure sore measured 4.7 cm (L) X 3.0 cm (W) X 0.4 cm (D). The wound appearance was red, and granular, scant bloody drainage, the wounds surrounding tissue was healthy, without odor.

A review of a "Skin Integrity Report", dated September 28, 2021, indicated the right buttock pressure sore had increased in size measured 6.0 cm (L) X 5.0 cm (W) X 0.2 cm (D). The wound appearance was red, and granular, with no drainage, the wounds surrounding tissue was healthy, without odor.

The "Skin Integrity Report", dated October 12, 2021, indicated that the night buttock pressure sore measured 5.0 cm (L) X 5.0 cm (W) X 0.1 cm (D). The wound appearance was granular, with no drainage, the wounds surrounding tissue is healthy, without odor.

A review of the TAR's for the month(s) of August 2021, September 2021, October 2021, and November 2021, revealed that the physician orders to cleanse Stage 2 to left buttock with wound cleanser, pat to dry, apply hydrogel, cover with bordered dressing every evening shift.
On November 3, 2021, this was discontinued, and a new order was received to cleanse Stage 2 to right buttock with wound cleanser, pat to dry, apply hydrogel, cover with bordered dressing every evening shift.

A review of a "Skin Integrity Report", dated November 16, 2021, indicated the right buttock pressure sore measured 4.0 cm (L) X 4.0 cm (W) X 0.2 cm (D). The wound appearance was 10 % slough, 90 % granular, with serous drainage, the wounds surrounding tissue is healthy, without odor.

Following surveyor inquiry during the survey ending November 19, 2021, regarding the healing progress of the resident's pressure sore with the current treatment of (hydrogel) for 5 months, from July 27, 2021, to November 18, 2021, with minimal healing of the pressure sore, the physician orders were changed on November 18, 2021, to cleanse the Stage II right buttock wound with NSS, pat dry, apply maxsorb, and cover with a border gauze. change every evening shift.

An observation on November 18, 2021, at approximately 11:35 AM, in the presence of Employee 2, Licensed Practical Nurse, of the right buttock wound, revealed a yellowish/tan saturated dressing without odor. The wound bed appeared red and white.

Interview on November 18, 2021, at approximately 1:50 PM, the Director of Nursing (DON) confirmed that the facility failed to accurately identify the correct location of the wound, on the monthly TARs for 5 consecutive months (July 19, 2021, - November 3, 2021), documenting left rather than right buttock wound and that the facility failed to timely evaluate and revise measures to promote healing and or prevent worsening of a pressure sore.


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

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

28 Pa. Code 211.5(f) Clinical records.



 Plan of Correction - To be completed: 01/04/2022

-Location of the pressure area on Resident 77 has been correctly identified on the Treatment Administration Record. Resident 77 is now being followed by a wound care physician. Current treatment and preventative measures were reviewed/revised.

-Locations of pressure areas on current residents will be reviewed on Treatment Administration Record for accuracy. Current residents with pressure areas will have their current treatments and preventative measures reviewed/revised and changes will be made as appropriate.

-Nurse Practice Educator/Designee will re-Inservice Nursing Staff on Pressure Ulcer/Skin Breakdown Clinical Protocol.

-Director of Nursing/Designee will complete weekly audits on residents with pressure areas to ensure the location of area is accurate on the Treatment Administration Record, and to ensure treatments/preventative measures are appropriate.

-Results of the audits will be presented at the monthly Quality Assurance Performance Improvement Meetings for review and/or recommendations.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on a review of clinical records and select facility policy, and staff interview, it was determined that the facility failed to attempt gradual dose reductions of psychoactive medications for two out of 7 sampled (Residents 17, and 42).

Findings include:

Review of the facility policy entitled, "Medication Management", reviewed by the facility May 1, 2021, indicated that if a resident is receiving psychopharmacologic medication, the facility attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated.

According to the 2019 American Geriatrics Society (AGS) BEERS Criteria contain six tables: Potentially inappropriate medications (PIMs) in older adults, drug-disease or drug-syndrome interactions that may exacerbate the disease or syndrome, drugs to be used with caution in older adults, drug-drug interactions that should be avoided in older adults, medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults, and drugs with a strong anticholinergic properties.

Clinical record review revealed that Resident 17 was admitted to the facility on August 21, 2019, with diagnosis of paranoid schizophrenia, and depression. The resident had a physician's order dated August 21, 2019 for Wellbutrin (antidepressant) 100 milligrams (mg) by mouth three times a day for depression, an order dated August 22, 2019, for Zoloft (Selective Serotonin Reuptake Inhibitor that treats depression) 100 mg by mouth one time a day for depression, and a physician's order dated December 7, 2019 for Abilify (Antipsychotic that treats schizophrenia) 30 mg by mouth one time a day for schizophrenia.

As of November 19, 2021, there were no changes made to the dosages of these medications.

Interview with Director of Nursing on November 19, 2021 at 10:30 a.m. confirmed that no attempts of a gradual dose reduction of Wellbutrin, Zoloft and Abilify had been made in the last year.

A review of Resident 42's clinical record revealed the resident was admitted to the facility on June 19, 2018, with diagnoses which have included Alzheimer's (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), Dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), chronic kidney disease, anxiety, and major depressive disorder.

Physician's orders initially dated May 22, 2020, were noted for Resident 10 to receive Zyprexa (Olanzapine, Antipsychotic medication) tablet 5 milligram (MG), give 1 tablet by mouth (PO) one time a day related to Dementia without behavioral disturbance, and on January 13, 2021, a physician order for Ativan (An antianxiety medication) tablet 0.5 MG, give 0.25 mg PO three times a day for anxiety. The resident continued to receive the same dosages of the psychoactive medications at the time of the survey ending November 19, 2021, without evidence of any attempts at a gradual dose reduction since initially ordered.

Interview with Director of Nursing (DON), on November 18, 2021 at approximately 1:20 PM, confirmed that a GDR had not attempted of either the Antipsychotic (Zyprexa), and or the Antianxiety (Ativan), medication for Resident 42 since initially ordered.

Refer F756



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

28 Pa. Code 211.12 (c)(3)(5) Nursing services

28 Pa. Code 211.5 (f)(g)(h) Clinical records

28 Pa. Code 211.2(a) Physician services







 Plan of Correction - To be completed: 01/04/2022

-Psychotropic medications for Resident 17 have been reviewed by the physician and supportive documentation has been provided as to why a Gradual Dose Reduction is contraindicated. Resident 42 has had her psychotropic medications reviewed and a Gradual Dose Reduction has been initiated.

-Current residents receiving psychotropic medications will be reviewed and a Gradual Dose Reduction will be initiated if applicable or documentation from the physician will be provided if a Gradual Dose Reduction is contraindicated.

-Nurse Practice Educator/Designee will re-Inservice Consultant Pharmacists, Nursing Staff, and Physicians on Medication Management with a focus on Gradual Dose Reductions.

-Director of Nursing/Designee will complete a monthly audit on random residents receiving psychotropic medications to ensure a Gradual Dose Reduction has been completed or appropriate documentation is present if the Gradual Dose Reduction is contraindicated.

-Results of the audits will be presented at the monthly Quality Assurance Performance Improvement Meetings for review and/or recommendations.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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.
483.45(c) Drug Regimen Review.
483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

483.45(c)(2) This review must include a review of the resident's medical chart.

483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on a review of clinical records, facility provided documents and select facility policy, and staff interview it was determined that the pharmacist failed to identify irregularities in the drug regimen of two residents out of 22 sampled residents (Residents 17 and 42).

Findings include:

Review of the facility policy entitled, "Medication Management", reviewed by the facility May 1, 2021, indicated that if a resident is receiving psychopharmacologic medication, the facility attempt a gradual dose reduction (GDR) in two separate quarters (with at least one month between the attempts) within the first year, unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated.

According to the 2019 American Geriatrics Society (AGS) BEERS Criteria contain six tables: Potentially inappropriate medications (PIMs) in older adults, drug-disease or drug-syndrome interactions that may exacerbate the disease or syndrome, drugs to be used with caution in older adults, drug-drug interactions that should be avoided in older adults, medications that should be avoided or have their dosage reduced with varying levels of kidney function in older adults, and drugs with a strong anticholinergic properties.

Clinical record review revealed that Resident 17 was admitted to the facility on August 21, 2019, with diagnosis of paranoid schizophrenia, and depression. The resident had a physician's order dated August 21, 2019 for Wellbutrin (antidepressant) 100 milligrams (mg) by mouth three times a day for depression, an order dated August 22, 2019, for Zoloft (Selective Serotonin Reuptake Inhibitor that treats depression) 100 mg by mouth one time a day for depression, and a physician's order dated December 7, 2019 for Abilify (Antipsychotic that treats schizophrenia) 30 mg by mouth one time a day for schizophrenia.

As of November 19, 2021, there were no changes made to the dosages of these medications and no evidence that the pharmacist had identified the lack of a gradual dose reduction attempt of any of the three psychoactive medications above in the past year.

There also was no indication that pharmacist identified the duplicate drug therapy for depression and the lack of physician documentation to clinically justify the resident's need for both medications for treatment of depression.

Interview with Director of Nursing on November 19, 2021 at 10:30 a.m. that the pharmacist failed to identify the lack of a gradual dose reduction for Resident 17 for the Wellbutrin, Zoloft and Abilify and lack of physician documentation of the clinical justification for duplicate drug therapy for depression.

A review of Resident 42's clinical record revealed the resident was admitted to the facility on June 19, 2018, with diagnoses which have included Alzheimer's (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), Dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), chronic kidney disease, anxiety, and major depressive disorder.

Physician's orders initially dated May 22, 2020, were noted for Resident 42 to receive Zyprexa (Olanzapine, Antipsychotic medication) tablet 5 milligram (MG), give 1 tablet by mouth (PO) one time a day related to Dementia without behavioral disturbance, and on January 13, 2021, a physician order for Ativan (An antianxiety medication) tablet 0.5 MG, give 0.25 mg PO three times a day for anxiety. The resident continued to receive the same dosages of the psychoactive medications at the time of the survey ending November 19, 2021, without evidence of any attempts at a gradual dose reduction since initially ordered.

A review of monthly pharmacy drug regimen reviews from February 2021 through November 2021, revealed that a review had been conducted during Feburary 2021, and the remaining monthly drug regimen reviews failed to identify the lack of a gradual dose reduction of the above psychoactive medications prescribed for Resident

Interview with Director of Nursing (DON), on November 18, 2021 at approximately 1:20 PM, confirmed that a GDR had not been attempted of either the Antipsychotic (Zyprexa), and or the Antianxiety (Ativan), medication for Resident 42 since initially ordered and the pharmacisit had not identified that irregularity in the resident's drug regimen.

Refer F758


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

28 Pa. Code 211.12 (c)(3)(5) Nursing services

28 Pa. Code 211.5 (f)(g)(h) Clinical records

28 Pa. Code 211.2(a) Physician services






 Plan of Correction - To be completed: 01/04/2022

-Psychotropic medications for Resident 17 & 42 have been reviewed by consultant pharmacist. Recommendations have been made and reviewed by the Physician.

-Current residents receiving psychotropic medications will be reviewed by consultant pharmacist and recommendations will be reviewed by the Physician.

-Nurse Practice Educator/Designee will re-Inservice Consultant Pharmacists on Medication Regimen Review Policy and Procedure.

-Director of Nursing/Designee will complete a monthly audit on random residents receiving psychotropic medications to ensure a drug regimen review is completed with recommendations as needed.

-Results of the audits will be presented at the monthly Quality Assurance Performance Improvement Meetings for review and/or recommendations.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(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 a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to consistently monitor residents' nutritional parameters, timely act upon significant weight changes and assess residents' nutritional status and planned regimens for appropriateness in maintaining adequate nutritional parameters for five residents out seven sampled (Residents 8, 95, 11, 20, 53)


Findings include:

Review of the facility Weights and Heights Policy dated May 1, 2021, indicated that residents are weighed upon admission and/or readmission, then weekly for four weeks, and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary team.

Review of facility Weight Procedure Policy dated May 1, 2021, indicated that a licensed nurse or designee will weigh the patient. If the body weight is not as expected re-weigh the patient. Significant weight changes (5% in one month or 10% in 6 months) will be reviewed by the licensed nurse for assessment. The licensed nurse will notify the physician and dietitian of significant weight changes. The licensed nurse will document the notification of the physician and dietitian in the electronic record weight change progress note. The licensed nurse will notify the physician of the dietitian recommendations. If the physician does not implement the dietitian recommendations, the licensed nurse will document the physician's refusal. The interdisciplinary care plan will be updated to reflect the individualized goals and approaches for managing the weight change.

Review of Resident 8's clinical record revealed the resident had a diagnosis of Alzheimer's disease. A review of the resident's weight record revealed the following recorded weights:
February 3, 2021 107.2 lbs
March 8, 2021 108.2 lbs
April 6, 2021 106.8 lbs
May 13, 2021 104 lbs
June 17, 2021 104.6 lbs
July 23, 2021 101.2 lbs
August 5, 2021 98 lbs
September 8, 2021 99.6 lbs

A nutritional evaluation dated November 11, 2021 noted that Resident 8 had a Body Mass Index (BMI- measure that uses height and weight to determine if at a healthy weight) of 15.1 and was underweight. It was noted that the resident's most recent weight was September 8, 2021. The resident's nutrition problem was identified as being underweight. Interventions planned included weights as ordered. The resident's goal was to consume appropriate amounts of food and fluids to maintain nutritional status and to not experience a significant change in weight through next review. Recommendations were for the resident to receive a regular puree diet, fortified cereal with breakfast and dinner, house supplement three times daily between meals, and juice shake twice daily with lunch and dinner. The plan to follow and monitor the resident as needed was also noted.

Further review of the clinical record and facility weight book revealed no documented evidence that the resident had been weighed during the month of October 2021.

Review of the facility weight book for the month of November revealed that Resident 8 was assigned to be weighed on November 3, 2021. However, there was no documented evidence that the resident had been weighed.

Interview with employee 1 (LPN) on November 17, 2021 at 1:30 PM confirmed there was no documented evidence that Resident 8's October 2021 weight was obtained. Employee confirmed that Resident 8's November weight was scheduled for November 3, 2021, but was unable to provided documented evidence it was completed.

A weight was obtained on November 17, 2021 after surveyor inquiry and documented as 96.2 lbs which reflected a 3.4 lb or 3.4% weight loss since September 8, 2021.

Interview with the director of nursing on November 18, 2021 at 8:30 AM confirmed that Resident 8 was to be weighed monthly to monitor and promote maintenance of the resident's nutritional parameters and to prevent further weight loss to the extent possible and confirmed that the facility had failed to do so.

Review of Resident 95's clinical record revealed the resident had a diagnosis of Alzheimer's disease. A review of the resident's weight record revealed the following recorded weights:

March 5, 2021 107.8 Lbs
April 2, 2021 106.0 Lbs
May 31, 2021 103.0 Lbs
June 18, 2021 105.0 Lbs
July 30, 2021 104.2 Lbs
August 20, 2021 106.0 Lbs

Further review of the clinical record and facility weight book revealed no documented evidence that the resident had been weighed during October 2021 or November 2021 as of November 18, 2021.

Interview with the Director of Nursing on November 18, 2021 at 9:45 a.m. confirmed that Resident 95 was to be weighed monthly and that there were no weights documented for October 2021 or November 2021 as of November 18, 2021.

Review of Resident 11's clinical record revealed the resident was admitted to the facility on June 10, 2021 and had diagnosis of diabetes and dementia. A review of the resident's weight record revealed the following recorded weights:

June 10, 2021 191.8 Lbs
June 22, 2021 190.9 Lbs
July 9, 2021 174.2 Lbs17.6 lbs 9.17% significant weight loss
July 21, 2021 173.2 Lbs
September 2, 2021 179.0 Lbs
August 19, 2021 181.2 Lbs9/2/2021 14:51 staff Correction
September 11, 2021 177.0 Lbs
October 7, 2021 190.0 Lbs
November 3, 2021 176.0 Lbs

There was no indication in this resident's clinical record that the facility identified the resident's weight loss on July 9, 2021, until a nutritional note on July 22, 2021, which indicated that the resident had a weight loss in one month. The note indicated that the resident's weight loss was discussed with the resident at this time (July 22, 2021) and the resident does not want additional nutrition provided at, or between meals, at this time. The entry also indicated that the resident's weekly weight will be monitored.

There was no documentation that the facility had obtained weekly weights as per the nutritional note on July 22, 2021. An October 7, 2021 weight indicated the resident was 190.0 pounds, with no reweight to verify the weight gain.

Interview with the Director of Nursing on November 18, 2021 at 9:45 a.m. confirmed that Resident 11 had a significant weight loss on July 9, 2021, which was not recognized until the nutritional note on July 22, 2021. The DON was unable to provide evidence that the physician or responsible party were notified of the weight loss. The DON also verified that the weight of 190 pounds on October 7, 2021 was not confirmed by a reweight.

Review of Resident 20's clinical record revealed the resident was admitted to the facility on August 23, 2021 and had diagnoses which included diabetes mellitus.

A review of the resident's weight record revealed that Resident 20 weighed 124.5 lbs on October 21, 2021. On November 14, 2021 the resident weighed 144.6 lbs, which was reflective of a 20.1 lb or 13.9% significant weight gain in one month.

Further review of the clinical record revealed no documented evidence that a reweigh was obtained based on the significant weight change. There was no documented evidence that the physician or dietitian were notified of the significant weight gain for clinical assessment.

Interview with the director of nursing (DON) on November 18, 2021 at 8:30 AM confirmed that a reweigh was not completed based on the significant weight gain. The DON failed to provide documented evidence the physician or dietitian were notified of the significant weight gain.

Review of Resident 53's clinical record revealed the resident had a diagnosis of cerebral infarction (stroke).

A review of the resident's weight record revealed that Resident 53 weighed 118.2 lbs on October 9, 2021. On November 9, 2021 the resident weighed 131 lbs which was reflective of a 12.8 lb or 9.7 % significant weight gain in one month.

Further review of the clinical record revealed no documented evidence that a reweigh was obtained based on the significant weight change. There was no documented evidence that the physician or dietitian were notified of the significant weight gain for clinical assessment.

Interview with the director of nursing (DON) on November 18, 2021 at 8:30 AM confirmed that a reweigh was not completed based on the significant weight gain. The DON failed to provide documented evidence the physician or dietitian were notified of the significant weight gain.



28 Pa Code 211.6(c)(d) Dietary services.

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

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





 Plan of Correction - To be completed: 01/04/2022

-Resident 8, 11, 20, 53, and 95 have been weighed and significant loss/gain verified by a reweight. If a significant loss/gain noted then the Physician, Dietician, and Resident/Responsible Party will be notified.

-Current residents with orders to be weighed will have weight completed. If a significant loss/gain noted then the Physician, Dietician, and resident/Responsible Party will be notified.

-Nurse Practice Educator/Designee will re-Inservice nursing staff on Weight and Height Policy and Weight Procedure.

-Director of Nursing/Designee will complete a weekly audit on random residents being weighed to ensure weight is being completed and follow up is occurring if significant loss/gain has been identified.

-Results of the audits will be presented at the monthly Quality Assurance Performance Improvement Meetings for review and/or recommendations.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to consistently provide restorative nursing services to maintain mobility of two of eight sampled residents (Residents 17 and 75).

Findings include:

Clinical record review revealed that Resident 17 was admitted to the facility on August 21, 2019, with diagnoses of diabetes and fracture of the right humerus.

The resident was on a Restorative Nursing Program (RNP) from May 20, 2021 for active range of motion (AROM) to bilateral upper extremities (BUE) and bilateral lower extremities (BLE) 3 sets of 10 reps in all planes twice daily, Put on right hand/wrist splint at 10AM off at 8 PM, splint can be adjusted for comfort and removed for hygiene, inspect skin after taking off, and resident is to be seated in wheelchair sinkside and provide grooming tools, allow resident to perform grooming tasks and provided assistance as needed twice daily.

Review of Tracking of the RNP for the AROM from August 1, 2021 to October 31, 2021 revealed no evidence that it was completed 6 occassions. Staff documented that the program was not applicable on 24 occassions during August 2021, not completed on four occassions and not applicable on 11 occassions during September 2021, and not completed on three occassions during October 2021.

Review of Tracking of the RNP for the splint from August 1, 2021 to November 17, 2021, revealed no documented evidence that the program was completed on six occassions and staff noted that the program was not applicable once during August 2021. During September 2021, there was no documented evidence that staff completed the program on four occassions during and on three occassions during October 2021.

Review of Tracking of the RNP for the ADLs from August 1, 2021 to November 17, 2021 revealed no documented evidence that staff completed the program on six occassions during August 2021, four occassions during September 2021, on three occassions during October 2021.

Clinical record review revealed that Resident 75 was admitted to the facility on June 18, 2021 with diagnosis of dementia, and fracture of the right hip.

The resident was on a Restorative Nursing Program from July 13, 2021 for passive range of motion (PROM) to bilateral lower extremities twice daily.

Review of Tracking of the RNP for the PROM from July 13, 2021 to the time of the survey ending November 19, 2021, indicated that the program was discontinued on September 9, 2021.

A restorative note on September 9, 2021, indicated that the RNP was reviewed, the resident was participating in program, and meeting goals. The note indicated that the program remained appropriate, and the plan "Will continue current program." There was no documented evidence why the program was discontinued on September 9, 2021.

Interview with the Director of Nursing on November 18, 2021 at 11:15 a.m. was unable to explain why Resident 75's RNP program was discontinued and verified that the facility failed to consistently provide the planned RNP programs to Resident 17.


28 Pa. Code: 211.5(f) Clinical records

28 Pa Code 211.12 (a)(c)(d)(5) Nursing services





 Plan of Correction - To be completed: 01/04/2022

-Resident 17 will have the restorative nursing programs for Active Range of Motion and Passive Range of Motion reviewed and revised as appropriate. Resident 75 is being evaluated by therapy to see if the restorative nursing program for Passive Range of Motion should be reinstated.

-Current residents with a restorative nursing program for Active Range of Motion and/or Passive Range of Motion will be reviewed and revised as appropriate.

-Nurse Practice Educator/Designee will re-Inservice nursing staff on the Restorative Nursing Policy and Process for Documentation in Point of Care.

-Director of Nursing/Designee complete a weekly audit on random residents ordered a restorative nursing program for Active Range of Motion and/or Passive Range of Motion to ensure the program is implemented and documented accurately.

- Results of the audits will be presented at the monthly Quality Assurance Performance Improvement Meetings for review and/or recommendations.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely consult with the physician and notify the resident and/or resident's representative of a change in condition, a significant weight loss, for two residents out of 22 sampled residents (Residents 31 and 62).

Findings include:

The facility policy "Weight Procedure" last reviewed by the facility on May 1, 2021, indicated that the licensed nurse will review significant weight change as defined as 5% in one month and 10% in six months, will notify the physician, and dietician of significant weight changes, document notification in point click care, and will notify the family/health care decision maker of the the weight change and document family notification.

A review of Resident 31's clinical record revealed admission to the facility October 17, 2020, with diagnoses to include diabetes, protein-calorie malnutrition and gastro-esophageal reflux disease (GERD).

Resident 31's clinical record reflected a primary representative (responsible party and emergency contact #1) as the resident's spouse.

A continued review of the resident's clinical record weight record revealed the following recorded weights:

January 7, 2021 (3:06 PM) - 132.2 Lbs
January 9, 2021 (1:57 PM) - 135.0 Lbs
February 9, 2021 (2:23 PM) - 135.6 Lbs
March 9, 2021 (12:51 PM) - 123.6 Lbs weight loss (8.85 %) in 30 days.
April 16, 2021 (2:50 PM) - 120.8 Lbs weight loss (10.91 %) in 66 days.

Resident 31 lost a total of 14.8 lbs. or 10.91 % of body weight in approximately two months, 66 days (February 9, 2021 to April 16, 2021).

There was no documented evidence that the facility had notified the physician and the resident resident and/or the resident's representative of the significant weight loss.

A review of the clinical record revealed that Resident 62 was admitted to the facility on October 8, 2021, with diagnoses to include an intestinal obstruction.

A review of the resident's weight record revealed the following recorded weights:

October 8, 2021- 182.6 Lbs
November 9, 2021 - 158.0 Lbs weight loss (13.4%) in 30 days.

Resident 62 lost a total of 24.6 lbs. or 13.4 % of body weight in 30 days (October 8, 2021 to November 9, 2021).

There was no documented evidence that the facility had notified the physician and resident, and/or the resident's representative of the significant unplanned weight loss.

Interview with the Director of Nursing (DON) on November 18, 2021, at approximately 1:20 p.m., confirmed the facility was unable to provide documented evidence that the physician and the resident's representative were notified of the significant unplanned weight loss.


28 Pa Code 211.12 (a)(c)(d)(3)(5) Nursing services

28 Pa Code 201.29(a)(l)(2) Resident rights









 Plan of Correction - To be completed: 01/04/2022

-The Physician, Resident and/or Responsible Party have been notified of significant weight loss for Residents 31 and 62.

-Current residents identified with a significant weight loss will have the Physician, Resident and/or Responsible Party notified.

-Nurse Practice Educator/Designee will re-Inservice Nursing Staff on Weight Procedure with focus on notification to the Physician, Resident, and/or Responsible Party for a significant weight loss.

-Director of Nursing/Designee will complete a weekly audit for any residents that trigger for a significant weight loss to ensure Physician, Resident and/or Responsible Party have been notified.

-Results of the audits will be presented at the monthly Quality Assurance Performance Improvement Meetings for review and/or recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on observations, review of clinical records and select facility policy and staff interviews it was determined that the facility failed to ensure the consistent implementation of infection control procedures designed to prevent the spread of infection during medication administration for one out of two residents sampled (Resident 6) and failed to assure resident surveillance of fever, respiratory illness, or other signs/symptoms of COVID-19 at least daily for residents to deter the spread of COVID-19 for two of five residents sampled, (Residents 296 and 297).

Findings include:

Review of facility policy entitled: "Administering Oral Medications", last reviewed by the facility on May 1, 2021, indicated that the purpose of this procedure was to provide guidelines for the safe administration of oral medications. The procedure for administering tablets or capsules from a bottle, was to pour the desired number into the bottle cap and transfer to the medication cup. Do not touch the medication with your hands. For unit dose tablets or capsules, place packaged medications directly into the medication cup.

Observation of medication administration pass beginning at approximately 8:20 AM, on November 17, 2021, revealed Employee 2, Licensed Practical Nurse, administering medications to Resident 6 on the Spruce hall.

Employee 2 was observed to use hand sanitizer, which was located on the top of the medication cart. After sanitizing his hands, however, Employee 2 then used the computer mouse, rearranged various items on the top of the medication cart, opened the medication cart drawer, rearranged the medication cards (blister packs) in time order and then removed medication cards for Resident 6. Employee 2 did not wash or sanitize his hands after these tasks.

Employee 2 removed (popped) the medications out of the medication cards (blister packs) and placed each medication (Eliquis, Gabapentin, Metformin, Magnesium, Jardiance, and Plavix) one at a time, in his bare hands. Employee 2 then placed each medication, one at a time, touching each medication, in a medication cup for administration to Resident 6.

After touching the medications, the nurse was observed touching various items on the medication cart (computer mouse, medication cart drawers, medication cart lock) and failed to wash or sanitize his hands before administering the medication to Resident 6.

Interview with Employee 2, LPN, on November 17, 2021 at approximately 8:40 AM, confirmed that he touched the resident's medications with bare hands and he had not adhered to infection control procedures during this medication pass.

Interview with the Director of Nursing (DON), on November 17, 2021 at approximately 1:15 PM, confirmed the facility had not adhered to infection control procedures during this medication pass.

A review of the Department of Health & Human Services Centers for Medicare & Medicaid Center for Clinical Standards and Quality/Survey & Certification Group: QSO-20-38-NH DATE: August 26, 2020 REVISED April 27, 2021 Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID19 Focused Survey Tool Memorandum Summary, CMS is committed to taking critical steps to ensure Americas healthcare facilities continue to respond effectively to the Coronavirus Disease 2019 (COVID-19) Public Health Emergency (PHE).

On August 25, 2020, CMS published an interim final rule with comment period (IFC). This rule establishes Long-Term Care (LTC) Facility Testing Requirements for Staff and Residents. Specifically, facilities are required to test residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19 based on parameters set forth by the HHS Secretary. This memorandum provides guidance for facilities to meet the new requirements.

Regardless of the frequency of testing being performed or the facility's COVID-19 status, the facility should continue to screen all staff (each shift), each resident (daily), and all persons entering the facility, such as vendors, volunteers, and visitors, for signs and symptoms of COVID-19.

Review of resident' clinical records revealed that upon admission a physician's order for "Daily Screening for COVID 19 Symptoms Observe for s/s of COVID 19: Document Temperature, Pulse, Respirations, O2 and document Y/N if new COVID 19 symptoms were noted. If new symptoms noted please proceed to notify physician and document COVID progress note specifying symptoms observed".

A review of the clinical record of Resident 296, conducted during the survey ending November 19, 2021, revealed admission to the facility on November 2, 2021, with diagnoses including pneumonia. Upon admission there was no physician order for daily COVID 19 screening and no documentation that daily screening including temperature, pulse, respirations and O2 had been completed since the resident's admission.

Clinical record review revealed that Resident 297 was admitted to the facility on November 9, 2021, with diagnoses including chronic obstructive pulmonary disease. Review of resident's clinical record revealed no physician order for daily COVID 19 screening and no documentation that daily screening including temperature, pulse, respirations and O2 were being completed since the resident's admission.

During interview on November 18, 2021, at 11:00 a.m. the director of nursing (DON)/infection preventionist confirmed that the facility was not documenting routine surveillance of fever, respiratory illness, or other signs/symptoms of COVID-19 at least daily for Residents 296 and 297.



28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services.

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




 Plan of Correction - To be completed: 01/04/2022

-Employee 2 has had a re-competency completed on Medication Administration/Administering Oral Medication with focus on infection control. Resident 296 has an order for daily screening for Covid-19 symptoms. Resident 297 has discharged from the facility.

-Current Licensed Nursing Staff will have a re-competency completed on Medication Administration/Administering Oral Medication with focus on Infection control. Current residents will be reviewed to ensure they have an order for daily screening for Covid-19 symptoms.

-Nurse Practice Educator/Designee will re-Inservice nursing staff on Medication Administration/Administering Oral Medication with focus on infection control. Nurse Practice Educator/Designee will re-Inservice Licensed Nursing Staff on Covid-19 Policy and Procedure with specific focus on screening for Covid-19 symptoms on all residents.

-Director of Nursing/Designee will complete weekly audits on random nurses to observe a medication pass to ensure infection control practices are being followed. Director of Nursing/Designee will complete weekly audits on random residents to ensure an order is present for screening signs/symptoms of Covid-19.

-Results of the audits will be presented at the monthly Quality Assurance Performance Improvement Meetings for review and/or recommendations.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations: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(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to timely provide the pneumococcal immunization as desired by two of 22 residents reviewed (Resident 35 and 196).

Findings include:

A review of the clinical record revealed that Resident 35 indicated that he was admitted to the facility on September 5, 2021. A consent form to receive the pneumococcal immunization was signed by the resident on admission on September 5, 2021, indicating that the resident agreed to receive the pneumococcal vaccine. There was no indication as of November 18, 2021, that the resident had received the pneumococcal vaccine or that it was medically contraindicated or the resident had already been immunized.

Review of the clinical record of Resident 196 indicated that he was admitted to the facility on November 4, 2021. A consent form for the pneumococcal immunization revealed that the resident gave verbal consent to receive the vaccine on admission on November 4, 2021, and agreed to receive the pneumococcal vaccine. There was no indication as of November 18, 2021, that the resident received the pneumococcal vaccine or that it was medically contraindicated or the resident has already been immunized.

Interview with the Director of Nursing on November 19, 2021, at approximately 10:30 a.m. she confirmed that Resident 35 and Resident 196 consented to receive the pneumococcal immunization on admission and neither received the immunization as of November 18, 2021.



28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services

28 Pa Code 201.29 (a) Resident rights




 Plan of Correction - To be completed: 01/04/2022

-Resident 35 has received the pneumococcal immunization. Resident 196 has been discharged.

-Current residents consenting to Influenza and/or Pneumococcal Immunization will receive the immunizations.

-Nurse Practice Educator/Designee will re-Inservice nursing staff on Influenza Vaccine and Pneumococcal Vaccine Policy.

-Director of Nursing/Designee will complete weekly audits on random residents to ensure influenza and/or pneumococcal immunizations are administered if consent has been received.

-Results of the audits will be presented at the monthly Quality Assurance Performance Improvement Meeting for review and/or recommendations.


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