Nursing Investigation Results -

Pennsylvania Department of Health
SHENANDOAH MANOR NSG CTR
Patient Care Inspection Results

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SHENANDOAH MANOR NSG CTR
Inspection Results For:

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SHENANDOAH MANOR NSG CTR - 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 December 10, 2021, it was determined that Shenandoah Manor Nursing Center was not in compliance with the following requirements of 42 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:


483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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.
§483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:


Based on review of clinical records and staff and resident interview, it was determined that the facility failed to incorporate preferred resident schedules into the residents' daily routine as evidenced by one of 19 sampled residents (Resident 58)

Findings include:

A review of Resident 58's clinical record revealed a significant change Minimum Data Set Assessment (MDS - federally mandated standardized assessment process conducted periodically to plan resident care) dated February 23, 2021 indicating that the resident's cognition was intact with a BIMS score of 15/15 and required extensive assistance of staff with activities of daily living for bathing.

A review of the resident's current plan of care initiated on November 11, 2020, and revised on February 24, 2021, revealed that the resident was to be bathed/showered on Mondays and Fridays, in the morning of the 7:00 am - 3:00 pm shift, and as needed, and required a total assist of 2 staff.

During an interview conducted with this Resident 58 on December 7, 2021, at 10:01 a.m. the resident was observed in bed. The resident stated that he has asked staff to provide him a shower on Mondays and Fridays around 9:00 AM. However, the resident stated that his preference for a shower on Monday and Friday mornings if often not accommodated. He stated that staff begin showers, by showering a female resident, and then bring in another female resident into the shower room, to begin her shower, while finishing up the first female resident because there is only one shower room on the side of the facility on which he resides. The resident stated that as a result of that practice his showers are frequently delayed until the afternoon hours.

Review of Resident 58's clinical record revealed that during October 2021, Resident 58 received 9 scheduled showers, and of the 9 showers provided, 5 were not provided until after 1:00 PM.

Review of Resident 58's clinical record revealed that during the month of November 2021, Resident 58 received 9 showers, and of the 9 showers 5 were not provided until after 12:00 PM.

Review of Resident 58's clinical record revealed that during December 2021, through the time of the survey ending December 10, 2021, Resident 58 was showered twice and one of the two showers was not provided until after 2 PM..

Interview with the Director of Nursing on December 11, 2021, at 2:30 PM, confirmed that the facility was not consistently accommodating resident's scheduling preference for showers during the morning hours.




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

28 Pa. Code 201.29(j) Resident rights


















 Plan of Correction - To be completed: 01/25/2022

Resident 58 is getting his showers according to his preference.

Current residents bathing/shower preferences have been reviewed and their preferences are being met.

Appropriate nursing staff have been re-educated on the importance of following bathing/shower preferences. Bathing/showering documentation will be reviewed weekly to ensure preferences are being met.

The DON/Designee will audit bathing/shower times and preferences to ensure compliance. Findings of the audits will be reviewed at QA meetings for review and recommendation.

483.80 (h)(1)-(6) REQUIREMENT COVID-19 Testing-Residents & Staff: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 (h) COVID-19 Testing. The LTC facility must test residents and facility staff, including
individuals providing services under arrangement and volunteers, for COVID-19. At a minimum,
for all residents and facility staff, including individuals providing services under arrangement
and volunteers, the LTC facility must:

§483.80 (h)((1) Conduct testing based on parameters set forth by the Secretary, including but not
limited to:
(i) Testing frequency;
(ii) The identification of any individual specified in this paragraph diagnosed with
COVID-19 in the facility;
(iii) The identification of any individual specified in this paragraph with symptoms
consistent with COVID-19 or with known or suspected exposure to COVID-19;
(iv) The criteria for conducting testing of asymptomatic individuals specified in this
paragraph, such as the positivity rate of COVID-19 in a county;
(v) The response time for test results; and
(vi) Other factors specified by the Secretary that help identify and prevent the
transmission of COVID-19.

§483.80 (h)((2) Conduct testing in a manner that is consistent with current standards of practice for
conducting COVID-19 tests;

§483.80 (h)((3) For each instance of testing:
(i) Document that testing was completed and the results of each staff test; and
(ii) Document in the resident records that testing was offered, completed (as appropriate
to the resident’s testing status), and the results of each test.

§483.80 (h)((4) Upon the identification of an individual specified in this paragraph with symptoms
consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the
transmission of COVID-19.

§483.80 (h)((5) Have procedures for addressing residents and staff, including individuals providing
services under arrangement and volunteers, who refuse testing or are unable to be tested.

§483.80 (h)((6) When necessary, such as in emergencies due to testing supply shortages, contact state
and local health departments to assist in testing efforts, such as obtaining testing supplies or
processing test results.
Observations:

Based on a review of clinical records, the facility's COVID-19 testing policy, and standards established by the Centers for Medicare & Medicaid Services, and staff interview, it was determined the facility failed to timely conduct testing of four residents exhibiting signs and symptoms of COVID-19 out of 19 sampled residents (Resident 18, Resident 33, Resident 71, and Resident 82).

Findings include:

According to the Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group QSO-Memo - 20-38-NH initially dated August 26, 2020 and revised on September 10, 2021, indicated that residents either vaccinated or unvaccinated who exhibit signs and symptoms of COVID-19 must be tested for COVID-19.

Review of a facility policy entitled "COVID-19 Testing and Vaccination of Residents and HCP (Health Care Personnel) that was revised on October 7, 2021, indicated that anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible and/or immediately test any resident or HCP (health care provider) who subsequently develops fevers or symptoms consistent with COVID-19.

A review of Resident 18's clinical record revealed nursing documentation dated August 25, 2021, at 9:36 PM that Resident 18 refused her shower and stated, "I have a cold and I'm hoarse and I don't want to get sicker." Staff noted that the resident's vital signs were all within normal limits.

Nursing Progress Notes dated September 6, 2021, at 10:05 PM, revealed that Resident 18 had a dry, forceful cough without expectoration and noted that it was similar to "hacking" that occurs with choking. Nursing noted that after coughing, the resident holds her chest and takes deep breaths. Resident stated that she does not feel well at all. The resident was noted to be afebrile and appeared to be fatigued per the RN's documentation. A rapid COVID-19 swab was obtained, and results were negative.

On September 22, 2021, nursing noted that the resident continued with a harsh cough and a new order was noted for Robitussin (cough med).

Further review of Resident 18's clinical record failed to reveal she was timely tested for COVID-19 when initially presenting with possible symptoms on August 25, 2021, as stated in the facility's policy and guidelines.

Review of Resident 33's clinical record revealed nursing documentation on December 3, 2021, that the resident had presented with a cough, congestion, postnasal drip, and sore throat with NON (new orders noted) for Robitussin Peak Cold DM Syrup (cough medicine) 10 ml by mouth every 6 hours for cough/congestion for 7 days and orders were obtained for Azithromycin (an antibiotic) 250 mg (milligram) one tablet by mouth for cough for five days.

Further review of Resident 33's clinical record failed to reveal she was tested for COVID-19 when presenting with potential symptoms, as stated in the facility's policy and guidelines.

Review of Resident 71's clinical record revealed nursing documentation on November 27, 2021, that the resident presented with head congestion and a dry cough with NON (new orders noted) for Mucinex DM Tablet Extended Release 12 Hour 30-600, give 1 tablet by mouth every 12 hours as needed for cough or congestion for ten days.

Review of Resident 71's clinical record failed to reveal she was tested for COVID-19 when presenting with potential symptoms, as stated in the facility's policy and guidelines.

Resident 82's clinical record revealed nursing documentation dated June 20, 2021, that the resident had a temperature of 101.4 degrees and was medicated with Tylenol as ordered.

Resident 82's clinical record failed to reveal she was tested for COVID-19 when presenting with a potential symptom, as stated in the facility's policy and guidelines.

During interview with the Director of Nursing (DON) conducted on December 7, 2021, at 11:24 AM, indicated that a COVID-19 PCR test [Polymerase chain reaction (PCR) is a laboratory technique that use primers that match a segment of the virus's genetic material] should be performed anytime a resident has complaints of symptoms or presents with COVID-19 symptoms such as cough, congestion (cold-like symptoms), and fatigue. Additionally, the DON confirmed that residents who present with signs and symptoms of COVID-19 should be tested for COVID-19 immediately.

Interview with the facility's Infection Preventionist, a RN (registered nurse), that was conducted on December 8, 2021, at 10:30 AM, indicated that it was up to the doctor to determine if a resident warranted COVID-19 testing, despite the facility's policy and current COVID test guidelines as per Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group.

Interview with Nursing Home Administrator (NHA) on December 8, 2021, at approximately 1:30 PM, confirmed these residents should have been tested for COVID-19 when their symptoms presented.




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

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

28 Pa. Code: 211.12 (c) Nursing services.

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



 Plan of Correction - To be completed: 01/25/2022

Resident 18, 33, 71, and 82 have been tested for Covid-19.

Current residents that are exhibiting symptoms have been tested for Covid-19.

Appropriate staff will be re-educated on the importance of testing residents who are exhibiting Covid-19 symptoms. Staff have been assigned to monitor daily documentation to ensure those that have exhibited symptoms have been tested.

DON/Designee will audit documentation, and speak with resident, to ensure all symptomatic residents have been tested.

483.20(g) REQUIREMENT Accuracy of Assessments: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.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on a review of clinical records and the Resident Assessment Instrument and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two residents out of 19 sampled (Residents 17 and 25).

Findings include:

Resident 17 had a physician order initially dated July 26, 2019, for a geri lounger, which was not a restraint for the resident according to the clinical record documentation.

MDS assessments dated July 18, 2021 (quarterly) and annual of May 3, 2021 both indicated that the resident did not utilize a restraint.

However, a review of Resident 17's quarterly MDS Assessment dated October 13, 2021, revealed in Section P0100 Physical Restraints Section G it indicated that Resident 17 had a chair that prevented rising. Resident 17's October 13, 2021, MDS assessment was inaccurate with respect to restraint use.

Review of Resident 25's clinical record, revealed that since the resident's admission on May 23, 2018, the resident's height was documented as 60 inches

Resident 25's Quarterly MDS assessments of August 4, 2021 and May 9, 2021 and significant change MDS of January 18, 2021, all indicated that Resident 25's height was 60 inches.

A review of Resident 25's quarterly MDS Assessment dated April 5, 2021, revealed in Section K0200 Height and Weight Section A Height that the resident's height was 66 inches.

Resident 25's quarterly MDS assessment dated April 5, 2021, was inaccurate.

Interview with the Director of Nursing on December 9, 2021 at 12:30 p.m. she confirmed the MDS errors.



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

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





 Plan of Correction - To be completed: 01/25/2022

Resident 17 and 25 MDS's were corrected to accurately reflect their status.

Current resident MDS's will be reviewed to ensure accurate reflection of status. Any coding errors will immediately be corrected.

Appropriate staff will be re-educated on the importance of the accurate assessments. The RNAC staff will be checking MDS daily for accuracy.

DON/Designee will audit MDS's for accuracy. Findings of the audits will be reviewed at the facilities QA meeting for review and recommendation.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:


Based on a review of clinical records and the facility's antibiotic stewardship program policy and staff interview it was determined the facility failed to implement its protocol for antibiotic use and failed to monitor actual antibiotic use for one resident out of 19 sampled (Resident 46).

Findings:

A review of the facility policy entitled: Antibiotic Stewardship (ASP) Program last reviewed January 2021 indicated an ASP will be an on-going and systematic effort to optimize the appropriate use of antibiotic medications, improve resident outcomes, reduce microbial resistance and decrease the spread of infections caused by multidrug- resistant organisms. Additionally, the policy indicates the medical director will be accountable for overseeing adherence to antibiotic prescribing practices for all clinical providers credentialed to deliver care and the facility will utilize infection criteria established by the Pennsylvania Safety Reporting System to evaluate symptoms to determine infections for Urinary Tract, Respiratory Tract, Gastrointestinal, Skin and Soft Tissue and Device- Related Bloodstream infections.

Review of Resident 46's clinical record revealed a progress note dated November 23, 2021, at 6:49 PM noting that the resident had increased confusion. The physician was made aware and a new order was received to obtain and urinalysis (UA- is a test or your urine used to detect and manage a wide range of disorders such as urinary tract infections) and a Culture & Sensitivity ( Culture- identification of microorganisms in a clinical a specimen [as in a sample of blood, cerebrospinal fluid, sputum or urine] and Sensitivity- a determination of the antibiotic, antifungal, or antiviral drugs that effectively kill them).

A progress note dated November 29, 2021, at 4:27 PM indicated that the physician was made aware of the urine culture results and a new order was received to begin Nitrofurantoin (an antibiotic) 100 mg BID (two times a day) for 7 days for a UTI (Urinary Tract Infection).

A physician order was noted, dated November 29, 2021, at 4:29 PM, for Nitrofurantoin Macrocrystal Capsule 100mg, give 100 mg by mouth two times a day for UTI for 7 days until finished.

This physician order was subsequently discontinued on November 29, 2021, at 4:31 PM .

A progress note dated November 29, 2021, at 7:44 PM indicated that the resident's Responsible Party was made aware of antibiotic ordered for UTI. The progress note indicated that the RP did not want the antibiotic stated until she checked with Resident 46's urologist in the morning. The physician was made aware and the antibiotic to be administered (Nitrofurantoin 100 mg) was held.

A progress note dated November 30, 2021, at 6:00 AM indicated that the resident received the first dose of Keflex ( an antibiotic) for UTI.

A physician order was noted on November 30, 2021 at 7:46 AM, Keflex (Cephalexin [an antibiotic]) , give 250 mg by mouth every 8 hours for a UTI until December 6, 2021, at 11:59 PM was ordered.

Interview with the Director of Nursing on December 9, 2021 indicated that the facility utilizes Loeb's Criteria (Loeb criteria are meant to be a minimum set of signs and symptoms which, when met indicate that the resident likely has and infection and that an antibiotic might be indicated) to determine if the resident meets criteria for a urinary tract infection. The policy indicated that the facility will utilize infection criteria established by the Pennsylvania Safety Reporting System.

The facility provided a form entitled "Urinary Tract Infection Worksheet, Asymptomatic bacteremia urinary tract infection- (ABUTI) to determine if criteria were met.

Review of the form filled entitled: " Urinary Tract Infection Worksheet, Asymptomatic bacteremia urinary tract infection- (ABUTI)" dated November 29, 2021, for Resident 46, revealed a note written indicating the resident's RP insisted that Resident 46 be treated with Keflex. Further review of this form indicated in order to be treated for an asymptomatic urinary tract infection both criteria 1 (in a voided urine with greater than 100, 000 cfu/ml of no more than 2 species of microorganisms) and criteria 2 (a positive blood culture with one matching organism in the urine culture) There was no indication that the resident met criteria for treatment with an antibiotic based on the facility's criteria.

Review of the urine culture resulted date of November 29, 2021, revealed the urine obtained via clean catch and was noted to have 10,000 to 100,000 cfu/ml (colony forming units/milliliter) with a bacteria identified as enterococcus species, therefore criteria 1 was not met.

Review of the clinical record failed to reveal a blood culture being performed as indicated on the form entitled, ""Urinary Tract Infection Worksheet, Asymptomatic bacteremia urinary tract infection- (ABUTI)"

Review of the November 2021 and December 2021 Medication Administration Record revealed Resident 46 received Keflex 250 mg, give 250 mg by mouth every 8 hours for UTI until December 6, 2021 at 11:59 PM, and received a total of 20 doses.

Review of the sensitivity report failed to reveal the antibiotic administered to the resident was effective against the organism identified.

Interview with the Director of Nursing on December 10, 2021, at approximately 2:00 PM confirmed that the facility failed to implement its Antibiotic Stewardship Program.




28 Pa. Code 211.10 (a)(c)(d) Resident Care Policies


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






















 Plan of Correction - To be completed: 01/25/2022

Resident 46 medications/treatments have been reviewed. Resident antibiotic therapy completed at this time.

Current resident's medications/treatments have been reviewed and criteria designated by the antibiotic stewardship program have been implemented and verified as following current policy.

Appropriate staff will be re-educated on antibiotic stewardship program and criteria utilized for identification of infection/need for initiation of antibiotic therapy.

DON/Designee will audit residents that are prescribed antibiotic therapy to ensure that proper criteria has been followed as designated in antibiotic stewardship program.


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