Nursing Investigation Results -

Pennsylvania Department of Health
ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are  145 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.
ST. FRANCIS CENTER FOR REHABILITATION & HEALTHCARE - 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 and abbreviated survey as a result of an incident completed on January 28, 2020, it was determined that St. Francis Center for Rehabilitation and Healthcare was not in compliance with the 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 related to the Health portion of the survey process.






 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Findings include:

Review of facility policy, "Labeling and Dating", with an effective date of November 28, 2017, states all food items must be labeled with either a manufacturer label or handwritten label. Food items will be dated with compliance of the 72-hour rule and labeled with a "use on or by" date, and all bulk pre-packaged prepared items, i.e. mayonnaise, pickles, barbecue sauce, etc. well be marked with an "opened date and discarded per FDA regulations. Review of the policy, "Machine Warewashing and Sanitizing - High Temperature", revealed that the final rinse temperature was to be a minimum of 180 degrees Fahrenheit; and that if low temperature chemical sanitizing is used for a high temperature machine the minimum wash cycle temperature is 120 degrees Fahrenheit with 50 PPM (parts per million concentration level).

An initial tour of the Food Service Department was conducted on January 3, 2020 at 8:45 a.m. with Employee E4, Clinical Dietitian, which revealed the following:

Observations in the loading dock and receiving area revealed two 55-gallon drums containing used kitchen grease which were uncovered outside the receiving door. Further observations outside the receiving door revealed 15 used wooden pallets haphazardly scattered around the loading dock area, along with empty milk crates and refuse including paper, plastic and used latex gloves.

Observations inside the loading dock door revealed ceiling tiles with brownish stains in rings, a heavy buildup of dirt and dust on the blower above the loading dock door and dirt, dust, paper and silverware on the floor behind a dusty plexiglass guard in front of a compressor next to the loading dock door.

Observations in the dry storage room revealed cardboard boxes and cans sitting directly on the floor and propping the door open, and dust and dirt on the floors including a dark colored build-up of dust and dirt in the corners and around the legs of the storage shelving, and scratches and gouges in the drywall near the can racks, and boxes stacked less than the required 18" from sprinkler head and metal ductwork above the storage racks.

Observations inside the roll-in refrigerator revealed cans of soda and 4oz foiled covered juice cups on the floor. Observations inside the third walk-in refrigerator revealed two 5 # white plastic tubs of Glenview Farm cottage cheese which had expiration dates of December 19, 2019, a gallon jug of BBQ Sauce and gallon container of pickles with no date when they were opened. Observations inside the walk-in freezer revealed a box of frozen peas and a box of frozen turkey sausage links were open with the inner plastic bag open to the circulating air, and a plastic bag containing a white unidentified frozen substance which was undated and unlabeled.

Observations inside the convection oven revealed a heavy build-up of black burned-on food spillage on the walls, racks and floor of the oven. Observations of the floors around the kitchen equipment revealed a build-up of dark stains around the legs and in the corners and also around the door openings of the walk-in coolers.

Observations in the dish room revealed a heavy blackish build-up of dark substance on the floors and a build-up of dust and dirt on the walls and ceiling, the floor had cracks and open areas and the painted walls inside and adjacent to the dish room had cracks and peeling paint.

Interview with Food Service Director (FSD) on January 3, 2020 at approximately 9:15 a.m. confirmed the above findings.

Observations during a follow-up visit to the kitchen on January 7, 2020 at approximately 9:50 a.m. revealed a final rinse temperature reading on the digital temperature display panel of the dish machine. Further observation revealed the dark brownish red dried, baked-on splattered food stains on the stainless-steel base and legs, and a whitish yellow build up on the galvanized steel undershelf of the prep table in the back of the kitchen near the steam kettle.

Interview with the Regional Food Service Director (RFSD) on January 7, 2020 at approximately 11:05 a.m. confirmed the above findings and also confirmed that the chemical sanitizer that was added to the dish machine due to not maintaining proper temperature was not properly sanitizing the dishes as noted when the FSD was observed testing the machine and could not obtain a reading using the chemical test kit. The RFSD also stated that lunch would be served on disposables due to the problems with the dish machine.

Observations during a follow-up visit to the kitchen on January 7, 2020 at approximately 12:55 p.m. revealed a dirty mop-sink in the chemical room which stained with a dark blackish build-up of dirt and grime, and the ceiling tiles were loose and missing along the back wall which contained copper pipes running up the wall into the ceiling creating an open access for pests to enter the kitchen. Further observation in the dish room revealed a crack in the welded dish table that was dripping a brown liquid down onto the top of the square box for the grease trap and piping and running across the floor into the central floor drain. Further observation revealed the repair technician from the chemical company was still working on the dish machine which showed 144 degrees Fahrenheit in the digital display and his portable temperature probe was reading 181 degrees Fahrenheit.

Interview with FSD and RFSD confirmed that the dish machine's internal temperature probe was faulty, and they had to physically/manually take the temperature with a probe until parts could be ordered, delivered and installed which they felt would take a few days.

The facility failed to store, prepare and serve food in accordance with professional standards for food service safety.

42 CFR 483.60(I)(1)(2) Food/Procure/Store/prepare/Serve-Sanitary
Previously cited 3/11/19

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 7/12/19, 3/11/19

28 Pa. Code 201.18(a)(b)(3) Management
Previously cited 3/11/19

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

28 Pa. Code 211.6(c) Dietary services






 Plan of Correction - To be completed: 03/24/2020

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.


Lids were provided for the 55-gallon drums. All other debris in the loading dock area was removed and discarded. Staff were in-serviced regarding proper maintenance of the loading dock area.

The ceiling tiles inside the loading dock door were replaced. Dusty and dirty areas were thoroughly cleaned.

The floor in the dry storage room was cleaned. Anything sitting directly on the floor was removed. Scratches and gouges in the drywall were repaired. Shelving was repositioned to ensure 18" clearance from
the sprinkler head and metal ductwork.

Items on the floor in the roll-in refrigerator had fallen from the storage racks and were immediately discarded. Outdated cottage cheese and items with missing open dates were also immediately discarded. Items in the freezer that were open to air were discarded. The unidentified substance was also discarded. All staff were in-serviced on proper labeling and dating and safe food storage.

The ovens were cleaned. The floor was detail cleaned around equipment legs, corners and door openings.

The dishroom was cleaned and painted prior to the conclusion of the survey.

The stainless steel base and legs of the dishmachine were cleaned. The prep table in the back of the kitchen near the steam kettle was also cleaned.

See POC under 0908.










The mop sink in the chemical room was immediately cleaned, ceiling tiles were set back into place.




The crack in the dish table has been sealed.














The internal temperature probe has been replaced and has confirmed that the rinse temperature does consistently reach 180 degrees or higher.


In addition to daily monitoring by the Food Service Director or designee the Food Service Director or Designee will conduct weekly audits for four weeks then monthly for the next three months to ensure compliance with storage of foods and sanitary conditions remain in compliance. Results will be forwarded to Quality Assurance and Performance Improvement Committee for review.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on observations and interviews with the Food and Nutrition staff, it was determined that the dishwasher was not maintained in proper working order to provide hot water sanitizing temperatures in the kitchen.

Findings include:

A review of the facility policy, Machine Warewashing and Sanitizing - High Temperature, revealed that the final rinse temperature was to be a minimum of 180 degrees Fahrenheit. Further review of the policy revealed that if low temperature chemical sanitizing is used for a high temperature machine the minimum wash cycle temperature is 120 degrees Fahrenheit with 50 PPM (parts per million concentration level).

The Food and Drug Administration Food Code 2017 specifies that in mechanical warewashing equipment the fresh hot water sanitizing rinse temperatures may not be less than 180 degrees Fahrenheit.

Observation of the dishwasher in operation, on January 7, 2020, at approximately 9:50 a.m. revealed the final rinse temperature was observed at 93 degrees Fahrenheit.

Interview with Employee E3, Food Service Director (FSD), on January 7, 2020, at approximately 9:55 a.m. confirmed that the dish washing machine was not up to temperature and that the chemical representative had been called in to repair the machine, stating that they had hard water and had recently replaced the internal temperature probes. The FSD also indicated that the machine was now operating with sanitizing chemical. When asked to see the log where they were recording the sanitizer concentration, he produced the temperature log which showed only wash and final rinse temperatures and there were multiple recordings where the final rinse was below the required 180 degrees Fahrenheit. When asked to test the sanitizer level the FSD unable to obtain a reading on his test kit.

Observation in the dish room on January 7, 2020, at approximately 11:05 a.m. revealed the SanTec representative, who was in to repair the dish machine, was unable to obtain a reading of the sanitizer level on the test paper. At this point Employee E5, the Regional Food Service Director, announced that they could not use the dishes that were just washed and to use paperware for the lunch meal.

Observation in the dish room, on January 7, 2020, at approximately 12:50 p.m. revealed the SanTec representative was holding a temperature prove in the rinse side to the dish machine and was able to get a reading of 181 degrees Fahrenheit.

Interview with the FSD on January 7, 2020, at approximately 12:55 p.m. confirmed that the tank temperature taken by the SanTec representative was not the same as the temperature reading on the dish machine control panel which was reading 144 degrees Fahrenheit.

The facility failed to maintain the dish machine in proper working order in order to monitor the final rinse temperature and ensure adequate sanitizing of dishware.

28 Pa. Code 201.18(b)(3) Management
Previously cited 3/11/19

28 Pa. Code 211.6(c) Dietary services





 Plan of Correction - To be completed: 03/24/2020

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

The machine temperature gauge was reading incorrectly and the repair technician was notified that the machine needed service. The repair technician had determined that the thermometer probe needed to be replaced, resulting in an incorrect temperature reading on the display. The repair technician was able to consistently get readings of 180 degrees or higher.

Attempts to test the level of the chemical sanitizer were unsuccessful because the high temperature within the machine was rendering the test strip ineffective.




















Until the cause of the difficulty in reading the test strips was determined the facility did run a paper service for the Noon meal.
Approximately two hours later we were able to obtain an accurate reading, within the presence of the surveyor, on the temperature within the rinse tank of 181 degrees.
This temperature did not match the display on the control panel as it had already been determined that the internal temperature probe was malfunctioning. The probe has since been replaced and the display consistently reads 180 degrees or higher.


All employees were in-serviced on the proper operation of the dish machine, including both high temperature and chemical sanitizing and accurate recording of temperature and sanitizer results.


Dish machine temperatures will be monitored daily by the Food Service Director or designee to ensure the dish machine is maintained in proper working order for adequate sanitizing of dishware.
Results will be forwarded to Quality Assurance and Performance Improvement Committee for review.

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 review of closed clinical records, facility documentation, and interview with staff, it was determined that the facility failed to ensure the accuracy of resident assessments for one of three closed clinical records reviewed (Residents R209).

Findings include:

Review of Resident R209's closed clinical record revealed that the resident was admitted to the facility on October 18, 2019 and was discharged from the facility to home on October 25, 2019.

A review the Discharge Minimum Data Set assessment (MDS -a comprehensive assessment of care needs) dated revealed that the resident discharge status was inaccurately coded. The discharged assessment indicated that that the resident was discharged to an "acute hospital" and not "home."

An interview conducted on January 8, 2019, at 10:30 a.m. with licensed nursing staff, Employee E7 confirmed that the facility failed to submit MDS information accurately for Resident R209.

The facility failed to ensure the accuracy of the MDS for Resident R209.

28 Pa. Code 211.5(f) Clinical records
Previously cited 7/12/19, 3/11/19








 Plan of Correction - To be completed: 03/24/2020

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident 209's MDS was corrected to reflect the resident's discharge status.
2. All MDS from January 1, 2020 were reviewed ensure the discharge status was correct. If the status was incorrect the MDS was corrected.
3. Nurses completing the MDS were educated on the importance of coding MDS correctly. The lead nurse overseeing the completion of MDSs will review MDS before transmitting to ensure the code status is correct.
4. Director of nursing or the designee will audit MDS discharge status to ensure coding is correct. The Audit will be conducted once a week for four weeks. The results of the audit will be reviewed at the Monthly QAPI meeting.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on observation, review of clinical records, and interviews with staff, it was determined that the facility failed to develop and implement person-centered plans of care that accurately reflected the resident's physical, medical and safety needs, for one of 44 resident records reviewed (Resident R258).

Findings include:

Review of an undated document from the Center for Disease Control (CDC) titled, "Neutropenia and Risk for Infection," defined neutropenia as a decrease in the number of white blood cells (WBC's-these cells are the body's main defense against infection), that neutropenia is a condition that is common after receiving chemotherapy (medications used to treat cancer), and increases a person's risk for developing infections. The CDC document suggested the following interventions to prevent infection when one is neutropenic including, but not limited to, use gloves for gardening (be cautious before coming in contact with live plants and flowers).

Review of facility policy, "Neutropenic Precautions," dated effective December 2018, revealed neutropenic precautions would be recommended for residents who have been deemed Immunodeficient (immunosuppression-a person's immune system has an inability to fight infectious diseases) by the resident's physician.

Review of manufacturer's information revealed that the prescription drug Zarxio is a medication that stimulates the growth of neutrophils (a type of white blood cell important in the body's fight against infections), and that some cancer treatments decrease white blood cells which can increase the risk of developing an infection. The manufacturer's information defined that a low level of neutrophils is known as neutropenia.

Review of the clinical record for Resident R258 revealed the resident was admitted to the facility on December 27, 2019, with diagnoses including, but not limited to non-Hodgkin's lymphoma (cancer of the lymphatic system-network of vessels that carry fluid to the heart) and leukopenia (condition where a person has a reduced number of WBC's-too few WBC's makes a person at higher risk for infection).

Review of a physician's order dated December 27, 2019, for Resident R258 instructed staff to maintain neutropenic precautions due to immunosuppression, and specified that no fresh flowers or fruit should be in the resident's room.

Review of a physician's clinical note dated December 31, 2019, indicated that Resident R258 was "presently on Neutropenic Precautions."

Observation on January 3, 2020, at approximately 11:17 a.m., revealed Resident R258's room had a sign posted on the door frame stating, "STOP NEUTROPENIC PRECAUTIONS... Visitors and Family - Follow Instructions Below... No FRESH FRUIT OR FLOWERS in room..." In addition, a cart was observed directly outside the resident's room containing face masks, gloves, yellow gowns and red trash bags (personal protective equipment and supplies used for residents who require isolation for infectious diseases). Continued observation revealed a green live houseplant was seen, with its roots submerged in a vase filled with water, inside the resident's room, located on a surface near the resident's bed.

Interview on January 3, 2020, at approximately 11:24 a.m., with Employee E7, Four Pavilion nursing unit manager, revealed that that the sign on Resident R258's door frame and cart outside of the resident's room were being implemented because the resident was on Neutropenic Precautions, stated that live plants are also included with the "no fresh flowers" instruction on the posted signage outside the resident's room, and confirmed the live houseplant should not have been in the resident's room due to Neutropenic Precautions.

Further review of the clinical record for Resident R258 on January 3, 2020, revealed no documentation that the resident's care plan included the necessity to maintain Neutropenic Precautions.

Further interview with Employee E7 on January 7, 2020, at approximately 11:28 a.m. confirmed on January 3, 2020, Resident R258's care plan did not include Neutropenic Precautions.

The facility failed to develop a comprehensive person-centered care plan to meet Resident R258's needs.

28 Pa. Code 211.11(a)(c) Resident care plan
Previously cited 07/12/19, 03/11/19

28 Pa. Code 211.11(b) Resident care plan

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 07/12/19, 03/11/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 03/11/19










 Plan of Correction - To be completed: 03/24/2020

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident R258's care plan was updated to include the infection control precautions.
2. Residents who have infection control precautions care plans were reviewed. If the infection control precautions were not identified on the care plan the care plan was updated.
3. The interdisciplinary team was in-serviced on the importance for updating care plans in a timely manner. During clinical meetings the Unit Managers or designee will work with the interdisciplinary team to update care plans timely.
4. Director of Nursing or designee will audit resident care plans who are on infection control precautions to ensure the care plans reflect the resident's current isolation status. The Audit will be conducted once a week for four weeks. The results of the audit will be reviewed at the Monthly QAPI meeting.

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 observations, interviews with staff and clinical record review, it was determined that the facility failed to follow physician's orders related to blood sugar checks, for three of 44 resident records reviewed (Residents R150, R180, and R64).

Findings include:

Review of the facility Policy and Procedures titled, "Obtaining Fingerstick Glucose Levels" effective date, November 2018, indicated, "Verify that there is a physician's order for this procedure."

A review of Resident R150's clinical record revealed that the resident was admitted to the facility on October 15, 2019, with diagnoses including diabetes (a disease that affects the way the body processes blood sugar (glucose)), coronary artery disease (damage or disease in the heart ' s major blood vessels) and end stage renal disease (when the gradual loss of kidney function reaches an advanced state).

A review of physician's orders dated October 22, 2019, revealed an order for blood glucose checks, two times a day, in the evening and night, if blood glucose is under 70 milligrams per deciliter or greater than 300 milligrams per deciliter notify the physician.

A review of blood glucose monitoring sheets for December 2019 and January 2020 revealed that on December 15, 2019 the resident's blood glucose was recorded as 390 milligrams per deciliter and on January 3, 2020 the resident ' s blood glucose was recorded as 352 milligrams per deciliter. There was no documentation available for review that the physician was notified on either of these dates as indicated in the physician's orders.

A review of Resident R180's clinical record revealed that the resident was admitted to the facility on March 14, 2019, with diagnoses including diabetes (a disease that affects the way the body processes blood sugar (glucose)) and hypertension (high blood pressure).

A review of physician's orders dated March 14, 2019, revealed an order for blood glucose checks, four times a day at 6:30 a.m., 11:00a.m., 4:30 pm and 9:00p.m., if blood glucose is under 80 milligrams per deciliter or greater than 300 milligrams per deciliter notify the physician.

A review of blood glucose monitoring sheets for November 2019 and December 2019 revealed that on November 3, 2019 the resident's blood glucose was recorded as 61 milligrams per deciliter, on November 9, 2019 the resident ' s blood glucose was recorded as 72 milligrams per deciliter, on November 14, 2019 the resident's blood glucose was recorded as 11 milligrams per deciliter, on December 9, 2019 the resident's blood glucose was recorded as 349 milligrams per deciliter. There was no documentation available for review that the physician was notified on any of these dates when the resident's blood glucose levels were under the parameter indicated int he physcian's orders.

An interview with licensed nursing staff, Employee E8, on January 6, 2020 at 11:20 a.m. confirmed that there was no documentation that the physician was notified.

A review of Resident R64's clinical record revealed that the resident was admitted to the facility on October 29, 2019, with diagnoses including diabetes (a disease that affects the way the body processes blood sugar (glucose)) and obesity.

A review of Resident R64's physician orders dated October 29, 2019, revealed an order for blood glucose checks, three times a day, in the morning, at noon and in the evening, if blood glucose is under 100 milligrams per deciliter or greater than 401 milligrams per deciliter to notify the physician.

A review of blood glucose monitoring sheets for December 2019 and January 2020 revealed that on December 9, 2019 the resident's blood glucose was recorded as 90 milligrams per deciliter. There was no documentation available for review that the physician was notified on this date of the resident blood glucose level.

An interview with the licensed nursing staff, Employee E6, on January 8, 2020 at 10:00 a.m. confirmed that there was no documentation that the physician was notified.

The facility failed to follow physician's orders for notifying the physician regarding blood glucose results for Resident R150, Resident 180, and Resident 64.

28 Pa. Code 211.12(1) Nursing services
Previously cited 7/12/19, 3/11/19

28 Pa. Code 211.12(2) Nursing services

28 Pa. Code 211.12(5) Nursing services
Previously cited 3/11/19








 Plan of Correction - To be completed: 03/24/2020

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident R150, R180, and R64 doctors were made are of the residents blood sugars that were out of range.
2. January 2020 Medication administration Records were reviewed for residents who are having their blood sugar taken. If there was a blood sugar out of range and the doctor was not made aware the clinical team promptly inform the doctor.
3. Nurses were in-serviced on the importance of informing the medical staff when a blood sugar is out of the prescribed range. During clinical rounds the unit manager or designee will review Medication Administration Records to ensure blood sugars out of the prescribed range is informed to the doctor.
4. Director of Nursing or designee will audit Medication Administration Records to ensure blood sugars out of the prescribed range is informed to the doctor. The Audit will be conducted once a week for four weeks. The results of the audit will be reviewed at the Monthly QAPI meeting.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of clinical records, facility documentation and staff interviews, it was determined that the facility failed to provide necessary staff supervision of a resident with known aggressive behaviors to prevent physical altercations with other residents for one of 44 residents reviewed. (Resident R25)

Findings include:

Review of Resident R25's clinical record revealed the resident was admitted to the facility on January 24, 2018, with a diagnosis to include traumatic brain injury (Brain dysfunction caused by an outside force, usually a violent blow to the head), cognitive communication deficit, alcohol abuse, extra pyramidal movement disorder, and anxiety disorder.

Review of the resident's care plan developed December 8, 2018 identified the resident at risk for harming himself or others related to impulsive behaviors. Interventions included to avoid confrontation with the resident during periods of aggressive behavior and re-approach later, engage assistance of co-workers or family that the resident responds well to during episodes of behaviors, if acting out against other, removed to a safe area, and encourage verbalization of feelings. Further review of the resident's care plan identified the resident as risk for changes in mood, related to anxiety, cognitive loss and diagnosis of traumatic brain injury. The interventions included but not limited to monitor behavior, assess for physical/environmental changes that may precipitate change in mood

Review of Resident R25's nurse note dated March 27, 2019, at 2:50 p.m. revealed that the "resident was anxious and agitated, entering other resident rooms and trying to chase after staff and swinging his hand. Resident went into another and hit him with a closed fist to the left side of his face while resident was in room in bed sleeping."

Review of Resident R25's nurse progress note dated April 24, 2019, revealed " Informed by nursing that resident [Resident R25] has been accused of going into another resident room [Resident R86], in his personal items kicking him and pushing him out of his bed according to the resident. Resident redirected for a short period of time."

Review of Resident R25's Januray 2020 physican's orders revealed that an order was obtained September 4, 2019 for the resident to be supervised/observation for aggressive behavior every shift.

Review of Resident R86's clinical record revealed a nurse progress note dated September 10, 2019, which revealed that "charge nurse notified this supervisor that [Resident R25] allegedly caused skin alteration to another resdient during altercation. [Resident] came into his room and attempted to hit him in the head but he moved and was poked in the arm with something in his hand a a pen or pencil. He was trying to hit me in the head but I moved and he got my arm."

Review of Resident R25's clinical record revealed a nurse progress note dated September 19, 2019, which revealed that " ... Resident was pacing, wandering, very agitated, as he walked past 2 different residents [Resident R20 and Resident R108], he randomly reached out and hit both resident in the neck "


The facility failed to provide necessary staff supervision of a resident with known aggressive behaviors to prevent physical altercations with other residents.


28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 7/12/19, 3/11/19

28 Pa. Code 201.18(b)(1) Management
Previously cited 7/12/19, 3/11/19

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 7/12/19, 3/11/19










 Plan of Correction - To be completed: 03/24/2020

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Resident 25 currently is utilizing the services of a staff member who closely monitors the residents movements to help him with his safety awareness.
2. A review of current facility census was conducted to identify any other resident who requires close monitoring due to aggressive behaviors. At this time no other resident was identified.
3. Clinical staff were educated on how to manage residents with aggressive behaviors to keep them and other residents safe. During routine clinical rounds the interdisciplinary team will monitor the safety of residents and provide interventions as required if aggressive behaviors are noted.
4. Director of Nursing or designee will audit reports of residents who are having aggressive behaviors to ensure the resident and other resident are kept safe. The Audit will be conducted once a week for four weeks. The results of the audit will be reviewed at the Monthly QAPI meeting.

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 observation, review of clinical records, facility policies and procedures, information from the Centers for Disease Control (CDC), drug manufacturer's information, and interviews with staff, it was determined that the facility failed to implement written standards for transmission-based precautions, for one of one resident in the facility on neutropenic precautions (Resident R258).

Findings include:

Review of an undated document from the CDC titled, "Neutropenia and Risk for Infection," defined neutropenia as a decrease in the number of white blood cells (WBC's-these cells are the body's main defense against infection), that neutropenia is a condition that is common after receiving chemotherapy (medications used to treat cancer), and increases a person's risk for developing infections. The CDC document suggested the following interventions to prevent infection when one is neutropenic including, but not limited to, use gloves for gardening (be cautious before coming in contact with live plants and flowers).

Review of facility policy, "Neutropenic Precautions," dated effective December 2018, revealed neutropenic precautions would be recommended for residents who have been deemed Immunodeficient (immunosuppression-a person's immune system has an inability to fight infectious diseases) by the resident's physician.

Review of manufacturer's information revealed that the prescritpion drug Zarxio is a medication that stimulates the growth of neutrophils (a type of white blood cell important in the body's fight against infections), and that some cancer treatments decrease white blood cells which can increase the risk of developing an infection. The manufacturer's information defined that a low level of neutrophils is known as neutropenia.

Review of the clinical record for Resident R258 revealed the resident was admitted to the facility on December 27, 2019, with diagnoses including, but not limited to, non-Hodgkin's lymphoma (cancer of the lymphatic system-network of vessels that carry fluid to the heart) and leukopenia (condition where a person has a reduced number of WBC's-too few WBC's makes a person at higher risk for infection).

Review of a physician's order dated December 27, 2019, for Resident R258 instructed staff to maintain Neutropenic Precautions due to immunosuppression, and specified that no fresh flowers or fruit should be in the resident's room.

Review of a physician's order dated December 28, 2019, for Resident R258 instructed staff to administer Zarxio 480 mcg / 0.8 mL (micrograms per milliliter), inject 0.8 mL (480 mcg) subcutaneously (SQ-injection under the skin but not into the muscle) every morning, for a diagnosis of non-Hodgkin's lymphoma.

Review of a physician's clinical note dated December 31, 2019, indicated that Resident R258 was, "presently on Neutropenic Precautions."

Observation on January 3, 2020, at approximately 11:17 a.m., revealed Resident R258's room had a sign posted on the door frame stating, "STOP NEUTROPENIC PRECAUTIONS... Visitors and Family - Follow Instructions Below... No FRESH FRUIT OR FLOWERS in room..." In addition, a cart was observed directly outside the resident's room containing face masks, gloves, yellow gowns and red trash bags (personal protective equipment and supplies used for residents who require isolation for infectious diseases). Continued observation revealed a live green houseplant, with its roots submerged in a vase filled with water, inside the resident's room, located on a surface near the resident's bed.

Interview on January 3, 2020, at approximately 11:24 a.m., with Employee E7, Four Pavilion nursing unit manager, revealed that that the sign on Resident R258's door frame and cart outside of the resident's room were being implemented because the resident was on Neutropenic Precautions, stated that live plants are also included with the "no fresh flowers" instruction on the posted signage outside the resident's room, and confirmed that the live houseplant should not have been in the resident's room due to Neutropenic Precautions.

The facility failed to establish and maintain an infection prevention and control program to help prevent the transmission of communicable disease and infection to one resident at high risk for development of infection.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 07/12/19, 03/11/19

28 Pa. Code 201.18(b)(1) Management
Previously cited 07/12/19, 03/11/19

28 Pa. Code 201.18(e)(1) Management
Previously cited 03/11/19

28 Pa. Code 201.20(c) Staff development

28 Pa. Code 211.10(d) Resident care policies
Previously cited 03/11/19

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 07/12/19, 03/11/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 03/11/19








 Plan of Correction - To be completed: 03/24/2020

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

1. Flowers were removed from the resident 258's room who was on neutropenic precautions.
2. A review of infection control precautions practices was conducted. All infection control precautions were being followed per policy.
3. The interdisciplinary team was educated on the facilities policy for Infection Prevention and Control Program. The infection preventionist or designee will oversee the Infection Prevention and Control Program routinely.
4. The Director of Nursing or designee will audit the infection prevention practices in the facility to ensure they are being implemented. The Audit will be conducted once a week for four weeks. The results of the audit will be reviewed at the Monthly QAPI meeting.



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