Nursing Investigation Results -

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

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SCENERY HILL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  51 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.
SCENERY HILL HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey, completed on January 17, 2020, it was determined that Scenery Hill Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.













 Plan of Correction:


483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders for the care of long-term intravenous catheters were followed for one of 28 residents reviewed (Resident 41).

Findings include:

Physician's orders for Resident 41, dated May 23, 2019, included an order for the resident's long-term intravenous (IV) catheter (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications) to be flushed with 10 cubic centimeters (cc's) of normal saline flush solution every shift for patency.

Resident 41's clinical record, including Medication Administration Records (MAR's) and Treatment Administration Records (TAR's), revealed no documented evidence that the long-term IV catheter was flushed during the day shift on May 27; June 6, 18 and 25; July 7, 9, 24 and 29; August 9 and 19; September 22 and 26; October 12, 17, 19 and 27; November 7; and December 22, 2019; during the evening shift on June 5, 6, 15 and 17; July 10; September 18; October 18; November 25 and 27; and December 11, 2019; and January 9 and 10, 2020; and during the night shift on June 24, 2019.

Interview with the Director of Nursing on January 16, 2020, at 3:36 p.m. confirmed that there was no documented evidence that Resident 41's long term IV catheter was flushed as ordered on the above dates and times and it should have been.

Physician's orders for Resident 41, dated May 24, 2019, included orders for staff to change the dressing and caps of the long-term IV catheter weekly; however, there was no documented evidence that the dressing and caps were changed weekly on July 26, October 4 and 18, November 8 and 15, and December 13, 2019.

Interview with the Director of Nursing on January 16, 2020, at 3:37 p.m. confirmed that there was no documented evidence that Resident 41's long term IV catheter dressing and caps were changed as ordered on the above dates and they should have been.

Physicians orders for Resident 41, dated May 24, 2019 included orders for staff to measure the upper arm circumference (in centimeters) of the long term IV catheter insertion site weekly and as needed and measure the length of the long-term IV catheter (in centimeters) from the insertion site to the port weekly and as needed.

Resident 41's clinical record, including MAR's and TAR's, revealed that Resident 41's arm circumference was documented as 35 cm, and the length of the catheter from the insertion site to the port was documented 5 cm on May 24, 2019. However, as of January 16, 2020, there was no documented evidence that these measurements were reassessed and recorded weekly as ordered by the physician.

Interview with the Director of Nursing on January 16, 2020, at 3:39 p.m. confirmed that there was no documented evidence that the results of the arm circumference or insertion site to port measurements were recorded in centimeters as ordered by the physician, and they should have been, in order to assess for potential migration of the catheter.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.





 Plan of Correction - To be completed: 03/11/2020

Director of Nursing reviewed Resident #41 Peripherally inserted central catheter line orders and added supplemental documentation area to (MAR) Medication Administration Record to ensure measurements are recorded.
Current residents with Peripherally inserted central catheter line orders were reviewed to assure orders being followed/documented.
Director of Nursing/designee will inservice licensed staff as well as newly hired nursing staff and agency staff on proper completion/documentation on Peripherally inserted central catheter line orders.
Director of Nursing/designee will audit Peripherally inserted central catheter line orders for measurements and flushes weekly x 4 weeks, then monthly x2, and Director of Nursing/designee will audit documentation of Peripherally inserted catheters to validate that circumference or insertion site to port measurements were recorded in centimeters in the electronic administration record. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.
483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
483.70(o) Hospice services.
483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in 418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at 483.24.
Observations:


Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 28 residents reviewed (Resident 36).

Findings include:

An agreement between the facility and a hospice provider (provider of end-of-life services), dated January 5, 2009, indicated that the hospice provider would provide the facility with sufficient information to ensure the provision of services under the agreement was in accordance with the hospice patient's plan of care, medication information, and hospice and attending physician orders.

Physician's orders and a care plan for Resident 36, dated December 30, 2019, and May 10, 2018, respectively, revealed that the resident was to receive hospice services from the facility's contracted hospice provider. As of January 17, 2020, there was no documented evidence in the resident's clinical record that information about the hospice visits were a part of the resident's clinical record.

Interview with Registered Nurse 4 on January 16, 2020, at 2:33 p.m. confirmed that the hospice notes and plan of care were to be kept in a binder or their paper chart. She was unable to locate the hospice documentation for Resident 36.

Interview with the Nursing Home Administrator on January 16, 2020, at 3:10 p.m. confirmed that as of that date, hospice records were not part of Resident 36's clinical record.

28 Pa. Code 211.5(f) Clinical records.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 03/11/2020

Hospice agency was immediately notified to deliver their hospice visits, care plan and all sufficient information on Resident # 36 and complied and added to the hospice binder
Current residents on hospice will be audited to validate that hospice notes are present within the facility
Education will be completed with the hospice companies on timely submission of resident documentation to the facility. Education will be completed by the Director of Nursing/designee.
Director of Nursing/designee will audit newly enrolled residents in hospice services to ensure documentation is received timely from hospice company and is part of resident record.


483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete dialysis communication forms for one of 28 residents reviewed (Resident 28).

Findings include:

The facility's written agreement for dialysis services (treatments to cleanse the blood when the kidneys do not function properly), dated November 26, 2001, indicated that the facility should provide relevant information to the dialysis clinic in a timely manner regarding the condition of the patient.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated November 9, 2019, revealed that the resident had renal (kidney) insufficiency and renal failure, and received dialysis treatment. Physician's orders, dated February 26, 2018, included that the resident was to receive dialysis treatments on Tuesdays, Thursdays, and Saturdays; and the resident's care plan, dated May 29, 2019, indicated that staff were to coordinate dialysis care with the dialysis treatment facility.

Review of Resident 28's dialysis communication forms for November 26, 2019, to Janaury 14, 2020, revealed that nineteen forms had incomplete vital signs, including temperature, heart rate, respirations and blood pressure, and incomplete information regarding the resident's access site, heart, lungs, skin and edema.

Interview with Registered Nurse 10 on Janaury 15, 2020, at 12:59 p.m. revealed that the night shift staff were to complete the dialysis communication forms for Resident 28 before he leaves for dialysis treatments.

Interview with the Director of Nursing on January 16, 2020, at 10:19 a.m. confirmed that there were nineteen incomplete dialysis communication records for Resident 28, and the forms should have been completed.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.






 Plan of Correction - To be completed: 03/11/2020

Facility cannot retroactively complete the dialysis communication forms for identified residents.
A clean copy of the dialysis communication form was obtained and implemented for Resident #28.
Director of Nursing/Designee will inservice Registered Nurses, new Registered Nurses and Agency Registered Nurses on need to complete Dialysis forms on current residents receiving Dialysis treatment and send communication form with them to dialysis appointments, and review upon return to facility that form was completed by dialysis and appropriate follow-up with any dialysis recommendations.
Director of Nursing/designee will audit Dialysis resident charts for form completion, 3x weekly x 4 weeks, then monthly x2 and results will be reviewed at with the Quality Assurance Performance committee meetings for further recommendations/needs until compliance is met



483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:


Based on the facility's housekeeping aide cleaning process, observations, and staff interviews, it was determined that the facility failed to ensure that housekeeping services were provided as necessary to maintain a sanitary, comfortable, and homelike interior for one of 28 residents reviewed (Resident 6).

Findings include:

The facility's housekeeping aide cleaning process, undated, revealed that housekeeping aides were to perform a daily 5-step resident room cleaning process, which included emptying the trash and spot cleaning the walls.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated October 22, 2019, revealed that the resident had unclear speech and was rarely understood, was usually able to understand others, was totally dependent upon staff for all daily care tasks, and was incontinent of bowel and bladder.

Observations in Resident 6's room on January 14, 2020, at 1:50 p.m.; January 15, 2020, at 2:22 p.m.; January 16, 2020, at 10:00 a.m.; and January 17, 2020, at 12:49 p.m. revealed that there was a dried, brown, smeared substance on the wall by the trash can that was approximately two inches long by one-quarter of an inch wide.

Interview with the Housekeeping Supervisor on January 17, 2020, at 12:49 p.m. confirmed the presence of the dried, brown substance on the wall in Resident 6's room and confirmed that the substance was in plain sight and should have been cleaned during the housekeeping staff's daily cleaning process.

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





 Plan of Correction - To be completed: 03/11/2020

Housekeeper immediately cleaned area of concern.
Housekeeping Supervisor checked other rooms for markings on wall at time of survey and found none.
Housekeeping Supervisor/Designee will inservice housekeepers on following the 5-step resident room cleaning process.
Housekeeping Supervisor/Designee will ensure process being followed with auditing 5 resident rooms 5 times per week x 2 weeks, then weekly x 2 weeks, then monthly x2 with results reviewed with Quality Assurance meetings for further recommendations/needs.

Housekeeping Supervisor/Designee will ensure process is being followed also through daily room monitoring 5 days per week for 1 month, thereafter, weekly for 4 weeks to ensure rooms are being cleaned properly, and 5-step room cleaning process is being followed.



483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised with new interventions for three of 28 residents reviewed (Residents 20, 40, 44).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated November 12, 2019, indicated that the resident was cognitively intact, required extensive assistance with daily care tasks, and had diagnoses that included anxiety and depression.

A nursing note for Resident 20, dated December 30, 2019, at 4:55 a.m. revealed that a nurse aide reported that the resident was groping her during morning care that day. The nurse spoke with the resident regarding his inappropriate behavior and instructed him to stop groping the staff, as this was offensive and unwelcome behavior. The resident verbalized his understanding.

Interview with Nurse Aide 6 on January 16, 2020, at 2:42 p.m. revealed that Resident 20 asked her to show him her breasts in the past but she was unsure when and stated that this was "a while ago." Interview with Nurse Aide 7 on January 16, 2020, at 2:45 p.m. revealed that Resident 20 never did or said anything, but she was aware that he has been having behaviors with certain staff "for a while."

Resident 20's care plan, dated April 11, 2019, included that he had behaviors, but there was no documented evidence that interventions were in place regarding his sexual behaviors toward staff.

Interview with the Director of Nursing on January 16, 2020, at 2:35 p.m. revealed that she was not aware that Resident 20 had sexual behaviors while at the facility, and she thought that these behaviors occurred only when he was at dialysis.

Interview with the Registered Nurse Assessment Coordinator on January 17, 2020, at 9:58 a.m. revealed that Resident 20's care plan should have been revised to include that he was having sexual behaviors.


A quarterly MDS assessment for Resident 40, dated December 23, 2019, indicated that the resident had moderately impaired cognition, required extensive to total assistance with daily care tasks, had impairment to the range of motion (joint movement) on one side of his upper and lower extremities, and had diagnoses that included cancer, high blood pressure, diabetes, stroke, and was unable to use one side of his body.

Observations of Resident 40 on January 16, 2020, at 2:00 p.m. revealed that his bed was in a high position, and the resident was asleep on his back in the bed.

Interview with Nurse Aide 6 on January 16, 2020, at 2:17 p.m. revealed that Resident 40's bed was too high and she lowered the bed. She stated that the resident controls his own bed at times. Interview with the Director of Nursing on January 16, 2020, at 2:40 p.m. confirmed that the resident's bed should not have been in a high position, but Resident 40 controls his own bed and can raise it on his own.

Resident 40's care plan for behaviors, dated June 1, 2018, revealed that it did not include information about the resident's behavior of raising the height of his bed.

Interview with the Registered Nurse Assessment Coordinator on January 17, 2020, at 11:20 a.m. confirmed that Resident 40's care plan should have included that he adjusts the height of his bed.


An admission MDS assessment for Resident 44, dated December 10, 2019, indicated that the resident was cognitively intact and required extensive assistance with daily care tasks. Physician's orders, dated January 11, 2020, included orders for the resident to receive 3.375 grams of piperacillin solution (Zosyn - an antibiotic) intravenously (IV - administered directly into a vein) twice daily.

Observations of Resident 44 on January 14, 2020, at 9:40 a.m. revealed that he had an IV pump present in his room with an infused bag of piperacillin hanging on it.

Nursing notes for Resident 44, dated January 15, 2020, at 9:44 a.m. revealed that the resident continued on IV Zosyn for sepsis (blood infection), the IV site was clean and dry with no redness or swelling, and the resident was tolerating the antibiotic therapy.

Resident 44's current care plan revealed that it did not include that he was receiving IV antibiotic treatment for an infection.

Interview with the Registered Nurse Assessment Coordinator on January 17, 2020, at 11:30 a.m. confirmed that Resident 44's care plan did not include information about his care needs related to IV antibiotic therapy and it should have.

28 Pa. Code 211.11(d) Resident care plan.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.



 Plan of Correction - To be completed: 03/11/2020

Care plans updated to include Resident #20 sexual behaviors, Resident #40 is independently adjusting the height of his bed, and Resident #44 Intravenous antibiotic and care needs related to antibiotic.
Current residents care plans were reviewed for sexual behaviors, independent lower or raising bed heights and current residents on antibiotic therapy. No other residents were identified as having sexual behaviors. No other residents were currently on Intravenous antibiotics. Staff identified 3 other residents that have been found to adjust their beds in high position and care plans were updated.
Nursing home Administrator/designee will inservice facility staff on reporting of behaviors/care plan needs/bed position and antibiotic therapy.
The interdisciplinary team reviews resident changes/orders as part of the morning meeting process. Care plans will be reviewed and revised to reflect changes with this review. Care plans will be reviewed quarterly with care conferences as needed.
Director of Nursing/Designee will audit care plans of residents having new Intravenous antibiotic orders/documented behaviors/and any independent bed adjusting issues to ensure implementations in place. This audit will be completed on 4 residents weekly x 4 weeks, then 4 residents monthly x 2 months with results reviewed at Quality Assurance meetings for further recommendations/needs.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act, facility policy, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of 28 residents reviewed (Resident 17).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing 21.11 (a)(1)(2)(4) indicated that the registered nurse was responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.

The facility's policy regarding seizure and epilepsy protocols, dated October 23, 2019, revealed that the nurse was to assess, document, and report information including vital signs, neurological assessment, change in level of consciousness, any seizure activity, any injury, the resident's age and sex, whether the resident has a seizure disorder or known history, the date of the most recent actual seizure activity, relation to any usual patterns, and the last blood level for any anticonvulsant medications.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated November 8, 2019, revealed that the resident was understood; could understand; required extensive assistance from staff for daily care tasks, including transfers and bed mobility; and had diagnosis that included traumatic brain injury and epilepsy with recurrent seizures (a condition that causes jerky muscle movements, loss of consciousness, or confusion). The resident's care plan, dated November 9, 2017, indicated that if a seizure occurred, staff were to place her on her side, maintain an airway, create a safe enviornment, obtain vital signs, and report the seizure activity including duration, characteristics, level of conscicousness, and speech.

A nursing note for Resident 17, dated October 27, 2019, and completed by a licensed practical nurse, revealed that the resident had seizure activity with thrashing for approximately three minutes in her wheelchair.

There was no documented evidence that a registered nurse completed an assessment of Resident 17's change in condition on October 27, 2019

Interview with the Nursing Home Administrator on January 17, 2020, at 10:48 a.m. confirmed that a registered nurse should have performed an assessment following Resident 17's seizure.

Interview with Registered Nurse 1 on January 17, 2020, at 2:37 p.m. confirmed that there was no documented evidence that Resident 17's change in condition was assessed by a registered nurse.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.







 Plan of Correction - To be completed: 03/11/2020

Resident was found at time of survey to have no seizure activity.
Audit of last 2 weeks of progress notes will be completed to validate that changes in condition had an Registered Nurse assessment completed ,if assessment not completed an Registered Nurse assessment will be completed to determine if change is current issue and follow up with attending physician will occur
Discussion/education held with Licensed Nurse involved by Director of Nursing on need to report resident seizures to Registered nurse on duty to assess.
Director of Nursing/Designee will educate Licensed Nurses and new licensed nurses and agency licensed nurses on assessing residents with seizure activity and completion of assessment/documentation and notifications of their attending physician.
Director of Nursing/Designee will audit 24 hour report with morning meeting process to identify any seizure activity and that Registered Nurse assessments were completed and documented within the medical record. This audit will be done on 3 residents, 3 x week x 4 weeks, then once weekly for 2 months with results reviewed at Quality Assurance meetings for further recommendations/needs.


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 clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that care-planned interventions to prevent falls and/or injury were followed for two of 28 residents reviewed (Residents 37, 41).

Findings include:

A quarterly Minimum Data Set (MDS) assessment for Resident 41, dated November 26, 2019, revealed that the resident was cognitively intact; required the extensive assistance of two staff for bed mobility, transfers and toileting; had impaired joint movement of one leg; and had diagnoses that included Parkinson's disease (a progressive disease of the nervous system that affects movement). The resident's care plan, revised August 27, 2019, indicated that she required the extensive assistance of two staff for bed mobility and to use a bed pan.

A nursing note for Resident 41, dated November 25, 2019, at 10:20 a.m. revealed that the resident rolled out of bed and onto the floor while the nurse aide was removing a bed pan from underneath her. The resident complained of right knee pain and x-rays were obtained. The facility's investigation documents revealed that the nurse aide attempted to take the resident off the bed pan by herself, the resident was rolled away from the nurse aide, and rolled out the opposite side of the bed.

Interview with the Director of Nursing on January 16, 2020, at 1:19 p.m. confirmed that staff did not follow Resident 41's care plan for toileting and bed mobility when taking the resident off the bed on November 25, 2019, and the resident fell out of bed.


An admission MDS assessment for Resident 37, dated December 20, 2019, revealed that the resident was cognitively impaired, required extensive to total assistance from staff for daily care tasks, and had diagnoses that included a stroke with one-sided paralysis. The resident's current care plan revealed that he was at risk for falls related to his one-sided paralysis from a stroke, and interventions for fall and/or injury prevention included to maintain his bed in a low position.

Observations of Resident 37 on January 16, 2020, at 2:00 p.m. revealed that the resident was in bed, and his bed was in a high position.

Interview with Nurse Aide 6 on January 16, 2020, at 2:17 p.m. revealed that Resident 37's bed was too high and should be lowered.

Interview with the Director of Nursing on January 16, 2020, at 2:40 p.m. confirmed that Resident 37's bed was to be in a low position and was not.

28 Pa. Code 211.11(d) Resident care plan.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.





 Plan of Correction - To be completed: 03/11/2020

Resident #37 bed was lowered at time of discovery. He is known to adjust his bed, his care plan was updated.
Audit of incident reports for last 3 weeks will be completed to validate that care plans were being followed at time of event.
Director of Nursing/designee will inservice nursing staff including new nursing staff and agency staff on following care plan for bed mobility/toileting and bed height when resident is in bed as well as consequences for not following care plan for safety.
Director of Nursing/designee will audit bed mobility during care on 3 residents weekly x 4 weeks, then monthly x 2 and results will be reviewed with Quality Assurance Performance Improvement committee for further recommendation/needs.



483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the physician was notified timely about a change in condition for one of 28 residents reviewed (Resident 6).

Findings include:

The facility's policy regarding pain assessment and management, dated October 23, 2019, indicated that significant changes in a resident's level of pain and/or prolonged, unrelieved pain despite care plan interventions were to be reported to the physician or practioner.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated October 22, 2019, revealed that the resident was severely cognitively impaired, had unclear speech, was rarely or never understood by others, was totally dependent on staff for daily care tasks, and had diagnoses that included dementia (affects memory and thinking skills). The assessment revealed that the resident did not receive any routinely scheduled or "as needed" pain medications and did not display any verbal or nonverbal indicators of pain during the assessment period. The resident's care plan, dated October 5, 2017, indicated that the physician was to be notified if the frequency and/or intensity of pain worsened or if the current pain control regimen was ineffective.

Physician's orders for Resident 6, dated January 25, 2019, included an order for the resident to receive two 325 milligram (mg) tablets of Tylenol (an over-the-counter pain medication) every four hours as needed for mild pain (pain rated as 1-3 on a scale of 0-10, where 10 is the worst pain). The resident's Medication Administration Record (MAR) for August 2019 revealed that she was medicated for pain with two 325 mg tablets of Tylenol twice that month - once on August 11 at 10:34 a.m. for "yelling out" and pain that was rated a 1, and once on August 28 at 3:52 a.m. for generalized discomfort that was not relieved with rest and position changes and pain that was rated as a 3.

Resident 6's MAR for September 2019 revealed that she was medicated with Tylenol on September 8, 2019, at 7:45 a.m. for pain that was rated as a 9, and a corresponding nursing note, dated September 8, 2019, at 7:48 a.m., revealed that the resident had been moaning and yelling when being repositioned and displayed grimacing when either leg/hip were touched. A nursing note dated September 9, 2019, at 5:10 a.m. indicated that a fax was sent to the physician's office regarding the resident yelling out when her legs were moved apart for incontinent care, that the pain was rated at a 9 using the facility's pain scale, and that Tylenol was administered, was only minimally effective, and no other pain medication was ordered for the resident. The fax also questioned whether the physician would like any x-rays of the hip or pelvis. The MAR for September 9, 2019, indicated that the resident was medicated with Tylenol at 7:37 a.m. for pain rated as a 3, and that the medication was ineffective in relieving the resident's pain.

There was no documented evidence that staff attempted to follow-up with Resident 6's physician regarding the fax sent early in the day on September 9, 2019, regarding the resident's "minimally effective" pain relief. The resident's MAR's further revealed that the resident was medicated with Tylenol on September 11, 2019, at 3:31 a.m. for pain rated as a 2.

A nursing note for Resident 6, dated September 13, 2019, at 5:00 p.m. revealed that a nurse aide reported that the resident was experiencing signs and symptoms of pain and increased behaviors during routine care, and the resident was assessed and was found to have swelling of the left lower leg extending from the hip to the foot, with the left knee bent inward and the left lower leg rotated inward. Subsequent nursing notes indicated that an order for an x-ray of the hip and pelvis was obtained from the physician, which revealed a fractured femur (bone in the upper leg), and the resident was sent out to the hospital.

Staff witness statements collected as part of the facility's investigation concerning Resident 6's femur fracture revealed that a nurse aide reported that the resident had increased pain when incontinent care was provided on the evening and night shift of September 8, 2019, and that the physician was faxed at 5:00 a.m. on September 9, 2019, regarding the change in condition and pain. The information was passed onto the next shift, both verbally and in writing on the 24-hour report. However, there was no documented evidence that staff made any other attempts to contact the physician regarding the need for possible x-rays and/or increased pain medication until September 13, 2019, at 5:28 p.m., which was five days after the issue was initially reported.

Interview with the Nursing Home Administrator on January 16, 2020, at 3:45 p.m. confirmed that there was no documented evidence that the physician responded to the fax sent on September 9, 2019, at 5:00 a.m., and no documented evidence that staff made further attempts to contact the physician regarding the resident's increase in pain, or the minimal effectiveness of Tylenol, until her condition worsened five days later on September 13, 2019.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 03/11/2020

The event occurred September 13, 2019. Cannot retroactively change
Review of the last 2 weeks of progress notes will be completed to validate that attending physicians were notified of changes in condition. Any areas of opportunity noted will have physician notification completed
Director of Nursing/Designee will educate staff on notification of Medical Doctor for residents with new signs and symptoms or increase in pain is noted for new interventions.
Director of Nursing/Designee will complete audits as part of morning meeting 5 times per week for 1 month then weekly for 1 month then monthly for 2 months to validate physician notification with changes in condition
Results of audits will be reviewed with the Quality Assurance Performance Improvement Committee until evidence of compliance is found.




483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 28 residents reviewed (Resident 36).

Findings include:

The facility's policy regarding controlled substances, dated October 23, 2019, indicated that controlled substances must be counted upon delivery, an individual resident's controlled substance record must be made for each resident who was to receive a controlled substance, and nursing staff must count controlled medications at the end of each shift.

Resident 36's care plan dated May 10, 2018, and physician's orders dated December 30, 2019, included that the resident was to receive hospice services (end-of-life care) due to a diagnosis of stroke.

Observations in the medication room on January 17, 2020, at 2:23 p.m. revealed that a double-locked box on the wall contained narcotics, including a "hospice comfort box" for Resident 36 that was unopened and contained Ativan (a controlled antianxiety medication) and Morphine (a controlled narcotic pain medication).

There was no documented evidence that the controlled medications in the hospice comfort box had controlled substance records created to account for medications.

Interview with Licensed Practical Nurse 8 on January 17, 2020, at 2:40 p.m. confirmed that the comfort box did not have controlled substance records or a sign-out sheet.

Interview with the Nursing Home Administrator on January 17, 2020, at 4:20 p.m. confirmed that control/accountability records for the Ativan and Morphine contained in Resident 36's hospice comfort box should have been created.

28 Pa. Code 211.9(a) Pharmacy services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 03/11/2020

Hospice company was immediately notified of need to only deliver narcotics with count form with each narcotic and not to be delivered via a "comfort kit".
Hospice nurse and Director of nursing counted Ativan and Morphine that was in the box and confirmed correct amount was present and signed off on count sheet.
Director of Nursing/designee will inservice licensed staff, newly hired licensed staff, and licensed agency staff that facility does not accept/or have any narcotics in building without count sheets. Comfort kits are not to be used all narcotics that are ordered are to be delivered separately and with narcotic sheets as are all other narcotics in facility.
Director of Nursing will monitor/audit the narcotic box and count sheets 3 times per week for 1 month then weekly for 1 month then monthly for 1 month to validate that current narcotics have a count sheet. Results of audits will be reviewed with the Quality Assurance Performance Improvement committee for further recommendations until compliance is met

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 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.
483.45(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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the pharmacist reported medication irregularities to the residents' attending physician, versus a non-physician practitioner, for one of 28 residents reviewed (Resident 17).

Findings include:

A medication regimen review policy, dated October 23, 2019, revealed that the findings and recommendations were to be reported to the director of nursing, the attending physician, and if appropriate, the medical director.

A Monthly Medication Review (MMR) completed by the consultant pharmacist for Resident 17, dated September 26, 2019, revealed that the resident had been on Zoloft (a medication used to treat depression) since September 2, 2019, and to evaluate the current dose and consider a gradual taper to ensure that the resident was using the lowest possible effective/optimal dose. Certified Physician Assistant 2 (PA-C - state licensed to practice medicine with a supervising physician) responded to the recommendation and signed the form. There was no documented evidence that Resident 17's attending physician was made aware of and acted upon the pharmacist's recommendation.

Interview with Director of Nursing on January 17, 2020, at 3:30 p.m. revealed that the form was missed as it was not flagged for the attending physician to review and sign.




 Plan of Correction - To be completed: 03/11/2020

Resident #17 pharmacy review of September 26, 2019 was reviewed and signed off by her physician.
Current resident pharmacy recommendations will be completed to validate that a physician has addressed and signed the recommendation form.
Director of Nursing/Designee will inservice licensed staff, newly hired licensed staff, and agency licensed staff on medication regime review policy to ensure compliance
Director of Nursing/designee will audit monthly pharmacy reviews for proper physician signatures x 3 months with results reviewed at Quality Assurance Performance Improvement Committee for further recommendations/needs until compliance is met

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly secured in one of two medication carts (South cart).

Findings include:

The facility's policies regarding medication storage, dated October 23, 2019, indicated that medication carts were to be kept closed and locked when not attended by personnel administering medications.

Observations of a medication cart on the South hall on January 17, 2020, at 11:32 a.m. revealed that the medication cart was placed in an alcove between rooms 17 and 18, was not locked, and was not attended by a nurse. Licensed Practical Nurse 4 was in the dining room on the other side of room 17 and out of the line of sight of the medication cart until 11:41 a.m.

Interview with Licensed Practical Nurse 4 on January 17, 2020, at 11:41 a.m. confirmed that the cart was unattended and unlocked while she was in the dining room setting up.

Interview with the Nursing Home Administrator on January 17, 2020, at 12:05 p.m. confirmed that the South cart should not have been unlocked when it was not attended by the nurse.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 12/13/18.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(1)Nursing services.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 03/11/2020

South hall cart was locked upon discovery by Administrator and Licensed nurse.
Licensed Nurse # 4 was educated/disciplined on not following process.
Director of Nursing/designee will inservice licensed staff, newly hired licensed staff, and agency licensed staff on proper locking of med carts when not attending.
Nursing Home Administrator/designee will audit med carts in halls 2x -5 days per week x 2 weeks, then 3x week x 2 weeks, then monthly x2 with results reviewed with the Quality Assurance Performance Improvement committee for recommendations until compliance is met.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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


Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 28 residents reviewed (Resident 21).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 21, dated November 13, 2019, indicated that the resident was cognitively intact and had diagnoses that included multiple mental health disorders. Physician's orders, dated August 15, 2018, included an order for the resident to receive 0.5 milligrams (mg) of Xanax (medication for anxiety) two times a day. The resident's Medication Administration Record (MAR) for November 2019 indicated that staff administered a 7:30 a.m. dose of Xanax on November 18, 2019.

A nursing note for Resident 21, dated November 18, 2019, at 8:56 a.m. revealed that the resident had no adverse reactions from the "medication error." However, the details of the medication error, and the nurse's assessment of the resident following the error, were not documented in the resident's clinical record and were only documented on an incident report, dated November 18, 2019, that was not part of the resident's clinical record. The incident report revealed that the resident was given his roommate's medication Klonopin (medication to control seizures) instead of his Xanax at 7:30 a.m.

Interview with the Nursing Home Administrator on January 17, 2020, at 2:10 p.m. confirmed that Resident 21's clinical record contained incomplete documentation of the medication error.

28 Pa. Code 211.5(f) Clinical records.





 Plan of Correction - To be completed: 03/11/2020

The event of November 18, 2019 R# 21 documentation cannot retroactively be corrected
Audit of last 2 weeks of incident reports regarding med errors will be completed to validate that assessment of resident is documented in the medical record as well as summary of the event.
Education will be completed with licensed nurses, newly hired licensed nurses, and agency nurses on comprehensive documentation in medical record post a medication error incident.
Director of Nursing/Designee will audit event reports and nursing documentation during morning meeting 3 times per week for 1 month then weekly for 1 month and then monthly for 1 month to validate routine comprehensive documentation is within the medical record for medication error incident. Results of audits will be reviewed with the Quality Assurance Performance Improvement committee for recommendations until compliance is met



483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction for previous surveys and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plan of correction for a State Survey and Certification (Department of Health) survey ending December 13, 2018, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 17, 2020, identified repeated deficiencies related to failures to ensure that medications were stored properly and to ensure that proper infection control practices were used during care.

The facility's plan of correction for a deficiency regarding medication storage, cited during the survey ending December 13, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding proper medication storage.

The facility's plan of correction for a deficiency regarding using proper infection control practices during care, cited during the survey ending December 13, 2018, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding proper infection control practices.

Refer to F761, F880.

42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities.
Previously cited 12/13/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/13/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 12/13/18.




 Plan of Correction - To be completed: 03/11/2020

With changes in management team and to ensure proper Quality Assurance is being followed, the QAPI (Quality Assurance Performance Improvement) team will be educated on following deficiencies through the committee by the Regional Clinical nurse/designee. With this education, the committee will review deficiencies monthly, (minimum quarterly) with committee members bringing/identify areas of concerns and reviewing current deficient areas/new concerns with altering performance improvement plans as needed until resolved and compliance met.
The Regional Clinical Nurse will audit committee minutes monthly x 3 to assure continued compliance.
The Management Team will be educated on root cause analysis utilizing the 5-wise process.

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 review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while obtaining blood sugar levels for one of 28 residents reviewed (Resident 30).

Findings include:

The facility's policy regarding blood glucose monitoring (testing blood sugar levels using a drop of blood inserted into a hand-held device), dated October 23, 2019, indicated that once used, the glucometer (the hand-held device used to test the drop of blood) should be cleaned and disinfected according to the manufacturer's instructions and current infection control standards of practice.

Current physician's order for Resident 30, included an order for the resident's blood sugar level to be checked three times a day before meals.

Observations of blood glucose testing on January 15, 2020, at 11:41 a.m. revealed that Registered Nurse Supervisor 3 obtained a blood sample from Resident 30 and tested it with a glucometer. She then placed the glucometer on the top of the medication cart on a paper towel that also contained a clean glucometer, removed her gloves, used alcohol gel on her hands, applied clean gloves, obtained a bleach wipe, wiped off the dirty glucometer, and placed it back onto the paper towel in the same spot where it had been placed when dirty.

Interview with Registered Nurse Supervisor 3 on January 15, 2020, at 11:47 a.m. confirmed that she placed the cleaned glucometer onto the same spot on a paper towel where it had been placed when it was dirty.

Interview with the Director of Nursing on January 15, 2020, at 1:20 p.m. confirmed that Registered Nurse Supervisor 3 should not have placed the clean glucometer onto a dirty surface.

42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/13/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/13/18.


 Plan of Correction - To be completed: 03/11/2020

Registered Nursing Supervisor #3 was educated immediately on infection control issue by Infection Prevention Nurse and acknowledged process.
Professional nurses were inserviced by Infection prevention Nurse/designee on proper cleaning/disinfecting of glucometer after use. In addition, newly hired licensed nurses and agency licensed nurses will be educated on proper disinfecting of glucometer.
Return demonstrations by licensed staff will be done to validate following proper use of clean/dirty surfaces.
Infection Nurse will do glucometer cleaning audits 3x week x 2 weeks, then weekly x2, then monthly x2 and results will be reviewed with the Quality Assurance Performance Improvement Committee for any further recommendations/needs until compliance is met



201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:


Based on review of Pennsylvania laws, facility policies, and attendance records, as well as staff interviews, it was determined that the facility failed to ensure that the Multi-Disciplinary Infection Control committee meetings included a representative from the pharmacy.

Findings include:

The Act 52 Infection Control Plan, dated, March 20, 2002, revealed that a health care facility should develop and implement an internal infection control plan that should be established for the purpose of improving the health and safety of residents and health care workers, and should include a multidisciplinary committee including a representative from each of the following. Applicable members included medical staff that should include the chief medical officer or medical director, the nursing home administrator, laboratory staff, nursing staff that could include the director of nursing or nursing supervisor, pharmacy staff, physical plant staff, a patient safety officer and a community member that may not be an agent, employer or contractor of the facility.

The facility's policy regarding the Infection Control Committee, dated October 23, 2019, revealed that the committee's membership would include the facility's pharmacy representative.

The Infection Control Committee attendance records, dated January 23, April 25, July 25 and October 23, 2019, revealed that the facility's pharmacy representative was not in attendance at any of the meetings.

Interview with the Director of Nursing on January 14, 2020, at 2:20 p.m. confirmed that there was no documented evidence that a representative of the facility's pharmacy attended the Infection Control Committee meetings held on the above dates.



 Plan of Correction - To be completed: 03/11/2020

The facility's Infection Control Committee will be held monthly (minimum quarterly) prior to Quality Assurance meeting and include membership required.
The Infection Control Nurse along with management team will be educated by Regional Clinical Nurse/designee on committee membership requirements. Infection Control Committee meeting held on January 23rd, 2020, included the Pharmacy Representative. The Regional Nurse/designee will audit Infection control meetings for compliance monthly x3 and results reviewed at Quality Assurance Performance Improvement Committee for recommendations until compliance is met.


201.20(b) LICENSURE Staff development.:State only Deficiency.
(b) An employe shall receive appropriate orientation to the facility, its policies and to the position and duties. The orientation shall include training on the prevention of resident abuse and the reporting of the abuse.
Observations:


Based on review of agency employee personnel records, as well as staff interviews, it was determined that the facility failed to provide orientation to the facility, its policies, and the employee's position and duties, for one of four employees reviewed (Licensed Practical Nurse 9).

Findings include:

Review of the agency employee file for Licensed Practical Nurse 9 revealed a hire date of October 17, 2019. There was no documented evidence that the nurse received orientation to the facility, the facility's policies, or the nurse's position and duties.

Interview with the Nursing Home Administrator on January 17, 2020, at 3:23 p.m. revealed that she could provide no documented evidence that the agency nurse received orientation to the facility, the facility's policies, or the employee's position and duties.



 Plan of Correction - To be completed: 03/11/2020

Licensed nurse #9 was provided reorientation to facility, its policies, position and duties and documentation completed prior to her next scheduled shift of work by Director of Nursing.
An audit of current employee files was completed to ensure the facility orientation checklist was completed.
The Director of Nursing and Business Office Manger were educated by the Nursing Home Administrator on completion of orientation files.
The Business Office Manager will audit new licensed staff orientation for completion of orientation paperwork weekly x 4 weeks, then monthly x2 with results reviewed at Quality Assurance meetings for further recommendations/needs.

211.5(f) LICENSURE Clinical records.:State only Deficiency.
(f) At a minimum, the resident's clinical record shall include physicians' orders, observation and progress notes, nurses' notes, medical and nursing history and physical examination reports; identification information, admission data, documented evidence of assessment of a resident's needs,
establishment of an appropriate treatment plan and plans of care and services provided; hospital diagnosis authentication--discharge summary, report from attending physician or transfer form--diagnostic and therapeutic orders, reports of treatments, clinical findings, medication records and discharge summary including final diagnosis and prognosis or cause of death. The information contained in the record shall be sufficient to justify the diagnosis and treatment, identify the resident and
show accurately documented information.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that closed clinical records contained a physician's discharge summary for one of three discharged residents reviewed (Resident 45).

Findings include:

A nursing note for Resident 45, dated November 13, 2019, revealed that the resident ceased to breathe and the physician gave the registered nurse permission to pronounce the body. An expired resident discharge summary, dated November 13, 2019, revealed that the physician did not sign the form, which was signed only by the nurse completing it.

Interview with the Nursing Home Administrator on January 17, 2020, at 6:05 p.m. confirmed that Resident 45's clinical record did not include a physicians's discharge summary.








 Plan of Correction - To be completed: 03/11/2020

Discharge summary for resident # 45 was completed.
Deceased resident charts for past 3 months were audited to ensure they contained completed discharge summaries.
Director of Nursing/Designee will educate Medical records,licensed nursing staff, and attending physicians on completing discharge summary on expired residents timely.
Medical records/Designee will audit discharges to ensure summaries are completed and signed monthly x3 months with results reviewed at Quality Assurance Performance Committee for recommendations until compliance is met.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:


Based on review of nursing staffing schedules and payroll records, as well as staff interviews, it was determined that the facility failed to provide the required minimum number of nursing care hours of 2.7 hours of direct resident care for each resident for one of 21 days reviewed.

Findings include:

The facility's nursing schedules and payroll records for the weeks of November 24, 2019; December 22, 2019; and January 10, 2020, revealed that the facility provided only 2.61 hours of direct nursing care per resident on December 25, 2019.

Interview with the Director of Nursing on January 22, 2020, at 2:40 p.m. confirmed that nursing staffing was below the required minimum number of nursing care hours on December 25, 2019.






 Plan of Correction - To be completed: 03/11/2020

The facility schedule was reviewed to ensure proper staffing is occurring.
The Nursing Home Administrator will reinservice the Director of Nursing/Staff Development Nurse and Charge Nurses on proper ratios.
Nursing department staffing will be reviewed with administrator at stand-up meetings to include projecting staffing to meet resident needs and ensure proper staffing ratios.
Business office manager will do daily nursing department payroll hour print-outs 5x weekly for 4 weeks, then monthly x2 and results reviewed with Quality Assurance Performance Improvement Committee for recommendations until compliance is met.


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