Nursing Investigation Results -

Pennsylvania Department of Health
CRAWFORD COUNTY CARE CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
CRAWFORD COUNTY CARE CENTER
Inspection Results For:

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CRAWFORD COUNTY CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, Civil Rights Compliance, and State Licensure Survey and an Abbreviated survey in response to a complaint, completed on January 17, 2020, it was determined that Crawford County Care Center, 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.




 Plan of Correction:


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 facility policy, observations and staff interview, it was determined that the facility failed to prevent the opportunity for potential unauthorized access of medications on one of six medication carts (Mauve Hall- memory care unit).

Findings include:

The facility policy entitled "Administering Medications," dated 1/16/20, indicated that the medication cart must be kept closed and locked when out of the nurse's view.

Observation on 1/14/20, at 3:53 p.m. revealed Registered Nurse (RN) Employee E1 administering medications from one of two medication carts (Mauve) parked in the hall on the Memory Gardens Unit. A second medication cart (Primrose) was noted to be unlocked. RN Employee E1 locked and left the Mauve medication cart unattended, walked down the hall to administer medications to a resident in their room and did not securely lock the Primrose medication cart which was left out of sight of RN Employee E1.

Further observation on 1/14/20, at 4:12 p.m. revealed that RN Employee E1 prepared medications for a resident from the Mauve medication cart, locked the cart, proceeded to the dining room to administer medications, and did not securely lock the Primrose medication cart which was left out of sight of RN Employee E1.

During an interview on 1/14/20, at 4:14 p.m. RN Employee E1 confirmed that he/she was administering medications out of both carts and that he/she had been into Primrose cart earlier in his/her shift and neglected to lock it, and that the medication cart should have been locked when out of his/her sight.

During an interview on 1/15/20, at 11:39 a.m. the Director of Memory Gardens confirmed that medication carts are to be locked when they are not in view of staff.

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

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

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









 Plan of Correction - To be completed: 02/28/2020

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Crawford County Care Center agrees with the allegations and citations listed on the statement of deficiencies. Crawford County Care Center maintains that the alleged deficiencies do not individually or collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. The plan of corrections shall operate as Crawford County Care Centers written credible evidence of compliance.
By submitting this plan of correction, Crawford County Care Center does not admit to the accuracy of the deficiencies. The plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Crawford County Care Center reserves all rights to raise possible contentions and defenses in any civil or criminal claim, action or proceeding.
No residents were affected by the medications carts being unlocked or unattended. The medication cart was locked after identification, without any adverse consequences. Employee 1 was educated immediately on the Medication Administration policy and procedure for storage of medications and securing the medication cart when left unattended.
All residents are at risk to be affected by this practice. All medications carts will be checked to validate they are locked and stored appropriately.
Licensed nursing staff will be educated on properly securing medication carts when unattended.
Random medication cart audits will be completed on various shifts daily for five days, weekly for three weeks and monthly for two months, then ongoing every month on all shifts during and after medication pass thereafter. Audit results will be reviewed by the Quality Assurance and Process Improvement Committee for further review and recommendation.
483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(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, review of facility policy, and staff interviews, it was determined that the facility failed to utilize gloves to prevent contamination during the direct handling of resident food in two of three dining areas (both dining areas on the Memory Gardens unit), and failed to label food brought into the facility with the resident's name and date it was opened.

Findings include:

Facility policy entitled, "Food Safety for Your Loved One" dated 1/16/20, revealed that food/beverages brought into the facility should be labeled and dated, food will be discarded three days after the marked date, and unmarked foods are to be labeled with the date the item was stored.

Observation on 1/15/20, at 11:01 a.m. of the pantry refrigerator on the Memory Gardens unit revealed 1/2 blueberry cake with graham cracker crust, and two cans of Pepsi which were not labeled with a resident name and/or date.

During an interview on 1/15/20, at 11:03 a.m. Licensed Practical Nurse Employee E4 confirmed the presence of the 1/2 blueberry cake, and two cans of Pepsi which were not labeled with a resident name and/or date.

During an interview on 1/15/20, at 11:09 a.m. the Dietary Manager confirmed that the blueberry cake and Pepsi are not provided by the facility and both should be labeled with the resident's name and the blueberry cake should have been dated.

Observation on 1/15/20, at 11:19 a.m. in Memory Gardens right dining area revealed Nurse Aide (NA) Employee E2 assisting Resident R27 with preparing a hamburger. NA Employee E2 used his/her bare hands to pick up the top bun, apply ketchup, replace the top bun, and cut the hamburger in half.

Observation on 1/15/20, at 11:23 a.m. in Memory Gardens left dining area revealed NA Employee E3 assisting Resident R58 with preparing a chicken breast sandwich. NA Employee E3 used his/her bare hands to hold and cut the sandwich in half.

During an interview on 1/15/20, at 11:39 a.m. the Director of Memory Gardens confirmed that staff should have worn gloves to directly handle resident food, and that food placed in the resident refrigerator was to be labeled and dated.

28 Pa. Code 211.6(f) Dietary services

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3) Management













 Plan of Correction - To be completed: 02/28/2020

No residents were affected by the deficient practice. E1 and E2 were educated on the policy and procedure for handling resident food. The blueberry cake was discarded and the Pepsi removed from the refrigerator.
The staff on Memory Garden had immediate education on proper food handling as well as labeling and dating of brought in for residents.
All staff will be educated on safe food handling and proper labeling and dating of foods to be stored.
Department Directors and managers will monitor dining rooms throughout the facility at different meal times to assure staff are handling resident foods safely, daily for two weeks, weekly for two weeks, monthly for two months then on a random basis thereafter.
The dietary department will audit resident refrigerators on each unit for unlabeled and undated foods and dispose of items accordingly daily for two weeks, weekly for two weeks and monthly for two months. Audit results will be reported to the Quality Assurance and Process Improvement committee for review and recommendation.

483.75(g)(1)(i)-(iii)(2)(i) REQUIREMENT QAA Committee:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.75(g) Quality assessment and assurance.
483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role;

483.75(g)(2) The quality assessment and assurance committee must:
(i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary.
Observations:


Based on review of facility documentation and staff interviews, it was determined that the facility failed to ensure the Medical Director/designee attended quarterly Quality Assurance Process Improvement (QAPI) committee meetings for one of four quarters (October 2019 to December 2019).

Findings include

Review of QAPI meeting sign-in sheets for October 2019, and November 2019, revealed that the Medical Director or designee was not in attendance. The facility was unable to provide documentation of a QAPI meeting taking place in December 2019, therefore there is no evidence to support the attendance of the Medical Director or designee at the QAPI meetings during the fourth quarter of 2019.

During an interview on 1/17/20, at 11:57 a.m. the Interim Nursing Home Administrator confirmed that there was no evidence that the Medical Director/designee attended the QAPI meeting in the fourth quarter of 2019.

28 Pa. Code 201.18(e)(1)(2)(3) Management








 Plan of Correction - To be completed: 02/28/2020

I hereby acknowledge the CMS 2567-A, issued to CRAWFORD COUNTY CARE CENTER for the survey ending 01/17/2020, AND attest that all deficiencies listed on the form will be corrected in a timely manner.
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 facility infection control policies and procedures, infection control surveillance, and staff interviews, it was determined that the facility failed to comply with the following requirements of MCARE Act 403(a)(1) for three out of six meetings held during the year of 2019 (August 2019, September 2019, and December 2019).

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:

(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

A review of the Infection Control Committee attendance records for calendar year 2019, revealed there was no medical staff present for the final quarter of the year meeting on 12/19/19. The pharmacy staff, laboratory personnel, and community member did not attend the August 2019, September 2019, and December 2019 meetings.

During review of the Infection Control Committee attendance records on 1/17/20, the Nursing Home Administrator confirmed there was no further evidence that all required representatives attended all the meetings as stated above.





 Plan of Correction - To be completed: 02/28/2020

A Quality Assurance and Process Improvement subcommittee meeting will be scheduled to establish the Quarterly Infection Control meeting dates for 2020. All required members will be notified of the quarterly meeting dates and the attendance requirement for the multidisciplinary committee by the Director of Medical Records.
The Quality Assurance and Process Improvement Committee will monitor the Infection Control quarterly meeting minutes to validate required members attended the scheduled quarterly meetings. If a member is unable to attend the scheduled meeting, the Administrator will arrange for an individual review, add any concerns or recommendations to the minutes and obtain appropriate signature(s).

209.8(a) LICENSURE Fire Drills.:State only Deficiency.
(a) Fire drills shall be held monthly. Fire drills shall be held at least four times per year per shift at unspecified hours of the day and night.
Observations:

Based on review of fire drill records and staff interview, it was determined that the facility failed to conduct fire drills on a monthly basis.

Findings include:

Facility fire drill records for January 2019, through December 2019, revealed that there was no evidence of monthly fire drills performed in July 2019, September 2019, November 2019, or December 2019.

During an interview on 1/16/20, at 9:47 a.m. the Nursing Home Administrator confirmed that there was no evidence to identify that fire drills were held monthly as required to include July 2019, September 2019, November 2019, or December 2019.




 Plan of Correction - To be completed: 02/28/2020

An ad hoc Quality Assurance Process Improvement meeting was held on January 17, 2020 to schedule and complete a fire drill and ongoing plan to monitor completion of fire drills
A fire drill was held January 21, 2020 on the daylight shift versus the 3-11 shift as noted in the plan, due to ongoing respiratory illness within the facility.
The new Director of Environmental Services will review and revise the fire drill schedule for the remainder of 2020.
The Nursing Home Administrator will review the fire drills for completion, monthly.
Results of the audit will be reported to the Quality Assurance and Process Improvement committee for further review and recommendation.


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