Nursing Investigation Results -

Pennsylvania Department of Health
LIFEQUEST NURSING CENTER
Patient Care Inspection Results

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LIFEQUEST NURSING CENTER
Inspection Results For:

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LIFEQUEST NURSING 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 February 12, 2020, it was determined that Lifequest Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to minimize the potential for diversion of controlled substances (fentanyl patch) for one of 25 sampled residents. (Resident 47)

Findings include:

Review of the facility policy entitled, "Controlled Substance Disposal," dated January 23, 2020, revealed that when a controlled substance was wasted or destroyed, it was to be done in the presence of two licensed nurses. Signatures of witnesses were to be entered on the controlled substances accountability record.

Clinical record review revealed that Resident 47 had diagnoses that included an above the left knee amputation. There was a physician's order to apply a fentanyl patch (a controlled substance) every third day for pain and to remove it per schedule with disposal to be verified by a second nurse. Review of the medication administration records for January 2020, and February 2020, and the facility's narcotic record book revealed that the narcotic (fentanyl) patch was applied and removed 12 times with no evidence that a witness was present for the removal. In an interview on February 12, 2020, at 11:38 a.m., the Administrator confirmed that there was a lack of documentation to support that a second nurse had signed as a witness for disposing of the narcotic.

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



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

The licensed nursing staff will be re-educated on the destruction of a controlled substance Policy. The D.O.N. and/or his designee will review the controlled substance accountability record at the morning risk meeting to ensure that there are two signatures recorded for the destruction of a narcotic. The D.O.N. and/or his designee will randomly audit the controlled substance accountability record weekly X 3 then monthly X 3 to ensure continued compliance. The results of the random audits will be presented to the Quality Assurance team for review and further recommendation as appropriate.
483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on clinical record review and observation, it was determined that the facility failed to ensure that resident dignity was promoted for seven of 25 sampled residents. (Residents 36, 37, 42, 59, 67, 77, 81)

Findings include:

Clinical record review revealed that Resident 36 had diagnoses that included a history of a stroke and weakness. The Minimum Data Set (MDS) assessment dated November 19, 2019, indicated that the resident had memory impairment and required extensive assistance with activities of daily living. Review of the current care plan identified an intervention for staff to check the resident's nail length, trim and clean as necessary. Observation on February 9, 2020, at 9:45 a.m., and again at 12:05 p.m., revealed that the resident was dressed and in his wheelchair and his nails were long and jagged.

Clinical record review revealed that Resident 37 had diagnosis that included neurogenic bladder. The MDS assessment dated November 20, 2019, indicated that the resident had an indwelling catheter and utilized a wheelchair. Observation on February 9, 2020, at 9:46 a.m., 11:40 a.m., and 2:00 p.m., revealed that the resident was dressed and in his wheelchair and the catheter bag was attached to the bottom of his wheelchair and was exposed.

Clinical record review revealed that Resident 42 had diagnoses that included need for assistance with personal care and muscle weakness. The MDS assessment November 22, 2019, indicated that the resident required extensive assistance with personal hygiene. Observation on February 9, 2020, at 10:30 a.m., on February 10, 2020, at 9:30 a.m., and again on February 11, 2020, at 9:10 a.m., revealed that the resident was dressed and in his reclining geriatric chair and had excess facial hair and was unshaven.

Clinical record review revealed that Resident. 67 had diagnoses that included heart disease and weakness. The MDS assessment dated December 17, 2019, indicated that the resident required extensive assistance from staff for activities of daily living. Observation on February 9, 2020, at 9:45 a.m., revealed that the resident was dressed and in his wheelchair and his nails were long, uneven and dirty.

Clinical record review revealed that Resident 59 had diagnoses that included lack of coordination and weakness. The current care plan indicated a nutritional risk due to a history of difficulty swallowing and that staff were monitor chewing and swallowing functions during meals.

Clinical record review revealed that Resident 77 had diagnoses that included lack of coordination and dementia. The MDS assessment dated December 31, 2019, indicated that the resident had memory impairment and required extensive assistance from staff for activities of daily living which included eating.

Clinical record review revealed that Resident 81 had diagnoses that included stroke and oropharyngeal dysphagia (difficulty swallowing food in the mouth). The current care plan indicated the residnt was at nutritional risk and an intervention was for staff to provide full assistance with meals.

Observation on February 9, 2020, from 12:05 p.m. through 12:12 p.m., revealed that the nurse aide (NA 2) stood while feeding Resident 59, Resident 77, and Resident 81. There was no attempt by NA 2 during this timeframe to sit with an individual resident and assist them to complete their meals with dignity.

CFR 483.10(a)(1)(2)(b)(1)(2) Resident rights/Exercise of rights
Previously cited 3/22/19



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

Resident R36 and R67 had their nails trimmed. Resident R37 had a privacy bag implemented. Resident R42 was shaved. R59, R77, R81 will continue to be fed individually and in a manner that promotes dignity. The nursing staff will be re-educated on dignity. Random audits on dignity will be completed by the N.H.A. and/or her designee weekly X 3 then monthly X 3 to ensure compliance. The results of the random audits will be presented to the Quality Assurance Team for review and further recommendations as appropriate.
483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

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

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

Based on clinical record review, observation and staff interview it was determined that the facility failed to provide services and treatment to prevent further limitations in range of motion or mobility for two of four sampled residents with limited range of motion. (Residents 61, 68)

Findings include:

Clinical record review revealed that Resident 61 had diagnoses that included dementia, Parkinson's disease, history of a stroke, and contractures of the left and right hand. The Minimum Data Set (MDS) assessment dated December 6, 2019, indicated that the resident had memory impairment, required extensive assistance from staff for activities of daily living including dressing and had limitations in range of motion on both sides of her upper and lower extremities. Review of an occupational therapy discharge summary dated October 4, 2019, revealed that the resident was to wear orthotic devices to both hands for eight hours a day in order to prevent the worsening of flexion contractures. The occupational therapist further recommended that staff apply palm protectors to both hands. On September 27, 2019, a physician ordered that staff apply bilateral palm protectors at all times. Observation on February 9, 2020, at 9:30 a.m., 12:30 p.m., and 2:00 p.m., revealed that the resident was dressed and seated in her reclining geriatric chair without the palm protectors in place. In an interview on February 12, 2020, at 9:12 a.m., the Administrator stated that the resident was to have the palm protectors in place as ordered by the physician.

Clinical record review revealed that Resident 68 had diagnoses that included muscle weakness, replacement of both knee joints, and abnormal posture. The MDS assessment dated December 20, 2019, indicated that the resident was alert and oriented, had limited range of motion of the lower extremity, and required staff assistance for transferring between surfaces. Physician's orders directed staff to provide the resident with restorative nursing services to assist with transfers and standing. In an interview on February 10, 2020, at 9:48 a.m., Resident 68 stated that she did not receive assistance from nursing staff to stand with the bar. In an interview on February 10, 2020, at 10:33 a.m., the nurse aide (NA1) assigned to Resident 68 stated that the resident was not provided restorative nursing services and that she was unaware of assisting the resident to stand with the bar. Review of the nurse aide task sheet revealed that although NA1 was unaware of the need to provide restorative nursing services for standing with the bar, she had documented that she completed it on January 6, 2020.

CFR 483.25(c)(1)-(3) Increase/Prevent Decrease in ROM/Mobility
Previously cited 3/22/19

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




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

A therapy screen has been initiated for R61 to ensure that the palm protectors are still an appropriate intervention. A therapy screen has been initiated for R68 to ensure an appropriate Restorative Program is in place. The Director of Therapy will review residents who are being discharged from therapy and transitioned to a splinting and/or Restorative Program at the morning risk meeting. The nursing staff will be re-educated on ROM/Mobility. The R.N.A.C. and/or her designee will conduct random audits of splinting and Restorative Programs to ensure continued compliance weekly X 3 then monthly X 3. The results of the random audits will be presented to the Quality Assurance Team for review and further recommendations as appropriate.
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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that adequate supervision to prevent unsafe wandering was provided for one of 25 sampled residents. (Resident 83)

Findings include:

Review of the facility policy entitled "Wanderguard Process," dated January 23, 2020, revealed that residents identified at risk for elopement were to have a Wanderguard (an alarm device that sounds when a resident leaves the building to alert staff) placed directly on the wrist or ankle of the resident to ensure their safety. The policy further indicated that a picture of the resident was to be placed in the "elopement book" (a book containing photographs of all resident at risk for unsafe wandering which was kept in the receptionist's area) for identification of the residents who have Wanderguards.

Clinical record review revealed that Resident 83 was admitted to the facility on January 3, 2020 and had diagnoses that included right eye blindness and dementia. Review of the Minimum Data Set (MDS) assessment, dated January 14, 2020, revealed that the resident had short and long term memory impairment. The elopement risk assessment dated January 3, 2020, indicated that the resident was at high risk for wandering. Review of the admission summary note on January 3, 2020, revealed that the resident was confused, talked about "going into the woods," and that nursing had placed a Wanderguard on his left ankle. The initial care plan identified that the resident was a risk for wandering and interventions included to ensure that the Wanderguard was in place and for staff to walk with the resident and redirect him.

A nursing progress note dated January 10, 2020, at 4:26 p.m., indicated that the resident was found outside of the building with his Wanderguard in place. There was lack of documentation to show that nursing staff knew the location of the the resident at the time of the incident.

In an interview on February 10, 2020, at 2:38 p.m., the front desk receptionist (Employee 1), stated that she had turned the door alarm off on January 10, 2020, when the elopement incident occurred at 4:13 p.m. without physically investigating the cause of the alarm to check if the resident who left the building was included in the "elopement book."

In an interview on February 11, 2020, at 3:03 p.m., the Nursing Home Administrator confirmed that staff failed to identify that a resident had left the building without supervision.

28 Pa. code 211.12(d)(1)(5) Nursing services.




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

Resident 83 was appropriately identified as at risk for wandering. The reception staff has been re-educated on their duties at the front desk. The receptionist, at the start of his or her shift, will be required to review the elopement book to ensure that they are aware of any changes. The N.H.A. and/or her designee will randomly audit incident reports weekly X 3 then monthly X 3 to ensure compliance with supervision. The results of the random audits will be presented to the Quality Assurance Team for review and further recommendation as appropriate.
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 clinical record review and staff interview, it was determined that the facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of as needed pain medication for two of 25 sampled residents. (Residents 103, 153)

Findings include:

Clinical record review revealed that Resident 103 was admitted to the facility on October 29, 2019, with diagnoses that included surgical repair of a left hip fracture and a left elbow fracture. The Minimum Data Set (MDS) assessment dated November 9, 2019, indicated that the resident was alert and oriented and had experienced frequent pain in the previous five days. Review of the current care plan identified the resident was at risk for pain related to the surgical repair of the left elbow and hip and neuropathy. There was an intervention for rest periods, a calm environment and position to facilitate relief when experiencing pain. On October 9, 2019, a physician ordered that staff administer hydrocodone (a pain medication) every four hours as needed for moderate pain, morphine (a pain medication) every eight hours as needed for severe pain, and oxycodone (a pain medication) every four hours as needed for pain. Review of the November 2019 Medication Administration Record (MAR) revealed that the resident had received the hydrocodone ten times, morphine eight times, and oxycodone 16 times. There was no documented evidence that staff offered non-pharmacological interventions prior to the administration of the as needed pain medication.

Clinical record review revealed that Resident 153 was admitted to the facility on December 4, 2019, with diagnoses that included encephalopathy, abnormal gain and osteoarthritis. The MDS assessment dated December 10, 2019, indicated that the resident was alert and oriented and had experienced frequent pain in the previous five days. Review of the current care plan identified the resident was at risk for pain related to osteoarthritis and fibromyalgia. There was an intervention for rest periods, and a quiet calm environment to facilitate relief when experiencing pain. On December 4, 2019, a physician ordered that staff administer Tylenol Arthritis (a pain medication) as needed and on December 12, 2019, a physician ordered that staff to administer Tylenol (a pain medication) two tablets every four hours as needed. Review of the December 2019, MAR revealed that the resident had received the Tylenol Arthritis 13 times and the Tylenol 14 times. There was no documented evidence that staff offered non-pharmacological interventions prior to the administration of the as needed pain medication.

In an interview on February 12, 2020, at 10:16 a.m., the Director of Nursing confirmed that there was no documented evidence that staff had offered non-pharmacological interventions prior to the administration of the as needed pain medication for the two aforementioned residents.



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

Resident 103 and 153 are both discharged residents. The licensed nursing staff will be re-educated on Non-Pharmacological interventions. At the morning risk meeting, the Director of Nursing and/or his designee will review PRN pain medication administration records to ensure that non-pharmacological interventions are documented. The D.O.N. and/or his designee will randomly audit PRN pain administration documentation to ensure that NPI'S have been documented weekly X 3 then monthly X 3. The results of the random audits will be presented to the Quality Assurance team for review and further recommendations as appropriate.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on observation, it was determined that the facility failed to ensure that sanitary conditions were provided during meal service for one of 25 sampled residents in the dining room. (Resident 86)

Findings include:

During observation of lunch on February 9, 2020, from 12:20 p.m. through 12:40 p.m., in the dining room, Registered Nurse 1 (RN1) was observed feeding Resident 86. RN1 was observed multiple times putting her finger in her mouth and then continued to feed Resident 86 with the hand that was in her mouth. RN1 did not wash or sanitize her hands before she continued to feed the resident.

CFR: 483.80(a)(1)(2)(4)(e)(f) Infection Control
Previously cited 3/22/19

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



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

The nursing staff will be re-educated on infection control and prevention and more specifically that no one should put his/her hand in their mouth while feeding a resident. The N.H.A. and/or her designee will randomly audit meals X 3 weeks then monthly X 3 to ensure that no staff member is putting his/her hands in their mouth while feeding a resident. The results of the random audits will be presented to the Quality Assurance team for review and further recommendations as appropriate.

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