Nursing Investigation Results -

Pennsylvania Department of Health
VIBRA REHABILITATION CENTER
Patient Care Inspection Results

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VIBRA REHABILITATION CENTER
Inspection Results For:

There are  68 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.
VIBRA REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure and Civil Rights survey completed on August 14, 2019, it was determined that Vibra 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:


483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.
Observations:


Based on select policy review, clinical record review and staff interview, it were determined that the facility failed to ensure that residents code status was accurate according to the residents wishes for two of 30 residents (Residents 2 and 189), which placed both residents at risk for harm and placed 28 residents at the facility in an Immediate Jeopardy situation (Residents 4, 8, 12, 18, 19, 23, 27, 28, 29, 30, 32, 34, 35, 37, 38, 39, 40, 41, 42, 43, 44, 45, 188, 190, 191, 192, 193, and 194).

Findings Include:

Review of the facility policy titled, "DNR" (Do Not Resuscitate-also known as no code or allow natural death, is a legal order indicating that a person does not want to receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating) with a review date of April 21, 2019, revealed "The Pennsylvania specific form should be used to specify whether to administer CPR [Cardio-pulmonary Resuscitation-a medical technique for reviving someone whose heart has stopped beating by pressing on their chest and breathing into their mouth] in case of a medical emergency. Pennsylvania specific form is: a. Pennsylvania Orders for Life-Sustaining Treatment (POLST)." "The Interdisciplinary Care Planning Team will review advance directives with the patient during the forty-eight-hour care plan meeting and with any change in condition to determine if the patient/legal representative wishes to make changes in such directives." "The patient's Attending physician will clarify and present any relevant medical issues and decisions to the patient's or legal representative as the patient's condition changes in an effort to clarify and adhere to the patient's wishes." "The physician will enter, sign, and date the Do Not Resuscitate (DNR) order in the following place: a. The POLST and/or Physician Order Sheet. b. The order must contain the words 'Do Not Resuscitate' or 'DNR'."

Review of the facility's admission packet (a packet of information to include information about rights as a resident of a nursing facility) revealed "d) Advance Directives [a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor]. The Resident has a right to formulate advance directives consistent with applicable state and federal law. The Community shall act in accordance with the Resident's advance directives, if the advance directives are legally binding under applicable state law and the Resident provides the Community with a copy of the executed advance directives. It is the responsibility of the Resident to timely provide the Community with copies of the Resident's advance directives for reference and incorporation into the Resident's medical record."

On August 11, 2019, at 11:50 AM surveyors requested the advanced directive policy from the Director of Nursing (DON). At 12:33 PM the surveyors were still waiting on the advanced directive policy. At that time the surveyor asked the receptionist to get the DON for an update on the policy. At approximately 12:40 PM the DON provided the surveyors with a copy of the DNR policy and the CPR policy. The DON stated those were the only policies she could find related to advanced directives.

Review of Resident's 2 clinical record revealed he was admitted to the facility on November 19, 2018, with diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and hypertension (elevated blood pressure). Further review of Resident 2's clinical record revealed a document titled, "Living Will Declaration" signed by Resident 2 and witnessed by a Notary Public on September 23, 2004, which revealed that Resident 2 did not want cardiac resuscitation. Further review of the Living Will revealed that Resident 2 appointed his wife as his surrogate and his children as additional surrogates, in case his wife is unable or unwilling to act for Resident 2. An additional review of Resident 2's clinical record revealed a POLST form, signed by Resident 2's daughter on November 22, 2018, and signed by the physician on December 17, 2018, stating that Resident 2 is a "Do Not Attempt Resuscitation/DNR (Allow Natural Death)."

Review of Resident 2's physician orders as of August 11, 2019, revealed an order dated November 19, 2018, for a "Full Code" (meaning that CPR will be performed in the event Resident 2's heart stops). Review of Resident 2's electronic medical record revealed that Resident 2 was listed as a Full Code. Review of Resident 2's Medication Administration Record (MAR), dated July 2019 revealed, "Communication: Pt's [patient's] electronic chart has pt. listed as FULL CODE revised on 11/19/18; pt's POLST in his chart signed 11/22/18, by decision maker says DNR; physician signed on 12/17/18-please re-eval [reevaluate] one time only for Verification on code status for 1 day" starting on July 29, 2019, at 6:00 AM. On July 29, 2019, at 2:40 PM Licensed Practical Nurse (LPN) 2 put a check mark on the MAR, indicating that the code status was verified. As of August 11, 2019, at 2:50 PM Resident 2's POLST stated DNR and Resident 2's physician order was for Full Code.

Review of Resident 189's clinical record revealed that he was admitted to the facility on August 9, 2019, with diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells) and hypertension. Further review of Resident 189's clinical record revealed a form titled "Living Will Health Care Directive" signed by Resident 189 and witnessed by Notary Public on March 16, 2005, that stated Resident 189 does not want cardiac resuscitation. As of August 11, 2019, at approximately 11:30 AM Resident 189 did not have a completed POLST in his clinical record. Review of Resident 189's active orders as of August 11, 2019, at 12:54 PM revealed an order written on August 9, 2019 for "Full Code." Review of Resident 189's electronic medical record revealed that Resident 189 was listed as a Full Code.

During an interview with Licensed Practiical Nurse (LPN) 3 on August 11, 2019, at 11:20 AM, LPN 3 revealed in the event of an emergency staff would run to the resident's chart behind the desk and look for the code status noted on the POLST. LPN 3 also stated she would not take the time to look in the computer system to determine the resident's code status.

During an interview with the nursing assistant (NA) 1 on August 11, 2019, at 11:43 AM, NA 1 revealed in the event of an emergency she would "find the nurse on my hall." NA 1 also stated she believes the resident code status is "kept on chart."

During an interview with Registered Nurse (RN) 1 on August 11, 2019, at 11:45 AM, RN 1 stated that if she needed to determine a resident's code status in an emergent situation, she would look in the paper chart at the physician orders, because it is easier than looking in the electronic medical record. She stated that in addition to the orders, she would also look at the resident's POLST. RN 1 was asked what she would do if there was a discrepancy with the orders and POLST and she stated that the Resident would be a Full Code until the discrepancy was verified.

During an interview with LPN 1 on August 11, 2019, at 11:47 AM, LPN 1 stated that if he didn't know a Resident's code status during an emergent situation, he would look in their electronic medical record.

On August 11, 2019, at 1:15 PM the Director of Nursing (DON) was asked what staff were to do if a resident was found unresponsive and staff needed to know the code status of the resident. The DON stated that staff would go to the electronic health record, not the paper chart because that is too cumbersome. She stated that staff are always near a Kiosk, which are located on the wall in the hallways.

The Nursing Home Administrator (NHA) and DON were notified of the Immediate Jeopardy situation on August 11, 2019, at 2:50 PM. An immediate action plan was requested.

The immediate action plan was provided by the NHA on August 11, 2019, at 4:10 PM and was accepted on August 11, 2019, at 5:05 PM. The plan included:

-The code status of Resident 2 and Resident 189 was verified and entered consistently into all relevant locations within the electronic medical record. Resident 2 and Resident 189's charts were reviewed by the CRNP (Certified Registered Nurse Practitioner); she spoke with residents and families-both have current, active orders for "Do Not Resuscitate."

-Determining the code status or presence/absence of Advance Directives is required for all residents. Therefore, all residents have the potential to be affected.

-The DON will educate social services, admission staff and all licensed nurses on duty regarding the documentation procedures for Advance Directives/code status. The RN on duty was trained and demonstrated a good understanding. He will educate all oncoming licensed staff regarding the documentation procedures for Advance Directives/code status. Education will be ongoing until all staff have been in-serviced. A chart audit of all residents was completed on August 11, 2019. Discrepant findings were addressed immediately, and all needed actions were completed on August 11, 2019.

-All new admissions will be reviewed at time of admission; then every 24 hours at daily stand up. Once facility is 100% compliant for 30 days, then weekly. For a period of three months, the Director of Social Services or designee will perform weekly medical record audits of new admissions and those residents on the MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) assessment schedule for consistent documentation of the resident's Advance Directive/code status throughout the electronic medical record and hard chart. After three months, the Director of Social Services will compete a random medical record audit of at least 10 records for consistent documentation. Results of the audits will be discussed monthly with the QAA committee until such time it is determined that substantial compliance is maintained.

On August 12, 2019, during an onsite visit, the Immediate Jeopardy was lifted at 2:05 PM after interviews were conducted with staff ensuring the immediate action plan had been implemented.

The facility failed to ensure that residents' code status were accurate according to the residents wishes for two of 30 residents (Residents 2 and 189), which placed both residents at risk for harm and placed 28 residents at the facility in an Immediate Jeopardy situation (Residents 4, 8, 12, 18, 19, 23, 27, 28, 29, 30, 32, 34, 35, 37, 38, 39, 40, 41, 42, 43, 44, 45, 188, 190, 191, 192, 193, and 194).

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/19/18, 10/10/18, 7/2/18.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 4/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17.

28 Pa. Code 201.18(b)(3) Management.
Previously cited 10/10/18, 7/2/18, 6/24/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 1/13/19, 12/19/18, 10/10/18, 7/2/18.

28 Pa. Code 201.20(a) Staff development.

28 Pa. Code 201.29(a) Resident rights.
Previously cited 7/20/17.

28 Pa. Code 201.29(d) Resident rights.
Previously cited 7/1/19.

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

28 Pa. Code 211.10(c) Resident care policies.
Previously cited 7/1/19.

28 Pa. Code 211.10(d) Resident care policies.
Previously cited 10/10/18, 6/24/18, 7/20/17.

28 Pa. Code 211.12(c) Nursing services.
Previously cited 7/1/19, 10/10/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17.

28 Pa. Code 211.12(d)(2) Nursing services.
Previously cited 12/19/18, 7/2/18, 5/7/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/1/19, 3/29/19, 10/10/18, 7/2/18, 5/7/18, 7/20/17.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 6/24/18, 5/7/18, 7/20/17.























 Plan of Correction - To be completed: 09/20/2019

678
1. The code status of RI# 189 and RI# 2 was verified and entered consistently into all relevant locations within the chart and the electronic medical record.

RI# 189 and RI# 2 have current DNR orders.

2. A chart audit of current residents was completed on 08/11/2019 by the Director of Nursing and the Transitional Care Nurse. No discrepancies were found.

3. The Director of Nursing educated social services, admission staff, the therapy staff and licensed nurses regarding the documentation procedures for Advance Directives/code status. Documentation procedures will be continued Director of Nursing
Nursing Staff and Nursing Home Administrator will have a Directed In-service by an approved vendor on 9/5/19 covering F678 and the accompanying guidelines.

4. The Social Service Director/designee will audit new admission charts five days a week times twelve weeks to verify that the codes status coincides with the Advanced Directives. Director of Social Services/designee will audit 10 random records per week times 12 weeks verify the codes status coincides with the Advanced Directives. Results of the weekly audits will be trended into a monthly report and presented to the Quality Assurance and Performance Improvement Committee until such time it is determined that substantial compliance is maintained.

483.70 REQUIREMENT Administration:This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:


Based on review of job descriptions, facility policy review, clinical record review, and staff interviews, it was determined that the facility administration failed to effectively manage the code status for residents to ensure accuracy in accordance with the resident wishes, which placed the residents at harm and in an Immediate Jeopardy situation.

Findings Include:

Review of the job description for the Nursing Home Administrator (NHA), with a revision date of May 2017, revealed in the "Position Summary: Responsible for daily operations of the Skilled Nursing Facility and Assisted Living Facility in accordance with current applicable Federal, State, and local standards, guidelines, and regulations as directed by the policies and procedures." "Ensures competence of the staff, appropriate staffing for resident setting, and facilitates clinical program development. Responsible for planning the appropriate utilization of resources, maintaining or improving the work environment, and monitoring and improving the quality and appropriateness of care."

Review of the job description for the Director of Nursing (DON), with a revision date of May 2017, revealed in the "Position Summary: Responsible for the administration of nursing services in the Skilled Nursing Facility." "Interprets facility policies and regulations to all nursing personnel and ensures compliance, as well as analyzes and evaluates nursing and related services rendered to improve quality of customer care and to better utilize staff time and abilities. Also ensures the provision of in-service training programs for nursing personnel." Further review of the job description under "Job Function" revealed "Ensures that all physician orders are current and being followed by nursing staff." "Knowledge and implementation of all applicable regulations, facility and personnel policies and procedures and keeping nursing department in compliance with same."

Review of the facility's admission packet (a packet of information to include information about rights as a resident of a nursing facility) revealed, "d) Advance Directives [a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor]. The Resident has a right to formulate advance directives consistent with applicable state and federal law. The Community shall act in accordance with the Resident's advance directives, if the advance directives are legally binding under applicable state law and the Resident provides the Community with a copy of the executed advance directives. It is the responsibility of the Resident to timely provide the Community with copies of the Resident's advance directives for reference and incorporation into the Resident's medical record."

Review of Resident 2's clinical record revealed he was admitted to the facility on November 19, 2018, with diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and hypertension (elevated blood pressure). Further review of Resident 2's clinical record revealed a document titled, Living Will Declaration signed by Resident 2 and witnessed by a Notary Public on September 23, 2004, revealed that Resident 2 does not want cardiac resuscitation. Further review of the Living Will revealed that Resident 2 appointed his wife as his surrogate and his children as additional surrogates, in case his wife is unable or unwilling to act for Resident 2. An additional review of Resident 2's clinical record revealed a POLST form, signed by Resident 2's daughter on November 22, 2018, and signed by the physician on December 17, 2018, stating that Resident 2 is a "Do Not Attempt Resuscitation/DNR (Allow Natural Death)."

Review of Resident 2's physician orders as of August 11, 2019, revealed an order dated November 19, 2018, for a "Full Code" (meaning that CPR will be performed in the event Resident 2's heart stops). Review of Resident 2's electronic medical record revealed that Resident 2 was listed as a Full Code. Review of Resident 2's Medication Administration Record (MAR), dated July 2019 revealed, "Communication: Pt's [patient's] electronic chart has pt listed as FULL CODE revised on 11/19/18; pt's POLST in his chart, signed 11/22/18, by decision maker says DNR; physician signed on 12/17/18-please re-eval [reevaluate] one time only for Verification on code status for 1 day" starting on July 29, 2019, at 6:00 AM. On July 29, 2019, at 2:40 PM Licensed Practical Nurse (LPN) 2 put a check mark on the MAR, indicating that the code status was verified. As of August 11, 2019, at 2:50 PM Resident 2's POLST stated DNR and Resident 2's physician order was for Full Code.

Review of Resident 189's clinical record revealed that he was admitted to the facility on August 9, 2019, with diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells) and hypertension. Further review of Resident 189's clinical record revealed a form titled "Living Will Health Care Directive" signed by Resident 189 and witnessed by Notary Public on March 16, 2005, that stated Resident 189 does not want cardiac resuscitation. As of August 11, 2019, at approximately 11:30 AM Resident 189 did not have a completed POLST in his clinical record. Review of Resident 189's active orders as of August 11, 2019, at 12:54 PM revealed an order written on August 9, 2019, for "Full Code." Review of Resident 189's electronic medical record revealed that Resident 189 was listed as a Full Code.

During an interview with Licensed Practical Nurse (LPN) 3, on August 11, 2019, at 11:20 AM LPN 3 revealed in the event of an emergency staff would run to the resident's chart behind the desk and look for the code status noted on the POLST. LPN 3 also stated she would not take the time to look in the computer system to determine the resident's code status.

During an interview with Nursing Assistant (NA) 1, on August 11, 2019, at 11:43 AM NA 1 revealed in the event of an emergency she would "find the nurse on my hall." NA 1 also stated she believes the resident code status is "kept on chart."

During an interview with Registered Nurse (RN) 1 on August 11, 2019, at 11:45 AM RN 1 stated that if she needed to determine a resident's code status in an emergent situation, she would look in the paper chart at the physician orders, because it is easier than looking in the electronic medical record. She stated that in addition to the orders, she would also look at the resident's POLST. RN 1 was asked what she would do if there was a discrepancy with the orders and POLST and she stated that the resident would be a Full Code until the discrepancy was verified.

During an interview with LPN 1 on August 11, 2019, at 11:47 AM LPN 1 stated that if he didn't know a resident's code status during an emergent situation, he would look in their electronic medical record.

The NHA and DON were notified of the Immediate Jeopardy situation on August 11, 2019, at 2:50 PM. An immediate action plan was requested.

The immediate action plan was provided by the NHA on August 11, 2019, at 4:10 PM and was accepted on August 11, 2019, at 5:05 PM. The plan included:

-The code status of Resident 2 and Resident 189 was verified and entered consistently into all relevant locations within the electronic medical record. Resident 2 and Resident 189's charts were reviewed by the CRNP (Certified Registered Nurse Practioner); she spoke with residents and families-both have current, active orders for "Do Not Resuscitate."

-Determining the code status or presence/absence of Advance Directives is required for all residents. Therefore, all residents have the potential to be affected.

-The DON will educate social services, admission staff and all licensed nurses on duty regarding the documentation procedures for Advance Directives/code status. The RN on duty was trained and demonstrated a good understanding. He will educate all oncoming licensed staff regarding the documentation procedures for Advance Directives/code status. Education will be ongoing until all staff have been in-serviced. A chart audit of all residents was completed on August 11, 2019. Discrepant findings were addressed immediately, and all needed actions were completed on August 11, 2019.

All new admissions will be reviewed at time of admission; then every 24 hours at daily stand up. Once facility is 100% compliant for 30 days, then weekly. For a period of three months, the Director of Social Services or designee will perform weekly medical record audits of new admissions and those residents on the MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) assessment schedule for consistent documentation of the resident's Advance Directive/code status throughout the electronic medical record and hard chart. After three months, the Director of Social Services will compete a random medical record audit of at least 10 records for consistent documentation. Results of the audits will be discussed monthly with the QAA committee until such time it is determined that substantial compliance is maintained.

On August 12, 2019, during an onsite visit, the Immediate Jeopardy was lifted at 2:05 PM after interviews were conducted with staff ensuring the immediate action plan had been implemented.

The facility administration failed to effectively manage the code status for residents to ensure accuracy in accordance with the resident wishes which placed the residents at harm and in an Immediate Jeopardy situation.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/19/18, 10/10/18, 7/2/18.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 4/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17.

28 Pa. Code 201.18(b)(3) Management.
Previously cited 10/10/18, 7/2/18, 6/24/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 1/13/19, 12/19/18, 10/10/18, 7/2/18.

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

28 Pa. Code 201.20(a) Staff development.

28 Pa. Code 211.12(c) Nursing services.
Previously cited 7/1/19, 10/10/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17.

28 Pa. Code 211.12(d)(2) Nursing services.
Previously cited 12/19/18, 7/2/18, 5/7/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/1/19, 3/29/19, 10/10/18, 7/2/18, 5/7/18, 7/20/17.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 6/24/18, 5/7/18, 7/20/17.



















 Plan of Correction - To be completed: 09/20/2019

F 835
1.The code status of RI# 189 and RI# 2 was verified and entered consistently into all relevant locations within the chart and the electronic medical record.
RI# 189 and RI# 2 have current DNR orders.

2. A chart audit of current residents was completed on 08/11/2019 by the Director of Nursing and the Transitional Care Nurse.
No discrepancies were found.

3. The Director of Nursing educated social services, admission staff, the therapy staff and licensed nurses regarding the documentation procedures for Advance Directives/code status. Documentation procedures will be continued Director of Nursing
Nursing Staff and Nursing Home Administrator will have a Directed In-service by an approved vendor on 9/5/19 covering F678 and the accompanying guidelines.

4. The Social Service Director/designee will audit new admission charts five days a week times twelve weeks to verify that the codes status coincides with the Advanced Directives. Director of Social Services/designee will audit 10 random records per week times 12 weeks verify the codes status coincides with the Advanced Directives. Results of the weekly audits will be trended into a monthly report and presented to the Quality Assurance and Performance Improvement Committee until such time it is determined that substantial compliance is maintained.

483.25 REQUIREMENT Quality of Care:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received treatment and care in accordance with physicians' orders, regarding treatment and assessment of an injury after a fall, resulting in harm of a fractured left 5th finger, which required surgery, for one of 14 resident records reviewed (Resident 19).

Findings Include:

Review of Resident 19's clinical record revealed diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and dementia (a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities).

Review of Resident 19's clinical record revealed that she had a fall on June 18, 2019. Review of facility's incident report for Resident 19 revealed that another resident at the facility observed Resident 19 attempt to wheel herself to the bathroom, lean to her left buttocks and begin to quickly slide onto her left knee. The witness stated that Resident 19 "was attempting to stop her fall with her left hand when her left small [report does not indicate what 'left small' means] got caught between the wheelchair and the pressure relieving cushion." The report goes on to say that the nurse attempted to evaluate Resident 19, but she became agitated and combative and "since it appeared, she was not injured, the staff assisted her back to bed." The Registered Nurse (RN) who was on duty assessed Resident 19 and noted a reddened and slightly swollen left pinky finger. Review of the RN statement on Resident 19's incident reported revealed "I saw her finger and asked if I could look at it, but she shied away from me. I told her I was concerned it might be injured. She refused. I suggested an X-ray; she adamantly refused. The patient is very protective of the finger and would not let staff near the finger."

Review of the incident report for Resident 19 revealed under "Immediate Action Taken: Patient was reassured and comforted. Ice offered. She did tape up her 'pinky finger.' She again refused to have the finger X-rayed." The report states that the on-call physician was notified of the incident and that the resident's daughter was made aware.

Review of Resident 19's progress note, written by the Nursing Home Administrator (NHA) who is also a RN dated June 18, 2019, at 5:30 PM revealed "I caught a glimpse of her left small finger. It was deep red/purple and asked her if I could see it. She quickly pulled her hand from out of my reach and shooshed me, saying it's okay." The progress note states that Resident 19 continuously asked for tape, the NHA gave Resident 19 tape and then left the room. When the NHA came back, the note states that Resident 19 had taped up her left pinky finger. The note states that Resident 19 was "very secretive and did not want anyone to know about the finger." Resident 19 stated that when she fell, she bent it backward on the wheelchair. According to the progress note, the NHA suggested an X-ray a few times, but Resident 19 refused. The NHA provided her with an ice pack, which the note states Resident 19 used off and on. The progress note concludes stating that the NHA "emphasized to the nurse to monitor her for pain, and to keep an eye on the left 'pinky' finger."

Review of progress notes revealed a note dated June 24, 2019, at 10:43 AM stating that the writer met with Resident 19 and noticed her left "pinky and middle finger were taped together." Resident 19 stated, "'I thought it would be better by now, but it is not." Resident 19 agreed to have an X-ray done since the finger was not getting better.

Review of Resident 19's progress notes revealed no mention of her pinky finger being assessed and no mention of the fingers being taped, since the initial note from June 18, 2019. Review of Resident 19's clinical record revealed no evidence that Resident 19 had been re-approached about getting an X-ray, since June 18, 2019 until June 24, 2019. Further review of the clinical record revealed no orders to tape the fingers or apply ice and no evidence that the physician assessed the finger.

On June 24, 2019, Resident 19 had an X-ray of the left hand. Review of the X-ray results revealed flexion/subluxation (an incomplete or partial dislocation of a joint) at the PIP (proximal interphalangeal joint-the joints between the proximal and middle bones of the fingers) area of the 5th finger. "Clinical correlation is recommended. Follow-up studies throughout therapy are also recommended for comparison."

Review of progress note dated June 28, 2019, by the CRNP (Certified Registered Nurse Practitioner) revealed no mention of the left 5th finger. Review of progress note dated July 1, 2019, revealed "Doctor in to see resident and evaluated left pinkie finger. States to leave unwrapped and no further treatment." Review of progress note from the CRNP dated July 2, 2019, at 1:35 PM revealed "left 5th finger deformity noted with significant subluxation of the finger. tender to palpations." "Left 5th finger subluxation, spoke to daughter at length regarding significant subluxation. Daughter request an orthopedic [a physician who specializes in diagnosis and surgical treatment of injuries and disorders involving the musculoskeletal system] eval [evaluation]. Will request referral to attempt to see in AM."

Review of Resident 19's form "Report of Consultation" revealed that she was seen by orthopedics on July 3, 2019. Review of the consultation revealed diagnoses of left pinky PIP dislocation and a tendon tear. Review of a nursing progress note dated July 8, 2019, revealed that Resident 19 is scheduled for surgery on her left 5th digit on July 11, 2019.

Review of Resident 19's physician note by the CRNP, dated July 9, 2019, revealed "Left 5th finger deformity noted with significant subluxation of the finger. tender to palpation." The progress note states that the resident was evaluated by orthopedics and was scheduled for surgical correction on July 11, 2019.

Review of Resident 19's progress note dated July 11, 2019, revealed that Resident 19 returned to the facility with a pinning of the left pinky finger with instructions for dressing to remain intact until her next appointment on July 23, 2019, and to elevate her left upper extremity and apply ice as needed. Resident 19 had a follow-up appointment with orthopedics on July 23, 2019, and they applied a splint to her left small finger.

During an interview on August 13, 2019, at 12:35 PM the NHA stated that at the time of the incident, Resident 19 was protective of her finger. She kept it taped up and she taped it herself. NHA stated that she reported off to the next nurse to monitor the finger. She stated that she would expect the nurses to assess Resident 19, re-approach her about her finger and X-ray, every shift or at least once a day. NHA stated that there was a delay in getting Resident 19 care for her finger. At that time, the NHA also stated that staff should have been assessing the finger since Resident 19 taped it herself, making sure the tape wasn't too tight, her finger had good circulation and that the tape wasn't causing additional injury. Resident 19 taped her finger herself and there was no physician order to do so.

The facility failed to ensure that residents received treatment and care in accordance with physicians' orders, regarding treatment and assessment of an injury after a fall, resulting in harm of a fractured left 5th finger, which required surgery, for one of 14 resident records reviewed (Resident 19).

42 CFR 483.25 Quality of Care.
Previously cited 7/1/19, 3/29/19, 10/10/18, 5/7/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/19/18, 10/10/18, 7/2/18.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 4/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17.

28 Pa. Code 201.18(b)(3) Management.
Previously cited 10/10/18, 7/2/18, 6/24/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 1/13/19, 12/19/18, 10/10/18, 7/2/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 5/7/18, 7/20/17.

28 Pa. Code 211.12(d)(2) Nursing services.
Previously cited 12/19/18, 7/2/18, 5/7/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 7/1/19, 3/29/19, 10/10/18, 7/2/18, 5/7/18, 7/20/17.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 7/1/19, 3/29/19, 12/19/18, 10/10/18, 7/2/18, 6/24/18, 5/7/18, 7/20/17.






















































 Plan of Correction - To be completed: 09/20/2019

F 684
1. R 19's finger was treated per physician order on July 11, 2019.

2. Nursing Director/designee will complete an audit of the previous 30 days risk. Management reports for current residents to verify no medical issues are outstanding.

3. Licensed Nurses will be educated by the Director of Nursing/designee on risk management follow up for 72 hours post an occurrence.
Nursing Staff and Nursing Home Administrator will have a Directed In-service by an approved vendor on 9/5/19 covering F684 and the accompanying guidelines.

4.Nursing Administration will review risk management reports and post occurrence notes five times a week to verify completion. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of 483.95(g).
Observations:


Based on review of personnel files and staff interview it was determined that the facility failed to complete a performance evaluation for every nurse aide for one of four employee records reviewed (Nurse Aide 4).

Findings include:

Review of the facility's current list of nurse aides revealed Nurse Aide 4 (NA) 4 with a hire date of April 17, 2018.

Review of NA 4's personnel file revealed no annual performance evaluation.

An interview with the Corporate Clinical Director, on August 14, 2019, at 9:48 AM confirmed NA 4 had no annual performance evaluation completed that was due April 2019.

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

28 Pa. Code 201.29 Personnel policies and procedures















 Plan of Correction - To be completed: 09/20/2019

F 730
1. Employee 4 will have an annual performance review completed by the Director of Nursing/designee.

2. An audit of current certified nursing assistants' employee files will be completed by Human Resources to identify certified nursing assistants needing annual evaluation. Evaluations will be completed by the Director of Nursing/designee.

3. Human Resources will be educated by the Nursing Home Administrator on identifying certified nursing assistants due for annual evaluation. Director of Nursing will be educated by the Nursing Home Administrator on completion of annual evaluations.

4. Human Resources/designee will identify certified nursing assistants in need of an annual evaluation by the twenty-fifth of the month prior. Human Resources will supply the Director of Nursing with documents needing to be completed. Human Resources will track completion weekly and report monthly to the Quality Assurance Performance Improvement Committee times three month.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
483.95(g) Required in-service training for nurse aides.
In-service training must-

483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

483.95(g)(2) Include dementia management training and resident abuse prevention training.

483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at 483.70(e) and may address the special needs of residents as determined by the facility staff.

483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:


Based on personnel file review and staff interview it was determined that the facility failed to ensure each nurse aide is provided the required in-service training that is no less than twelve hours per year and includes dementia management and resident abuse prevention for four of four nurse aide employee records reviewed (Nurse Aides 2, 3, 4, and 5).

Findings Include:


Review of Nurse Aide 2's (NA) 2's employee training record revealed training completed on April 2, 2019, in the amount of 1.5 hours and August 11, 2019, in the amount of 2 hours.

NA 2's total hours of annual training provided equaled 3.5 hours and included none related to abuse prevention or dementia management.

Review of Nurse Aide 3's (NA) 3's employee training record revealed training completed on August 1, 2018, in the amount of 8 hours, May 6, 2019, in the amount of .5 hours, May 7, 2019, in the amount of .5 hours, August 7, 2019, in the amount of 2 hours, and August 9, 2019, in the amount of .5 hours.

NA 3's total hours of annual training provided equaled 11.5 hours and included none related to abuse prevention or dementia management.

Review of Nurse Aide 4's (NA) 4's employee training record revealed training completed on April 10, 2019, in the amount of 1.0 hour and included none related to abuse prevention or dementia management.

Review of Nurse Aide 5's (NA) 5's employee training record revealed training completed on April 5, 2019, in the amount of 1.0 hour, April 15, 2019, in the amount of .5 hours, May 31, 2019, in the amount of .5 hours, July 21, 2019, in the amount of .5 hours, and July 31, 2019 in the amount of 2 hours.

NA 5's total hours of annual training provided equaled 4.5 hours and included none related to abuse prevention or dementia management.

An interview with the Nursing Home Administrator on August 14, 2019, at 11:13 AM confirmed the selected staff do not have the required annual training.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 201.20 (a) (c) Staff development

28 Pa. Code 201.29 (d) Resident rights





















 Plan of Correction - To be completed: 09/20/2019

F 947
1. Employee 2, 3, 4, and 5 will have twelve hours of annual education completed by 09/06/2019.

2. Audit of current certified nursing assistants will be completed by Human Resources to identify those in need of twelve hours of annual education. Education will be completed by the Director of Nursing/designee.

3. Human Resources will be educated by the Nursing Home Administrator on the need for twelve hours of annual in servicing for certified nursing assistants. Facility will establish a monthly education program for certified nursing assistants, which will meet the twelve-hour annual education requirement.

4. Human Resources will track certified nursing assistant attendance at the monthly education program. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training: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.
483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12.

483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

483.95(c)(3) Dementia management and resident abuse prevention.
Observations:


Based on personnel file review and staff interview it was determined that the facility failed to ensure each nurse aide is provided the required in-service training that includes procedures for reporting incidents of abuse, neglect, exploitation or the misappropriation of resident property, activities that constitute abuse, neglect, exploitation and the misappropriation of resident property and dementia management and abuse prevention for four of four nurse aide employee records reviewed (Nurse Aides 2, 3, 4, and 5).

Findings Include:

Review of Nurse Aide 2's (NA) 2's employee training record revealed training completed on April 2, 2019, in the amount of 1.5 hours and August 11, 2019, in the amount of 2 hours.

NA 2's total hours of annual training provided equaled 3.5 hours and included none related to abuse prevention or dementia management.

Review of Nurse Aide 3's (NA) 3's employee training record revealed training completed on August 1, 2018, in the amount of 8 hours, May 6, 2019, in the amount of .5 hours, May 7, 2019, in the amount of .5 hours, August 7, 2019, in the amount of 2 hours, and August 9, 2019, in the amount of .5 hours.

NA 3's total hours of annual training provided equaled 11.5 hours and included none related to abuse prevention or dementia management.

Review of Nurse Aide 4's (NA) 4's employee training record revealed training completed on April 10, 2019, in the amount of 1.0 hour and included none related to abuse prevention or dementia management.

Review of Nurse Aide 5's (NA) 5's employee training record revealed training completed on April 5, 2019, in the amount of 1.0 hour, April 15, 2019, in the amount of .5 hours, May 31, 2019 in the amount of .5 hours, July 21, 2019, in the amount of .5 hours and July 31, 2019, in the amount of 2 hours.

NA 5's total hours of annual training provided equaled 4.5 hours and included none related to abuse prevention or dementia management.

An interview with the Nursing Home Administrator on August 14, 2019, at 11:13 AM confirmed the selected staff do not have the required annual training.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 201.20(a)(c) Staff development

28 Pa. Code 201.29(d) Resident rights


















 Plan of Correction - To be completed: 09/20/2019

F 943
1. Nurse Aide 2, 3, 4, and 5 will receive education on dementia and the facility abuse policy.

2. Audit of current certified nursing assistants will be completed by Human Resources to identify those in need of abuse and dementia education. Education will be completed by the Director of Nursing/designee.

3. Human Resources and the Director of Nursing will be educated by the Nursing Home Administrator on the need for annual In-servicing on abuse and dementia for certified nursing assistants.

4. Human Resources will track certified nursing assistant attendance to verify completion of the annual education on abuse and dementia. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:


Based on review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent for 26 medication observed administered.

Findings include:

Observations during medication administration on August 13, 2019, revealed that five medication administration errors were made during 26 opportunities for error, resulting in a medication administration error rate of 19.23 percent.

During medication administration on August 13, 2019, at 9:02 AM, Licensed Practical Nurse (LPN) 3 administered Voltaren Gel (applied for pain relief) to Resdient 12's knee. The physcian order was for Voltaren Gel 4 grams (g) to right knee. Observation of LPN 3 revealed she squeezed the gel into the palm of her hand and applied it to Resident 12's knee.

During an interview with LPN 1 at 9:05 AM about how she knew how much gel to administered to equal 4 g, she stated, "I just know because I have been doing it for years". LPN 3 stated that there was no measurement tool with the gel to measure it.

During medication administration on August 13, 2019, at 9:18 AM, LPN 3 administered Gabapentin 300 milligram (mg) (medication to treat nerve pain) to Resident 29. Review of the physician order revealed that Resident 29 was ordered Gabapentin 100 mg.

At 9:18 AM, LPN 3 administered Systane 0.6% (lubricating eye drop) to Resident 29's right eye. Review of the medication instructions revealed that after administering the drops to "Close your eyes for 2 or 3 minutes with your head tipped down, without blinking or squinting. Gently press your finger to the inside corner of the eye for about 1 minute, to keep the liquid from draining into your tear duct"."Wait at least 10 minutes before using any other eye drops your doctor has prescribed". LPN 1 did not instruct the resident to close his eyes for 2-3 minutes or hold pressure for one minute. One minute later LPN 3 administered another eye drop.

At 9:19 AM, LPN 3 administered Timolol 0.5% eye drop (used to treat glaucoma) to Resident 29's right and left eye. Review of the the medication instructions revealed that after the drops are administered "Tilt your head back and drop drug into the eye. After use, keep your eyes closed. Put pressure on the inside corner of the eye. Do this for 1 to 2 minutes. This keeps the drug in your eye. Blot extra solution from the eyelid. If more than 1 drug is being used in the same eye, use each drug at least 5 minutes apart". LPN 3 did not apply pressure to the inside corner of the eye.

Observation of medication administration for Resident 32 revealed LPN 1 prepared Senna-S (combination of 50 mg docusate stool softer and 8.6 mg senna laxative) for administration. Review of Resident 32's physician orders revealed that Resident 32 had an order for only Senna 8.6 mg.

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









 Plan of Correction - To be completed: 09/20/2019

F 759

1. Employee 1 & 3 will be educated and observed on medication administration by the Director of Nursing/designee.
R 12, R 29, R 32 were discharged without incident.

2. Licensed Nurses will be observed on medication administration by the Director of Nursing/designee.

3. Nursing Administration will educate licensed nurses on the medication administration policy.

4. Nursing Administration will observe five nurses per week times twelve weeks during medication pass to ensure correct process is followed. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

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 observation and staff interview it was determined that the facility failed to ensure each resident is treated with respect and dignity in a manner and environment that promotes and enhances his or her quality of life for two of four resident areas reviewed (100 and 200 Halls).

Findings Include:

Review of the Facility's policy titled, "Promoting/Maintaining Resident Dignity," dated June 28, 2019, revealed that staff are to respect the residents living space.

Observations on August 11, 2019, at 10:00 AM and 10:09 AM revealed the Licensed Practical Nurse (LPN 3) entering two resident rooms on the 100 Hall without first knocking or requesting permission to enter.

An observation on August 13, 2019, at 10:22 AM revealed LPN 3 entering a resident room on the 200 Hall without first knocking or requesting permission to enter.

On August 13, 2019, Licensed Practical Nurse (LPN) 3 was observed entering Resident's rooms at 9:02 AM, 9:06 AM, 9:09 AM and 9:12 AM without knocking or requesting permission prior to entering.

28 Pa. Code 201.29(j) Resident rights









 Plan of Correction - To be completed: 09/20/2019

Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists.

This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the facility's credible allegation of compliance.

F550
1. Employee 3 was counseled and educated on resident rights related to knocking on doors, introducing self and addressing patient by proper name completed by the Director of Nursing on 8/20/19.

2. Social Service and Activities/designee will educate current patients on Resident Rights with emphasis on staff entering their room.

3. Employees will be educated by Social Service/designee on Resident Rights with emphasis on knocking on doors and/or requesting permission to enter resident rooms.

4. Social Service/designee will complete three observations five days a week for twelve weeks to verify staff are knocking on resident doors or requesting permission to enter. Weekly reports will be trended into a monthly report by Social Service/designee and presented to the Quality Assurance and Performance Improvement Committee monthly times three months


483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by 483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:


Based on observation, staff and resident interview, it was determined that the facility failed to ensure each resident the right to self-administer medications if the interdisciplinary team has determined the practice is clinically appropriate for one of fourteen residents reviewed (Resident 23).

Findings Include:

Review of Resident 23's August 2019, physician orders revealed diagnoses including Hypertension (elevated blood pressure) and Chronic Kidney Disease (a condition characterized by a gradual loss of kidney function over time).

An observation in Resident 23's room, on August 11, 2019, at 9:42 AM, revealed three pills sitting on her bedside table along with a medication cup containing multiple medications.

An interview with Resident 23 revealed the Licensed Practical Nurse (LPN 3) drops the medications off at her room as she (LPN 3) makes her way down the hall with the medication cart. Resident 23 stated she, herself, usually mixes the medications in oatmeal and self administers the medications at her leisure.

Review of the facility's policy titled, "Self Administration of Medications," most recently reviewed on November 28, 2016, reads "Facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether Self-Administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition." Also, "If a resident Self-Administers his/her medications, Facility, in conjunction with the Interdisciplinary Care Team, should routinely assess the resident's cognitive, physical and visual ability to carry out this responsibility per Faciltiy policy."

Review of Resident 23's clinical record revealed no assessment or interdisciplinary plan of care determining Resident 23's ability to self-administer her medications.

Review of Resident 23's Medication Administration Record (MAR) revealed LPN 3 documented on August 11, 2019, that the medications due in the morning were administered to Resident 23.

An interview with the Nursing Home Administrator (NHA), on August 13, 2019, at 12:30 PM confirmed there was no care plan or assessment for self administration of medications in place for Resident 23. The NHA also confirmed best practice would have been the assessment and care plan development for Resident 23 in regards to the self-administration of medications.

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services


















 Plan of Correction - To be completed: 09/20/2019

F554
1. R 23 is no longer a resident at VibraLife.

2. Current Residents medical records were reviewed by the Director of Nursing/designee to verify they had not requested to self-administer medications. No current residents were identified as requesting self-administration of medication. Tour completed of resident rooms by the Nursing Home Administrator on 08/11/2019, no medications were observed at bedside.

3. Licensed nurses will be educated by the Director of Nursing/designee on policy for resident self-administration of medications.

4. New Admissions will be asked if they want to self-administer medications during the admission process by the Registered Nurse. The Director of Nursing/designee will conduct rounds five times a week for twelve weeks to ensure medications are not left at bedside. Director of Nursing/designee will review requests for self-medication administration during clinical meeting five days a week and initiate the assessment and care plan. A weekly report will be completed for twelve weeks by the Director of Nursing/designee. Weekly reports will be trended into a monthly report by the Director of Nursing/designee and presented to the Quality Assurance and Performance Improvement Committee monthly times three months.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:


Based on observations, resident and staff interviews, it was determined that the facility failed to prominently post the contact information of the grievance official with whom a grievance can be filed, his or her name, business address (mailing and email) and business phone number for one of four resident areas reviewed and during one Resident Council meeting held.

Findings Include:

During the Resident Council group meeting, held August 13, 2019, at 10:05 AM, the residents in attendance revealed they are not aware of a grievance official identified by the facility.

Observations throughout the facility on August 11, 2019, August 12, 2019, and August 13, 2019, revealed no signs posted identifying the facility's grievance official or his or her contact information.

An interview with the Nursing Home Administrator (NHA) on August 13, 2019, at approximately 1:00 PM revealed her belief the grievance official information to be posted at a location observed over three days by the survey team.

An observation on August 13, 2019, at 1:13 PM revealed the receptionist (RC 1) attempting to post a framed sign with the name of the grievance official in the hall previously observed by the survey team.

An immediate interview withe RC 1 revealed she thinks the grievance official posting information must have "fallen off the wall."

28 Pa. Code 201.18(b)(2)(3) Management

28 Pa. Code 201.29(a)(b) Resident rights













 Plan of Correction - To be completed: 09/20/2019

F 585
1. Social Service posted the Grievance Notification process on 8/12/19.

2. Social Service met with current residents on 8/12/19 and reviewed the grievance process.

3. Social Service will be educated by the Nursing Home Administrator on the importance of verifying grievance process is posted.

4. Social Service will interview five residents a week for twelve weeks to verify understanding of the grievance process. Social Service will visualize the grievance posting weekly for twelve weeks. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for one of fourteen residents reviewed (Resident 8).

Findings Include:

Review of the clinical record for Resident 8 revealed diagnoses that included atrial fibrillation (irregular heart beat) and hypertension (elevated blood pressure).

The quarterly Minimum Data Set (MDS) (periodic assessment tool) dated May 29, 2019, was coded that Resident 8 was receiving hospice services. Review of the clinical record revealed that the resident was not on hospice.

During an interview with the Director of Nursing on August 13, 2019, at 2:41 PM, she confirmed that the resident was not on hospice.

28 Pa. Code 211.12(d)(3)(5) Nursing services.






 Plan of Correction - To be completed: 09/20/2019

F 641
1. R 8 Minimum Data Set will be modified by the Registered Nurse Assessment Coordinator to remove the hospice coding.

2. Current residents Minimum Data Set will be audited by the Registered Nurse Assessment Coordinator to verify proper coding of hospice.

3. Registered Nurse Assessment Coordinator will be educated by the Nursing Home Administrator/designee on double-checking coding of hospice prior to submitting.

4. Social Services/designee will audit five assessments weekly times twelve weeks to verify coding of hospice is accurate. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:


Based on facility policy review, clinical record review and staff interview, it was determined that the facility failed to develop and implement a baseline care plan for each resident within 48 hours of resident's admission for one of 14 residents reviewed (Resident 189).

Findings Include:

Review of facility policy titled "Appropriate Use of Indwelling Catheters" (a thin, sterile tube inserted into the bladder to drain urine) with an effective date of June 28, 2019, revealed "The plan of care will address the use of an indwelling urinary catheter, including strategies to prevent complications."

Review of Resident 189's clinical record revealed that he was admitted to the facility on August 9, 2019, with diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells), hypertension (elevated blood pressure), and retention of urine (difficulty urinating and completely emptying the bladder).

Review of Resident 189's current physician orders revealed an order for a Foley catheter (indwelling catheter) for urinary retention, with an order date of August 9, 2019. Review of Resident 189's baseline care plan revealed that the Foley catheter was not part of the care plan.

During an interview on August 13, 2019, at approximately 2:45 PM the Nursing Home Administrator stated that the Foley catheter should have been included in Resident 189's baseline care plan.

28 Pa. Code 211.5(f) Clinical records.

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






 Plan of Correction - To be completed: 09/20/2019

F 655
1. R 189's Foley Catheter was added by the Director of Nursing to the Baseline Care Plan.

2. Current residents with Foley catheters will be audited by the Director of Nursing to verify they are on the baseline care plan.

3. Licensed Nurses will be educated by the Registered Nurse Assessment Coordinator/designee on completion of the baseline care plan.

4. Registered Nurse Assessment Coordinator/designee will audit Baseline Care Plans of new admissions to verify inclusion of Foley catheters times twelve weeks. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

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


Based on clinical record review and staff interview, it was determined that the facility failed to develop comprehensive care plans for two of 15 resident records reviewed (Residents 12 and 24).

Findings Include:

Review of Resident 12's August 2019, physician orders revealed diagnoses including anxiety (a feeling of worry, nervousness, or unease) and major depressive disorder (a mental health disorder characterized by loss of interest and depressed mood).

Review of Resident 12's clinical record revealed an Admission Minimum Data Set (MDS-a tool used to assess all areas specific to the resident) dated June 28, 2019.

Further review of the MDS revealed Resdient 12 triggered in the Care Area Assessment (CAA- areas that may require further assessment and review) for Psychotropic Drug Use.

Review of the CAA Worksheet revealed Resident 12 is prescribed antianxiety and antidepressant medications.

Additional review of the CAA Worksheet revealed the staff decision to proceed to develop care plans to address Resident 12's use of the psychotropic medication.

Review of Resident 12's interdisciplinary plan of care revealed none developed to address the use of the psychotropic medications.

An interview with the Nursing Home Administrator on August 13, 2019, at 12:32 PM confirmed a care plan for the psychotropic drug use should have been developed based on the CAA trigger.

Review of the clinical record for Resident 24 revealed diagnoses that included a femur (upper leg) fracture, atrial fibrillation (irregular heartbeat) and hypertension (elevated blood pressure).

Review of the physcian orders revealed that Resident 24 was ordered an anticoagulant (blood thinner) Eliquis 5 milligrams (mg).

Review of the current care plan revealed that the use of the anticoagulant was not on the care plan.

During an interview with the Director of Nursing on August 14, 2019, at 1:20 PM, she confirmed there was no careplan that addressed the use of an anticoagulant

28 Pa. Code 211.11(d) Resident care plan

28 Pa. Code 211.12(d)(3)(5) Nursing services.

















 Plan of Correction - To be completed: 09/20/2019

F 656
1. R 12's psychotropic care plan was updated by the Director of Nursing.
R 24 no longer resides at VibraLife.

2. Current patients care plans will be audited to verify inclusion of psychotropic medications and anticoagulation therapy.

3. Licensed nurses will be educated by the Registered Nurse Assessment Coordinator/designee on developing a care plan to include psychotropic medications and anticoagulation therapy.

4. Registered Nurse assessment Coordinator/designee will audit five care plans a week for twelve weeks to verify care plans are reflective of psychotropic medications and anticoagulation therapy utilization. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

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 clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 14 residents reviewd (Resident 19).

Findings Include:

Review of Resident 19's clinical record revealed diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and dementia (a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities).

Review of Resident 19's progress notes revealed a note dated June 21, 2019, at 5:00 PM stating "Daughter was in visiting last pm; observed her mom's medications on the over-the-bed table. Mom was rummaging through her drawers frantically looking for something when she arrived. The daughter is worried she may be hoarding her pain medication in the clothing drawer." Resident 19 gave permission for the facility to search her drawers; no pills were found. "Reassured daughter nursing will stay with her mother until she has finished consuming all her medications."

During an interview with the Nursing Home Administrator (NHA) on August 13, 2019, at 12:50 PM she confirmed that medications were left at the bedside by Licensed Practical Nurse (LPN) 4. The NHA stated that she spoke with LPN 4 who stated she was giving Resident 19 her medications when the Resident across the hall was getting out of bed, so she left Resident 19's medications at her bedside while attending to the other Resident. The NHA stated she does not have an investigation of the incident nor documentation of the conversation with LPN 4, but confirmed that LPN 4 did leave medications at Resident 19's bedside.

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

















 Plan of Correction - To be completed: 09/20/2019

F 658
1. Licensed nurse 4 who was identified as leaving medications at the bedside is no longer employed at the facility.

2. Audit of facility was completed by the Nursing Home Administrator to verify no medications were left at the resident bedside.

3. Licensed Nurses will be educated on leaving medications at the bedside by the Director of Nursing/designee.

4. Nursing Administration/designee will complete rounds five times a week for twelve weeks to verify no medications are left at the bedside. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:


Based on facility policy review, clinical record review and staff interview, it was determined that the facility failed to obtain a complete order for an indwelling catheter and failed to follow physician orders related to changing the indwelling catheter for one of one residents reviewed for catheters (Resident 189).

Findings Include:

Review of facility policy titled, "Appropriate Use of Indwelling Catheters," (a thin, sterile tube inserted into the bladder to drain urine) with an effective date of June 28, 2019, revealed "The use of an indwelling urinary catheter will be in accordance with physician orders, which will include the diagnosis or clinical condition making the use of the catheter necessary, size of the catheter, and frequency of change (if applicable).

Review of Resident 189's clinical record revealed that he was admitted to the facility on August 9, 2019, with diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells), hypertension (elevated blood pressure), and retention of urine (difficulty urinating and completely emptying the bladder).

Review of Resident 189's current physician orders revealed an order for a Foley catheter for urinary retention. In the order, the space designated for the size of the catheter is blank and the space designated for the amount of water for the balloon is blank (a balloon on the end of the catheter is filled with water to help keep the catheter in place). Further review of the physician orders revealed an order to change the foley catheter every 30 days and as needed.

Review of Resident 189's Treatment Administration Record (TAR), dated August 2019, revealed that the Foley Catheter was scheduled on the TAR to be changed every other day. Further review of the TAR revealed that the Foley catheter was signed off as being changed on August 9 and on August 11.

On August 13, 2019, at 9:58 AM the Director of Nursing (DON) stated that she put the order for the catheter in the system and it wasn't put in correctly. At that time, she confirmed that the order was not on the TAR correctly and the catheter had been changed both of the aforementioned days. When asked how staff would know what size of catheter to use and how many milliliters to inflate the balloon with when changing the catheter, she stated that the staff would use the same size of the catheter that had previously been inserted.

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



















 Plan of Correction - To be completed: 09/20/2019

F 690
1. R 189's catheter order was updated by the Director of Nursing to include size, amount of water for balloon and clarification of changing.

2. An audit of current patients with catheters was completed by the Director of Nursing to verify catheter orders are complete.

3. Licensed nurses will be educated by the Director of Nursing on catheter order requirements.

4. Nursing Administration will review new catheter orders five times a week for twelve weeks to verify orders contain all required information. Nursing administration will notify attending physician of incomplete Foley catheter orders and obtain clarification. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Performance Improvement Committee for three months.

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 clinical record review and staff interview, it was determined that the facility's consultant pharmacist failed to identify drug irregularities and report them to the attending physician, the medical director and the director or nursing, to be acted upon, for one of five residents reviewed for unnecessary medications (Resident 12).

Findings Include:

Review of Resident 12's August 2019, physician orders revealed diagnoses that included anxiety (a feeling of worry, nervousness, or unease) and major depressive disorder (a mental health disorder characterized by loss of interest and depressed mood).

Further review of Resident 12's physician orders revealed a prescription for Ativan Tablet 0.5 MG every 24 hours PRN (as needed) for anxiety, with a start date of June 23, 2019.

Review of the facility's Required Consultant Services policy, provided on August 12, 2019, pertaining to the contracted pharmacy provider, reads in part, "Consultant shall conduct a medication regimen review ("MRR") for each Facility resident at least once a month." Also, "Consultant shall identify any irregularities as defined in the State Operations Manual."

Review of the pharmacy's Consultation Report revealed Resident 12's clinical record was reviewed by the consultant pharmacist on July 25, 2019 with no new recommendations made to the attending physician, medical director or director of nursing regarding Resident 12's PRN use of the Ativan.

Further review of the Consultation Report reads "...residents were reviewed and based upon the information available at the time of the review...it is my professional judgment that at such time, the residents' medication regimens contained no new irregularities."

An interview with the Clinical Coordinator, on August 14, 2019, at 11:18 AM confirmed staff contacted the prescribing practitioner on that date for the rationale and specific duration for Resident 12's use of the PRN Ativan ordered on June 23, 2019.

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

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









 Plan of Correction - To be completed: 09/20/2019

F 756
1. R 12's physician was contacted by nursing on August 14, 2019 to clarify rationale and duration for the prn Ativan.

2. Pharmacy Consultant reviewed PRN psychotropic medication orders on 08/15/2019. Pharmacy recommendations were made for three patients. Pharmacy recommendations were reviewed with physician by nursing administration/designee.

3. Pharmacy Consultant will be educated by Omnicare on identifying irregularities for psychotropic medications.

4. Pharmacy Consultant will review new psychotropic orders weekly for irregularities. Pharmacy recommendations will be forwarded to the Director of Nursing/designee for review with the attending physician. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:


Based on clinical record review and staff interview it was determined that the facility failed to ensure each resident's use of a PRN (as needed) psychotropic medication is limited to 14 days without documentation of a rationale for use and a specific duration of the medication for three of five resident records reviewed for unnecessary medications (Residents 12, 19, and 35).

Findings Include:

Review of Resident 12's August 2019, physician orders revealed diagnoses that included anxiety (a feeling of worry, nervousness, or unease) and major depressive disorder (a mental health disorder characterized by loss of interest and depressed mood).

Further review of Resident 12's physician orders revealed a prescription for Ativan (antianxiety medication) Tablet 0.5 MG every 24 hours as needed for anxiety, with a start date of June 23, 2019.

Review of Resident 12's clinical record revealed no documentation by the physician or prescribing practitioner of the rationale for the use of the Ativan beyond 14 days and an indication of a specific duration.

An interview with the Clinical Coordinator, on August 14, 2019, at 11:18 AM confirmed staff contacted the prescribing practitioner on that date for the rationale and specific duration for Resident 12's use of the PRN Ativan ordered on June 23, 2019.

Review of Resident 19's clinical record revealed diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and dementia ( a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities).

Review of Resident 19's current physician orders revealed an order for Ativan 0.5 mg (miligrams) every 12 hours as needed for anxiety, with an order date of July 20, 2019.

Review of Resident 19's clinical record revealed no documentation by the physician or prescribing practitioner of the rationale for the use of the PRN (as needed) Ativan beyond 14 days and an indication of a specific duration.

During an interview with the Nursing Home Administrator (NHA) on August 13, 2019, at 12:45 PM she stated that the Ativan should have been reassessed after 14 days, with a rationale given for continued use.

Review of Resident 35's clinical record revealed diagnoses that included Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood) and sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts).

Review of Resident 35's current physician orders revealed an order for Xanax (antianxiety medication) 0.5 mg every 24 hours as needed for anxiety, with an order date of July 25, 2019.

Review of Resident 35's clinical record revealed no documentation by the physician or prescribing practitioner of the rationale for the use of the PRN Xanax beyond 14 days and an indication of a specific duration.

During a staff interview on August 14, 2019, at 11:25 AM the NHA stated that Resident 35's PRN Xanax should have been reevaluated at 14 days.

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

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




 Plan of Correction - To be completed: 09/20/2019

F 758
1. Justifications for PRN psychotropic medications were obtained for R 35, R 19 & R 12 by the Director of Nursing/designee.

2. Audit of current residents on PRN psychotropic will be completed by Consultant pharmacist/designee to verify justification and/or stop date are present.

3. Licensed Nurses will be educated by the Director of Nursing/designee on requirements for PRN psychotropic orders.

4. Consultant Pharmacist will review PRN psychotropic orders weekly to verify and/or justification is met. Pharmacy recommendations will be forwarded to the Director of Nursing/designee for review with the attending physician. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

483.60(e)(1)(2) REQUIREMENT Therapeutic Diet Prescribed by Physician: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(e) Therapeutic Diets
483.60(e)(1) Therapeutic diets must be prescribed by the attending physician.

483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law.
Observations:


Based on clinical record review and staff interviews, it was determined that the facility failed to assess resident diet per physician order, in order to support the resident's treatment plan and plan of care in accordance with his or her goals for one of 14 residents reviewed (Resident 2).

Findings Include:

Review of Resident's 2 clinical record revealed he was admitted to the facility on November 19, 2018, with diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and hypertension (elevated blood pressure).

Review of Resident 2's current physician orders revealed an order, dated November 30, 2018, for a Regular diet-Mechanical soft, ground meats texture, regular consistency, for diet and an order dated July 26, 2019, for a Regular diet- Regular texture, regular consistency for dysphagia (difficulty swallowing). Review of Resident 2's current meal slip for breakfast, lunch, and dinner revealed a diet order of mechanical soft/ground meats.

During an interview with the CDM (Certified Dietary Manager) on August 14, 2019, at 11:23 AM he stated that Resident 2 has always been on a mechanical soft diet and always received mechanical soft. He stated a diet summary report is done at least five days a week which is posted on the unit and the nurse aides can go and look at it.

On August 14, 2019, at 11:25 AM the Nursing Home Administrator stated that the diet order should have been clarified, since there were two different orders.

28 Pa Code 211.6(c)(d) Dietary Services

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













 Plan of Correction - To be completed: 09/20/2019

F 808
1. R2's diet order was clarified by nursing administration to reflect the correct diet.

2. Registered Dietitian/designee will complete an audit of current residents to verify the diet order is correct.

3. Licensed nurses will be educated by the Director of Nursing/designee on discontinuing the old diet order when a new diet order is received.

4. Registered Dietitian will review new diet orders five times a week for twelve weeks to verify diet order is correct and old diet order was discontinued. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance Process Improvement Committee for three months.

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 observations, facility policy review and staff interview, it was determined that the facility failed to follow acceptable infection control practices related to foley catheter bags for one of one residents reviewed for catheters (Resident 189).

Findings Include:

Review of facility policy titled, "Infection Prevention and Control Program," with a revise/review date of June 28, 2019, revealed "It is a policy of VibraLife Mechanicsburg to 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."

Review of Resident 189's clinical record revealed that he was admitted to the facility on August 9, 2019, with diagnoses that included anemia (a condition in which the blood doesn't have enough healthy red blood cells), hypertension (elevated blood pressure), and retention of urine (difficulty urinating and completely emptying the bladder).

Surveyor observation on August 11, 2019, at 9:58 AM revealed Resident 189 sitting in a chair in his room with his Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) bag laying on the floor.

During staff interview on August 13, 2019, at approximately 2:45 PM the Nursing Home Administrator and Director of Nursing stated that Resident 189's catheter bag laying on the floor is not okay.

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













 Plan of Correction - To be completed: 09/20/2019

F 880
1. R 2's Foley catheter bag was removed from the floor by Nursing Administration.

2. An audit of Foley catheter bags was completed by Nursing Administration to verify no other bags were on the floor.

3. Nursing staff will be educated by the Assistant Director of Nursing/designee on infection control related to care of Foley catheter bags.

4. Assistant Director of Nursing/designee will complete an audit five times a week times twelve weeks to identify issues related to Foley catheter bags being on the floor. Weekly reports of findings will be trended into a monthly report and presented to Quality Assurance and Performance Improvement Committee for three months.


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