Nursing Investigation Results -

Pennsylvania Department of Health
WHITESTONE CARE CENTER
Patient Care Inspection Results

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Severity Designations

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

There are  99 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.
WHITESTONE CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Revisit Survey and Abbreviated Complaint Survey completed on September 24, 2019, it was determined that Whitestone Care Center corrected the federal deficiency cited during the survey ending July 30, 2019, but failed to correct the deficiencies cited during the survey ending August 9, 2019, and continued to be out of 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:


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

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

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

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

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

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

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

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

Based on observation and staff interview it was determined that the facility failed to maintain resident care equipment for one resident out 18 sampled (Resident 15) and the resident environment in a clean and orderly manner on two floors of the facility (1st and 2nd).



Findings include:

Observations conducted on September 24, 2019, at 2:00 PM revealed Resident 15 seated in a wheelchair in the hallway on the second floor of the facility. The wheelchair and wheelchair seat cushion were observed to be soiled with dried food particles and food stains. The metal parts of the wheelchair arms were covered in debris.

Observations conducted on September 24, 2019, at 10 AM and throughout the day of the survey ending September 24, 2019, revealed that the carpeting in the hallways on both the first and second floor resident units was dirty, threadbare and ripped away from the floor and walls in multiple areas.

During interview on September 24, 2019, at approximately 4:45 p.m the Nursing Home Administrator confirmed that resident care equipment should be kept clean and confirmed the soiled and worn appearance of the carpeting on the resident units.


483.10 Safe/Clean/Comfortable/Homelike Environment
Continuing deficiency of 8/9/19


28 Pa. Code 207.2 (a) Administrator's responsibility
Continuing deficiency of 8/9/19
Previously cited 7/30/19, 7/20/18






 Plan of Correction - To be completed: 10/23/2019

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

1. Resident #18's wheelchair was cleaned. A work order has been signed and a contractor has been secured to replace flooring. Flooring has been ordered with a delivery date of 10/9/2019. Installation will begin shortly after with an anticipated finish date in early November pending no installation issues.
2. To identify other residents that have the potential to be affected the facility completed an audit of all resident wheelchairs to ensure resident care equipment is maintained. Corrections will be made as needed. To identify other areas that have the potential to be affected the Maintenance Director did a facility audit of units to ensure there were no other carpeting that was dirty, threadbare or ripped away from the floor. Until flooring will be replaced, in the interim all loose threads will be cut down.
3. To prevent this from recurring the facility staff was educated by the DON/designee on maintaining resident care equipment and ensuring resident environment is in a clean and orderly manner. Maintenance and Housekeeping were educated by the DON/designee on maintaining resident care equipment and ensuring resident environment is in a clean and orderly manner.
4. To monitor and maintain ongoing compliance department heads will audit 5 residents weekly and each hall weekly to ensure resident care equipment is maintained and environment is in a clean and orderly manner.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observations and interviews with residents and staff, it was determined that the facility failed to maintain an effective pest control program.

Findings include:

Interview with Resident 7 on September 24, 2019, at 11 AM revealed that the resident stated that recently she has seen ants in her room at the facility.

Interview conducted on September 24, 2019 at 11:15 AM revealed that Resident 10 stated that she had also recently seen ants in her room.

During an interview on September 24, 2019, at approximately 11 AM the Director of Maintenance stated that around the mid-August, facility staff contacted him at home on the weekend and notified him of ants in resident room 108. He confirmed that there were ants in this resident room at that time. He also stated that he contracted the facility's pest control company and it was decided that their monthly scheduled visit was scheduled soon so the company would not come to the facility at the time of this contact.

The maintenance director stated that he then went to a local store, bought some ant traps and put them in several resident rooms. He confirmed that it was several weeks before the pest control company visited the building to perform their scheduled monthly maintenance service. The Director of Maintenance stated that he does not keep a log of maintenance issues, including those involving pests or vermin and therefore was unable to provide specific dates and times for the ant complaints. He further stated that at that time ants were observed in multiple resident rooms, on both on the first and second floors of the facility.

A review of the facility's contract with a pest control company, signed June 2, 2011, and renews itself yearly, revealed that the company's monthly service program provides for inspection and treatment for pests, including common ants.

A review of a pest control invoice for service to the the facility dated August 31, 2019, revealed that the pest control company visited the facility on that date. There was no indication on the invoice of the services that were provided on that date. Further review of monthly pest control invoices dated from March 2019 through August 2019 revealed that these invoices did not identify or detail the services provided to the facility on those dates.

A review of the pest control company's monthly inspection invoices revealed that the facility was inspected on March 31, 2019 and April 30, 2019, May 31, 2019, June 30, 2019, July 31, 2019 and August 31 2019.

During an interview conducted on September 24, 2019, at approximately 12:30 PM Employee 4 (housekeeping) stated that she has recently seen ants in multiple resident rooms on the first floor, especially when there is food and crumbs on the floor. She stated that she did see ant traps on the floor in resident rooms and stated that she throws them away when she discovers them.

There were no inspection reports to demonstrate that the necessary services were provided during the monthly pest control visits when requested during the survey ending September 24, 2019, including the August 31, 2019, report in response to the complaints of ants in the facility.




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

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











 Plan of Correction - To be completed: 10/23/2019

1. The maintenance director did place ant traps in several rooms at time of concern.
2. The Maintenance Director /designee completed an audit of resident rooms. Corrections will be made as needed. The pest control company completed an inspection on 10/04/2019. No issues were identified.
3. To prevent this from reoccurring the NHA/designee educated Maintenance Director on maintain maintenance logs, effective pest control program, and obtaining detailed report of visit.
4. To monitor and maintain ongoing compliance the Maintenance Director/designee will observe 5 rooms weekly x4 then monthly x2 to ensure facility maintains an effective pest control program. Corrections will be made as needed.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on a review of clinical records and interviews with staff and emergency personnel it was determined that the facility failed to promptly report an injury of unknown origin to the State Survey Agency for one resident (Resident CR2) out of 18 residents sampled.

Findings include:

A review of facility policy entitled "Pennsylvania Resident Abuse" revised by the facility on March 3, 2017, revealed that the facility will notify the State Agency within 24 hours when the facility receives a complaint of alleged abuse or neglect.

A review of the clinical record revealed that Resident CR2 was admitted to the facility on August 29, 2019, with a diagnosis of cirrhosis of the liver (Chronic liver damage from a variety of causes leading to scarring and liver failure).

A review of the resident's 5-day MDS Assessment (Minimum Data Set Assessment - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 5, 2019, indicated that the resident was severely cognitively impaired with BIMS score of 7 - (brief interview for mental status score of 7, a score of 0-7 equates to severe cognitive impairment) .

A review of the resident's admission nursing assessment dated August 29, 2019, at 9:54 AM revealed that the resident was admitted to the facility with scabbing on the left toes, an old paracentesis (the perforation of a cavity of the body with a hollow needle to remove fluid) area to the right abdomen, a skin tear to the right arm and a Stage II pressure sore (partial-thickness skin loss) to the sacrum (an area at the base of the spine). No other skin issues were noted by the facility upon the resident's admission.

A review of information received by the State Survey Agency on September 8, 2019, revealed that the resident was sent to the hospital on September 8, 2019. Upon examination at the hospital the resident was found with extensive bruising on the neck, shoulder, chest wall, and flank (the side of a person's body between the ribs and the hip). The hospital had reported the resident's significant bruising to proper agencies as well as the facility.

A review of the ambulance company report of the resident's transfer to the hospital dated September 8, 2019, revealed that the ambulance arrived on scene (at the facility) at 12:51 PM and was with the resident at 12:53 PM. Upon assessment of the resident, the ambulance crew indicated that the resident was lying in bed unattended. The crew member had to leave the room to search for a nurse to get transfer information. The crew member returned to the resident's room with Employee 3, RN, and paperwork for the resident's transfer. Employee 3 left the room stating that he needed to continue what he was doing. Further review of the ambulance report indicated that upon arrival at the facility and prior leaving the facility, the resident had had bruising on the neck left and right arms, chest, and left abdomen. It was also noted that the resident's bed contained scrambled eggs and flies were landing on and around the resident. The ambulance departed the facility at 1:13 PM and arrived and the hospital at 1:18 PM.

On September 24, 2019, at 1:53 PM, the surveyor interviewed a representative of the ambulance company that transported the resident to the hospital. The representative indicated that the EMS crew was on scene at 12:51 PM on September 8, 2019. The EMS crew conducted an assessment of the resident at the facility prior to transport, which revealed that the resident had bruising on the neck, chest and arms.

The facility failed to report the resident's injuries of unknown origin to the State Survey Agency as of the date of the survey ending September 24, 2019.

Interview conducted on September 24, 2019, at approximately 5:00 PM revealed that the NHA (nursing home administrator) confirmed that the facility had not reported the resident's injuries of unknown origin to the State Survey Agency. The NHA stated that the resident's injuries of unknown source were not reported because the facility did not have documentation that the resident's bruising had been identified prior to the resident leaving the facility.

Refer F610



28 Pa. Code: 201.14 (a)(c)(e) Responsibility of licensee.
Continuing deficiency of 8/9/19

28 Pa. Code: 201.18 (e)(1) Management.
Previously cited 7/20/19

28 Pa. Code 211.12 (c)(d)(5) Nursing services
Continuing deficiency of 8/9/19
Previously cited 7/20/19,1/27/19, 1/3/19, 7/30/19











 Plan of Correction - To be completed: 10/23/2019

F609 Reporting of Alleged Violations:
1. Resident CR2 no longer resides at the facility. The facility had no documentation that Resident CR2 had bruising prior to leaving the facility. The facility did complete an investigation.
2. To identify other residents that have the potential to be affected, facility department heads conducted abuse questionnaires with interviewable residents to identify any concerns of abuse. Education was provided to residents at time of interview on reporting if needed. Any negative findings will be reported and investigated as needed. For noninterviewable residents, nursing completed body checks for any signs or symptoms of abuse (injury of unknown origin). Any negative findings will be reported and investigated as needed. An audit of residents whom left the facility in the past 7 days will reviewed to ensure a departure skin check was completed.
3. To prevent this from recurring, the NHA /designee will educate staff on the abuse and neglect policy; with emphasis on reporting (injury of unknown origin) and licensed nursing staff on completing and documentation of skin assessments upon admission, departure, and weekly.
4. To monitor and maintain ongoing compliance the DON/designee will review 5 progress notes weekly x4 then monthly x2 to ensure any potential injuries of unknown origin or concerns or abuse are reported and 5 skin check audits weekly x 4 then monthly x 2 to ensure completion.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on observation, review of the facility's abuse prohibition policy, clinical records and facility documents and interviews with residents, staff and emergency services personnel it was determined that the facility failed to timely and thoroughly investigate alleged neglect and an injury of unknown origin for two of 15 residents reviewed (Residents 13 and CR2).

Findings include:

A review of the facility policy entitled Resident Abuse, no date of revision, indicated the facility's definition of neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or mental illness. When the facility is made aware of the allegation or suspicion an investigation will be conducted.

A review of the clinical record revealed that Resident 13 was admitted to the facility on August 6, 2019, with a diagnosis of a fracture of her left ankle and foot.

A review of the resident's 30-day MDS Assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to pan resident care) dated September 3, 2019, indicated that the resident was cognitively intact, with a BIMS score of 15 (brief interview for mental status score - tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact).

A review of physician's orders dated September 12, 2019, revealed an order that a clean, dry dressing was to be applied to the posterior incision site to be changed every 3 days and the incision site was to be kept clean and dry.

An interview conducted with Resident 13 on September 24, 2019 at 12:10 p.m. revealed that the resident stated that she requires a dressing change to the surgical site on her left leg.
The resident stated her dressing needed to be changed on September 21, 2019. The resident stated that she questioned Employee 2, a licensed practical nurse (LPN) regarding the scheduled dressing change. Resident 13 stated that Employee 2 replied "I don't have time to do your dressing, I have three others to do!".

Resident 13 stated she then proceeded to change her dressing herself. Observation of the resident's dressing on September 24, 2019, revealed a dry dressing with an ace wrap surrounding the resident's left leg underneath an immobilizer. The resident stated "look I can show you I did it myself." The resident then removed the immobilizer (brace to ensure movement of extremity is limited after an injury) and an ace wrap (woven elastic material bandage for wrapping or binding a body part) was present, but poorly wrapped around her leg. The resident also stated that she had informed the facility that Employee 2 had refused to change her dressing.

A review of the resident's treatment record revealed staff initials on September 21, 2019 at 8:00 p.m. indicating that Employee 2 had performed the resident's dressing change on the date Resident 13 alleged that Employee 2 did not complete the dressing change. Employee 2 was unavailable at the time of the survey for interview.

There was no documented evidence at the time of the survey ending September 24, 2019, that the facility had investigated Resident 13's allegation of neglect by Employee 2. The NHA confirmed during interview on September 24, 2019, at 4 PM that the facility was unable to provide evidence that Resident 13's allegation of neglect had been investigated.

A review of Resident CR2's clinical record revealed admission to the facility on August 29, 2019, with a diagnosis of cirrhosis of the liver (scarring of the liver caused by many forms of liver diseases).

A review of the resident's 5-day MDS dated September 5, 2019 indicated the resident had a BIMS score of 7 indicating severe cognitive impairment.

A review of the resident's admission nursing assessment dated August 29, 2019, at 9:54 AM revealed that upon the resident's admission to the facility the facility noted scabbing on the left toes, an old paracentesis (the perforation of a cavity of the body with a hollow needle to remove fluid) area to the right abdomen, a skin tear to the right arm and a Stage II pressure sore (partial-thickness skin loss) to the sacrum (an area at the base of the spine). No other skin issues were noted at the time of the resident's admission.

A review of a skin assessment completed on September 5, 2019, at 3:05 PM revealed that the resident left the facility for paracentesis and returned at 2:45 PM. The documentation indicated that the resident's skin was intact and no new issues were found upon the resident's return to the facility.

A review of a skin assessment completed on September 6, 2019, at 12:07 AM revealed that the resident's documented skin issues included an area to the right heel, left heel, sacrum and a skin tear to right arm.

A review of nursing documentation revealed on September 8, 2019, at 12:27 PM Resident CR2 was lethargic (sluggish), had generalized weakness and decreased urine output. The physician ordered that the resident be transported to the hospital due to the change in condition.

A review of information received by the State Survey Agency on September 8, 2019, revealed that upon the resident's arrival at the hospital on September 8, 2019, examination revealed that the resident had extensive bruising on the neck, shoulder, chest wall and flank (the side of a person's body between the ribs and the hip). The hospital notified the applicable agencies as well as the facility.

A review of hospital documentation revealed that the resident presented to the hospital on September 9, 2019, due to a change in mental status. The resident was identified with bruising and the hospital was questioning if the resident had a fall in the facility prior to coming to the hospital.

The hospital conducted a CT Scan (computerized tomography combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images \ of the bones, blood vessels and soft tissues inside your body) on September 9, 2019 at 2:17 PM, which revealed the resident had a new compression fracture of the T11 vertebrae (a bone in the spine).

On September 13, 2019, the resident's bruising to left flank measured 32 cm x 20 cm, bruising to the left shoulder 12 cm x 11 cm, bruising to the left shoulder 15 cm x 16 cm and bruising the left breast measuring 10 cm x 6 cm.

A review of a time line completed by the facility in response to surveyor inquiry during the survey ending September 24, 2019, indicated that the resident had bruises to the right and left arm upon admission which reportedly were not documented on the initial nursing skin assessment.

The hospital called the facility on September 8, 2019, informing them of the resident's extensive bruising.

On September 12, 2019, the facility questioned its staff to determine if the resident had fallen. The staff reported that the resident had no witnessed falls and if the resident fell unwitnessed, she would not have been able to put herself back in bed.

On September 17, 2019, the facility reportedly placed a call to the ambulance company who had transported the resident and a left a voice mail.

A review of Employee 3's RN (registered nurse) witness statement dated September 17, 2019 (no time written) revealed that the employee was the nurse who had assessed and facilitated the resident's emergency transfer. Employee 3's statement noted the presence of bruising on both arms and scattered bruising on abdomen from paracentesis.

However, this bruising was not documented in the change on condition note in the nursing documentation the day the resident was transferred from the facility.

On September 24, 2019, at 12:51 PM the surveyor contacted the ambulance company that the facility believed had transported the resident. The State Survey Agency was informed at the time that the identified ambulance company did not transport Resident CR2 at any time in September 2019. However, the ambulance company did provide the State Survey Agency the name of the correct company who had transported the resident on September 8, 2019.

On September 24, 2019, at 1:53 PM the surveyor interviewed a representative of the ambulance company that had transported the resident to the hospital. The representative indicated that their EMS crew was on scene at 12:51 PM on September 8, 2019. An assessment was completed at the facility by the EMS crew prior to the resident's transport. Upon their assessment the EMS crew noted that the resident had bruising on the neck, chest and arms.

A review of the ambulance company report from the resident's transfer to the hospital dated September 8, 2019, revealed that the ambulance arrived on scene (the facility) at 12:51 PM and was with the resident at 12:53 PM. Upon assessment the ambulance crew indicated that the resident was lying in bed unattended. The crew member had to leave the room to search for a nurse to get transfer information on the resident. The crew member returned to the resident's room with Employee 3, RN, and paperwork for the resident's transfer. Employee 3 left the room, stating that he needed to continue what he was doing. Further review of the EMS report revealed that the EMS crew noted, before leaving the facility, that the resident had bruising on the neck, left and right arms, chest, and left abdomen. The EMS crew noted in their report that the resident's bed contained scrambled eggs and flies were landing on and around the resident. The ambulance departed the facility at 1:13 PM and arrived and the hospital at 1:18 PM.

An interview with the NHA (nursing home administrator) on September 24, 2019, at approximately 5:00 PM confirmed that the facility had not timely and thoroughly investigated the resident's injuries of unknown origin.



483.12(c)(2) Have evidence that all allegations of abuse are thoroughly investigated
Continuing deficiency of 8/9/19

28 Pa. Code: 201.14 (a)(c)(e) Responsibility of licensee.
Continuing deficiency of 8/9/19

28 Pa. Code: 201.18 (e)(1) Management.
Previously cited 7/20/19


28 Pa. Code 211.12 (c)(d)(5) Nursing services
Continuing deficiency of 8/9/19
Previously cited 7/20/19,1/27/19, 1/3/19, 7/30/19










 Plan of Correction - To be completed: 10/23/2019

1. Resident #13 no longer resides at the facility. Resident CR2 no longer resides at the facility. The facility did complete an investigation.
2. To identify other residents that have the potential to be affected, the DON /designee completed observations of resident dressings to ensure dressings are being completed per physician orders. There were no negative findings. Interviewable residents with dressing changes were interviewed to ensure dressings are being completed per physician orders. There were no negative findings. To identify other residents that have the potential to be affected, facility department heads conducted abuse questionnaires with interviewable residents to identify any concerns of abuse. For noninterviewable residents nursing completed body checks for any signs or symptoms of abuse (injury of unknown origin).
3. To prevent this from recurring, the DON/designee educated licensed nursing on completing and documenting treatments per physician orders and educated staff on the abuse and neglect policy; with emphasis on reporting (injury of unknown origin).
4. To monitor and maintain ongoing compliance the DON/designee will complete observations of 5 non interviewable resident dressings weekly x4 then monthly x2 to ensure dressing changes are being completed and documented per physician orders. The DON/designee will interview 5 interviewable residents weekly x4 then monthly x2 to ensure dressing changes are being completed and documented per physician orders. Also the DON/designee will review 5 progress notes weekly x4 then monthly x2 to ensure any potential injuries of unknown origin or concerns or abuse are reported. Any negative findings will be reported and investigated as needed.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

483.21(c)(1)(i)-(ix) REQUIREMENT Discharge Planning Process: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(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by 483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.
Observations:

Based on a review select facility policy and clinical records, observations and resident and staff interview it was determined that the facility failed to develop and implement an individualized discharge plan for one of 18 residents reviewed (Resident 9) to meet the resident's post-discharge needs.

Findings Include:

A review of a facility policy for discharge planning policy documentation dated as reviewed November 2018 revealed that when a resident's discharge is anticipated, the facility will develop and implement a discharge plan that focuses on the resident's discharge goals, the preparation of resident's to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions.

The post discharge plan of care that is developed with the participation of the resident and, with the residents consent, the resident representative, which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care will indicate where the individual plans to reside and any post-discharge medical and non-medical services.

Clinical record review revealed tht Resident 9, a cognitively intact resident, was admitted to the facility on September 16, 2019, at 5 :40 PM with diagnoses to include post surgical repair of a bowel obstruction with a wound requiring a wound vac (Vacuum-assisted closure of a wound is a type of therapy to help wounds heal, also known as wound VAC, during the treatment, a device decreases air pressure on the wound. This can help the wound heal more quickly. The gases in the air around us put pressure on the surface of our bodies. A wound vacuum device removes this pressure over the area of the wound. This can help a wound heal in several ways. It can gently pull fluid from the wound over time).

Physician admission orders dated September 16, 2019, included a wound vac to the abdominal wound and to change the dressing three times a week.

A review of nursing documentation revealed that on September 16, 2019, at 10:38, the wound vac was delivered to the facility and applied to Resident 9's abdominal wound by nursing staff. This resident did not have the wound vac in place at the time of her admission to the facility.

Additional Physicians orders dated September 21, 2019, indicated that the resident was to be discharged home on September 24, 2019. The physician discharge orders did not include the wound vac.

A review of a facility discharge instruction (to the resident) form dated as completed on September 23, 2019 indicated that Resident 9 was to be discharged from the facility to home on September 24, 2019. The form was incomplete, missing data to include: Primary care physician's name and contact information, any follow-up appointments noted, if follow-up home health agency appointments and name and telephone number and the primary diagnosis that she was being treated for at the facility. The form also indicated that Resident 9 did not have a wound present at the time of discharge.

A review of an additional discharge summary dated September 23, 2019, indicated in the social services summary that the resident was to be discharged on September 24, 2019, with in home health services. Medical equipment ordered to include a tub transfer bench and a walker. The nursing summary stated that the course of treatment while in the facility included "small bowel obstruction" with no information or reference to resident's abdominal wound, corresponding treatment or medical equipment required for at home treatment.

An observation and interview with Resident 9 on September 24, 2019, at approximately 11 AM revealed that the resident was lying in bed and the wound vac in place and running. Resident 9 stated that the wound vac, which she was currently using as a resident in the facility was hers and that she would be discharged to home later that day with the machine. The resident stated that the abdominal dressing associated with the wound vac had a large amount of tape included with the application and removal of the dressing. Resident 9 stated that it hurt her when the dressing was removed and that the current dressing had been applied the evening prior and would not need to be changed for three days.

During an observation of a conversation between the Director of Nursing (DON), Resident 9 and Resident 9's daughter on September 24, 2019, at approximately 11:30 PM the DON informed Resident 9 that the wound vac that she had in place at that time was rented by the facility from an outside company and because of insurance guidelines could not leave the facility with her at the time of her discharge today. The DON stated that the facility had made an error in not ordering the wound vac in advance of her discharge so that the would vac could go home with her to ensure no interruption in care.

Resident 9 replied that the wound vac came with her from the prior hospitalization and would go home with her. The DON informed the resident that the dressing could be removed, another applied prior to discharge from the facility and the home health agency nursing staff would reapply a new dressing along with the wound vac that would to be ordered by the facility prior to her discharge or she could remain in the facility for an additional day. The DON stated that the machine would be delivered to the facility and applied prior to her discharge if the resident remained in the facility for another day.

Resident 9 again replied that the dressing had been changed the evening prior and that it was a very uncomfortable procedure. The resident appeared upset and stated that she wanted to go home that day. She agreed to have the wound vac removed and a new dressing applied. The resident was discharged to home that afternoon, during the survey ending September 24, 2019.

During an interview on September 24, 2019, at approximately 3 PM the DON stated that the Social Services Director was supposed to order Resident 9's wound vac in advance of the resident's scheduled discharge from the facility to ensure continued care after discharge. The DON confirmed that Resident 9's wound vac was not ordered timely prior to Resident 9's discharge from the facility. The facility failed to timely identify the resident's discharge and post-discharge needs, including medical equipment.





28 Pa. Code 201.25 Discharge policy

28 Pa. Code 211.16(a) Social Services










 Plan of Correction - To be completed: 10/23/2019

1. Resident 9 was discharged home with home health services .
2. Social Services reviewed discharges for the past week to ensure a follow up call was made post discharge to ensure proper discharge and post discharge needs, including medical equipment was in place. Corrections will be made as needed.
3. To prevent this from recurring the DON / Designee will educate the interdisciplinary Team on the requirements of the discharge planning process .
4. To monitor and maintain ongoing compliance the facility will review 5 discharges weekly x4 weeks then monthly x2 to ensure proper discharge and post discharge needs, including medical equipment are set up. Corrections will be made as needed.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on observation, clinical record review and staff interview, it was determined the facility failed to provide necessary services to maintain adequate personal grooming and hygiene for a resident unable to carry out activities of daily living for one of 15 residents reviewed (Resident 15).

Findings include:

Review of Resident 15's clinical record revealed a diagnosis of Alzheimer's disease (decline in brain function which causes memory loss and causes brain tissue to breakdown).

A quarterly Minimum Data Set (MDS - a federally mandated standardized assessment conducted periodically to plan resident care) completed August 2, 2019, revealed that the resident required an extensive assistance of one person for dressing and personal hygiene. The resident was also identified with a BIMS score of 3 (brief interview for mental status - a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 0-7 equates to having severe cognitive impairment).

Observation on September 24, 2019, at approximately 2:00 p.m. revealed that the resident was seated in a wheelchair in the hallway on second floor unit. The thighs of the resident's pants were covers in food debris and white/beige spots of dried on particles. Under each forearm, the resident's sleeves were covered in caked on food debris.

Interview with Employee 1, LPN at the time of the observation revealed that the nurse stated "looks like the aides have some work to do" and he wheeled the resident up the hallway.

The facility failed to ensure that the resident was provided the necessary care and services, in at timely manner, to maintaining good personal hygiene and grooming.



483.24(a)(2) ADL Care Provided for Dependent Residents
Continuing deficiency 8/9/19

28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services.
Continuing deficiency 8/9/19
Previously cited 7/30/19 1/27/19, 1/3/19, 7/20/18

28 Pa. Code 201.29 (j) Resident rights
Continuing deficiency 8/9/19
Previously cited 7/30/19,7/20/18







 Plan of Correction - To be completed: 10/23/2019

1. Resident #15 had her clothing changed.
2. To identify other residents that have the potential to be affected, the DON/designee completed an audit of current resident to ensure necessary care and services are provided in a timely manner to maintain good personal hygiene and grooming.
3. To prevent this from recurring the DON /designee educated nursing staff on ensuring necessary care and services are provided in a timely manner to maintain good personal hygiene and grooming.
4. To monitor and maintain ongoing compliance the DON/designee will do observations of 5 residents weekly x4 then monthly x2 to ensure necessary care and services are provided in a timely manner to maintain good personal hygiene and grooming.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations .


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