Nursing Investigation Results -

Pennsylvania Department of Health
WHITESTONE CARE CENTER
Patient Care Inspection Results

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WHITESTONE CARE CENTER
Inspection Results For:

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

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint Survey completed on February 21, 2020, it was determined that Whitestone Care Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.25 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 review of clinical records, hospital records and documentation from emergency management services and staff, physician and family interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to demonstrate consistent clinical monitoring and provision of person-centered care in response to changes in resident condition, resulting in delays in these residents receiving the necessary level of care and services, which compromised their clinical condition for two residents out of two residents reviewed who experienced changes in condition requiring hospitalization (Resident 125 and Resident 127).

Findings include:

According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

A review of the clinical record of Resident 125 revealed admission to the facility on January 24, 2020, with diagnoses, which included rheumatoid lung disease (group of lung problems related to rheumatoid arthritis. The condition can include blockage of the small airways, fluid in the chest, high blood pressure in the lungs), COPD (chronic obstructive pulmonary disease is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing) and congestive heart failure (a chronic progressive condition that affects the pumping power of your heart muscles. While often referred to simply as "heart failure," CHF specifically refers to the stage in which fluid builds up around the heart and causes it to pump inefficiently).

A review of interdisciplinary progress notes dated January 27, 2020, for 10:20 AM, but written at 6:05 PM, revealed that staff responded to the resident's room with EMS (emergency medical services, medical professionals who respond to 911) when the resident called 911. The resident stated that she wanted to return to the hospital because she wasn't happy in the facility. Staff noted that the resident stated no one would give her water and if she didn't get ginger ale, she would go to the hospital to get it. The resident received a drink and declined to go the hospital.

However, a review of an EMS ambulance report dated January 27, 2020, revealed that the ambulance was dispatched to the facility at 10:24 AM and attended to the resident at 10:32 AM. The report indicated that that ambulance was dispatched due the resident stating she felt as if she was being neglected. The resident had complaints of trouble breathing. The resident's oxygen bottle was empty and her nasal canula (device used to deliver supplemental oxygen) was lying on the floor next to her bed. The resident's oxygen level was found to be 75% (normal levels are 90% or above). The ambulance crew placed the resident on 3 liters of oxygen. The EMS report further indicated that the facility staff acknowledged the resident's low oxygen level and that her oxygen tank was empty. The facility staff stated to the EMS crew they would bring the resident an oxygen concentrator and keep her on oxygen. At that time the resident had no further complaints and did not desire EMS assistance and they left the facility.

Review of facility documentation for January 27, 2020, revealed no documentation of the resident's oxygen tank being empty or the resident having a low oxygen level of 75% as noted in the EMS report.

A review of an interdisciplinary team meeting progress note dated January 29, 2020, at 11:43 AM revealed that the team discussed that the resident called 911 due to her wanting water. No documentation was found that the team discussed the resident low oxygen level or having an empty tank of oxygen.

A nursing progress note dated January 30, 2020, at 7:45 AM revealed that the resident had a change in condition. The resident was complaining of being short of breath. The resident had abnormal lung sounds. Nursing noted at that time that the resident's oxygen level was 90% on room air. A physician order was obtained to administer albuterol nebulizer treatments (to treat wheezing and shortness of breath caused by breathing problems) every four hours as need for shortness of breath and a chest x-ray.

A review of a facility "Change in Condition evaluation" dated January 30, 2020, at 7:45 AM revealed that the resident had audible wheezing and shortness of breath was noted. The resident received an albuterol nebulizer treatment.

A review of a nursing progress note dated January 30, 2020, at 8:30 AM revealed the resident was complaining of being short of breath. The resident's lung sounds were diminished in the bases (lung sounds that are decreased and harder to hear due to poor air flow) and was noted to have a moist nonproductive cough. Further documentation revealed that the nurse was unable to obtain an oxygen level due to the resident's "cold hands."

A review of a progress note dated January 30, 2020, at 10:27 AM revealed the resident called 911, stating that she was on the floor and needed to go to the hospital, but nursing noted that the resident was observed lying in bed and had no difficulty breathing.

A review of an EMS ambulance report dated January 30, 2020, revealed that the ambulance was dispatched to the facility and attended to the resident at 10:31 AM. The report indicated that the resident called 911 due to the resident needing medical attention. However, the facility staff then called and cancelled the ambulance. Subsequently, the resident's daughter then proceeded to call 911 stating that her mother could not breathe and requested EMS go to the facility.

Further review of the ambulance report revealed that EMS arrived at the facility on January 30, 2020, 10:28 AM to find the resident unattended in her room. The resident was noted to be tachypneic (abnormally rapid breathing) and in obvious distress. The resident was only able to speak in short sentences. The resident stated to the EMS crew she had been short of breath all morning. The resident's vital signs were obtained and was noted to have a respiratory rate of 36 breaths per minute (normal 12 to 20 breaths per minute) and her oxygen level was 83% on 4 liters of oxygen.

A review of facility documentation dated January 30, 2020, at 10:27 AM revealed that Employee 7 RN (registered nurse) noted that the resident "was sent to the hospital because her needs were unable to be met due to the resident stating she had respiratory distress after several attempts to convince the resident and educate her on her condition."

An interview with the DON (director of nursing) on February 21, 2020, at approximately 10:30 AM revealed that she was not aware that the facility cancelled the ambulance when the resident called 911 to go to the hospital on January 30, 2020. The DON was unable to identify the employee who cancelled the ambulance. The DON stated if the resident wanted to go to the hospital then she should have been allowed to go.

An interview with Employee 6, LPN (license practical nurse) on February 21, 2020, at 11:00 AM revealed that this nurse stated that the resident was complaining of being short of breath. She stated the resident's vital signs at that time were "okay." The employee informed the Employee 7, RN, of the resident's change and notified the physician to get an order for nebulizer treatments. The employee further stated she believes the resident call 911 for assistance, but someone in the facility canceled the ambulance. The employee was not sure who cancelled the ambulance. The employee stated then either the resident or the resident's daughter called 911 again and the facility sent the resident to the hospital.

An interview with Employee 7, RN, on February 21, 2020, at 11:08 AM revealed the employee stated the resident called the ambulance but claimed all the resident wanted was a ginger ale so the employee cancelled the ambulance. The employee stated the resident's daughter called 911 back and requested they take the resident to the hospital. Employee 7 stated he did not see the resident in respiratory distress. He further stated the note he wrote on January 30, 2020, at 10:27 AM indicated he was trying to convince the resident she was stable and in no distress and did not need to go the hospital.

An interview with the resident's sister on February 21, 2020, at 11:37 AM revealed that she spoke with the resident on the day she was transferred to the hospital on January 30, 2020. The resident's sister stated that the resident called her that morning stating she could not breathe. The resident's sister further stated her sister told her that she "had been feeling bad for days and the facility won't let her go to the hospital." The resident's sister stated that while speaking with the resident "you could tell she was short of breath." She was having trouble speaking sentences and "you can hear she was short of breath." The sister stated when she found out the facility had cancelled the ambulance the resident had called, she called the resident's daughter to call 911. The sister further stated she had spoken with the facility before and was told that "the facility can do whatever a hospital can do, and she doesn't need to go to the hospital. "

A review of emergency department records dated January 30, 2020, at 11:05 AM revealed that the resident presented to the emergency department with shortness of breath. The resident was short of breath and 911 was called, but the facility canceled the 911 call. 911 was called again and the resident was transported to the hospital. Upon physical examination the resident was noted to appear ill and in respiratory distress. The resident's lungs were assessed and was noted to have rales (abnormal lung sounds the sound crackly or wet depending on the amount of fluid in the lungs) and rhonchi (rattling sound in the lungs often cause by an obstruction or secretions) throughout her lungs. The resident was diagnosed with multilobar (multiple lobes of the lungs) pneumonia, congested heart failure (heart failure where fluid builds up around the heart causing it not to pump properly) and influenza type A.

No documentation was found in the resident's clinical record that the resident was in any physical/respiratory distress on the day she was transferred to the hospital. Further review of documentation in the resident's clinical record revealed that the facility's nursing documented the resident's oxygen level was 90% on room air at 10:36 AM, which was not consistent with the ambulance report. The EMS crew were already present in the facility with the resident, assessing her at 10:31 AM and found that the resident had an oxygen level of 83% on 4 liters of oxygen.

An interview with the resident's daughter on February 24, 2020, at approximately 7:00 PM revealed that she received a "frantic" phone call from the resident's sister on January 30, 2020. The daughter stated she was told the resident was having trouble breathing and the facility would not let her go to the hospital. The daughter indicated at that time she called 911 to have an ambulance take her mother to the hospital. The daughter further stated she met the resident at the hospital. When the daughter saw the resident, she stated she looked "really sick.". The resident was having trouble breathing and could barely make sentences because she was so out of breath. The daughter further indicated her mother had passed away on February 6, 2020, because her body could not fight the illnesses.

Interview with the Director of Nursing on February 21, 2020 at approximately 2:15 PM confirmed that the facility staff failed to provide nursing services consistent with professional standards of quality to ensure that this resident received timely and necessary treatment and services at the level required to address the resident's clinical condition.

A review of the clinical record revealed that Resident 127 had diagnoses, which included dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning).

A quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated September 27, 2019, indicated that the resident was moderately cognitively impaired. The resident required staff assistance for activities of daily living which included bed mobility and transfers.

Review of information dated October 7, 2019, submitted by the facility revealed that on October 4, 2019, Resident 127 had a witnessed fall in front of the nurses station. Nursing assessed the resident and no pain or shortening (of the leg) was noted. Nursing noted that on October 6, 2019, the resident complained of pain. An x-ray and pain medication were ordered. On October 7, 2019, an x-ray showed a foreshortening of the left femoral neck (hip area) which was suspicious for an impacted hip fracture. The physician was notified and ordered to follow up with ortho according to this information. The family was made aware and requested that the resident be transferred to the emergency room for evaluation.

The resident had a current physician order initially dated, September 20, 2019, for acetaminophen 325 mg one tablet by mouth as needed every 8 hours for mild pain and
for acetaminophen 325 mg two tablets by mouth as needed every 8 hours for severe pain.

Review of the resident's October Medication Administration Record (MAR) revealed that the resident's pain level was rated as a 7 on October 5, 2019, at 9:49 PM (pain level of 1-3 is mild; 4-7 moderate pain; 8-10 severe pain). Acetaminophen 650 mg was administered and noted to be effective. The resident's pain level increased to an 8 on October 6, 2019, at 5:37 AM. Acetaminophen 650 mg was administered and noted to be effective.

Review of the resident's recorded pain levels also noted that on October 6, 2019, at 6:26 AM the resident had a pain level of 2 (mild pain) and at 9:10 AM had a pain level of 4 (moderate pain).

A nurses note dated October 6, 2019, at 7:40 PM indicated that the resident was status post fall and complained of left leg pain. The physician was contacted and ordered Meloxicam (nonsteroidal anti-inflammatory medication) 15 mg by mouth once daily for pain. The resident's responsible party was notified.

A physician order dated October 6, 2019, at 7:48 PM noted an order for a left hip x-ray.

An x-ray completed October 6, 2019, and reviewed by the radiologist October 6, 2019, at 9:59 PM noted the exam was limited by positioning. The conclusion was foreshortening of left femoral neck suspicious for an impacted fracture.

A nurses note dated October 7, 2019 at 1:00 AM indicated that the resident was received in bed, alert, and in no distress. X-ray received. Physician notified and order to keep on pain medications and schedule an orthopedic appointment. Registered nurse supervisor made aware.

A nurses note dated October 7, 2019, at 11:00 AM indicated that the resident's responsible party requested that the resident be sent to the emergency room.

A nurses note dated October 7, 2019, at 11:20 AM indicated that the resident was transferred to the emergency room.

Review of the hospital discharge summary dated October 11, 2019, revealed that the resident was admitted to the hospital on October 7, 2019, with a diagnosis of left displaced femoral neck fracture and required an open reduction internal fixation (ORIF- surgery to fix severely broken bones. It is used for serious fractures which cannot be treated with a cast or splint).

Interview with the Director of Nursing on February 21, 2020, at approximately 10:00 AM failed to provide documented evidence that the physician was timely notified of the resident's reported pain, which was initially noted on October 5, 2019, in an effort to provide appropriate and timely services and treatment following the resident's fall on October 4, 2019.

During interview with the resident's physician on February 21, 2020, at 11:00 AM the physician stated that he did not recall being made aware of Resident 127's x-ray result, as noted in the facility's documentation. The physician stated that the timely and appropriate response, based on the results of the resident's x-ray results, would have been to transfer the resident to the hospital and not to schedule an ortho appointment.





28 Pa. Code Clinical records

28 Pa. Code Clinical records

28 Pa. Code Nursing services

28 Pa. Code Nursing services

28 Pa. Code Nursing services

28 Pa. Code Nursing services


















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

1. R# 125 and R# 127 no longer resident in the facility.
2. To identify residents with the potential to be affected the DON/designee completed an audit of progress notes from 3/2/20 to 3/4/20 on residents who were identified with a change of condition and fall to ensure RN assessment completed and appropriate medical treatment as indicated.
3. To prevent from recurring current licensed nursing staff were educated by the DON/designee on the need for RN assessment and any change of condition.
4. To monitor and maintain ongoing compliance the DON/Designee will audit 3 residents with a noted change in condition weekly x4 then monthly x2 to ensure RN assessment and change in condition from 24 hour report.
5. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on review of the clinical record of a resident who was provided with a 30 day Discharge Notice initiated by the facility and staff interview, it was determined the facility failed to provide a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, failed to include the location to which the resident is to be transferred or discharged for one of one residents reviewed (Resident 65) and failed to ensure that a written notice of facility initiated transfer to the hospital was provided to the resident and the residents' representative for three of six residents transferred to the hospital (Residents 46, 3, and 40).

Findings include:

Review of Resident 65's clinical record revealed that on January 29, 2020, the nursing home administrator met with the resident representative to notify the representative that the facility was providing a 30-day notice of their intent to discharge the resident for the safety of individuals in the facility that would otherwise be endangered due to the resident's clinical or behavioral status. The notice indicated that the resident was to be discharged/transferred from the facility on February 29, 2020.

Interdisciplinary team meeting progress note documentation dated January 30, 2020, indicated that the resident's behavior of yelling at residents and staff, making fun of residents and the alcohol in her room was discussed with the family. The director of nursing explained that the resident could have alcohol, but a doctor's order would be necessary to ensure the safety of the resident. The administrator explained the interventions implemented for the resident's behaviors, but the behaviors continued and were progressively getting worse (no description noted). The resident's family acknowledged the resident's behaviors and the alcohol. The resident's family inquired about other facilities that would better suit the resident. The family was made aware of personal care homes and memory care facilities and requested that social services look into those facilities. The resident's family consented for the social services director to contact any facility that would be better to manage the resident's behaviors. The family agreed and would inform social services if they locate a facility they would like.

Interview with the nursing home administrator (NHA) on February 20, 2020, at approximately 10:00 AM confirmed the facility failed to provide a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. The NHA confirmed that there was no proposed location for the resident to be discharged and failed to include the location to which the resident was to be transferred/discharged on the notice.

A review of the clinical record revealed that Resident 46 was transferred to the hospital on February 10, 2020, and returned to the facility on February 12, 2020.

A review of the clinical record revealed that Resident 3 was transferred to the hospital on October 6, 2019, and returned to the facility on October 15, 2019, and was also transferred to the hospital on October 17, 2019, and returned November 9, 2019.

A review of the clinical record revealed that Resident 40 was transferred to the hospital on January 30, 2020 and returned February 3, 2020.

Further review of these residents' clinical records revealed no evidence that written notice was provided to the resident and their representatives regarding the transfer that included the required contents: reason for the transfer in manner and language they understand, a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; the name of the State Long-Term Care Ombudsman.

An interview with the Regional Director of Clinical Services on February 20, 2020, at approximately 10:30 a.m. confirmed that written notices of the facility initiated transfer, were not provided to the residents and residents' representatives.




28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code: 201.29(f) Resident rights

28 Pa. Code 201.29(g) Resident rights

28 Pa. Code 201.29(h) Resident rights
















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

1. R# 46, R# 3, and R# 40 and resident representatives were provided copies of the written notice of transfer. R#65 30 day discharge was revoked by the facility.
2. To identify residents with the potential to be effective the NHA/designee completed an audit from 2/14/20 3/2/20 on residents who required a written notice of transfer to ensure the documentation was provided to the resident and the resident representative. Resident #65 was the only resident who resides in the facility that has received a 30 day discharge notice.
3. To prevent this from recurring current licensed nursing staff, Social Services, and BOM were educated by the DON/designee on the written notice of transfer and the need to provide documentation to the resident and the resident representative. The RVPO educated the NHA on the documentation of location, notification to State Ombudsman, and required documentation by resident's physician when providing residents with a 30 day facility initiated transfer.
4. To monitor and maintain ongoing compliance the NHA/designee will audit 3 transfers weekly x4 then monthly x2 to ensure that residents requiring a written notice of transfer were provided with documentation in a language or manner that could be understood for the reason for transfer. Any negative findings will be immediately corrected. The NHA/designee will review all residents that receive a 30 day facility initiated transfer to ensure appropriateness of the discharge and that documentation clearly reflects what needs of the resident cannot be met at this facility. The NHA/designee will ensure the State Ombudsman and Department of Health are notified of residents receiving a 30 day facility initiated discharge. Any negative findings will be immediately correct.
5. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations.

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 and facility in-service education records and staff interview, it was determined the facility failed to complete a performance review at least once every 12 months and provide individualized in-service education accordingly for five out of five sampled nurse aides (Employees 1,2,3, 4 and 5).

The findings include:

A review of the training records of nurse aides, Employees 1, 2, 3, 4 and 5, revealed there was no documented evidence the facility had completed a performance review of these nurse aides in the last 12 months.

Review of the facility nurse aide training records revealed that nurse aide Employees 1, 2,3,4 and 5 were not provided regular in-service education based on the outcome of an annual performance review during the last 12 months of their employment.

The facility was unable to provide documented evidence that the above nurse aide employees had received specific in-service training based on the results of an annual performance review in the last 12 months.

An interview with the Nursing Home Administrator on February 21, 2020, at approximately 10:30 AM, confirmed the facility did not have evidence that Employees 1,2,3,4,and 5 had a performance review completed during the last 12 months.




28 Pa. Code 211.12 (c) Nursing services
Previously cited 10/30/19, 7/31/19, 12/7/18

28 Pa. Code 201.20 (a)(c)(d) Staff Development











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

1. Facility cannot retroactively correct missing performance review for employees 1, 2, 3, 4 and 5.
2. To identify staff with the potential to be affected, Human Resources will complete an audit on current certified nurse aides to determine date performance evaluations are to be completed. Moving forward the facility will complete performance evaluations on certified nurse aides annually and provide education as identified.
3. To prevent this from recurring the Nursing Home Administrator will educate DON and ADON on completion of performance evaluations and completing education as identified.
4. The Director of Human Resources will complete weekly audit of 3 employees weekly x4 then monthly x2 to track performance evaluations and education as identified. Any negative findings will be immediately addressed.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for three residents (Resident 55, 67, and 57) of 19 residents reviewed.

Findings include:

A review of Resident 55's clinical record revealed current physician's orders, initially dated January 29, 2020, for Oxycodone HCL 5 mg (narcotic pain medication) one tablet by mouth every 12 hours, as needed, for severe pain.

A review of the resident's February 2020 Medication Administration Records (MARs) revealed that staff administered this narcotic pain medication nine (9) times during the month of February 2020. Of the nine doses given in the month of February 2020, all were administered without evidence of attempts at the use of non pharmacological interventions prior to giving the narcotic pain medication.

A review of Resident 67's clinical record revealed current physician's orders initially dated January 29, 2020, for Hydrocodone-Acetaminophen 5-325 mg (narcotic pain medication) one tablet by mouth every 6 hours, as needed, for severe pain and increased to every 4 hours as needed on February 1, 2020.

A review of the resident's January 2020 Medication Administration Records (MARs) revealed that staff administered this narcotic pain medication seven (7) times during the month of January 2020. Of the seven doses given in the month of January, six were administered without evidence of non-pharmacological interventions attempted to alleviate pain prior to administering the narcotic pain medication.

A review of the resident's February 2020 Medication Administration Records (MARs) revealed that staff administered this narcotic pain medication 27 times during the month of February 2020. Of the 27 doses given in the month of February, 21 were administered without first attempting non-pharmacological interventions prior to administering the narcotic pain medication.

On each of the above occasions there was no documented evidence that the facility staff had attempted any non-pharmacological interventions to alleviate the resident's pain prior to the administration of the pain medication.

Interview with the DON (director of nursing) on February 21, 2020, at approximately 2:15 PM confirmed that there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of prn pain medication.

Resident 57 had a physician order dated October 20, 2019 for the following pain medications;
Acetaminophen 325 mg one tablet by mouth every eight hours as needed for "mild" pain;
Acetaminophen 500 mg one tablet by mouth every eight hours as needed for "moderate" pain;
Acetaminophen 325 mg two tablets by mouth every eight hours as needed for "severe" pain; and Oxycodone HCL 5mg one tablet by mouth every eight hours as need for pain.

The resident received pain medication seven (7) times in the month of December 2019 and four (4) times in the month of January 2020. Upon administration of the pain medication on each occasion, there was no evidence that any non-pharmacological interventions were attempted prior.

There was no indication of the type or severity of pain for administration of the the narcotic Oxycodone HCL other than "pain"

During an interview with Director of Nursing on February 20, 2020, at 1:00 PM she stated that the faciity administered pain medications on a numeric scale of 1 to 10 for severity. She stated 1-3 indicated mild pain, 4-7 moderate pain and 8-10 severe pain.

During the month of December the resident had pain rated between 6 and 7 on three occassions and was administered Oxycodone HCL, a narcotic to treat severe pain.

In January 2020 she received Oxycodone HCL for a pain rating of 6, which would indicate moderate pain as per the faciity pain assessment scale.

The DON confirmed during an interview on February 21, 2020 at 2:15 p.m. that the faciity did not attempt non-pharmacological interventions prior to the administration of the as needed pain medications nor assured that pain medications were properly ordered for the degree of pain exhibited by the resident according to their pain scale.




28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.5(g) Clinical records

28 Pa. Code 211.12(a) Nursing Services

28 Pa. Code 211.12(c) Nursing Services

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

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










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

1. The facility cannot retroactively correct the missing documentation of non-pharmacological interventions for R# 57 and R# 67. R# 55 no longer resides in the facility. Moving forward the facility will ensure that resident receiving pain medications will have non pharmacological interventions prior to or in conjunctions with prn pain medication administration.
2. To identify residents with the potential to be affected the DON/designee completed and audit on progress notes for the last 24 hours for residents to ensure residents have had non-pharmacological interventions prior to or in conjunction with prn pain medication administration. Unable to correct missing documentation.
3. To prevent this from recurring the DON/designee provided education to current licensed nursing staff on the utilization of non-pharmacological intervention prior to or in conjunction with pain medication administration.
4. To monitor and maintain ongoing compliance the DON/designee will audit 3 residents receiving pain medications weekly x4 then monthly x2 to ensure non pharmacological interventions were provided prior to or in conjunction with pain medication administration. Any negative findings will be immediately addressed.
5. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations.

483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice: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(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:

Based on a review a closed resident record and staff interview, it was determined the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form regarding financial responsibility for one of two records reviewed (Resident 65).

Finding include:

A review of the form "Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN)-Form CMS-10055," (a notice that informs residents/beneficiaries prior to providing care that Medicare usually covers, but may not pay for, because the care is not medically reasonable and necessary; or is considered custodial. The SNFABN provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF provides the beneficiary with SNFABN, form CMS-10055, the facility has met its obligation to inform the beneficiary of his or her potential liability for payment and related standard claim appeal rights. Issuing the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123, to a beneficiary only conveys notice to the beneficiary of his or her right to an expedited review of a service termination and does not fulfill the facility's obligation to advise the beneficiary of potential liability for payment. A facility must still issue the SNFABN to address liability for payment).

The provider must ensure that the beneficiary or their representative signs and dates the SNF ABN to demonstrate that the beneficiary or their representative received the notice to address liability for payment.

Clinical record review revealed that Resident 65's Medicare Part A skilled services started on September 8, 2019, and the resident's last covered day of Part A services was October 11, 2019.

The CMS 10123-NOMNC (a notice that informs the recipient when care received from skilled nursing facility is ending and how you can contact a Quality Improvement Organization (QIO) to appeal) was provided to and signed by the resident representative on October 8, 2019.

There was no evidence that the resident or representative had been provided the SNF ABN Form CMS-10055 to decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility despite Resident 65 continuing to reside in the facility.

Interview with the nursing home administrator (NHA) on February 20, 2020, at approximately 9:30 AM confirmed that the form was not provided as required.


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

28 Pa. Code 201.29(a) Resident rights







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

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. Facility cannot retroactively provide the SNF ABN form to R# 65 as last day of skilled service was 10/11/2019. Moving forward the facility will ensure that residents are provided with SNF ABN forms at the time skilled services are ended.
2. To identify other residents that have the potential to be affected the Social Services Director completed an audit of residents discharged from 2/14/20 3/2/20 that remained in the facility. Facility cannot retroactive provide the SNF ABN forms. Moving forward the facility will ensure that residents are provided with SNF ABN forms at the time skilled services are ended.
3. To prevent this from recurring the RDCS / NHA will provide education to Department heads on the Medicare cut letter policy.
4. To monitor and maintain compliance BOM will audit 3 Medicare A discharged residents weekly x4 then monthly x2 to ensure residents and/or resident representatives receive the ABN notice. Any negative finding will be immediately corrected
5. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on observations and staff interview, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment and resident care equipment in one of 52 resident rooms (Resident 58)

Findings include:

Observations of Resident 58 on February 18, 2020, at 9:35 a.m., on February 19, 2020 at 9:30 a.m. and 12:35 p.m. in her room, revealed that the resident's tube feeding stand and frame were soiled with dried tube feeding solution. In addition, the floor near the pump, the wall by the right side of the bed were also soiled with spilled tube feeding solution.

Interview with the director of nursing (DON) and nursing home administrator (NHA)on February 20, 2020 at approximately 2:00 p.m., confirmed that resident equipment and the environment was to be maintained in a clean and sanitary manner.


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





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

1. R# 58 tube feed stand and frame, floor near the pump, and wall were immediately cleaned.
2. To identify other areas that have the potential to be affected, housekeeping completed an audit of all tube feed stands and frames, floors near the pump and wall. Equipment was cleaned or replaced as needed.
3. To prevent this from recurring the NHA/designee will provide education to current staff on keeping a clean and well-kept environment.
4. To monitor and maintain compliance 3 random equipment poles will be checked by Director of Housekeeping 3x week x4 weeks the monthly x2 to ensure a clean and well-kept environment for the residents. Any negative findings will be immediately corrected.
5. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide evidence of written information of the facility's bed hold policy provided upon transfer to the hospital for one of six residents transferred to the hospital (Residents 3).

The findings include:

A review of Resident 3's clinical record revealed that the resident was transferred to the hospital on October 6, 2019, and returned on October 15, 2019.

The facility was unable to provide documented evidence that the facility had provided the resident and/or the resident's representatives written information, at the time of transfer, of the specifics of the facility's bed hold policies, including notice of the duration of the bed-hold policy and the cost of holding a bed.

The lack of documented evidence of the provision of written notice of the facility's bed hold policy upon hospital transfer of the above resident, was confirmed by the Director of Nursing during an interview on February 20, 2020, at 11:00 a.m.


28 Pa Code 201.18 (e)(1) Management

28 Pa Code 201.29 (b) Resident rights

28 Pa Code 201.29 (d)Resident rights

28 Pa Code 201.29 (f) Resident rights








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

1. Facility cannot retroactively provide written information of the bed hold policy. R# 3 has already returned to the facility.
2. To identify residents with the potential to be effective the NHA/designee completed an audit on residents who required a bed hold notice from 2/14/20 to 3/2/20 to ensure the notice was provided to the resident and the resident representative. Unable to retroactively provide written information on the bed hold policy on residents who have returned to the facility or who have been discharged. Moving forward the facility will ensure the residents and their representatives are provided with written information on the bed hold policy upon transfer to the hospital.
3. To prevent this from recurring current licensed nursing staff, Social Services, and BOM were educated by the DON/Designee on the bed hold notification policy.
4. To monitor and maintain ongoing compliance the NHA/designee will audit 3 resident transfers weekly x4 then monthly x2 to ensure resident and/or resident representative notification of the bed hold policy. Any negative finding will be immediately corrected.
5. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of clinical records and interviews with residents and facility staff it was determined the facility failed accurately assess and provide care consistent with professional standards of practice for one of one residents sampled with pressure sores (Resident 124)

Findings include:


A review of the clinical record revealed that Resident 124 was admitted to the facility on February 7, 2020, with diagnoses, which included history of falls, seizures (a medical condition where body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body), urinary incontinence (inability to hold urine) and a spinal fusion (surgery to permanently connect two or more vertebrae in your spine, eliminating motion between them to stabilize the spine and relieve pain) on January 28, 2020. The resident was at home after the spinal surgery, but slipped in the shower on January 30, 2020, and was admitted to hospital with a deep vein thrombosis (DVT a condition in which blood clots (or thrombi) form in deep veins in the legs or other areas of the body. Veins are the blood vessels that carry blood from the body's tissues to the heart. Deep veins are located deep in the body, away from the skin's surface) in his right lower extremity.

A report obtained from the transferring hospital received on February 7, 2020, prior to the resident's arrival to the facility indicated that he had a purple area to his left buttocks described as a deep tissue injury (DTI- injury to the underlying tissue below the skin's surface that results from prolonged pressure in an area of the body. Similar to a pressure sore, a deep tissue injury restricts blood flow in the tissue causing the tissue to die).

A review of the resident's admission assessment completed by Employee 8, a registered nurse (RN), indicated that the resident was at low risk for skin breakdown as evidenced by a Braden Score of 17 (scale to predict pressure sore risk a resident is at risk for pressure sores if the score is less than 17) indicating he is at low risk for developing pressure sores.

A biweekly skin check completed on February 7, 2020, by the ADON (assistant director of nursing), Employee 7, indicated that the resident was admitted to the facility, from the hospital, with a 2 cm x 1.8 cm skin shear, but the location of this impaired area was not indicated. The resident also had a surgical incision in the lumbar area, but no description was noted.

A second skin assessment dated February 8, 2020, at midnight completed by a licensed practical nurse (LPN) Employee 9, solely noted that the resident had a surgical incision to his lumbar area with no description if the actual incision such as size.

Upon the resident's admission to the facility on February 7, 2020, a pressure reducing cushion was ordered to be placed on his wheelchair and a pressure reducing mattress to his bed. Skin prep to his heels and barrier cream (a protective cream placed on the skin to be a physical barrier between the skin and any contaminants that may irritate the skin) was ordered to be applied to his buttocks every shift.

A review of the resident's February 2020 medication administration record revealed that barrier cream was applied to this resident's buttocks on February 7, 2020, on the night shift and applied every shift on February 8, 2020.

There was no documentation indicating that the resident had skin breakdown or impairment on his buttock area from February 7, 2020, until February 10, 2020, at 3:59 PM.

A progress note dated February 10, 2020, at 3:59 PM written by Employee 10, RN, indicated that the resident had a DTI on his left buttocks measuring 5 cm x 5 cm, which was noted as present upon the resident's admission to the facility, although the skin assessments documented by Employees 7 and 8 failed to identify this area. The entry indicated that the pressure area was a new wound, but also that the skin impairment was present on admission.

Nursing documentation on this same date, February 10, 2020, at 4:01 PM indicated that the wound type was MASD (moisture-associated skin damage, is defined as inflammation and erosion of the skin caused by prolonged exposure to moisture and its contents, including urine, stool, perspiration, wound exudate, mucus, or saliva) measuring 2 cm x 2 cm. "Area was not present on admission, area is a new wound."

Interview with the resident on February 21, 2020 at 9:00 AM confirmed he had the pressure area upon admission to the facility and had had developed it while he was in the hospital due to an extended period in moisture. The resident would not permit the surveyor to observe the resident's pressure sore at the time of the survey ending February 21, 2020, therefore an observation of the pressure area was not completed.

Interview with Employee 10, the RN on February 21, 2020 at 11:00 a.m. who first documented the pressure area revealed that the employee stated that the resident was admitted with MASD and a DTI developed. Employee 10 confirmed that there was no assessment/documentation of the pressure area upon admission although the report received from the hospital on February 7, 2020, indicated that the resident had a purple area on his left buttocks.

The facility failed to ensure a resident who had pressure sores received the proper treatment and services consistent with professional standards. It was not until three days after admission to the facility that nursing accurately assessed the area and treatments were implemented.

The wound care physician was consulted and treated the resident on February 12, 2020, and noted at that time that the resident was observed to have an unstageable (due to necrosis) wound to his left buttocks measuring 3 cm x 2 cm. Santyl ointment (debriding ointment) was ordered to soften the eschar (dead tissue). On February 19, 2020, the wound care physician surgically removed the necrotic (dead) tissue from the are and noted an improvement.

The facility failed to ensure a resident's wound was assessed timely and accurately and failed to implement prompt measures to prevent the decline of the area.


28 Pa. Code 211.5(f)(g)(h) Clinical records

28 Pa. Code 211.12(a) Nursing Services

28 Pa. Code 211.12(c) Nursing Services

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

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

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






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

1. R# 124 no longer resides in the facility.
2. To identify residents with the potential to be affected body audits were completed for residents on 3/2/20. Skin impairments were assessed and properly identified by RN staff and appropriate treatments were initiated if needed.
3. To prevent this from recurring the RDCS provided education to current Registered Nursing Staff on proper identification of pressure ulcer.
4. To monitor and maintain ongoing compliance the DON/designee will audit 3 admissions/readmissions weekly x4 then monthly x2 to ensure accurate identification of pressure ulcers. Any negative findings will be immediately corrected.
5. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations.

201.18(b)(1)-(3) LICENSURE Management.:State only Deficiency.
(b) The governing body shall adopt and enforce rules relative to:

(1) The health care and safety of the residents.

(2) Protection of personal and property rights of the residents, while in the facility, and upon
discharge or after death.

(3) The general operation of the facility.
Observations:

Based on a review of three closed clinical records it was determined that 2 of 3 records did not contain documentation to indicate the disposition of the resident's personal belongings at the time of discharge or death (Resident 76 and Resident 75)

Findings include:

A review of the clinical record of Resident 76 revealed that the resident was discharged to home on January 25, 2020. An "Inventory of Personal Possessions" form dated and signed by the resident on November 14, 2019, indicated he had clothing, and a cell phone and charger during admission to the facility, but there was no evidence of the disposition of the resident's belongings upon discharge from the facility.


A review of Resident 75's clinical record revealed that the resident passed away at the facility on January 21, 2020. The resident's "Inventory of Personal Possessions" form dated and signed by the resident on November 19, 2019, indicated that the resident had personal clothing during admission at the facility. There was no evidence of the disposition of Resident 35's personal belongings upon her death.

The Director of Nursing confirmed the above findings during interview on February 21, 2020, at 10:00 a.m.




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

1. R# 76 and R# 75 no longer reside in the facility. Moving forward the facility will ensure to provide disposition of resident belongings upon discharge from the facility.
2. To identify residents with the potential to be affected Medical Records/designee completed an audit on residents discharged from 2/25/20 3/3/20 to ensure proper disposition of resident belongings upon discharge from the facility. The facility cannot retroactively correct missing documentation on the inventory sheet. Moving forward the facility will ensure accurate documentation on the inventory sheet on discharge.
3. To prevent this from recurring the DON/designee will provide education to Medical Records and current licensed nursing staff on the disposition of resident belongings upon discharge from the facility.
4. To monitor and maintain ongoing compliance Medical Records/designee will audit 3 discharges weekly x4 then monthly x2 to ensure accurate documentation of inventory sheets upon discharge. Any negative finding will be immediately corrected.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

201.22(e) LICENSURE Prevention, control and surveillance of TB.:State only Deficiency.
(e) The 2-step intradermal tuberculin skin test shall be the method used for initial testing of residents and employes. If the first test is positive, the person tested shall be considered to be infected. If the first test is negative, a second test should be administered in 1--3 weeks. If the second test is positive, the person tested shall be considered to be previously infected. If the second test result is negative, the person is to be classified as uninfected.
Observations:

Based on a review of clinical records and staff interview it was determined that the facility failed to obtain a baseline Tuberculosis status by means of a 2-step Tuberculin skin test (PPD) for one resident (Resident 65) out of 19 sampled.

Findings include:

The clinical record of Resident 65 indicated that the resident was admitted to the facility on September 8, 2019.

A PPD test was administered in the resident's right forearm on September 8, 2019.

According to the 2019 Medication Administration Record (MAR) the results were read as 0 mm (negative result) on September 10, 2019.

The second step PPD was scheduled to be given on September 17, 2019.

There was no documented evidence on the resident's September 2019 MAR that the second step PPD was administered.

An interview with the director of nursing on February 19, 2020, at approximately 10:00 AM failed to provide documented evidence of the completion of a 2-step intradermal tuberculin skin test to obtain a baseline TB status of Resident 65.









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

1. R #65 had a TB assessment completed. The physician was notified and a new order was received to administer a 2 step PPD. RP was made aware.
2. To identify residents with the potential to be affected. The NHA/designee completed an audit on current residents. One resident was identified and a new 2 Step PPD was administered per physician order.
3. The DON/designee will provide education to current licensed nursing staff on PPD administration per CDC recommendation.
4. To monitor and maintain ongoing compliance the DON/designee with audit 3 new admission records weekly x4 then monthly x2 to ensure PPD administration per CDC guidelines. Any negative findings will be immediately corrected.
5. The results of the audit will be forwarded to facility QAPI committee for further review and recommendations.

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

Based on review of clinical records and staff interview, it was determined that the facility failed to include a discharge summary in one of three closed records reviewed (Resident 127).

Findings include:

Review of Resident 127's clinical record revealed that the resident was admitted to the facility on September 28, 2015.

The resident was transferred to the hospital on October 7, 2019, and then discharged from the facility.

A review of the resident's clinical record conducted during the survey ending February 21, 2020, revealed no documented evidence of a discharge summary in the clinical record.

Interview with the Director of Nursing on February 20, 2020 at 11:20 AM confirmed that a discharge summary was not completed.



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

1. R #127 no longer resides in the facility.
2. To identify residents with the potential to be affected Medical Records/designee completed an audit on residents discharged 2/25/20 3/3/20 to ensure discharge summaries are completed. The facility cannot retroactively correct missing information on the discharge summary. Moving forward the facility will ensure documented evidence of a discharge summary.
3. To prevent this from recurring the NHA/designee provided education to IDT on completion of discharge summaries.
4. To monitor and maintain ongoing compliance Medical Records/designee will audit 3 discharges weekly x4 then monthly x2 to ensure documented evidence of discharge summaries. Any negative findings will be immediately corrected.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.


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