Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES - WALLINGFORD
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANORCARE HEALTH SERVICES - WALLINGFORD
Inspection Results For:

There are  157 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.
MANORCARE HEALTH SERVICES - WALLINGFORD - 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 Survey, and investigation of one complaint, completed on December 5, 2019, it was determined that ManorCare Health Services- Wallingford was not in compliance with the following requirements of 42 CFR 483, Subpart B, Requirements for Long Term Care and the 28 Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.





 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on a review of facility policy, observations and staff interview, it was determined that the facility failed to store food in a sanitary manner in the refrigerator, freezer and dry storage area and maintain the kitchen in a sanitary condition.

Findings include:

Review of facility policy titled "Food Safety Polices Food Safety Product Labeling and Dating Guide", undated, revealed that all foods prepared must be covered and labeled as to contents, date of preparation, use by date and employee name/initials prior to storage in refrigerators, freezers and dry storage. Review of the facility form, Freezer Temperature Log, dated August 2009, revealed that the freezer temperature should be maintained at 0 degrees Fahrenheit or below during stable times.

Observation during the initial tour of the kitchen on December 2, 2019 at approximately 1:00 p.m., accompanied by the Director of Dining Services, Employee E3, revealed the walk-in freezer temperature at 5 degrees Fahrenheit as indicated by the thermometer located behind the freezer fan. Additional temperature of the walk-in freezer was taken by Employee E3 at approximately 1:15 p.m with a handheld kitchen thermometer and the temperature at that time at the lowest was 7.8 degrees Fahrenheit. Observation at that same time of the walk-in refrigerator revealed a tray of wrapped sandwiches which had not been labeled as per policy. Additionally, there was a large bowl of prepared tuna fish salad which was only partially covered with plastic wrap.

Observation of the dry storage area at this same time revealed three plastic storage bins which did not have the lids closed and which contained dry cereal. Additionally, the lid for the sugar storage bin was not completely closed.

Further observation of the kitchen revealed one of two sanitizing buckets which did not meet the 200 ppm requirement for the cleaning solution as per the testing strip. The surveyor observed crumbs and debris in the storage trays for silverware. Additionally, the steam and hold machine had an accumulation of debris and the kitchen floor corners and areas around the equipment and counters were observed to have debris and a black substance. Interview with Employee E3 at that time confirmed that it did not appear that these areas were cleaned as they should have been and also confirmed the aforementioned findings.

28 PA Code 201.14(a) Responsibility of licensee
Previously cited 10/30/2019

28 PA Code 201.18(b)(1)(3) Management
Previously cited 10/30/2019; 8/16/2019; 11/8/2018

28 PA Code 201.18(e)(1) Management
Previously cited 10/30/2019; 8/16/2019

28 PA Code 211.6(f) Dietary services









 Plan of Correction - To be completed: 01/14/2020

Uncovered food was removed. Food is wrapped and labeled properly.
A new hanging thermometer was placed in the freezer for accurate recording of temperature.
All dry goods stored in bins have tightly fitting lids.
Sanitizer bucket was emptied and filled to meet the proper 200 ppm requirement.
The silverware caddy and flatware that had crumbs was immediately washed and sanitized
The outside of the steamer was cleaned where the build up of dirt was

All identified sanitation issues were corrected before end of survey.


Dining service staff have been in-serviced on proper cleaning assignments for all areas within kitchen.

A weekly acute cleaning list will be completed and assigned weekly with signatures of completion. All dining service staff have been in-serviced on proper dating and labeling of all food/relating products within the department. All dining staff have been educated on proper PPM for sanitation buckets.

Complete by 12-19-2019


A weekly acute cleaning list will be completed and assignments weekly with signatures of completion. Manager check and review on POC audit.

Audits will be completed 5x per week for the first month, then continuing to one audit per week the following the first month will be conducted to ensure there are no unsealed/undated food items in any kitchen areas. Also, including sanitation walk through that all cleaning assignments have been completed and signed off on and proper temperatures for all walk-in refrigerators/freezers are in correct range.

Results will be presented to the QAPI committee for follow up and recommendations as warranted.

483.25 REQUIREMENT Quality of Care: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 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 a review of clinical records and staff interviews, it was determined that the facility failed to follow physician orders for four of 34 residents (Resident #56, #138, #144 and #11).

Findings include:

A Review of Resident #11's diagnosis list revealed a diagnosis of cerebral infarction due to embolism (an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain).

A review of the facility documentation, progress note dated April 2, 2019, revealed that Resident #11 had a surgical procedure, left side hemicraniectomy (a surgical procedure where a large flap of the skull is removed to give space for the swollen brain to bulge and reduce the pressure). A review of the same note revealed that the Resident had to wear a helmet at all times when out of bed.

An observation on December 3, 2019, at approximately 11:00 a.m., revealed that Resident #11 was seated in a recliner chair with a helmet on.

During an observation on December 4, 2019, at approximately 2:00 p.m., Resident #11 was in the recliner chair,and the resident was observed with no helmet. The resident's helmet was kept at the highest shelf inside the resident ' s closet.

A review of the Resident's physician orders revealed no documented order for Resident #11 to wear a helmet.

A review of the resident's care plan revealed no documentation when to apply the helmet.

An interview with the unit manager, Employee E5 revealed that Resident #11 had an order to wear a helmet at all times when out of bed when the resident was initially admitted on April 2, 2019. The resident was hospitalized on April 10, 2019, and was readmitted to the facility on April 15, 2019. Employee E5 confirmed that the order for the helmet was dropped when the resident was readmitted on April 15, 2019.

A review of the physician orders revealed an order dated December 4, 2019, for Resident #11 to wear a helmet at all times when out of bed.

Review of Resident #56's diagnosis list revealed a diagnosis of esophageal obstruction. Review of the resident's clinical record revealed the resident had ongoing issues with nausea and vomiting.

Review of Resident #56's September, 2019, physician's orders revealed orders dated both September 6, 2019, and September 20, 2019, for the resident to have a gastroenterologist (physician specializing in the gastroinstestinal, or digestive, system) consult.

Review of Resident #56's clinical record failed to reveal that a gastroenterologist consult was obtained as ordered.

Interview with the Director of Nursing on December 5, 2019 at 1:45 p.m. revealed that Resident #56 had a gastroenterologist appointment scheduled for October 11, 2019 and allegedly refused to go to the appointment.

Review of Resident #56's clinical record failed to reveal documented evidence that the resident refused to go to the gastroenterologist appointment or that the physician was made aware that the resident refused the appointment.

Review of Resident #138's physician orders revealed the resident had a PEG tube (percutaneous endoscopic gastrostomy- a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) and was ordered NPO (nothing by mouth).

Observation of Resident #138's room on December 3, 2019, at 12:20, revealed a sign above resident's bed which read: Pleasure Feedings Only, No Ice Cream. Interview with Resident #138 on December 3, 2019 at the time of the observation revealed he has not been offered anything to eat in a long time and did not know why the sign was there.

Review of Resident #138's Speech Language Pathologist discharge summary, dated September 30, 2019 revealed diet recommendation of pleasure feedings of pureed texture only and no ice cream and nectar thick liquids.

Review of Resident #138's physician orders revealed an order dated September 16, 2019 at 10:00 a.m. for pureed pleasure feeding only.

Review of Resident #138's progress notes revealed a dietary entry dated September 19, 2019 at 1:34 p.m. stating patient was cleared by speech language pathologist for mildly thick liquids. Estimated energy needs continue to be fully met via tube feeding. No reported swallowing issues noted.

Interview with the Director of Nursing on December 5, 2019 at 2:13 p.m. confirmed there was an order for the resident to have pleasure feedings on September 16, 2019, but this order was never followed.

Review of Resident #144's diagnosis list revealed diagnoses to include atrial fibrillation (an abnormal and irregular heart rhythm) and heart failure (condition in which your heart muscle is too weak to pump enough blood to your body). Review of the resident's nursing note dated November 18, 2019 revealed that his test for the international normalized ratio (INR) (a laboratory measurement of how long it takes blood to form a clot which is used to determine the effects of oral anticoagulants \ on the clotting system) was high, which resulted in a physician order to hold the resident's coumadin (anticoagulant) beginning November 18, 2019 and to hold the medication until his next INR which was scheduled for November 21, 2019. Review of the resident's November 2019 Medication Administration Record (MAR) revealed that the coumadin was held on November 18, 2019 but was administered to the resident on November 19, 2019. Interview with licensed staff Employee E4 on December 5, 2019 at approximately 1:00 p.m. confirmed that the MAR documented that the coumadin was administered on November 19, 2019, contrary to physician order.


28 PA Code 211.5(f) Clinical records
Previously cited 10/30/2019; 11/8/2018

28 PA Code 211.12(d)(1)(5) Nursing services
Previously cited 10/30/2019; 11/8/2018






 Plan of Correction - To be completed: 01/14/2020

The facility failed to follow MD orders for four of 34 residents (#56 #138, #144 and #11 )
Resident #11's order for helmet was obtained and input on 12/4/2019. The resident continues to wear the helmet when out of bed. Refusals will be documented.
Resident #138 was evaluated by Speech therapy and an order for Regular diet/puree texture was input 12/5/2019.
Resident #144's receives coumadin per Physician orders.
Resident #56s NP will see resident and offer to reschedule GI visit for requested 2nd opinion. Refusal will be documented.
Current Residents and new admissions who receive specialized equipment, consult appointments, pleasure feedings, and coumadin will be reviewed to ensure they are receiving appropriate care and service Utilizing the QAPI tools for Coumadin, Consults, Adaptive Equipment and Pleasure feeds.
Licensed Nurses will be educated on Focus on F Tag 684 Quality of Care
Utilizing the QAPI tools for Coumadin, Consults, Adaptive Equipment and Pleasure feeds random audits will be completed by DON/designed weekly x 4
Trends to be submitted to QAA for review and recommendations as indicated

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

Based on a review of clinical records, observations and staff interview, it was determined that the facility failed to assure that a care plan related to vision was developed to meet the overall healthcare needs of one of 34 residents (Resident #87).

Findings include:

Review of Resident #87's quarterly assessment, dated November 14, 2019 revealed diagnoses to include anemia (condition marked by a deficiency of red blood cells) and dementia (irreversible, progressive degenerative disease of the brain). Further review indicated that the resident had a score of seven on the Brief Interview of Mental Status which indicates severe cognitive impairment, although the resident was able to answer simple questions during an interview.

Observation of Resident #87 on December 2, 2019 at approximately 11:30 a.m., revealed resident sitting in her wheelchair next to her bed. Interview with the resident revealed her main concern which was that she "can't see, I'm blind". When asked if she knew where her call bell was, the resident stated that she didn't know because she couldn't see it. The surveyor next observed the resident during her lunch meal on December 3, 2019 at approximately 12:30 p.m. The resident was using her hands to find the different food items on her lunch tray as again she stated that she was blind and couldn't see the items. When asked, the resident indicated her preference to eat in her room even though there would be more assistance for her if she ate in the dining room. Observation of Resident #87 on December 5, 2019 at approximately 10:30 a.m. as she was eating her morning meal (resident prefers getting up later in the morning) revealed that she was having the same difficulty finding her food on the tray. The resident stated that she hadn't received her bacon or her cereal yet so the surveyor described to her where the foods were located on her tray.

Review of opthomology consultation, dated August 27, 2019, revealed that the resident was noted to have cataracts in the right and left eyes and was blind in the right eye.

Review of the resident's active care plan revealed no evidence of care plan interventions developed related to the resident's vision issues.

Interview with licensed staff Employee E4, unit manager, on December 5, 2019 at approximately 1:00 p.m, confirmed that a care plan had not been developed to address interventions for the resident's vision issues. Interview with the nursing home administrator on that same date at approximately 1:15 p.m. confirmed that a care plan for vision had not been developed for the resident.

28 PA Code 211.5(f) Clinical records
Previously cited 10/30/2019; 11/8/2018

28 PA Code 211.11(d) Resident care plan
Previously cited 11/8/2018

28 PA Code 211.12(c)(d)(1) Nursing services
Previously cited 10/30/2019; 11/8/2018

28 PA Code 211.12(d)(5) Nursing services
























 Plan of Correction - To be completed: 01/14/2020

The facility failed to develop and implement a comprehensive care plan related to vision to meet the overall healthcare needs of one of 34 residents.
Cited Resident: #87
Resident #87's care plan for visual impairment was reviewed and updated on 12/5/2019.
Current Residents and new admissions with visual impairment will be reviewed for the presence of a comprehensive care plan using the Care Plan QAPI Tool.
Licensed Nurses will be educated on Focus on F Tag 656 Develop/Implement Comprehensive Care Plan
Utilizing the Care Plan QAPI Tool random Audits of residents with visual impairment will be completed by DON/designed weekly x 4
Trends to be submitted to QAA Committee for review and recommendations as indicated

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 clinical records review, hospital records review, and staff interview, it was determined that the facility failed to accurately assess and provide wound care in a timely manner for one of eight residents reviewed (Resident #63).

Finding include:

Review of Resident #63' s diagnosis list revealed diagnoses of diabetes (failure of the body to produce insulin to enable sugar to pass from the bloodstream to cells for nourishment), heart disease, severe protein-calorie malnutrition (occurs when the body does not get enough nutrients), and peripheral vascular disease (PVD- poor circulation of the extremities).

A review of the clinical record of Resident #63 revealed that the Resident was admitted to the facility on September 19, 2019. Review of the admission assessment documentation dated September 19, 2019, revealed that Resident #63's right buttock site was black with a measurement of 2.0 x 2.0 centimeters. The Resident also had a surgical incision in the abdomen.

Review of the Physician Order Sheet (POS) revealed an order on September 19, 2019, to cleanse sacrum with wound cleanser, apply Venelex (An ointment that is used to increase circulation in the wound site area) and cover with a foam dressing.

Review of the facility progress note dated September 24, 2019, documented by the unit manager, Employee E5 revealed that Resident #63 had a wound to left and right buttock that was present upon admission and not sacral as previously noted. The note further revealed that the right buttock wound measured 3.4 centimeters x 2.0 centimeters, with 90 % brown/yellow slough (covering on the base of the wound that can prevent a wound from healing properly). The left buttock wound measured 4.0 centimeters x 2.0 centimeters, with 90 % brown/yellow slough. Review of the same note revealed that the Resident was also admitted to the facility with a Deep Tissue Injury (DTI- Purple or a maroon localized area of discolored intact skin or blood-filled blister from pressure) on left heel.

Review of the hospital records dated September 14, 2019, revealed that Resident #63 had a heel pressure injury, left sacrum and right buttock wound, and a midline surgical incision in the abdomen.

A review of the September 2019 Treatment Administration Record (TAR) revealed an order for a hydrocolloid dressing (An occlusive, waterproof dressing that is generally indicated for superficial wounds with low amounts of drainage) to left and right buttock every three days. A review of the TAR revealed that the treatment was started on September 25, 2019. A review of the same TAR revealed an order for a skin prep (a liquid film-forming dressing that acts as a protection to the skin) to left heel every shift for DTI, the treatment was started on September 24, 2019.

An interview with the Director of Nursing and Employee E5 on December 5, 2019, at approximately 10:30 a.m., was conducted. Employee E5 confirmed that Resident #63 was admitted to the facility with a wound to right and left buttock, and a DTI on the left heel. Employee E5 confirmed that the wound care order was only made for the sacral wound on September 19, 2019, which was later clarified as the left buttock wound. Employee E5 also confirmed that the wound care order for Resident #63's right buttock was not started until September 25, 2019, and left heel DTI order was not started until September 24, 2019. No documentation that the right buttock and the left heel wound was appropriately treated from September 19, 2019, until September 24, 2019.

The facility failed to accurately assess Resident #63's wounds and failed to provide wound care in a timely manner.


28 Pa. Code 211.5(f) Clinical Records
Previously cited 10/30/19, 11/8/18


28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 10/30/19, 11/18/18





 Plan of Correction - To be completed: 01/14/2020

The facility failed to accurately assess and provide wound care in a timely manner for one of eight residents #63.
Resident #63 is receiving treatment according to physician orders.
Current residents and new admissions with pressure ulcers will be reviewed for appropriate wound care treatments using the Skin QAPI tool
Licensed Nurses will be educated on Focus on F Tag 686 Treatment/Svcs to Prevent/Heal Pressure Ulcers
Utilizing the Skin QAPI Tool random Audits will be completed on residents with pressure ulcers to assure appropriate care and services by DON/designed weekly x 4
Trends to be submitted to QAA for review and recommendations as indicated

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

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

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

Based on observation, staff and resident interview, facility policy and procedure review, and clinical record review it was determined the facility failed to provide proper care and services for a resident with a Foley catheter for one of 4 residents reviewed. (Resident 138)

Findings include:

Review of facility policy and procedure, titled Indwelling Catheters and dated 2012, revealed the physician ' s decision to use an indwelling catheter is based on valid clinical indicators. A comprehensive evaluation includes underlying factors supporting the medical justification for the initiation and continuing need for catheter use.

Observation of Resident 138 on December 3, 2019 at 12:33 p.m. revealed the resident had a Foley catheter (sterile tube inserted into the bladder to drain urine). Interview with resident 138 at the time of the observations revealed the resident first had the Foley catheter inserted in the hospital before coming to the facility and has had it since admission.

Review of Resident 138's physician orders revealed an order for a Foley catheter but there was no diagnosis for the catheter. Further review of Resident 138's entire clinical record revealed there was no clinical rationale for the use of the catheter and there were no assessments completed to determine the need for the continued use of the catheter.

Interview with the Director of Nursing on December 5, 2019 at 2:13 p.m. confirmed there was no clinical rationale for the use and continued use of the Foley catheter documented for resident 138.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 11/8/18

28 Pa. Code 201.18(b)(3) Management
Previously cited 10/30/19, 11/8/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 10/30/19, 8/16/19, 11/8/18

28 Pa. Code 211.10(c)(d) Resident care policies
Previously cited 10/30/19, 11/8/18

28 Pa. Code 211.12(c)(5) Nursing services
Previously cited 11/8/18

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 10/30/19, 11/8/18



 Plan of Correction - To be completed: 01/14/2020

The facility failed to provide proper care and services for a resident with a Foley catheter for one of four residents #138 Resident #138 Foley catheter was d/c on 12/10/2019 and a voiding trial was initiated per MD orders. The resident remains without the Foley catheter.
Current residents and new admissions with catheters will be reviewed for appropriate care and services using the Incontinence/Catheters QAPI Tool.
Nursing Staff will be educated on Focus on F Tag 690 Bowel/Bladder Incontinence, Catheter, Uti
Utilizing the Incontinence/Catheter QAPI Tool random Audits of residents with catheters will be completed by DON/designee weekly x 4
Trends to be submitted to QAA for review and recommendations as indicated

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



Based on clinical records review, and resident and staff interviews, it was determined that the facility failed to accurately assess and managed the pain of one of eight residents reviewed (Resident #105).

Findings include:

A review of Resident #105's diagnosis list revealed diagnoses of osteoarthritis (OA- is a type of joint disease that results from breakdown of joint cartilage and underlying bone) of the knee, traumatic subarachnoid hemorrhage (bleeding into the space between the surface of the brain) without loss of consciousness, cerebral infarction (stroke), and dementia ( irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability.

A review of Resident #105's Quarterly Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated October 31, 2019, revealed that the Resident had severe cognitive impairment.

A review of the medical practitioner's note dated November 8, 2019, revealed that Resident #105 awakes to name being called and then falls back to sleep. Further review of the same note revealed that the Resident had a history of extensive expressive aphasia (characterized by partial loss of the ability to produce language).

A review of the Physician Order Sheet (POS), revealed an order made on April 12, 2019, for Acetaminophen 650 mg as needed for mild pain. On August 27, 2019, an order for Oxycodone (a narcotic pain medication to treat pain) five milligrams every six hours as needed for moderate pain. On May 4, 2019, an order for Cyclobenzaprine (muscle relaxant) five milligram one tab at HS (hours of sleep) for spasm.

A review of the progress note dated November 9, 2019, at 7:36 a.m., revealed that Resident #105 was administered Oxycodone five milligrams for a pain level of six. A review of the same note revealed "Resident complained of pain in her leg, positioning unsuccessful". There was no follow-up documentation if the medication administered was effective.

A review of the progress note dated November 14, 2019, at 12:06 p.m., revealed that Resident #105 was administered Oxycodone five milligrams for a pain level of six. A review of the same note revealed: "Resident screaming in her room, verbalized pain in the leg". There was no follow-up documentation if the medication administered was effective.

A review of the progress note dated November 18, 2019, at 12:37 a.m., revealed that Resident #105 was administered Oxycodone five milligrams for a pain level of seven. A review of the same note revealed: "Resident crying out loud, inconsolable, repositioning done with no positive effect". There was no follow-up documentation if the medication administered was effective.

A review of the progress note dated November 22, 2019, at 2:34 p.m., revealed that Resident #105 was administered Oxycodone five milligrams for a pain level of six. A review of the same note revealed "Resident complained pain in her knee". There was no follow-up documentation if the medication administered was effective.

A review of the progress note dated November 23, 2019, at 7:45 a.m., revealed that Resident #105 was administered Oxycodone five milligrams for a pain level of six. Review of the same note revealed, "Resident yelling, trying to climb out of bed, turned the television on and repositioned, still complaining and unable to stay still". There was no follow-up documentation if the medication administered was effective.

A review of the progress note dated November 24, 2019, at 10:55 a.m., revealed that Resident #105 was administered Oxycodone five milligrams for a pain level of six. A review of the same note revealed: "Resident repeating, my leg, my leg, repositioned resident and turned light off, night nurse reported resident was up all night". There was no follow-up documentation if the medication administered was effective.

Review of Resident #105's clinical records revealed no documentation that the physician was notified regarding Resident #105's frequent pain.

Review of the November 2019 Medication Administration Record (MAR) revealed that Resident #105 was medicated with Oxycodone five milligrams 18 times during the month of November with a pain scale level ranging from three to seven.

During an observation on December 2, 2019, at approximately 10:30 a.m., Resident #105 was lying in bed. The resident just looked at the surveyor when greeted. The resident did not respond to any of the surveyor's questions.

During an observation on December 4, 2019, at approximately 2:00 p.m., Resident #105 was lying in bed, no response when greeted by the surveyor.

On December 5, 2019, at approximately 2:00 p.m., Employee E5 was asked by the surveyor how is a numeric pain level scale utilized to assess the pain of a resident who has aphasia and with severe cognitive impairment.
Employee E5 was not able to provide an answer to the surveyor.

The facility failed to accurately assess, manage and treat Resident #105 pain.


28 Pa Code 211.12 (d)(1)(5) Nursing Services
Previously cited 10/30/19, 11/8/18

28 Pa. Code 211.5(f) Clinical Records
Previously cited 10/30/19, 11/8/18















 Plan of Correction - To be completed: 01/14/2020


The facility failed to accurately assess and manage pain of one out of eight residents reviewed #105
Resident #105's pain was reassessed by CRNP on 12/09/2019 and the resident is being assessed for the effectiveness of treatment.
Current Residents and new admissions receiving as needed pain medication will be reviewed for accurate pain assessment and management using the QAPI Pain Tool.
Licensed Nurses will be educated to Focus on F Tag F697 Pain Management
Utilizing the QAPI Pain Tool random Audits of residents receiving as needed pain medication will be completed by DON/designee weekly x 4
Trends to be submitted to QAA for review and recommendations as indicated

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive 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, observations, resident interview and staff interview it was determined the facility failed to ensure proper care and services for a resident receiving dialysis for two of three residents reviewed. (Residents #121 and #100)

Findings include:

Review of Resident #100's diagnosis list revealed diagnoses of End Stage Renal Disease (ESRD - failure of kidney function to remove toxins from blood) and dependence on Renal Dialysis (process of removing waste products and excess water from the body).

During the initial tour on December 2, 2019, at approximately 1:00 p.m., Resident #100 was not in the room. An interview with Employee E6 revealed that Resident #100 was on dialysis. Employee E6 further stated that the resident usually returns to the facility during the afternoon shift (3-11 shift).

Review of the facility documentation revealed that Resident #100 goes to an outside center to have dialysis every Monday, Wednesday, and Friday. The pick-up time was 9:45 a.m.

On December 4, 2019, at approximately 4:00 p.m., Resident #100 was still at the dialysis center. Review of the progress note dated December 4, 2019, revealed that the Resident returned from the dialysis center at 5:30 p.m.

Review of the Physician Order Sheet (POS) revealed an order made on November 11, 2019, for Voltaren Gel (pain medication)1%, apply two grams transdermal (a route of administration wherein active ingredients is delivered across the skin for systematic distribution) four times a day for pain for 30 days. The administration time was 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. Review of the November 2019 medication administration record (MAR) revealed that the Voltaren gel was not administered every Monday, Wednesday and Fridays at 1:00 p.m. MAR documentation revealed that the Resident was out of the center.

Review of the POS revealed an order made on November 12, 2019, for an Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/dl (a medication that helps to increase airflow in the lungs), one application every six hours. The administration time was 12:00 a.m., 6:00 a.m., 12:00 noon., and 6:00 p.m. November 2019 MAR revealed that the medication was not administered every Monday, Wednesday, and Friday at 12:00 noon. MAR documentation revealed that the Resident was out of the center.

Review of the October 2019 MAR revealed an order for Calcium Acetate (a medication used to prevent high blood phosphate levels in patients who are on dialysis due to severe kidney disease) 667 milligrams, give one capsule by mouth with meals. Administration time was 8:00 a.m., 12:00 noon, and 5:00 p.m. Review of the same MAR revealed that the medication was not administered every Monday, Wednesday, and Friday at 12:00 noon. MAR documentation revealed that the Resident was out of the facility.

An interview with Employee E5 on December 5, 2019 at approximately 2:00 p.m., confirmed that Resident #100 did not received the medications scheduled on the days and time that the Resident was on dialysis.

Review of facility policy and procedure titled Assessment of Arteriovenous Shunts, Fistulas, and Grafts, last updated July 2017, revealed the frequency of assessment is determined by the patient ' s condition and medical practitioner order with a minimum frequency of daily. The procedure states to place a hand over the site and palpate for the presence of thrill (motion of blood flowing through the site) and using a stethoscope, auscultate over the site for the presence of bruit (a sound which may range from a whooshing noise to a whistle-like sound).

Observation of Resident 121 on December 3, 2019 at 12:12 p.m. revealed the resident had an AV fistula (a surgically created connection between an artery and a vein for hemodialysis treatment) in the upper left arm.

Interview with Resident 121 on December 3, 2019 at 12:12 revealed that staff do not check the AV fistula for bruit and thrill.

Review of resident 121 ' s Clinical record revealed there was no documented evidence Resident 121's bruit and thrill were being checked at least daily per facility policy.

Interview with the Director of Nursing on December 5, 2019 at 2:13 p.m. confirmed there was no documented evidence the facility was checking Resident 121's bruit and thrill.

28 Pa. Code: 211.5(f) Clinical records
Previously cited 10/30/19, 11/8/18

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 10/30/19, 11/8/18




 Plan of Correction - To be completed: 01/14/2020

The facility failed to ensure proper care and services for a resident receiving dialysis for two of three residents reviewed (#121 #100)
Resident #121 had monitoring of Bruit/Thrill orders added to their plan of care on 12/5.2019.
Resident #100 is receiving medications around her dialysis treatments.
Current residents and new admissions on dialysis will be reviewed for appropriate care and services using the Hemodialysis QAPI tool
Licensed Nurses to be educated to Focus on F Tag F698 Hemodialysis
Utilizing the Hemodialysis QAPI Tool random Audits for residents on dialysis will be completed by DON/designee weekly x 4
Trends to be submitted to QAA for review and recommendations as indicated

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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



Based on review of facility procedure, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents did not receive antianxiety medications unless necessary and that behavior interventions were attempted before use for two of five residents reviewed (Residents #109 and #127).

Findings include:

Review of the facility's "Behavioral Symptom Evaluation and Documentation Process" of 2017 revealed that when a patient demonstrates a new onset behavior, staff are to document the observed behavior. Additionally, the interdisciplinary team is to develop, modify, and initiate a care plan with individualized nonpharmacological interventions.

Review of Resident #109's physician's orders revealed an order for Ativan Solution 0.5 milligrams sublingually (under the tongue) every four hours as needed for anxiety related to anxiety disorder.

Review of Resident #109's October Medication Administration Record (MAR) revealed that Ativan was administered on October 6, 11, and 24, 2019. Review of Resident #109's November MAR revealed that Ativan was administered on November 1, 4, 13, 20, and 23.

Further review of the clinical record revealed that no behaviors were documented prior to the administration of Ativan on October 11, 24, 2019, and November 1, 4, 13, and 23, 2019. Additionally, there was no documented evidence that behavior interventions were attempted before the administration of Ativan on October 6, 2019, and November 20, 2019.

Review of Resident #127's physician's orders revealed an order for Ativan Solution 0.25 milliliters every two hours as needed for anxiety.

Review of Resident #127's November MAR revealed that Ativan was administered on November 22, 23, 26, 28, and 29, 2019. Review of Resident #127's December MAR revealed that Ativan was administered on December 1 and 2, 2019.

Further review of the clinical record revealed that no behaviors were documented prior to the administration of the Ativan.

Interview with the Director of Nursing on December 5, 2019, at 11:05 a.m. confirmed that behaviors and/or behavior interventions were not documented prior to the administration of Ativan.


42 CFR 483.45 (c)(3) Unnecessary Medications
Previously cited 11/8/18

28 Pa. Code: 201.18(b)(1) Management
Previously cited 10/30/19, 8/16/19, 11/8/18

28 Pa. Code: 211.5(f) Clinical records
Previously cited 10/30/19, 11/8/18

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 11/8/18

















 Plan of Correction - To be completed: 01/14/2020

The facility failed to ensure that residents did not receive antianxiety medications unless necessary and that behavior interventions were attempted before use for two of five residents reviewed #109 and #127
Non-pharmacological interventions have been added to both Resident's #109 and #127 Antianxiety medication orders. CRNP will complete a medication review for antianxiety medications for both residents.
Current residents and new admissions prn psychotropic medications will be reviewed for appropriate care and services using the Psychotropic Medication QAPI Tool
Licensed Nurses will be educated to Focus on F Tag F758 Free from Unnec Psychotropic Meds/Prn Use
Utilizing the Psychotropic Medication QAPI Tool Random Audits of resident on prn psychotropics will be completed by DON/designee weekly x4
Trends to be submitted to QAA for review and recommendations as indicated


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