Nursing Investigation Results -

Pennsylvania Department of Health
WEXFORD HEALTHCARE CENTER
Patient Care Inspection Results

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WEXFORD HEALTHCARE CENTER
Inspection Results For:

There are  124 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.
WEXFORD HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Revisit Survey completed on November 15, 2019, it was determined that Wexford Health Center failed to correct all the federal deficiencies cited for the survey ending September 20, 2019, and new deficiencies were identified under the 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 Facilities Licensure Regulations.



 Plan of Correction:


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to properly store medications and biologicals in two of seven medication carts (Second Floor D Wing front hall cart and Second Floor D Wing back hall cart) and failed to accurately date a medication in one of seven medication carts (Third Floor E Wing cart).

Finding include:

The facility policy "Storage of Medications" dated 3/25/19, indicated that medications and biologicals are stored safely, securely, and properly. Orally administered medications are kept separate from externally used medications and treatments. Eye medications are kept separate. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. Medication storage areas are to kept clean and free of clutter.

During an observations on 11/13/19, at 12:07 p. m. of the Second Floor D Wing Medication Room and at 12:12 p.m. of the Second Floor D Wing Front Hall medication cart the following was observed:

The medication room contained staff members personal bags on the counter top.
The medication cart contained insulin vial mixed with eye medications and numerous looses pills in the bottom of a drawer.

During an interview on 11/13/19, at 12:15 p. m. Licensed Practical Nurse (LPN) Employee E3 confirmed that the facility failed to properly store medications in the Second Floor D Wing medication Room and the D Wing front hall medication cart.

During an observation on 11/13/19, at 12:16 p.m. of the Second Floor D Wing back hall medication cart the following was observed:
Medication cup of loose pills.
Dressing supplies- stack of 4x4's open to air, bottle of saline, and ointment no label or name.
Lidocaine/Prilocaine cream no bag, label or resident name.
Container of Cholestyramine powder scoop in powder.

During an interview on 11/13/16, 12:20 p.m. LPN Employee E4 confirmed that the facility failed to store properly store medications and biologicals.

During an observation on 11/13/19 at 1:30 p.m. of the Third Floor E Wing front hall medication cart the following was observed: opened Pulmicort (respiratory inhaler) opened date written 10/6/19, and a sticker "Beyond Use Date open 10/16/19."

During an interview on 11/13/19, at 1:35 p. m. Licensed Practical Nurse Employee E5 confirmed that the facility failed to accurately label medications in the Third Floor E Wing front hall medication cart.

28 Pa. Code: 2211.9 (a) (1) (h) (i) Pharmacy services.

28 Pa Code: 211.12 (d) (1) (2) (3) (5) Nursing services.






 Plan of Correction - To be completed: 12/03/2019

Preparation for and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set for the on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

Staff personal items removed from medication room on D wing. D-Wing front hall medication cart: Insulin vial removed from eye medication compartment. Cart cleaned and cleared of all loose medications and medications discarded on 11/13/19. D- Wing back hall medication cart: Medication cup of loose pills discarded, dressing supplies of 4x4's bottle of saline and ointment, and lidocaine cream discarded. Scoop in container of Cholestyramine discarded. E Wing front hall medication cart: Pulmicort discarded.
All medication rooms checked and staff personal items removed. All med carts audited and improperly stored and expired items discarded on 11/13/19.All discarded medications restocked as needed, per order.
The Director of Nursing/Designee to educate licensed staff on personal items not permitted to be stored in medication rooms, appropriate dating when meds opened, separation of medications from dressing supplies and loose pills stored in cart by 12/3/19
Audit med carts by the Director of Nursing/designee for appropriate storage of medications and appropriate dating of meds when open, audit 4 carts per week X 4 weeks. Audit 2 medication rooms 3 X per week X 4 weeks for improperly stored personal items. The results of these audits will be reported to the Quality Assurance Committee who will evaluate the results and make recommendations as needed.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:

Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending 9/20/19, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending 11/15/19, identified repeated deficiencies related to proper infection control procedures not maintained during the dressing change, improper storage of medications and biologicals which both created the potential for cross contamination and the potential spread of infections and diseases.

The facility's plan of correction for a deficiency regarding proper infection control procedures, revealed that the facility would complete audits, educate staff and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880 and F761, revealed that the facility's QAPI committee was ineffective in developing and implementing corrective actions for noncompliance by staff on procedures related to dressing change and infection control and the proper storage of medication and biologicals.

Refer to F761 and F880.




 Plan of Correction - To be completed: 12/03/2019

There have been no reported resident negative effects due to alleged deficient QAPI process. Nursing Home Administrator and Director of Nursing have been educated by Regional Director of Operations on 11/27/19 on QAPI procedures. Ad hoc QAPI meeting to be held 12/3/19 with ED, DON, Medical Director, Infection Preventionist and RN Supervisor. Content to be reviewed include infection control relating to dressing change and proper storage of medications and biologicals. Applicable weekly audits to be reviewed and discussed for compliance.
QAPI meeting weekly X 4 weeks to review continued compliance of QAPI plan relating to infection control with dressing change and proper storage of medications and biologicals
Regional Director of Operations/Designee will review weekly QAPI meeting minutes and applicable audits X 4 weeks and monthly thereafter for 2 months.
The results of these audits will be reviewed with the Facility QA Committee.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:
Based on review of facility policies, observation, and staff interview, it was determined that the facility failed to make certain that proper infection control practices were followed during dressing change which created the potential for cross contamination for one of one residents (Resident R9).

Findings include:

Review of the facility policy "Standard Precautions" dated 3/25/19, indicated that the facility will provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. Practicing hand hygiene is a simple but effective way to prevent the spread of infections by breaking the chain of infection. Hand hygiene will be performed before and after direct contact with resident's intact skin, after contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or dressing change. After glove removal.

Review of the facility policy "PPE Gloves" dated 3/25/19, indicated that hand hygiene is to be performed before gloves are applied and after gloves are removed. The policy reviews the process of glove removal, then discard in proper container and perform hand hygiene.

During an observation of a dressing change on 11/13/19, at 11:25 a.m. the Unit Manager Registared Nurse (RN) Employee E1 and Wound Care RN Employee E2 prepared Resident R9 for a dressing change of the right inner ankle area. The following was observed:

Wound Care RN Employee E2 removed gloves, carried sanitizing wipe container into restroom, opened door to restroom failed to perform handwashing when gloves were removed. Wound Care RN Employee E2 with ungloved hands placed wipe container in the wound cart. Wound Care RN Employee E2 then applied gloves, removed a sanitizing wipe, cleaned scissors, removed gloves and then gathered supplies for the dressing change without performing handwashing when gloves were removed. Wound Care RN Employee E2 removed Resident R9's old dressing, failed to place clean field under Resident R9's wound to protect the bedding. When dressing change was complete Unit Manager RN Employee E1 removed gloves, removed trash bag from bedside, placed the soiled wound dressing trash in the trash in the resident restroom without performing handwashing when gloves were removed. Wound Care RN Employee E2 verbalized that the dressing change was complete but did not label and date the new dressing and failed to return to Resident R9's room to sanitize overbed table.

During an interview on 11/13/19, at 12:00 p.m. Unit Manager RN Employee E1 and Wound Care RN Employee E2 confirmed that proper infection control procedures were not maintained during the dressing change which created the potential for cross contamination.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 201.20(c) Staff development.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services










 Plan of Correction - To be completed: 12/03/2019

Verified with PA Department of Health, Pittsburgh field office surveyor that dressing change observed on Resident E9 was to the left inner knee. Resident E9 wound area assessed 11/19/19, had no negative effect related to alleged deficient infection control practice.
Residents in house, with wound dressings had been assessed for signs and symptoms of infection by 11/20/19 by wound care nurse
The Director of Nursing and or designee has completed education with employee 1 and employee 2 on 9/13/19. The Director of Nursing and or designee will in-service Licensed Nurses on proper infection control procedures during dressing changes with wound dressing change competency by 12/3/19 The Director or Nursing or designee will complete proper handwashing technique with return demonstration with all staff by 12/3/19.
The Director of Nursing/Designee will complete audits of proper infection control procedures during dressing changes and proper handwashing procedures when donning and doffing gloves during dressing changes 3nurses weekly X 4 weeks. The results of these audits will be reported to the Quality Assurance Committee who will evaluate the results and make recommendations as needed.


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