Nursing Investigation Results -

Pennsylvania Department of Health
WEXFORD HEALTHCARE CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WEXFORD HEALTHCARE CENTER
Inspection Results For:

There are  144 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 Medicare/Medicaid Recertification, State Licensure, Abbreviated Survey, in response to two complaints, and COVID-19 Focus Survey completed on November 11, 2021, it was determined that Wexford Healthcare 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:


483.10(j)(1)-(4) REQUIREMENT Grievances:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

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

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

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

Findings include:

The facility "Resident grievance" policy last reviewed 3/4/21, indicated that a grievance is an official statement of a complaint over something believed to be wrong or unfair. The facility will provide a venue for residents, and others involved in patient are, to voice concerns, complaints, or grievances to facility leadership and external parties. The facility will make available to all residents information of the right to file grievances, and the right to file grievances anonymously.

During a resident council group interview on 11/8/21, at 1:33 p.m. nine residents did not know where the grievance forms were located or how to file an anonymous grievance.

During observations of the Second floor on 11/8/21, at 3:01 p.m. the resident common area and nursing units were found without grievance forms.

During an interview on 11/8/21, at 3:02 p.m. interview with Registered Nurse (RN) Employee E3 stated that the grievance forms were in a drawer behind the nurses station.

During an interview on 11/8/21, at 3:05 p.m. Agency Registered Nurse (RN) Employee E4 stated that the grievance forms were in a drawer behind the nurses station.

During observations of the Third floor on 11/08/21, at 3:12 pm grievance signage was observed, but no observation of grievance forms on the nursing unit or the resident common areas.

During an interview on 11/8/21, at 3:14 pm Registered Nurse (RN) Supervisor Employee E5 observed obtaining grievance forms from behind the Third floor nursing station.
She stated that the grievance forms are usually in a filing cabinet.

During an interview on 11/08/21, at 3:20 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure anonymous grievance forms are readily accessible for resident use on two of three floors.

28 Pa Code: 201.29(l) Resident rights

28 Pa Code: 201.18 (e )(4) Management







 Plan of Correction - To be completed: 12/14/2021

F0585

The facility will continue to ensure that anonymous grievance forms are readily accessible for residents to use on all floors.
No residents identified an unaddressed grievance as a result of form availability.
To identify other residents that have the potential to be affected the facility placed grievance forms immediately upon notification of their absence in designated areas on each floor of facility. Location of forms was reviewed with residents during resident council on 11/29/21. Social Service will review grievance process and location of grievance forms with current residents by 12/3/21.

To ensure proper practice continues the social worker will be educated by the Administrator or designee on the policy and process to make grievance forms available to residents on all floors of the facility by 11/29/21.

To maintain ongoing compliance the social worker or designee will re-stock grievance forms on each floor 2x week. An audit will be conducted by the Administrator or designee 3x week for 4 weeks to ensure that forms are readily available on each floor of the facility.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:
Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to make certain that weight loss was identified and addressed in a timely manner for two of five residents (Residents R13 and R94) and failed to assess a resident nutritional needs after developing a wound (Resident R26).

Findings include:

The facility "Resident Weight" policy, last reviewed on 3/4/21, indicated that it is the policy of the facility that a resident weight be accurately obtained. Obtain weight using similar clothing and the same scale. Document the weight indicting the method of weight obtained. If weight variance of five pounds or more is noted, reweigh the resident to verify within 24 hours. It is recommended residents with tube feedings be weighed weekly.

The facility "Medical Nutrition therapy: assessment and care planning" policy, last reviewed on 3/4/21, indicated that a registered dietitian/nutritionist is responsible for completion of a comprehensive nutrition assessment for all residents for the purpose of identifying and planning the nutrition care based on the needs of the resident. The Registered dietitian will be responsible for ensuring follow up and appropriate documentation of recommended changes in the plan of care, and ensuring that all assessments meet current standards of practice.

Review of Resident R13's admission record indicated he was admitted on 5/8/21, with diagnoses that included hemiplegia, vascular dementia, dysphagia, blindness, and hypertension.

Review of Resident R13's quarterly MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 8/6/21, indicated that the diagnoses remained current.

Review of Resident R13's care plan dated 6/18/21, indicated to obtain weekly weights if unplanned weight loss was identified.

Review of Resident R13's physician orders dated 7/30/21, indicated he was on pureed texture diet due to dysphagia. The physician orders also indicated that he was to receive enteral feed (tube feeding) via PEG tube.

Review of Resident R13's weight documentation indicated a decline of eight pounds from September 2021 to October 2021.

Review of Resident R13's weight documentation indicated a decline of seven pounds from October 2021 to November 2021.

Review of Resident R13's weight change progress note dated 11/3/21, indicated a weight loss of 7.2%, and the Registered Dietitian (RD) Employee E11 requested a reweigh for Resident R13. Further review of Resident R13's weights and nurse progress notes did not indicate that the he was reweighed for accuracy.

Review of Resident R26's admission record dated 5/29/19, indicated she was admitted with diagnoses that included dementia, anxiety disorder, history of pulmonary embolism, vitamin deficiency, and hyperlipidemia.

Review of Resident R26's annual MDS assessment dated 8/20/21, indicated that the diagnoses remained current. MDS annual assessment Section-M0300B indicated a "1" for the number of Stage-2 pressure ulcers Resident 26 had upon assessment.

Review of Resident R26's care plan dated 6/4/21, indicated that she has nutrional problems, monitor meal intake, and provide nutritional consult as needed.

Review of Resident R26's wound assessment dated 10/5/21, indicated Resident R26 had developed an area to the left elbow measuring .5 cm x 1.57 cm x 0 cm.

Review of Resident R26's nurse progress notes, dietitian assessments, and physician assessments did not include an assessment of dietary needs related to the newly developed pressure ulcer.


The clinical record indicated that Resident R94 was admitted to the facility on 10/5/21 with diagnosis that included respiratory failure(condition in which your blood doesn't have enough oxygen) and pneumonia (lung inflammation caused by bacteria).

Review of Resident R 94's weight record indicated the following weights:

9/8/21 180 pounds
11/2/21 156 pounds a 13% weight loss

During an interview on 11/9/21, at 2:15 p.m. Registered Dietitian (RD) Employee E11 confirmed that the facility failed to provide a comprehensive dietitian assessment after Resident R26 developed a pressure area.

During an interview on 11/10/21, at 10:40 a.m. Registered Dietitian (RD) Employee E11 confirmed that Resident R13 reweigh was not completed as per her request.

During an interview on 11/10/21 at 11:17 a.m. Registered Dietitian Employee E11 confirmed that the facility did not obtain a reweigh for Resident R94

28 Pa. Code 201.18(b)(1)Management
Previously cited 7/8/20.

28 Pa Code: 211.6 (b) Dietary services.

28 Pa Code: 211.10 (c )(d) Resident care policies

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







 Plan of Correction - To be completed: 12/14/2021

F692

The facility will continue to ensure that weight loss is identified and addressed in a timely manner and an assessment of resident nutritional needs after developing a wound is conducted.

Re-weights for R13 was obtained 11/17/2021 and R94 had been discharged. A comprehensive dietician assessment for R26 was conducted on 11/9/2021
To identify other residents that have the potential to be affected the facility will conduct an audit of any resident with a 5 pound weight variance-loss or gain since previous weight by _12/10/2021 to ensure re-weight was obtained. An audit will also be conducted on any resident with wounds by 12/8/2021to ensure that a comprehensive dietary assessment was conducted.

To ensure proper practice continues licensed nurses and nursing assistants will be re-educated by staff development coordinator or designee by 12/14/2014 to obtain a re-weigh for any 5lbs weight variance-loss or gain since previous weight. Administrator or designee will re-educate dietician by 12/2/2021 on conducting a comprehensive dietician assessment on any resident with wounds.

To maintain ongoing compliance the DON or designee will audit weights of 3 residents with wounds to ensure that re-weights are obtained for any 5 pound variance-gain or loss and audit orders 3x a week for any new wounds to ensure a comprehensive dietary assessment is conducted. Audits will be conducted for 4 weeks.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained.

483.15(a)(1)-(7) REQUIREMENT Admissions Policy: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(a) Admissions policy.
483.15(a)(1) The facility must establish and implement an admissions policy.

483.15(a)(2) The facility must-
(i) Not request or require residents or potential residents to waive their rights as set forth in this subpart and in applicable state, federal or local licensing or certification laws, including but not limited to their rights to Medicare or Medicaid; and
(ii) Not request or require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits.
(iii) Not request or require residents or potential residents to waive potential facility liability for losses of personal property.

483.15(a)(3) The facility must not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may request and require a resident representative who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources.

483.15(a)(4) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other consideration as a precondition of admission, expedited admission or continued stay in the facility. However,-
(i) A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State plan as included in the term ''nursing facility services'' so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident's admission or continued stay on the request for and receipt of such additional services; and
(ii) A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid eligible resident.

483.15(a)(5) States or political subdivisions may apply stricter admissions standards under State or local laws than are specified in this section, to prohibit discrimination against individuals entitled to Medicaid.

483.15(a)(6) A nursing facility must disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility.

483.15(a)(7) A nursing facility that is a composite distinct part as defined in 483.5 must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under paragraph (c)(9) of this section.
Observations:
Based on review of facility policy, admission packet documentation, resident records, closed resident records and staff interview it was determined that the facility failed to provide a comprehensive review of resident admission rights and maintain documentation of newly admitted resident records for three out of four newly admitted residents (Resident R69, Resident R124, and Closed Record ResidentCR96).

Findings include:

The facility "Admission paperwork" policy last reviewed on 3/4/21, indicated that it is the policy of the facility to complete the admission packet within 48 hours of admission. Once the resident has been admitted, the Admission director must generate the resident admission packet. The admissions packet must be reviewed and signed with the resident or resident representative within 48 hours of admission. The admission packet items include Resource guide, Resident Rights, payer detail page, compliance information and Medicare/Medicaid service list, must each be reviewed with the resident or representative during the admission process. At least tow master copies of the admission packet, along with a face sheet, must be kept on file in the admission office.

The facility Admission packet contained the following documents for each newly admitted resident: admission agreement, consent to treat, Pennsylvania Responsible party agreement, Assignment of benefits, Pennsylvania Guarantor agreement, photograph consent, Vendor consultation consent, Authorization to share medical information, MA-401 (Pa Admission notice), Alternative dispute resolution agreement, and Receipt of information.


Review of Resident R69's admission record indicated that she was admitted on 9/19/21, with diagnoses that included multiple sclerosis, hyperlipidemia, seizures, and muscle spasm.

Review of Resident R69's admission MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 9/26/21, indicated that the diagnoses remained current.

Review of Resident R69's admission documentation dated 10/21/21, included a letter indicating that Resident R69's representative asked for the admissions documentation to be mailed.

Review of Resident R69's admission record did not include any other documentation or evidence indicating that resident rights were reviewed with Resident R69 or her representative.

Review of Resident R124's admission record indicated that she was admitted on 10/20/21, with diagnoses that included hypertension, dysphagia, altered mental status, and fall history.

Review of Resident R124's admission MDS assessment dated 10/27/21, indicated that the diagnoses remained current.

Review of Resident R124's admission documentation dated 10/21/21, included a form MA 401 and a letter from Director of Social Services Director Employee E. The letter stated that the admission packet was enclosed.

Resident R124's admission record did not include any other documentation or evidence indicating that resident rights were reviewed with Resident R124's representative.

Review of Resident Closed Record CR96's admission record indicated that he was admitted on 10/6/21, with diagnoses that included injury to the rotator cuff, osteoarthritis, hypertension, and sleep apnea.

Review of Resident Closed Record CR96's admission MDS assessment) indicated that the diagnoses were current and accurate.

Review of Resident Closed Record CR96's admission documentation signed 10/6/21, did not include an admission agreement, Pennsylvania Responsible party agreement, Assignment of benefits, Pennsylvania Guarantor agreement, photograph consent, Vendor consultation consent, Authorization to share medical information, form MA-401 (Pa Admission notice), Alternative dispute resolution agreement, and a Receipt of information.

During an interview on 11/8/21, at 12:50 p.m. the Director of Social Services Employee E1 confirmed that the facility failed to provide evidence of a comprehensive review of resident admission rights and maintain documentation of newly admitted resident records for Resident R69, Resident R124, and Closed Resident Record CR96 as required.



28 Pa Code: 201.18 (b)(2) Management

28 Pa Code: 201.24 (a ) Admission policy

28 Pa Code: 201.19 (i) Resident rights







 Plan of Correction - To be completed: 12/14/2021

F620

The facility will continue to ensure that a comprehensive review of resident admission rights will be provided and documentation of newly admitted resident records will be maintained.
Resident for CR96 no longer resides in the facility. Review and documentation of resident right review for R69 and R124 was completed on 11/15/2021.
To identify other residents that have the potential to be affected the facility will review resident rights with all current residents by 12/3/2021. Additionally, resident rights will be reviewed in the next resident council meeting.

To ensure proper practice continues social services will be re-educated by Administrator or designee to provide a comprehensive review of resident rights and maintaining documentation of new admitted resident records by 12/2/2021.

To maintain ongoing compliance the Administrator or designee will audit new admission files for up to 3 random residents (if applicable) admitted after 12/2/2021 to ensure resident rights were reviewed and resident record maintained for 4 weeks.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:
Based on the Resident group meeting, resident interview, observations and staff interview, it was determined that the facility failed to answer call bells timely for one of five nursing units (D wing nursing unit).

Findings include:

During the Resident Council group meeting on 2/8/21, at 1:30 p.m. nine of nine residents indicated that call bells are not answered timely. Five of nine residents reside on the D wing nursing unit.

During an observation on 11/9/21, at 8:05 a.m. of the D wing nursing unit, the light for room 224 illuminated, the call bell was not responded to until 8:35 a.m. 30 minutes later.

During an interview on 11/9/21, at 8:35 a.m. Nurse Aide (NA) Employee E20 confirmed the above findings.

During an observation on 11/9/21, at 8:11 a.m. of the D wing nursing unit, the light for room 220 illuminated, the call bell was not responded to until 8:42 a.m. 31 minutes later.

During an interview on 11/9/21, at 8:42 a.m. Nurse Aide (NA) Employee E21 confirmed the above findings.

During an interview on 11/10/21, at 11:00 a.m. the Director of Nursing confirmed the above findings and concern being brought forward from group, and the facility failed to

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












 Plan of Correction - To be completed: 12/14/2021

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 forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required.

F558

The facility will continue to ensure that call bells are answered timely.
Residents in rooms 224 and 220 were interviewed and grievance forms completed by social service on 11/23/21. Concerns brought forward were addressed at the time the grievance form was completed.
To identify other residents that have the potential to be affected the Social Service Director/Designee will conduct an audit by 12/4/21 for the residents on the D unit to asssess needs are being met and call lights are being answered timely.

To ensure proper practice continues, all staff will be re-educated by staff development coordinator or designee on the process to answer call bells and meet resident needs by 12/14/2021.

To maintain ongoing compliance the DON or designee will audit 5 random residents to ensure call bells are in reach, call bell response time is acceptable and resident needs are being met 3x week for 4 weeks.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained.


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:
Based on a review of facility policy and clinical records and staff interview, it was determined that the facility failed to make certain that clinical records were complete and accurate for one of three residents reviewed (Resident R133).

Findings include:

A review of the facility policy "Clinical Documentation Standards" dated 3/4/21, indicated nurses will follow the basic standard of practice for documentation including a timely and accurate account of resident information in the medical record.

A review of the facility policy "Death Pronouncement" dated 3/4/21, indicated cessation of respirations and heartbeat must be assessed by the nurse and fully documented in the medical record.

A review of the clinical record indicated Resident R133 was admitted to the facility on 10/18/21, with diagnoses that included dementia and prostate, lung, and bone cancer.

A review of a nurse progress note dated 10/24/21, indicated to release the body to the funeral home.

A review of a hospice progress note dated 10/24/21, indicated arrived at facility and resident R133 was already pronounced by facility Registered Nurse (RN) Employee E20. The clinical record did not include assessment and cessation of respirations and heartbeat by the nurse.

During an interview on 11/9/21 at 12:55 p.m., RN Employee E20 conformed the above findings and stated "I got busy and forgot to put in the assessment when Resident R133 passed away."

During an interview on 11/10/21 at 3:00 p.m., the Director of Nursing confirmed the facility failed to make certain that clinical records were complete and accurate for Resident R133.

28 Pa. Code 211.5(f) Clinical records.


 Plan of Correction - To be completed: 12/14/2021

F842

The facility will continue to ensure that clinical records are complete and accurate as it relates to resident death.

Late Entry note entered on 11/10/21 by Nurse E20 that resident R133 expired on 10/24/21 to reflect end of life assessment documentation.
To identify other residents that have the potential to be affected EHR/designee will conduct an audit of medical records for residents who died in November 2021 by12/3/21 to ensure that end of life assessment is documented.

To ensure proper practice continues licensed nurses will be re-educated by staff development coordinator or designee by 12/14/201 on proper documentation of end of life assessment.

To maintain ongoing compliance the DON or designee will audit records of each resident death weekly for 4 weeks to ensure that proper documentation of end of life assessment is complete.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained.


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 review of facility policy, resident clinical record and staff interviews it was determined that the facility failed to obtain urology consultation as per physician order for one of eleven residents with a catheter (Resident R69).

Findings include:

The facility "Catheter care" policy, last reviewed on 3/4/21, indicated that it is the policy of the facility to provide resident care that meets psychosocial, physical and emotional needs. Catheter care is performed at least twice daily.

The facility " Physician orders" policy, last reviewed on 3/4/21, indicated that the nurse that takes the physician order will be responsible for executing the order or provide for the safe hand-off to the next nurse. This includes contacting laboratory services, radiology, pharmacy, therapy or other outside vendors as required to execute the medical order, and document contacts in the medical record.

Review of Resident R69's admission record indicated that she was admitted on 9/19/21, with diagnoses that included multiple sclerosis, hyperlipidemia, seizures, neurogenic bladder, and muscle spasm.

Review of Resident R69's admission MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 9/26/21, indicated that the diagnoses remained current. The MDS assessment Section H0100 indicated an "X" for the use of an indwelling catheter.

Review of Resident R69's care plan dated 9/20/21, indicated to provide catheter care.

Review of Resident R69's physician orders dated 9/20/21, indicated an order for 18 French locking Supra-pubic catheter.

Review of Resident R69's physician orders dated 10/26/21, indicated an order for urology consultations due to leaking from catheter site.

Review of Resident R69's physician assessment dated 10/26/21, indicated that her catheter was leaking from the side.

Review of Resident R69's clinical nurse progress notes and scheduled appointments did not include an appointment for the urologist.

During an interview on 11/09/21, at 10:07 a.m. with Licensed Practical Nurse (LPN)/Medical records personnel Employee E9 confirmed that the facility failed to obtain urology consultation as per physician order for Resident R69 as required.

28 Pa Code: 201.14 (a) Responsibility of licensee
Previously cited 5/19/21.

28 Pa code: 211.10 (c)(d) Resident care policies

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


 Plan of Correction - To be completed: 12/14/2021

F690

The facility will continue to ensure that a urology consultation is obtained per physician orders.

A urology consultation appointment was made for R69. R69 went to appointment on 11/5/2021.
To identify other residents that have the potential to be affected the facility will conduct an audit of any resident with an indwelling catheter by 12/3/2021 to ensure that any order for a urology consultation is followed.

To ensure proper practice continues licensed nurses will be re-educated by staff development coordinator or designee by 12/14/2021 to notify medical records assistant or designee of any orders for consultations so appointments can be made. Administrator or designee will re-educate medical records assistant by 12/14/2021 on setting up consultations appointments timely.

To maintain ongoing compliance the DON or designee will audit orders for any new consultation orders to ensure that appointments are made and followed 3x week for 4 weeks.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:
Based on review of facility policy and clinical records, and staff interview it was determined that the facility failed to provide adequate supervision and implement effective fall interventions to provide a safe transfer for one of three residents (resident R182).

Findings include:

A review of the facility policy "Restorative Program" dated 3/10/20, indicated the facility will meet the physical needs of residents and the clinical team will implement resident specific care to maintain mobility safely.

During an interview on 11/10/21 at 10:30 a.m., Regional Director of Clinical Operations Employee E19, revealed resident transfer status will be transcribed on the kardex and care plan for staff to follow.

A review of the resident face sheet indicated that Resident R182 was admitted to the facility on 12/24/19, with diagnoses that included heart failure, arthritis, and unsteadiness on feet. A review of the MDS (Minimum Data Set - resident care assessment screening) dated 8/20/20, indicated the diagnoses remained current and the resident was alert and oriented and able to make needs known. The resident required assistance of one person for transfers.

A review of a physical therapy summary dated 10/2/20, indicated transfer status contact guard assist (assisting person has one or two hands on the body) with wheeled walker.

A review of Resident R182's kardex, undated, did not include transfer status contact guard assist.

A review of Resident R182's care plan, initiated 12/24/20, did not include transfer status contact guard assist.

A review of a nurse progress note dated 10/4/20 at 10:50 a.m., indicated resident R182 fell while walking to the bathroom, swelling and 4 cm laceration noted to left upper head. Swelling noted to left ear. Swelling and bruising noted to left lower eyelid. Blood noted to left nostril.

A review of an incident report dated 10/4/20, and witness statements dated 10/4/20 and 10/5/20, indicated NA Employee E17 transferred Resident R182 to the bathroom without contact guard assistance.

During an interview on 11/9/21, at 2:50 p.m. NA Employee E17 confirmed they transferred Resident R182 on 10/4/20, without using contact guard assistance. Stated "It was not on the kardex and care plan and someone said they could walk on their own."

During an interview on 11/9/21, at 3:30 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide adequate supervision and implement effective fall interventions to provide a safe transfer for Resident R182.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 5/19/21.

Pa. Code 201.18(b)(1)(3)(e)(1) Management.

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

28 Pa. Code 211.10(d) Resident care policies.
Previously cited 7/8/20, 5/19/21.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 7/8/20.


 Plan of Correction - To be completed: 12/14/2021

F689

The facility will continue to ensure that adequate supervision is provided and effective fall interventions to provide a safe transfer are implemented.

R182 no longer resides at the facility.
To identify other residents that have the potential to be affected the DON or designee will conduct an audit of all residents by 12/10/2021 to ensure that transfer status on Kardex and careplan is present and accurate.

To ensure proper practice continues licensed nurses and nursing assistants will be re-educated by staff development coordinator or designee by 12/14/2021 on where to locate transfer status for residents on the Kardex and careplan Unit Managers and RNAC's will be re-educated by DON or designee by 12/14/2021 on updating the Kardex and careplan to reflect the resident's current transfer status.

To maintain ongoing compliance the DON or designee will review transfer status changes during clinical meeting for 4 weeks. Any change to transfer status will be added to the Kardex and careplan accordingly.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained

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 facility policy and clinical record reviews, and staff interviews, it was determined that the facility failed to assess pressure ulcer for two of three residents with pressure areas (Resident R69 and R94)

Findings include:

A review of the facility policy "Skin Care & Wound Management" dated 3/4/21, indicated residents admitted with or develop skin integrity issues will receive treatment as indicated based on location, stage and drainage.

Review of Resident R69's admission record indicated that she was admitted on 9/19/21, with diagnoses that included multiple sclerosis, hyperlipidemia, seizures, neurogenic bladder, and muscle spasm.

Review of Resident R69's admission MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs) dated 9/26/21, indicated that the diagnoses remained current. The admission MDS assessment Section M0300C. indicated a "2" for the number of Stage three pressure areas Resident R69 has upon admission.

Review of Resident R69's care plan dated 9/20/21, indicated that she had impaired skin integrity, to administer treatments as ordered by medical provider, complete weekly skin checks, and administer medications as per order.

Review of Resident R69's physician orders dated 9/21/21, indicated the following orders for wound care:
Cleanse coccyx wound with NSS, apply medihoney and dry dressing.
Cleanse right heel wound with NSS, apply medihoney, calcium alginate every day.
Cleanse right lower leg wound with NSS. Apply medihoney, calcium alginate every day.
Consult nurse practitioner for chronic wounds

Review of Resident R69's Certified Registered Nurse Practitioner (CRNP) assessment dated 10/6/21, indicated that the resident had a Stage two pressure ulcer to her coccyx and that she was being followed by Wound care services for assessments.

Review of Resident R69's wound assessments dated 10/12/21, indicated that she had a Stage two wound to her sacrum measuring 2.45 cm x 1.37 cm x .10 cm. She also had an Stage three pressure ulcer, acquired 9/21/21, to her right heel measuring 2.18 cm x 1.74 cm x .20 cm.

Review of Resident R69's wound assessment documentation, nurse progress notes, and CRNP/physician assessments for the previous week (the week of 10/5/2021) did not indicate that a wound assessment was completed.

A review of Resident R94's admission skin assessment dated 10/5/21 indicated no skin areas noted.

A review of skin/wound note dated 10/12/21 indicated that Resident R94 presented with a right & left arm skin tear, left upper back skin tear and a sacral-gluteal MASD.

During an interview on 11/10/21 at 10:00 a.m. the Director of Nursing confirmed that the admission assessment was improperly documented.

During an interview on 11/10/21, at 11:13 a.m. the Director of Nursing (DON) confirmed that the facility failed to provide a comprehensive weekly wound assessment for Resident R69 as required.

28 Pa Code 211.5(f) Clinical records

28 Pa Code: 211.10 (a )(c )(d) Resident care policies

28 Pa Code: 211.12 (d)(1)(2)(3)(5) Nursing services
Previously cited 5/19/21.








 Plan of Correction - To be completed: 12/14/2021

F686

The facility will continue to ensure that assessment of pressure ulcer are conducted.
A comprehensive wound assessment was conducted on R94 and R69, treatments required as a result of these assessments to be followed per physician orders.
To identify other residents that have the potential to be affected the facility will complete skin assessment on all residents to have accurate baseline of skin integrity. Those residents identified with wounds will have appropriate comprehensive wound assessment completed by 12/10/21

To ensure proper practice continues licensed nurses will be re-educated by staff development coordinator or designee on the process to assess and document pressure ulcers by 12/14/2021.

To maintain ongoing compliance the DON or designee will audit weekly 5 random residents with wounds to ensure that weekly wound assessments are completed timely for 4 weeks.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:
Based on review of facility policies, clinical records, hospital documents, employee statements, and staff interviews, it was determined that the facility failed to make certain residents were free from neglect by not providing the necessary servicesfor Resident R184 (three staples on the head) and Resident R182 (intracranial hemorrhage-bleeding in the brain), two of five residents reviewed.

Findings include:

A review of the facility policy "Abuse Neglect and Misappropriation" dated 3/10/20, indicated the facility will prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all residents through the implementation of screening, training, prevention, identification, investigation, protection, and reporting.

A review of the facility policy "Mechanical Lifts and Transfer" dated 3/4/21, indicated the use of mechanical lifts requires a competent and skilled user and requires the use of two employees to perform a lift safely, for the resident and the employees.

A review of the facility policy "Restorative Program" dated 3/10/20, indicated the facility will provide resident care that meets physical needs of the resident. The clinical team will assess and implement a plan of action for resident care to maintain or improve mobility.

A review of the quarterly Minimum Data Set assessment (MDS - a periodic assessment of resident care needs) dated 7/16/20, indicated that Resident R184 was admitted on 7/13/20, and had diagnoses that included high blood pressure, diabetes and asthma. A review of Section C0500 Brief Interview for Mental Status (test for cognitive function) revealed a score of 15 (highest score possible).

A review of Resident R184's kardex (instructions to staff on transfer status) dated 7/13/20, indicated transfer status assist of two with full body mechanical lift.

A review of Resident R184's care plan dated 7/14/20, indicated transfer status full body mechanical lift.

A review of R184's nurse progress notes dated 8/22/20, at 12:23 p.m. indicated the resident being transferred from bed to wheelchair via hoyer lift (full body mechanical lift) when the lift fell on top of her head resulting in a gash 3 cm (centimeters) by 1.5 cm. Contacted physician to send to emergency department for evaluation.

A review of Nurse Aide (NA) Employee E12's witness statement dated 8/22/20, indicated I was transferring the resident into her wheelchair. I turned her around, she was sitting with her back towards the chair, I grabbed the two black pieces on the hoyer pad and the whole machine fell.

A review of Registered Nurse (RN) Employee E13's witness statement dated 8/22/20, indicated she interviewed Resident R184 and the resident asked the NA "aren't you supposed to have two people to use that machine?" "I asked her twice", the NA "had been on the phone" when she was in the room to do her care.

A review of the prior Director of Nursing (DON) witness statement dated 8/22/20, indicated she interviewed Resident R184 upon her return from the hospital. The resident asked the NA if she was able to transfer by herself and the NA Employee E12 said I think I can. The resident said the chair was next to her bed facing it, it happened so fast she wasn't able to put her hand up or move out of the way.

A review of the Emergency Department after hospital care plan for Resident R184 dated 8/22/20, indicated their main medical problem was a laceration of the scalp.

A review of the Certified Registered Nurse Practitioner (CRNP) Employee E15's note dated 8/24/20, indicated the hoyer lift fell on Resident R184's head and they had a laceration, where she was to have three staples put into place. Resident R184 reported having a headache and localized pain.

During an interview on 11/9/21, at 3:31 p.m. the DON and Nursing Home Administrator (NHA) confirmed the facility failed to follow Resident R184's care plan and Kardex, and transferred the resident with one staff which resulted in actual physical harm (three staples to the head). This deficiency is cited as past non-compliance.

On 10/22/20, the facility initiated education for all nursing staff including Registered Nurse's(RN's), Licensed Practical Nurses (LPN's), and Nurse Aides (NA's) to ensure that mechanical lifts transfers status are performed as ordered.

This plan included the following:

Immediate suspension of Employee E12 during the investigation ending in termination.

Immediate education included direct care competencies on mechanical lift transfers on all 83 direct care staff employed at the time. Hoyer taken out of service and the hoyer company inspected and passed all hoyer lifts by 8/24/20.

The facility has demonstrated compliance with the regulation since 10/22/20.

During an interview on 11/9/21, at 3:31 p.m. the DON and NHA and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety interventions during mechanical lifts transfers

A review of the resident face sheet indicated that Resident R182 was admitted to the facility on 12/24/19, with diagnoses that included heart failure, arthritis, and unsteadiness on feet. A review of the MDS (Minimum Data Set - resident care assessment screening) dated 8/20/20, indicated the diagnoses remained current and the resident was alert and oriented and able to make needs known. The resident required assistance of one person for transfers.

A review of a physical therapy summary dated 10/2/20, indicated transfer status contact guard assist (assisting person has one or two hands on the body) with wheeled walker.

A review of Resident R182's care plan, initiated 12/24/20, indicated requires staff participation with transfers.

A review of a nurse progress note dated 10/4/20 at 10:50 a.m., indicated resident R182 fell while walking to the bathroom, swelling and 4 cm laceration noted to left upper head. Swelling noted to left ear. Swelling and bruising noted to left lower eyelid. Blood noted to left nostril.

A review of a nurse progress note dated 10/4/20 at 7:00 p.m., indicated resident R182 was not responding to verbal stimuli. Opens eyes but does not follow commands. Resident transferred to ER (emergency room) for evaluation.

A review of the hospital "Inpatient Discharge Summary-Brief Overview" form dated 10/7/20, indicated the admitting diagnosis was intracranial hemorrhage and Resident R184 passed away on 10/7/20.

A review of an incident report dated 10/4/20, and witness statements dated 10/4/20 and 10/5/20, indicated NA Employee E17 transferred Resident R182 to the bathroom without contact guard assistance.

During an interview on 11/9/21, at 2:50 p.m. NA Employee E17 confirmed they transferred Resident R182 on 10/4/20, without using contact guard assistance. Stated "I made a mistake and did not follow the transfer status."

During an interview on 11/9/21, at 3:30 p.m. the Director of Nursing (DON) confirmed that the facility failed to follow the physical therapy recommendations orders for Resident R182's transfer needs which resulted in actual physical harm (intracranial hemorrhage).

On 10/5/21, the facility initiated education for all nursing staff including Registered Nurse's
(RN's), Licensed Practical Nurses (LPN's), and Nurse Aides (NA's) to ensure that residents transfer status are performed as ordered.

This plan included the following:

Immediate suspension of Employee E17 during the investigation.

Immediate education regarding falls, transfers, and neglect was provided to all facility and agency nursing staff which included RN's, LPN's, and NA's, which occurred on 10/5/20.

Interview with NA Employee E17 confirmed the facility initiated education.

All residents were reviewed for transfer status and updated on the kardex. Random weekly audits for resident transfer status started 10/4/20 times 2, then monthly times three until January 2021. The results of the audits were reviewed in QAPI (Quality Assurance and Performance Improvement) by the NHA. The facility has demonstrated compliance with the regulation since 10/5/20.

During an interview with the NHA and DON on 11/10/21 at 3:00 p.m., and review of the facility's immediate actions, education, and review of the QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction and achieved compliance ensuring residents are provided adequate safety interventions during transfers.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 5/19/21.

28 Pa Code 201.18(b)(1) Management.
Previously cited 5/19/21 and 7/8/20.

28 Pa Code 201.29(a) Resident rights.

28 Pa Code 211.12(d)(1)(5) Nursing services
Previously cited 5/19/21 and 7/8/20

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 5/19/21.












 Plan of Correction - To be completed: 12/01/2021

Past noncompliance: no plan of correction required.
483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:
Based on review of facility policy, clinical record and staff interview it was determined that the facility failed to notify a physician of abnormal blood glucose levels as per order for one out of three residents (Resident R102).

Findings include:

The facility "Blood Glucose point of care testing" policy last reviewed on 3/4/21, indicated that blood glucose is a measure of the concentration of glucose levels, sugar, in the blood by testing a blood sample to determine normal and abnormal ranges. The importance of glucose monitoring is necessary to detect extremes of high or low blood glucose levels to evaluate the effectiveness of the treatment plan. Record the point of care results, retest if out of range, and contact the provider if out of range.

The facility "Physician notification for change in condition reporting" policy, last reviewed on 3/4/21, indicated that the facility will make notifications for changes in condition. The nurse will report based on the following criteria for reporting to the physician: blood glucose levels greater than 300 or less than 70 if diabetic.

Review of Resident R102's admission record indicated she was admitted on 10/9/21, with diagnoses that included right sided multiple rib fractures, chronic obstructive pulmonary disease, diabetes, and anxiety disorder.

Review of Resident R102's admission MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs), dated 10/15/21, indicated that the diagnoses remained current.

Review of Resident R102's care plan dated 10/11/21, indicated that Resident R102 has diabetes, administer insulin as per orders, observe for signs of hyperglycemia, and report any abnormal findings to the medical provider.

Review of Resident R102's most recent physician orders dated 10/21/21, indicated to administer Admelog solution at the following sliding scale: 70-140=0 units, 141-180=2 units, 181-220=4 units, 221-260=6 units, 261-300=8 units, 301-340=10 units, >341=12 units call the physician, subcutaneously before meals and at bedtime for diabetes.

Review of Resident R102's insulin levels indicated abnormal blood glucose levels for the following dates: 10/23/21=392, 10/29/21=366, 10/31/21 =435, and 11/1/21 =568.

Review of Resident R102's insulin levels and insulin administration for 10/23/21, 10/29/21, 10/31/21, 11/1/21 did not include physician notifications for abnormal glucose levels.

During an interview on 11/09/21, at 11:26 a.m. with Registered Nurse (RN) Supervisor Employee E2 confirmed that the facility failed to notify a physician of abnormal glucose levels as per order for Resident R102 as required.




28 Pa Code: 201.18 (b)(1)(3) Management

28 Pa Code: 211.10 (c ) Resident care policies

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







 Plan of Correction - To be completed: 12/14/2021

F0580

The facility will continue to ensure that physicians are notified of abnormal lab results.
Glucose trends for R102 were reviewed with physician and new orders to be followed as they arise.
To identify other residents that have the potential to be affected the facility will conduct an audit of residents with orders for blood sugars by 12/7/21 to ensure that physicians were notified of any abnormal results per physician orders.

To ensure proper practice continues licensed nurses will be re-educated by staff development coordinator or designee on the process to notify a physician of abnormal blood glucose levels per physician orders by 12/14/2021_.

To maintain ongoing compliance the DON or designee will audit 5 random residents with orders for blood glucose monitoring to ensure the physician was notified of any abnormal results per order 3x week for 4 weeks.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained.

51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:
Based on review of facility documents and staff interviews, it was determined that the facility failed to notify the Department of Health, Division of Nursing Care Facilities, of a disruption of services.

Findings include:

During a tour of the main kitchen 11/7/21 it was discovered that the dishroom was nonfunctional. Culinary Aide Employee E6 stated it has been out of service since October 31, 2021.

Review of facility supplied documents from May-November 2021 indicated no report of disruption of service.

During interview on 11/7/21, at 1:01 p.m., the Nursing Home Administrator confirmed that the Division of Nursing Care Facilities was not notified of the disruption of service, discovered on 11/7/21.


 Plan of Correction - To be completed: 12/14/2021

H0009

The facility will continue to notify the Department of Health, Division of Nursing Care Facilities of a disruption of services.

The facility administrator notified DOH of dish machine removal for floor replacement on 11/7/2021
All residents have the potential to be affected. No resident was negative impacted as a result of the dish machine being out of service. The outage was pre-planned and dishware for residents to be served meals on were in place at all times. Meals were delivered per schedule throughout dish machine disruption. The dish machine was put back into service and dishroom fully operational as of 11/29/2021.

To ensure proper practice continues facility Administrator will be re-educated by Senior Administrator or designee by 12/1/2021 on notification of disruption of services to the Department of Health, Division of Nursing Care Facilities.

To maintain ongoing compliance the administrator/designee will audit needed reports of any disruption of service to the Department of Health. Division of Nursing Care Facilities Weekly X 4 weeks

The results of the disruption of service will be forwarded to the facility QAPI committee for further review and recommendation until substantial compliance is maintained.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port