Nursing Investigation Results -

Pennsylvania Department of Health
SQUIRREL HILL WELLNESS AND REHABILITATION CENTER
Patient Care Inspection Results

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SQUIRREL HILL WELLNESS AND REHABILITATION CENTER
Inspection Results For:

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SQUIRREL HILL WELLNESS AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights compliance, and an Abbreviated Survey in Response to two complaints completed on March 14, 2022, it was determined that Squirrel Hill Wellness and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long-Term Care and the 38 PA Code, Commonwealth of Pennsylvania Long-Term Care Licensure Regulations.



 Plan of Correction:


483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir: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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of 11 residents (Resident R5, R74, R85, R94, R102, R121, R139, and R345).

Findings include:

A review of the facility policy "Advanced Directives" last reviewed 1/13/22, indicated the facility will provide information on admission concerning advanced directives, and if the resident indicates he/she has not established advanced directives they will be given the opportunity to accept or decline this option.

A review of the medical record indicated Resident R5 was admitted to the facility on 2/14/20, with diagnoses that included diabetes, high blood pressure, and cancer.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R5 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R74 was re-admitted to the facility on 4/13/21, with diagnoses that included muscle weakness, diabetes, high blood pressure.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R74 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R85 was admitted to the facility on 5/1/21, with diagnoses that included muscle weakness, and insomnia (trouble falling and/or staying asleep).

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R85 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R94 was admitted to the facility on 6/15/21, with diagnoses that included cancer, diabetes, and low back pain.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R94 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R102 was re-admitted to the facility on 9/6/20, with diagnoses that included cancer, diabetes, and anxiety.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R102 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R121 was admitted to the facility on 5/30/18, with diagnoses that included diabetes, high blood pressure, and depression.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R121 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R139 was admitted to the facility on 2/10/22, with diagnoses that included depression, insomnia, and traumatic brain injury (a head injury causing damage to the brain by external force).

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R139 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R345 was admitted to the facility on 3/2/22, with diagnoses that included depression, and anxiety, .

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R345 was given the opportunity to formulate an Advanced Directive.


During an interview on 3/9/22, at 12:00 p.m. the Director of Nursing confirmed that the clinical record did not include documentation that residents were afforded an opportunity to formulate an Advance Directive (POA or Living Will) for Resident R5, R74, R85, R94, R102, R121, R139, and R345.


28 Pa. Code: 201.29(b)(d)(j) Resident rights.
Previously cited 12/23/19






 Plan of Correction - To be completed: 04/13/2022

1. Resident 5, 74, 85, 94, 102, 121, 139 and 345 have been informed by the Director of Social Services or designee if they would like to fill out a Advanced Directive.

2. Resident 5, 74, 85, 94, 102, 121, 139 and 345 signed or declined Advance Directives when asked by the Director of Social Services or designee on The Advance Director Questioner

3. Director of Social Services and Admissions Director was educated by the Administrator on the Advance Directive Questioner

4. New Residents will be communicated with on the Advance Directive Questioner by the Director of Social Services or designee upon admission to the facility.

5. A one time audit will be performed by the Director of Social Services or designee on all residents to insure the Advance Directive Questioner is filled out by all in-house residents.

6. An audit will be performed by the Director of Social Services or designee on all new admissions and residents returning from the hospital to ensure the Advance Directive Questioner is up to date and sign

7. Results of the audit by the director of Social Services or designee will be reviewed by the Administered or designee in the facilities Quality Assurance meeting for the next three meetings.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:
Based on facility policy, observation, clinical record review and staff interview, it was determined that the facility failed to administer medications with a medication error rate that was less than five percent for three of seven residents (Residents R5, R123 and R347) and failed to ensure that residents were free from significant medication errors for two of ten Residents reviewed (Resident R67 and Resident 96) .

Findings included:

Three medication errors occurred during 25 observed opportunities, which resulted in a 12 percent medication error rate.

A review of the facility policy "Administering Medications" reviewed 1/13/22, indicated medications shall be administered in a safe and timely manner, and as prescribed, and prior to administering insulin with an insulin pen, the nurse will prime the pen with 2 units of insulin.

A review of the medical record indicated Resident R5 was admitted to the facility on 2/14/20, with diagnoses that included diabetes, high blood pressure, and cancer.

During an observation on 3/7/22, at 1:30 p.m. Resident R5's fingerstick glucose resulted at 281.

A review of a physician order dated 2/9/22, indicated to inject 10 units of Humalog Lispro insulin (a short-acting recombinant form of insulin administered by injection in the treatment of type 1 and type 2 diabetes) with meals and a sliding scale of 261-300 an additional 4 units of insulin requiring a total of 14 units of Humalog Lispro insulin.

During an observation on 3/7/22, at 1:37 p.m. of Resident R5's medication administration Registered Nurse (RN) Employee E7 failed to prime the insulin needle for the Lispro insulin pen prior to administrating 14 units of Lispro Humalog.

A review of the medical record indicated Resident R123 was admitted to the facility on 2/11/22, with diagnoses that included diabetes, high blood pressure, and repeated falls.

During an observation on 3/7/22 at 1:40 p.m. Resident R123's fingerstick glucose resulted at 295.

A review of a physician order dated 2/11/22, indicated a sliding scale of 261-300 requiring 12 units of Humalog Lispro insulin to be injected.

During an observation on 3/7/22, at 1:45 p.m. of Resident R123's medication administration RN Employee E7 failed to prime the insulin needle for the Lispro insulin pen prior to administrating 12 units of Lispro Humalog.

A review of the medical record indicated Resident R347 was admitted to the facility on 2/25/22, with diagnoses that included diabetes, high blood pressure, and depression.

During an observation on 3/7/22, at 1:42 p.m. Resident R347's fingerstick glucose resulted in 180.

A review of a physician order dated 2/25/22, indicated to inject 3 units of Humalog lispro insulin with meals and a sliding scale of 151-300 requiring 6 units of Humalog Lispro insulin to be injected, for a total of 9 units.

During an observation on 3/7/22, at 1:45 p.m. of Resident R347's medication administration RN Employee E7 failed to prime the insulin needle for the Lispro insulin pen prior to administrating 9 units of Lispro Humalog.

During an interview on 3/7/22, at 1:59 p.m. RN Employee E7 confirmed she did not prime the insulin needles prior to administration.

During an interview on 3/7/22, at 3:00 p.m. the Corporate Employee E66 confirmed that the insulin pens need to be primed before administration.

Review of the facility policy "Administering Medications" dated 11/10/21, indicated " If a medication is not available during med pass, this medication may be flagged in MAR so that staff can look for medication after med pass is complete. If medication not available on unit, nurse will look in medication machine located on the 6th floor. If medication not available, medication to be marked unavailable and nurse will contact pharmacy and notify MD."

The Admission Record indicated Resident R96 was admitted on 12/24/21, with the diagnosis of obstructive sleep apnea (sleep related breathing disorder that involves a decrease or halt in airflow), and heart failure ( a chronic progressive condition in which the heart muscle is unable to pump enough blood to meet the body's need). The Minimum Data Set (MDS-periodic assessment of resident care needs) dated 2/9/22, included the same diagnosis.

Physician orders dated 3/3/1/22, indicated that Resident R96 was to receive the following medication:
Glimepiride (used to treat high blood sugar) tablet 4mg - give 4mg by mouth one time a day for diabetes
Pramipexole Dihydrochloride (medication for restless leg) tablet 1.5mg - give 1.5mg by mouth one time a day for restless leg
Protonix (for stomach problems) tablet delayed releaser 40mg - give one tablet by mouth one time a day


Review of Resident R96 clinical record progress note indicated the following:

1/23/22 9:46 a.m. eMar-Medication Administration Note Pramipexole Dihydrochloride Tablet 1.5mg give 1.5mg by mouth one time a day - med not available
1/22/22 20:14 p.m. eMar-Medication Administration Note Pramipexole Dihydrochloride Tablet 1mg Give 2mg by mouth at bedtime - missing med
1/22/22 10:03 a.m. eMar-Medication Administration Note Pramipexole Dihydrochloride Tablet 1.5mg Give 1.5mg by mouth one time a day - medication is missing
1/22/22 10:02 a.m. eMar-Medication Administration Note Glimepiride Tablet 4mg Give 4mg by mouth onetime a day - medication is missing
1/19/22 10:54 eMar-Medication Administration Note Pramipexole dihydrochloride Tablet 1.5mg Give 1.5mg by mouth one time a day - med unavailable
1/11/22 16:49 p.m. eMar-administration Note Protonix Tablet Delayed Release 40mg Give 1 tablet by mouth one time a day - med unavailable
12/28/21: 5:54 a.m. eMar-Medication Administration Note Protonix Tablet Delayed Release 40mg Give 1 tablet by mouth one time a day - not available

The admission record indicated Resident R67 was admitted to the facility on 11/19/21, with diagnosis of transient cerebral ischemic attack, hypertension. The Minimum Data Set (MDS a periodic assessment of resident needs) dated 1/28/22, included the same diagnosis.

Physician orders dated 1/22/22, indicated that Resident R67 was to receive the following medication:
Levothyroxine Sodium Tablet (used to treat underactive thyroid) 75mcg give one tablet by mouth
Norco (used to relieve moderate to severe pain) tablet 5-325mg Give 1 tablet by out every 8 hours
Lidocaine Patch (help to relieve pain) 5% apply to back, feet topically every 12 hours as needed
Atorvastatin Calcium (used to lower bad cholesterol) Tablet 20mg Give 1 tablet by mouth at bedtime
Lido Pac Kit 5% (used to stop itching and pain) Apply to affected areas topically one time a day for pain

Review of Resident R96 clinical record progress notes indicated the following:

1/24/22 18:03 eMar-Medication Administration Note 18:03 Norco 5-325MG Give 1 tablet by mouth every 8 hours for pain
1/23/22 7:01 e-Mar Medication Administration note Levothyroxine Sodium Tablet 75mcg - Give one tablet by mouth one time a day
1/22/22 8:43 eMar-Administration Note Norco Tablet 5-325 give 1 tablet by every 8 hours medication not available
12/12/21 eMar -Administration Note Lidocaine Patch 5% Apply to back, feet topically every 12 hours for pain apply to top of feet -not available
12/11/21 9:52 a.m. Levothyroxine Sodium Tablet 75mcg Give 1 tablet by mouth in the morning - not here
12/6/21 21:53 p.m. Atorvastatin Calcium Tablet 20mg Give 1 tablet by mouth at bedtime - med missing
12/3/21 8:45 a.m. Levothyroxine Sodium Tablet 75mcg Give one tablet by mouth in the morning - not available
1/30/22 11:49 a.m. Lido Pac Kit 5% Apply to affected areas topically one time a day for pain - not on hand

During an interview on 3/11/22, at 2:48 p.m. Director of Nursing confirmed that medications are documented as not being available and or missing, and the facility failed to make sure that residents were free from significant medication errors

28 Pa. Code 211.12(d)(1)(5): Nursing services.
Previously cited 9/23/21

28. Pa. Code 201.14(a)Responsibility of licensee.
Previously cited 12/23/19, 9/23/21

28. Pa. Code 201.18(b)(1)e(1)Management.
Previously cited 12/23/19, 9/23/21



 Plan of Correction - To be completed: 04/13/2022

1. no ill effects were noted to resident 5, 123, 347 due to staff member not priming insulin pen before administration of prescribed insulin

2. no ill effects noted to residents 67 and 96 when medication was not available to administer.


3. Licensed staff will be educated by the Director of Nursing or designee on priming insulin pens with 2 units of insulin before administrating prescribed physician ordered insulin to the resident.

4. An audit will be performed by the Director of Nursing or designee 5 times per week for three weeks then three times per week for two weeks on insulin administration and priming of 2 units of insulin prior to administrating by the med nurse.

5. All licensed nurses will perform a proper insulin pen administration competency by the Director of Nursing or designee.

6. Audits will be performed on 4 licensed nurses per day by the Director of Nursing or designee 5 times per week for the next three weeks then weekly for the next two weeks



7. Licensed staff were educated by the Director of Nursing or designee on if medication is unavailable in the emergency box or Omnicell, to notify the physician, and Pharmacy and to document corrected action if medication was given or not.

8. Audits will be performed by the Director of Nursing or designee 5 times per week for the next three weeks then 3 times a week for two weeks on medication availability which consist of if medication is unavailable if physician, and Pharmacy were notified and corrected documentation performed of medication outcome.

9. Results of the education and audits by the Director of Nursing or designee will be reviewed by the Administrator or designee in the Felicities Quality Assurance meeting for the next three meetings.
483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on facility policy, observation, clinical record review and staff interview, it was determined that the facility failed to administer medications with a medication error rate that was less than five percent for three of seven residents (Residents R5, R123 and R347).

Findings included:

Three medication errors occurred during 25 observed opportunities, which resulted in a 12 percent medication error rate.

A review of the facility policy "Administering Medications" reviewed 1/13/22, indicated medications shall be administered in a safe and timely manner, and as prescribed, and prior to administering insulin with an insulin pen, the nurse will prime the pen with 2 units of insulin.

A review of the medical record indicated Resident R5 was admitted to the facility on 2/14/20, with diagnoses that included diabetes, high blood pressure, and cancer.

During an observation on 3/7/22, at 1:30 p.m. Resident R5's fingerstick glucose resulted at 281.

A review of a physician order dated 2/9/22, indicated to inject 10 units of Humalog Lispro insulin (a short-acting recombinant form of insulin administered by injection in the treatment of type 1 and type 2 diabetes) with meals and a sliding scale of 261-300 an additional 4 units of insulin requiring a total of 14 units of Humalog Lispro insulin.

During an observation on 3/7/22, at 1:37 p.m. of Resident R5's medication administration Registered Nurse (RN) Employee E7 failed to prime the insulin needle for the Lispro insulin pen prior to administrating 14 units of Lispro Humalog.

A review of the medical record indicated Resident R123 was admitted to the facility on 2/11/22, with diagnoses that included diabetes, high blood pressure, and repeated falls.

During an observation on 3/7/22 at 1:40 p.m. Resident R123's fingerstick glucose resulted at 295.

A review of a physician order dated 2/11/22, indicated a sliding scale of 261-300 requiring 12 units of Humalog Lispro insulin to be injected.

During an observation on 3/7/22, at 1:45 p.m. of Resident R123's medication administration RN Employee E7 failed to prime the insulin needle for the Lispro insulin pen prior to administrating 12 units of Lispro Humalog.

A review of the medical record indicated Resident R347 was admitted to the facility on 2/25/22, with diagnoses that included diabetes, high blood pressure, and depression.

During an observation on 3/7/22, at 1:42 p.m. Resident R347's fingerstick glucose resulted in 180.

A review of a physician order dated 2/25/22, indicated to inject 3 units of Humalog lispro insulin with meals and a sliding scale of 151-300 requiring 6 units of Humalog Lispro insulin to be injected, for a total of 9 units.

During an observation on 3/7/22, at 1:45 p.m. of Resident R347's medication administration RN Employee E7 failed to prime the insulin needle for the Lispro insulin pen prior to administrating 9 units of Lispro Humalog.

During an interview on 3/7/22, at 1:59 p.m. RN Employee E7 confirmed she did not prime the insulin needles prior to administration.

During an interview on 3/7/22, at 3:00 p.m. the Corporate Registered Nurse Employee E1 confirmed that the insulin pens need to be primed before administration.

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







 Plan of Correction - To be completed: 04/13/2022

1. no ill effects were noted to resident 5, 123, 347 due to staff member not priming insulin pen before administration of prescribed insulin

2. Licensed staff will be educated by the Director of Nursing or designee on priming insulin pens with 2 units of insulin before administrating prescribed physician ordered insulin to the resident.

3. An audit will be performed by the Director of Nursing or designee 5 times per week for three weeks then three times per week for two weeks on insulin administration and priming of 2 units of insulin prior to administrating by the med nurse.

4. All licensed nurses will perform a proper insulin pen administration competency by the Director of Nursing or designee.

5. Audits will be performed on 4 licensed nurses per day by the Director of Nursing or designee 5 times per week for the next three weeks then weekly for the next two weeks

6.. Results of the education and audits by the Director of Nursing or designee will be reviewed by the Administrator or designee in the Felicities Quality Assurance meeting for the next three meetings.
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 observation, clinical record review, staff interview, and facility policy it was determined that the facility failed to administer and check blood glucose levels and failed to notify a physician of abnormal glucose readings as per physician's order for two out of five residents (Residents R21 and R140), the facility failed to provide nutritional services by enteral feeding as ordered by the physician for two of four residents reviewed (Residents R108 and R342), and the facility failed to obtain weights as ordered for four of 12 residents (Resident R108, R342, R97, and R139).

Findings include:

A review of the facility policy "Tube Feeding" last reviewed 11/10/21, indicated that the facility staff will administer tube feedings (delivery of food or medication via tube surgically inserted into stomach) as ordered by physician.

The facility "Diabetes-clinical protocol" policy last reviewed on 11/10/21, indicated that residents who meet the criteria for diabetes testing, the physician will order pertinent screening. The physician will order desired parameters for monitoring and reporting information related to diabetes or blood sugar management. The staff will incorporate such parameters into such parameters into the Medication Administration Record and care plan. The staff will identify and report complications such as hypoglycemia.

The facility "Notification of change in resident's condition" policy last reviewed on 11/10/21, the physician, responsible family members or legal representatives shall be notified as soon as possible, or within 24 hours, of any changes in the resident's condition. The charge nurse shall be responsible for notifying when a change occurs in the resident's condition. The charge nurse shall document the notification.

Review of Resident R21's admission record indicated he was originally admitted on 2/16/18, and readmitted on 12/1/21, with diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hypertension (high pressure in arteries impacting blood flow), moderate protein malnutrition, and chronic obstructive pulmonary disease (a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs).

Review of Resident R21's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 1/18/22, indicated that the diagnoses remained current upon review.

Review of Resident R21's care plan dated 5/28/20, indicated that he has potential for hypoglycemia or hyperglycemic episodes, administer diabetes medication as ordered, and to report signs of hyperglycemia or hypoglycemia to the physician as needed.

Review of Resident R21's physician order's dated 12/1/21, indicated to administer insulin (Humalog solution) subcutaneously via insulin pen using blood glucose monitoring and the following protocol:
70-140=0 units
141-180=1 units
181-220=2 units
221-260=3 units
261-300=4 units
301-340=5 units
Blood glucose greater than 341 and above give 6 units and call the physician.

Review of Resident R21's blood sugar monitoring summary did not include a glucose check or insulin administration during the evening shifts on 1/4/22 and 1/29/22.

Review of Resident R21's Medication Administration Record for January 2022 did not include a glucose check or insulin administration during the evening shift on 1/4/22 and 1/29/22.

Review of Resident R21's nurse progress notes dated 1/4/22 and 1/29/22 did not include a blood glucose check or indicate an administration of Resident R21's insulin.

Review of Resident R140's admission record indicated that he was admitted on 9/3/21, with diagnoses that included vascular dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory), diabetes, chronic obstructive pulmonary disease, and hypertension.

Review of Resident R140's quarterly MDS assessment dated 2/18/22, indicted that the diagnoses remained current upon review.

Review of Resident R140's care plan dated 9/22/21, indicated that he has potential for hypoglycemia or hyperglycemic episodes and to report signs of hyperglycemia or hypoglycemia to the physician as needed.

Review of Resident R140's physician's orders dated 12/16/21, indicated to administer insulin (Humalog solution) subcutaneously via insulin pen using blood glucose monitoring and the following protocol:
70-140=0 units
141-180=1 units
181-220=2 units
221-300=4 units
301-340=5 units
Blood glucose greater than 341 and above give 6 units and call the physician

Review of Resident R140's physician order's dated 2/17/22, indicated to administer insulin (Humalog solution) subcutaneously via insulin pen using blood glucose monitoring and the following protocol:
Blood Glucose lower than 70, initiate blood glucose protocol and call the physician
70-140=0 units
141-180=1 units
181-220=2 units
221-260=3 units
261-300=4 units
301-340=5 units
Blood glucose greater than 341 and above give 8 units and call the physician.

Review of Resident R140's blood sugar monitoring summary indicated the following high glucose levels:
1/10/22=408
1/21/22=463
2/20/22=439

Review of Resident R140's nurse progress notes dated 2/16/22, indicated he was found lying on the floor and his blood glucose read at 39. He was administered Glucagon and transported to the hospital. Further review of Resident R140's nurse progress notes did not indicate a notification to the physician about the high glucose levels on 1/10/22, 1/21/22, and 2/20/22.

During an interview on 3/9/22, at 08:40 a.m. the Registered (RN) supervisor Employee E6 that the facility failed to administer and check blood glucose levels and failed to notify a physician of abnormal glucose readings as per physician's order for Resident R21 and R140 as required.

A review of the clinical record revealed Resident R108 was admitted to the facility on 2/8/22, with diagnoses that included cancer, anemia (a condition in which the blood does not have enough healthy red blood cells) and underweight.

A review of a physician order dated 2/9/22, indicated Osmolite 1.2 (a high protein, low residue tube feeding formula) via tube feeding at 65 milliliters (ml) per hour (hr) for 20 hours from 12:00 p.m. until 8:00 a.m. daily.

During an observation on 3/8/22, at 10:53 a.m. the Osmolite 1.2 tube feeding rate was running at 55 ml/hr.

During an observation on 3/9/22, at 12:32 p.m. the Osmolite 1.2 tube feeding rate was running at 55 ml/hr.

During an interview on 3/9/22, at 12:39 p.m., Licensed Practical Nurse Employee E9 confirmed that Resident R108's tube feeding order for Osmolite 1.2 was to be administered at 65 ml/hr.

A review of a physician order for Resident R108 dated 2/8/22, indicated to obtain weights weekly for four weeks.

A review of the clinical record for Resident R108 revealed weights completed on 2/9/22, and 2/14/22. Weights were not completed for the weeks beginning on 2/21/22 and 2/28/22.

A review of the clinical record revealed Resident R342 was admitted to facility on 2/18/22, with diagnoses that included hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), dysphagia (difficulty swallowing) and Alzheimer's (a progressive disease that destroys memory and other important mental functions).

A review of a physician order dated 2/22/221, indicated Isosource 1.5 (a high calorie, high protein tube feeding formula) via tube feeding at 60 ml/hr for 20 hours from 12:00 pm until 8:00 a.m. daily.

During an observation on 3/9/2022, at 1:43 p.m. the Isosource 1.5 tube feeding rate was running at 50 ml/hr.

During an interview on 3/9/2022, at 1:45 p.m., Registered Nurse Unit Manger E10 confirmed that Resident R342's tube feeding order for Isosource 1.5 should be administered at 60 ml/hr.

A review of a physician order for Resident R342 dated 2/8/22, indicated to obtain weights weekly for four weeks.

A review of the clinical record for Resident R342 revealed weights completed on 2/18/22, and 2/22/22. Weights were not completed for the weeks beginning 2/28/22, and 3/7/22.

A review of the clinical record revealed Resident R97 was admitted on 12/17/21, with diagnosis that included diabetes, chronic obstructive pulmonary disease (COPD - lung disease that causes obstructed airflow from the lungs) and dementia.

A review Resident R97's physician order dated 2/4/22, indicated to obtain weights weekly for four weeks.

A review Resident R97's clinical record revealed weight was completed on 2/4/22. Weights were not completed for the weeks beginning 2/7/22, 2/14/22, and 2/21/22.

A review of clinical record revealed Resident R139 was admitted to facility on 2/10/22, with diagnosis that included tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to breathing), acute respiratory failure (inability of respiratory system to meet oxygen requirements) and Parkinson's (a disorder of the central nervous system that affects movement, often including tremors),

A review of a physician order dated 2/10/22, indicated to obtain weights weekly for four weeks.

A review of the clinical record revealed weight completed on 2/10/22. Weights were not completed for the weeks beginning 2/14/22, 2/22/22, and 2/28/22.

During an interview on 3/10/22, at 1:25 p.m. Registered Nurse Unit Manger E10 confirmed that weekly weights were not obtained as ordered for residents R108, R342, R97, and R139.

28 Pa. Code: 211.10(c)(d)Resident care policies.
Previously cited 7/24/19 and 4/28/21

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
Previously cited 7/24/18 and 4/28/21


 Plan of Correction - To be completed: 04/13/2022

1. Resident 108 and 342 enteral feedings were adjusted by the Director of Nursing or designee per physicals orders.

2. there was no ill effects noted to resident 108 and 342 due to not following physicians orders on enteral feedings.

3. No ill effects noted to resident 21 and 140 due to not following physicians orders by notification to physician when blood sugars our below or above ordered perimeter's.

4. no ill effects noted to resident 108, 342, 97, and 139 for not obtaining weekly weights per physician orders.

5. Licensed staff have been educated for the director of Nursing or designee on enteral feedings and following physicians orders on fluid volume.

6. Licensed staff were educated by the Director of Nursing or designee on notification of physician if residents blood sugars or outside the ordered perimeters

7. Licensed staff were educated by the Director of Nursing or designee on following physician orders on weekly weights.

8. an audit will be performed by the Director of Nursing or designee on all enteral feedings to ensure physicians order are followed three times a week for the next three weeks, then weekly for the next two weeks.

9. An audit will be performed by the Director of Nursing or designee on weekly weights to ensure weights or performed per physician orders weekly for the next three weeks.

10. An Audit will be performed by the Director of Nursing or designee, on all resident glucose levels to ensure parameters are followed and physician notification is obtained 5 times per week for three weeks then 3 times per week for two weeks.

11. Resident glucose levels and weekly weights will be discussed in the facilities clinical meeting 5 times per week by the Director of Nursing or designee.

12. Results of the education and audits by the Director of Nursing or designee will be reviewed in the facilities Quality Assurance meeting by the Administrator or designee for the next three meetings.
483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

483.10(f)(6) The resident has a right to participate in family groups.

483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:
Based on facility policy and documentation, resident and staff interviews interview, it was determined that the facility failed to demonstrate response to grievances from resident council for eight of eight months ( July 2021, August 2021, September 2021, October 2021, November 2021, December 2021, January 2022, and February 2022).

Findings include:

Review of the facility policy "Grievance/Concern Resolution" dated 11/10/21, indicated to resolve resident concerns in a timely manner, facility utilizes a grievance form to identify concerns and track via a monthly log.

A review of resident council meeting minutes indicated the following concerns:

July 2021: develop cleaning area for common area to stay tidy, request of variety of additional activities, workshop classes for internet and technology services, additional phones, remotes and batteries, and clock, more advertisement on laundry services.

August 2021: residents request vehicle to be able to go out to appointments

September 2021: more art activities, casino night in place of being able to go out to the casino, residents would like an accommodation or starfish program setup to acknowledge staff that go above and beyond, would like evening snacks to be offered and not having to ask

October 2021: residents want to have more choice in their meal orders, residents would like laundry cleaned and returned faster.

November 2021: celebrate birthdays with a small cake, residents suggested having a liaison to collect concerns and bring them to the next resident council.

December 2021: tarp or some sort of protection from the elements on the back porch, request for more phones, remote controls, and batteries.

January 2022: more options on menu, request of more phones, TV remote controls, batteries, weatherization of smoking area, faster turnaround in laundry.

February 2022: turnaround time for laundry, clocks for each unit lounge, request for more frequent linen changes.

During an interview on 3/9/22, at 10:30 a.m. and 10:50 a.m. Residents indicated that residents' concerns are not being addressed and are on-going.

During an interview on 3/9/22, at 2:28 p.m. Director of Social Services Employee E16 confirmed that residents have on-going concerns and the facility is not using concern forms to follow upon resident council and could not produce documentation showing they addressed the residents' concerns.

28 Pa. Code 201.18 e(1)Management.
Previously cited 12/23/19, 9/23/21


 Plan of Correction - To be completed: 04/13/2022

1. All request and concerns from July 2021 thru Feb 2022 at the residents council, were written up on the facilities grievance forms by the Director of Social Services or designee, and was addressed and discussed with the resident council president, on 3/10/2022 and was resolved on 3/11/2022

2. Resolved concerns will be addressed in the resident council meeting on 3/30/2022 by the Director of Social Services or designee.

3. Remotes, batteries, clocks and phones were purchased and received by the Maintenance Director or designee and given out to those residents that did not have remotes or phones. Batteries were used to replaced those that needed to be replaced.

4. Extra staff were hired by the Housekeeping Director to assist faster turn around of linen and personal belongings

5. The facility housekeeping will continue to clean the lounge areas and the Housekeeping Manager or designee will assess area through out the day to insure the area is still clean.

6. The Activity Department will discuss with the residents to see who has the interested or the ability to participate in a workshop or class for internet and technology services. If enough interested is mentioned a workshop will be set up.

7. The request for a vehicle to be able to go out to appointments, The facility is contracted with a medical transport service to provided transportation services for appointments.

8. The request for casino night have been placed on the activity calendar by the Activity Director or designee for the month of March.

9. The facility recognizes outstanding employees with the employee of the month program. Residents will been informed by the Activity Director or designee during the resident council meeting for March, of any staff member they would like to be acknowledge that go above and beyond.

10. All Pantry's are stocked with snacks by the Dietary staff or designee. Nursing staff will be educated by the Director of Nursing or designee to offer snacks to all residents in the evening shift hours.

11. New dietary management system has been in place to offer residents more choices in their meals. (optima solutions) by the Dietary Manager

12. A monthly birthday party for all residents with a birthday in that month is celebrated once a month by the Activity Director or designee.

13. At the March resident council meeting, residents will be informed by the Activity Director or designee that they can address concerns individual or can act as a liaison for their floor.

14. The request for a tarp of some sort of protection from the elements on the back porch is unable to be accommodated for safety reasons. The patio is used as a smoking area and for outdoor activities as weather is permitted.

15. The Activity Director and social service director has been educated by the Administrator on grievance forms and when a residents has concerns during the resident council meeting.

16. The Activity Director or designee and director of Social Services, will meet after the residents council meetings to audit concerns or request from the residents monthly. The concerns or request will be reviewed and placed on the facilities grievance forms and addressed with the appropriate departments for resolution.

17. The concern or grievance forms addressed by the Activity Director or designee and Director of Social Services will be reviewed at the facilities quality assurance meeting monthly by the Administrator or designee, for the next three meetings.
483.10(f)(10)(iv)(v) REQUIREMENT Notice and Conveyance of Personal Funds: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(f)(10)(iv) Notice of certain balances.
The facility must notify each resident that receives Medicaid benefits-
(A) When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and
(B) That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

483.10(f)(10)(v) Conveyance upon discharge, eviction, or death.
Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.
Observations:


Based on review of facility documentation and staff interview it was determined that the facility failed to close the account within 30 days of death or discharge for 29 residents (CR500 to CR528).

Findings include:

Review of the Funds Balance Report for 3/4/22, indicated the following:

Resident CR500 ceased to breathe (CTB) on 2/16/22, and had a balance of $260.
Resident CR501 discharge to home on 8/5/21, and had a balance of $45.
Resident CR502 was on a hospital non-bed hold 10/6/21, and had a balance of $45.
Resident CR503 was on a hospital non- bed hold 4/5/21, and had a balance of$140.
Resident CR504 CTB on 1/7/22, and had a balance of $180.
Resident CR505 was on a hospital non-bed hold 12/5/20, and had a balance of $591.70.
Resident CR506 CTB on 9/7/21, and had a balance of $ 8,092.91.
Resident CR507 discharged to home on 11/5/21 and had a balance of $90.
Resident CR508 was on a hospital non-bed hold on 12/6/20, and had a balance of $45.
Resident CR509 was on a hospital non-bed hold on 4/2/20, and had a balance of $45.16.
Resident CR510 was on a hospital non-bed hold on 2/14/22, and had a balance of $1,163.23.
Resident CR511 was on a hospital non-bed hold on 9/14/19, and had a balance of $40.
Resident CR12 was admitted to another facility on 7/30/19, and had a balance of $182.67.
Resident CR513 was on a hospital non-bed hold on 1/12/22, and had a balance of $315.
Resident CR514 CTB on 10/19/21, and had a balance of $45.
Resident CR515 was on a hospital non-bed hold on 12/18/20, and had a balance of $.01.
Resident CR516 CTB on 8/19/21, and had a balance of $.06.
Resident CR517 CTB on 3/23/21, had a balance of $405.03.
Resident CR518 was on a hospital non-bed hold on 8/18/21, and had a balance of $.05.
Resident CR519 was on a hospital non-bed hold on 4/9/20, and had a balance of $270.08.
Resident CR520 CTB on 10/13/21, and had a balance of $270.
Resident CR521 was on a hospital non - bed hold on 10/29/21, and had a balance of$225.
Resident CR522 was admitted to another facility on 6/4/21, and had a balance of $3,381.39.
Resident CR523 was a hospital non-bed hold on 1/3/21, and had a balance of $45.03.
Resident CR5524 was a hospital non - bed hold on 1/10/22, and had a balance of $3,922.95.
Resident CR525 CTB on 8/8/21, and had a balance of $.05.
Resident CR526 CTB on 9/6/21, and had a balance of $280.
Resident CR527 was admitted to another facility on 6/9/21, and had a balance of $1,504.96.
Resident CR528 was a hospital non-bed hold on 10/16/21, and had a balance of $2784.21.

During an interview on 3/14/22, at 12:54 p.m. Nursing Home Administrator confirmed that the facility failed to release the monies within 30 days of residents discharge/death. Upon further review the facility failed to release monies for residents who were closed and financial status was listed as inactive and were hospital non bed holds or were admitted to another facility.

28. PA Code: 201.18e(1) Management.
Previously cited 12/23/19 and 9/23/21

28 Pa. Code:201.18(b)(2)(3)Management.

28. PA Code: 201.29(a) Resident rights.
Previously cited 12/23/19






 Plan of Correction - To be completed: 04/16/2022

1. Residents 500,501,502,503,504,505,506,507,508,509,
510,511,512,513,514,515,516,517,518,519, 520,521,522,523,524,525,526,527,528, will have money reimbursed back to them, their responsible party or state, by the facilities outside vendor source Quality Healthcare by 4/7/2022.

2. Quality Healthcare personal have been re-educated by the Administrator on resident refunds policy and procedure.

3. Ann audit will be performed by the Medical Records director of any resident that has left the building or CTB to insure any left over money in the residents account will be refunded within 30 days.

4. Results of the audit performed by the Medical Director will be reviewed in the facilities Quality Assurance meeting by the Administrator or designee for the next three meetings.
483.10(f)(10)(vi) REQUIREMENT Surety Bond-Security of Personal Funds: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(f)(10)(vi) Assurance of financial security.
The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.
Observations:
Based on review of facility documents and staff interview it was determined that the facility failed to have authorization forms for responsibility of resident trust fund for one of three residents reviewed (Resident R529).

Findings include:

Review of "Patient Trust Fund " dated 3/4/22, indicated that Resident R529 Had $8,383.24

Review of facility documentation failed to include authorization for Resident R529 account.

During an interview on 3/14/22, at 12:54 p.m. Nursing Home Administrator confirmed that the facility failed to have authorization forms for responsibility of Resident R529's account.

28 Pa. Code:201.18e(1)Management.
Previously cited 12/23/19 and 9/23/21






 Plan of Correction - To be completed: 04/13/2022

1. Resident 529 signed authorization and agreement to handle resident funds form after discussion from Director of Social Services.

2. Director of Social Services was educated by the Administrator or designee on release forms that are required to manage residents trust funds.

3. Current residents who have a trust fund within the facility will be audited by the Administrator or designee, to ensure an Authorization and agreement to handle residents funds is present, any missed signatures, facility will attempt to retrieve from the RP

4. Education and audits performed by the Director of Social Services or designee and the Administrator or designee will be reviewed by the Administrator or designee in the facilities Quality Assurance Meeting for the next three meetings


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

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

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

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

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

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

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

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

Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, comfortable and homelike environment for two out of four resident floors (7th floor resident rooms and 4th floor resident rooms).

Findings include:

The facility "Homelike environment" policy last reviewed on 11/10/21, indicated that residents are provided with a safe, clean, comfortable, and homelike environment. The facility management and staff maximize the characteristics of the facility, these characteristics include a clean, sanitary and orderly environment.

During observations on 3/07/22, at 09:41 a.m. observation of the 7th floor found a hand rail not returning to the wall next to room 715.

During an interview on 3/8/22, at 9:30 a.m. Resident R119 indicated that they needed the bathroom cleaned as there was a brown like substance in the toilet and had been there since yesterday. Resident R80 agreed, indicating they share a bathroom with the room on the other side and brown like substance in the toilet from the shared room since yesterday.

During an observation on 3/8/22, at 9:40 a.m. a brown like substance was in the toilet of the shared bathroom for residents R119 and R80.

During an interview on 3/8/22, at 9:49 a.m. Licensed Practical Nurse Employee E17 confirmed that there was a brown like substance in the toilet and that the facility failed to maintain a clean and homelike environment.


During observations on 3/8/22, at 10:25 a.m. a tour of the 7th floor with Registered Nurse (RN) Supervisor Employee E6 found the following:

At 10:25 a.m. observation of Resident R124's room found chipped paint on the wall behind the bed.
At 10:27 a.m. observations of Resident R27's room found chipped paint behind both beds,
At 10:30 a.m. observations of Resident R75's room found no functional night light in the room.
At 10:32 a.m. observations of Resident R100's room found a hole in the wall behind the door.
At 10:33 a.m. observations of the hallway near Resident R100's room hand found a hand rail not returning to the wall.
At 10:34 a.m. observations of the Resident R19's room found chipped paint behind bed near the door and chipped paint near the window.
At 10:38 a.m. observations of Resident R141's room found chipped paint behind the bed, near the door and a nonfunctional night light.
At 10:39 a.m. observations of Resident R104's room found a non-functional night light observed in room, and the night light panel was smashed in with a visible hole.
At 10:40 a.m. observations of Resident R115's room found no functional night light in the room.
At 10:43 a.m. observations of Resident R93's room found chipped paint behind bed near the door.
At 10:44 a.m. observations of Resident R55's room found a cable wire sticking out at the wall, a hole behind the bedroom door, and a non- functional night light.
At 10:46 a.m. observations of Resident R117's room found a toilet upon flushing began to circle water that would not go down the commode.

During an interview on 3/8/22, at 10:49 a.m. Registered Nurse (RN) Supervisor Employee E6 confirmed that the facility failed to provide a clean, comfortable homelike environment for residents on the 7th floor as required.


28 Pa. code: 207.2 (a) Administrator's Responsibility










 Plan of Correction - To be completed: 04/13/2022

1. Repairs to Resident 717, 718, 719, 720, 721, 714, 723, 724, 704, 712, and 705 were completed by the Maintenance director or designee.

2. The areas identified by resident 119, 80, 124, 27, 75, 100, 19, 141, 104, 115, 93, 95, and 117 as we3ll as handrail near room 715 have been repaired by the Maintenance director or designee.

3. All Maintenance staff were educated on homelike environment by the Administrator.

4. Education will be provided to the clinical staff by the Director of Nursing or designee to fill out maintenance request on repairs needed to residents areas.

5. Maintenance staff will be educated by the Administrator or designee to review maintenance request daily for needed repairs.

5. A full house audit will be performed by the Maintenance Director or designee to insure area to walls are repaired, night lights are functioning, and handrails are repaired.

6. Repairs will be made to all areas of concern by the Maintenance Director or designee.

7. An ongoing monthly audit will be performed by the Maintenance Director or designee of residents areas to insure areas are in good repair.

8. Results of the audit by the Maintenance director or designee will be reviewed in the faculties' Quality Assurance meeting by the Administrator or designee for the next three meetings
483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.15(c) Transfer and discharge-
483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with 483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:

Based on review of facility policies, closed resident records and staff interview, it was determined that the facility failed to acquire and document a physician's order for one out of five closed resident records (Closed Resident Record R142).

Findings include:

The facility "Resident discharge" policy last reviewed on 11/10/21, a resident may be discharge to his home or another facility. A discharge order signed within 24 hours shall be adequate.

Closed Resident Record R142's admission record admitted 1/26/22, and re-admitted on 2/3/22, with diagnoses that included dysfunction of the bladder, hypertension, chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and Urinary tract infection (UTI-infection of urinary tract system).

Closed Resident Record R142's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs ) dated 2/7/22, indicated that the diagnoses remained current.

Closed Resident Record R142's nurse progress note dated 2/7/22, indicated that Nurse on duty received a call from his doctor stating that he and his family requested that he be discharged to the hospital. They feel as though he needs further treatment for his condition that cannot be provided at the facility. Staff spoke with Closed Resident Record R142's daughter and he was transported to Hospital via paramedics.

Closed Resident Record R142's physician orders did not indicate a signed order for him to discharge out to the hospital.

During an interview on 3/09/22, at 11:51 a.m. the Director of Nursing (DON) confirmed that the facility failed to document a physician's order for Closed Resident Record R142's as required.



28 Pa Code: 201.25 Discharge policy.
Previously cited 12/23/19

28 Pa Code: 201.29 (f) Resident rights.
Previously cited 12/23/19

28 Pa Code: 201.29 (g) Resident rights
Previously cited 12/23/19



 Plan of Correction - To be completed: 04/13/2022

1.Hospital transfer order obtained for resident 142 by the Director of Nursing

2. Education was provided by the Director of Nursing or designee to all licensed staff to obtain physicians order to transfer to hospital

3. Physician order to transfer residents out to the hospital will be reviewed by the Director of Nursing or designee in the facilities clinical morning meeting.

4. An audit will be performed by the Director of Nursing or designee on all residents transfer to the hospital to insure a Physician order is obtained to transfer out of the facility 5 times per week for the next 3 weeks then weekly for the next two weeks.

5. Results of the audit and education performed by the Director of Nursing or designee will be reviewed by the Administrator or designee in the facilities Quality assurance meeting for the next three meetings.
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 review of facility policy, closed records and staff interview it was determined that the facility failed to acquire a dialysis service physician's order for one out of five closed resident Records (Closed Resident Record CR241).

Findings include:

The "Dialysis care" policy last reviewed on 11/10/21, indicated that hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices. The facility will approve a fully executed contract with a dialysis provider. The patient will be assessed as indicated and an order on the chart for dialysis to include location, days, and times.

Review of Closed Resident Record CR241's admission record indicated she was admitted on 2/4/22, with diagnoses that included hypertension (high pressure in arteries impacting blood flow), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), end stage renal disease (gradual loss of kidney function). and Chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs).

Review of Closed Resident Record CR241's MDS assessment (MDS-Minimum Data Set Assessment: periodic assessment of resident care needs), dated 2/5/22, indicated that the diagnoses were current upon review.

Review of Closed Resident Record CR241's care plan dated 2/5/22, indicated a careplan for dialysis.

Review of Closed Resident Record CR241's nurse progress notes dated 2/5/22, indicated she was awaiting pickup for dialysis on lobby via wheelchair van. CR241's nurse progress note on 2/5/22, she returned from dialysis with her husband.

Review of Closed Resident Record CR241's physician's orders did not include an order to go out to dialysis, the days of dialysis services, and the location of dialysis services.

During an interview on 3/08/22, at 5:04 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to acquire a dialysis service physician's order for Closed Resident Record CR241 as required.

28 Pa. Code: 201.14(a) Management

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

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

28 Pa Code: 211.2 (a )(c)(d)(1)(2) Physician Services.


 Plan of Correction - To be completed: 04/13/2022

1. A one time audit will be performed by the Director of Nursing or designee on all dialysis residents' to insure physician orders are obtained for Dialysis including days of dialysis services and location of dialysis upon admission.

2. an audit will be performed by the Director of Nursing or designee on new dialysis residents and return from the hospital dialysis residents to insure physicians orders are obtained for Dialysis, Dialysis location and dialysis days of service.

3. All licensed staff will be educated by the Director of Nursing or designee on physician orders that include an order to go out to dialysis, the days of dialysis services, and the location of dialysis services.

4. Review of the physician orders for dialysis will be performed by the Director of nursing or designee as part of the facilities clinical meeting 5 times per week.

5. Results of the audit and education performed by the Director of Nursing or designee will be reviewed in the facilities monthly Quality Assurance meting by the Administrator or designee for the next three meetings.
201.19 LICENSURE Personnel policies and procedures.:State only Deficiency.
Personnel records shall be kept current and available for each employe and contain sufficient information to support placement in the position to which assigned.
Observations:
Based on review of personnel records and staff interviews, it was determined that the facility failed to maintain complete and accurate records for five of seven employees (Employee E5, E11, E12, E13, E14).

Findings include:

Review of the personnel records for Dishwasher Employee E5, with a hire date of 1/4/22, lacked reference checks.

Review of the personnel records for Licensed Practical Nurse Employee E11, with a hire date of 12/14/21, lacked reference checks.

Review of personnel records for Security Employee E12, with a hire date of 2/15/22, lacked reference checks.

Review of personnel records for Dietary Employee E13, with a hire date of 1/4/22, lacked reference checks.

Review of personnel records for Temporary Nurse Aide E14, with a hire date of 2/1/22, lacked reference checks.

During an interview on 3/9/22, at 9:45 a.m., the Human Resources Director Employee E15 confirmed that Employee E5, E11, E12, E13, and E14 personnel record did not include reference checks.



 Plan of Correction - To be completed: 04/13/2022

1. Departments Heads responsible for interviewing and hiring of new staff, have been educated by the Administrator to obtain reference checks prior to employment.

2. Audit will be performed by the Human Resource Director or designee of all new hires in the past three months to insure reference checks were obtained.

3. Audits will be performed by the Human Resource Director or designee monthly to insure all reference checks on new hires are completed.

4.results of the audit performed by the Human Resource Director or designee will be reviewed by the Administrator or designee in the facilities Quality Assurance meeting for the next three meetings


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