Nursing Investigation Results -

Pennsylvania Department of Health
ST. MONICA CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. MONICA CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are  107 surveys for this facility. Please select a date to view the survey results.

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ST. MONICA CENTER FOR REHABILITATION & HEALTHCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to three complaints, completed on January 28, 2020, it was determined that St. Monica Center for Rehabilitation & Healthcare, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.



 Plan of Correction:


483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
483.24(c) Activities.
483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on observation, clincial record review, activities calendars and staff interviews, it was determined that the facility failed to ensure that a resident centered activity programs were implemented and designed to meet the interest of and support the physical, mental and psychosocial well-being of residents for four out of thirty-nine residents on the second floor nursing unit (Resident R93, R104, R154, R418).

Findings include:

Review of the interdisciplinary notes for Resident R93 revealed that the resident was admitted into the facility on November 25, 2019 with diagnoses that included, but not limited, arthritis, dementia (dementia-a group of symptoms that affects memory, thinking and interferes with daily life) with behavioral disturbance, dysphagia (dysphagia -difficulty swallowing).

Review of the resident's Admission Minimum Data Set Assessment (MDS- an assessment of a resident's needs) completed December 6, 2019 indicated that the resident as cognitively impaired.

Review of the resident's person-centered care plan provided by the facility revealed that Resident R93 included interventions for the Resident R93's elopement risk related to dementia, which included a care plan for the resident to engage in activities and tasks to keep occupied. The resident's care plan also included the resident's preference for Christian music and news, and that the resident should be encouraged with a low stress activities such as music and small group activities.

During observations on January 23, 2020 at approximately 10:00 a.m. through approximately 10:25 a.m. and at approximately 2:25 p.m. Resident R93 was observed sitting in front of the television on the second floor nursing unit.

Review of the activity calendar for January 23, 2020 revealed no scheduled activities on the second floor nursing unit for any of the residents.

On January 24, 2020, from approximately 9:00 a.m. through 10:10 a.m. Resident R93 was observed sitting in front of the television on the second floor nursing unit. During a second observation on January 24, 2020 from approximately 10:22 a.m. through approximately 11:30 a.m. Resident R93 was observed sitting in front of the television on the second floor nursing unit for the entire day.

Review of the activity calendar for January 24, 2020 revealed only one scheduled activity for the second floor nursing unit for that day, entitled, "Sensory Group" that was scheduled at 11:00 a.m. but no scheduled activity during this time was observed.

On January 27, 2020 at approximately 9:25 a.m. through approximately 10:00 a.m. Resident R93 was observed sitting in front of the television on the second floor nursing unit. During a second observation on the above referenced date at approximately 11:05 p.m. Resident R93 was observed sitting in front of the television on the second floor nursing station.

Review of the activity calendar for January 27, 2020 revealed no scheduled activities for residents on the second floor nursing unit for the entire day.

Review of the interdisciplinary notes for Resident R104 revealed that the resident was admitted into the facility on December 8, 2019 with diagnoses that included, but not limited to, dementia, and diabetes (diabetes- a disorder in which an individual can have high blood sugars for prolonged periods of time).

Review of the resident's Admission MDS completed December 15, 2019 indicated that the resident was severely cognitively impaired.

Review of the resident's personal centered care plan that was provided by the facility indicated a care plan which stated that the resident should engaged in low stress activities such as music and small group activities due to cognitive loss related to the resident's diagnosis of dementia.

During observations on January 23, 2020 at approximately 10:00 a.m. through approximately 10:25 a.m. and at approximately 2:25 p.m. Resident R104 was observed sitting in front of the television on the second floor nursing unit.

Review of the activity calendar for January 23, 2020 revealed no scheduled activities on the second floor nursing unit for any of the residents.

On January 24, 2020, from approximately 9:00 a.m. through 10:10 a.m. Resident R104 was observed sitting in front of the television on the second floor nursing unit. During a second observation on January 24, 2020 from approximately 10:22 a.m. through approximately 11:30 a.m. Resident R104 was observed sitting in front of the television on the second floor nursing unit for the entire day.

Review of the activity calendar for January 24, 2020 revealed only one scheduled activity for the second floor nursing unit for that day, entitled, "Sensory Group" that was scheduled at 11:00 a.m. but no scheduled activity during this time was observed.

On January 27, 2020 at approximately 9:25 a.m. through approximately 10:00 a.m. Resident R104 was observed sitting in front of the television on the second floor nursing unit. During a second observation on the above referenced date at approximately 11:05 p.m. Resident R104 was observed sitting in front of the television on the second floor nursing station.

Review of the activity calendar for January 27, 2020 revealed no scheduled activities for residents on the second floor nursing unit for the entire day.

Review of the interdisciplinary notes for Resident R154 revealed that the resident was admitted into the facility on December 30, 2019 with diagnoses that included, but not limited to, dementia, diabetes, and dysphagia.

Review of the resident's Admission MDS completed January 6, 2020 indicated that the resident was severely cognitively impaired.

Review of the resident's personal centered care plan that was provided by the facility revealed a care plan which stated to invite the resident to participate in activities such as trivia, reminiscence and current events/newspaper

During observations on January 23, 2020 at approximately 10:00 a.m. through approximately 10:25 a.m. and at approximately 2:25 p.m. Resident R154 was observed sitting in front of the television on the second floor nursing unit.

Review of the activity calendar for January 23, 2020 revealed no scheduled activities on the second floor nursing unit for any of the residents.

On January 24, 2020, from approximately 9:00 a.m. through 10:10 a.m. Resident R154 was observed sitting in front of the television on the second floor nursing unit. During a second observation on January 24, 2020 from approximately 10:22 a.m. through approximately 11:30 a.m. Resident R154 was observed sitting in front of the television on the second floor nursing unit for the entire day.

Review of the activity calendar for January 24, 2020 revealed only one scheduled activity for the second floor nursing unit for that day, entitled, "Sensory Group" that was scheduled at 11:00 a.m. but no scheduled activity during this time was observed.

On January 27, 2020 at approximately 9:25 a.m. through approximately 10:00 a.m. Resident R154 was observed sitting in front of the television on the second floor nursing unit. During a second observation on the above referenced date at approximately 11:05 p.m. Resident R154 was observed sitting in front of the television on the second floor nursing station.

Review of the activity calendar for January 27, 2020 revealed no scheduled activities for residents on the second floor nursing unit for the entire day.

Review of the interdisciplinary notes for Resident R418 revealed that the resident was admitted into the facility on January 15, 2020 with diagnoses that included, but not limited, blindness, history of falling, dementia and dysphagia. Further review of the interdisciplinary notes indicated that the resident was cognitively impaired.

Review of the resident's "Preferences for Routine & Activities" that was completed upon admission indicated that it was "somewhat important" for her to be able to listen to music, keep up with the news, do her favorite activities and participate in religious services or practices.

During observations on January 23, 2020 at approximately 10:00 a.m. through approximately 10:25 a.m. and at approximately 2:25 p.m. Resident R418 was observed sitting in front of the television on the second floor nursing unit.

Review of the activity calendar for January 23, 2020 revealed no scheduled activities on the second floor nursing unit for any of the residents.

On January 24, 2020, from approximately 9:00 a.m. through 10:10 a.m. Resident R418 was observed sitting in front of the television on the second floor nursing unit. During a second observation on January 24, 2020 from approximately 10:22 a.m. through approximately 11:30 a.m. Resident R418 was observed sitting in front of the television on the second floor nursing unit for the entire day.

Review of the activity calendar for January 24, 2020 revealed only one scheduled activity for the second floor nursing unit for that day, entitled, "Sensory Group" that was scheduled at 11:00 a.m. but no scheduled activity during this time was observed.

On January 27, 2020 at approximately 9:25 a.m. through approximately 10:00 a.m. Resident R418 was observed sitting in front of the television on the second floor nursing unit. During a second observation on the above referenced date at approximately 11:05 p.m. Resident R418 was observed sitting in front of the television on the second floor nursing station.

Review of the activity calendar for January 27, 2020 revealed no scheduled activities for residents on the second floor nursing unit for the entire day.

During an interview with Licensed Practical Nurses (Employee E4 and Employee E5) on January 27, 2020 at approximately 1:45 p.m. both employees identified Residents R93, R104, R154, R418, as fall risk who are cannot stay in their rooms alone and are brought out of their rooms and sit on the unit.

During a discussion with the Nursing Home Administrator (NHA) on January 27, 2020 at approximately 2:30 p.m. regarding the observations on the above referenced dates, and that the activity calendar provided by the facility did not reflect any activities for the second floor for the days of the above-referenced observations, the NHA stated that the residents can be taken by staff to the other units to participate in activities on those units.

The facility failed to ensure that a resident centered activity programs were implemented and designed to meet the interest of, and support the physical, mental and psychosocial well-being of residents for four residents.

28 Pa. Code 211.10 (d) Resident care policies






 Plan of Correction - To be completed: 03/17/2020

F679
It is the practice of the facility to provide resident centered activity programs implemented and designed to meet the interest of and support the physical, mental and psychosocial well-being of the resident.
-Resident centered activity programs were provided for Resident 93, 104, 154 and 418. Resident 154 and 418 have discharged from facility.
-Other residents at risk will be provided with resident centered activity programs.
-Education will be completed by the Activity Director/designee with appropriate staff to ensure that residents are provided with resident centered activity programs implemented and designed to meet the interest of and support the physical, mental and psychosocial well-being of the resident.
-The Activity Director will complete a weekly audit for 3 months to ensure that residents are provided with resident centered activity programs. Results of audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss need for further audits.
-To be completed by 3/17/2020.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of clinical records, facility policies and procedures, and facility documentation, and interviews with staff, it was determined that the facility failed to report incidents of injuries of unknown source to the State Department of Health as required for one of 37 resident records reviewed (Resident R113).

Findings include:

Review of facility policy, "Abuse Prevention," dated last revised July 2019, defined that a sign of possible resident abuse and/or neglect included unexplained injuries. The policy further indicated that the facility would report all alleged violations involving abuse and/or neglect to the Department of Heath, Division of Nursing Care Facilities.

Review of the clinical record for Resident R113 revealed the resident was readmitted to the facility on October 15, 2019, with diagnoses including, but not limited to, left hip fracture (broken hip) with internal fixation nail (surgical procedure to repair a broken bone); Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) with behavioral disturbance (refusing care, medications, activities, and/or food at times); and osteopenia (condition that causes low bone density-weak bones).

Review of a Medicare 5-Day Minimum Data Set assessment (MDS-periodic assessment of needs) dated October 21, 2019, revealed that Resident R113 was always incontinent of bladder and bowel (inability to voluntarily pass or control urine or stool).

Review of a nursing progress note dated December 3, 2019, at 1:02 p.m., revealed Resident R113 was complaining of pain, that the resident's physician was made aware, and that the resident's physician ordered an X-ray and doppler (ultrasound-medical test using an electronic device to determine via sound waves the amount of blood flow through major arteries) of the resident's right leg. Review of a nursing progress note dated December 3, 2019, at 1:28 p.m., revealed Resident R113 continued complaining of pain in the right leg, that the nurse noted no swelling or bruising of the leg, that pain medication was administered without effectiveness, and that the resident's pain level remained a 10/10 (pain scale-10/10 indicates pain of the maximum severity). Review of a nursing progress note dated December 3, 2019, at 2:48 p.m., revealed Resident R113 refused to have the right leg X-ray and doppler, that the resident's physician was notified of the resident's refusal, and that the physician ordered staff to send the resident to an acute care hospital for evaluation. Review of a nursing progress note dated December 3, 2019, at 6:19 p.m., revealed Resident R113 was admitted to an acute care hospital with a diagnosis of hip fracture (unspecified right or left hip). Review of a nursing admission/readmission note dated December 7, 2019, at 5:59 p.m., revealed Resident R113 was readmitted to the facility from the hospital with diagnosis of right hip fracture with nail placed (surgical repair of the right hip).

Review of facility documentation dated December 9, 2019, regarding Resident R113 revealed on December 3, 2019, the resident was complaining of right leg pain, that the resident refused to have the X-ray and ultrasound (doppler) performed as ordered while at the facility, and upon transfer to the hospital, the resident was found to have a right hip fracture requiring surgical repair. The facility documentation dated December 9, 2019, revealed that it was possible that Resident R113's right hip fracture may have occurred during incontinence care.

Review of information submitted by the facility from December 3, 2019 through January 24, 2020, revealed no documentation that Resident R113's injury of unknown source was reported to the Department of Health.

Interview with the Nursing Home Administrator and Assistant Director of Nursing on January 27, 2019, at approximately 1:45 p.m. confirmed that there was no documentation that Resident R113's right hip fracture, considered by the facility as an injury of unknown source, was reported to the Department of Health as required.

The facility failed to report Resident R113's injury of unknown source to the State Department of Health as required.

Refer to F610

28 Pa. Code 201.14(a)(d)(1)(2)(e) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(1) Management
Previously cited 09/05/19, 06/27/19, 03/08/19

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.10(d) Resident care policies
Previously cited 03/08/19

28 Pa. Code 211.12(c) Nursing services
Previously cited 03/08/19

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 06/27/19, 04/25/19, 03/08/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 09/20/19, 06/27/19, 04/25/19, 03/08/19






 Plan of Correction - To be completed: 03/17/2020

The submission of this response to the statement of deficiencies by the undersigned does not constitute an admission that the deficiency existed and/or required correction. This response is prepared, executed and submitted solely as a requirement of the provisions of federal and state law.



F609
It is the practice of the facility to report incidents of injuries of unknown sources to the State Department of Health.

-Resident's (113) injury was investigated and the State Department of Health was notified and reviewed incident.

-Other residents identified at risk will have injuries of unknown sources reported to the State Department of Health.
- Education will be completed by DON/Designee with appropriate staff to ensure that incidents of unknown sources are reported to the State Department of Health.
--The DON/Designee will complete a weekly audit for 3 months to ensure that injuries of unknown sources are reported to the State Department of Health. Results of audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss need for further audits.
-To be completed by 3/17/2020.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of clinical records, facility policies and procedures, and facility documentation, and interviews with staff, it was determined that the facility failed to conduct a complete and thorough investigation for an incident to rule out abuse and/or neglect, for one of 37 resident records reviewed (Resident R113).

Findings include:

Review of facility policy, "Abuse Prevention," dated last revised July 2019, defined that a sign of possible resident abuse and/or neglect included unexplained injuries. The policy further indicated that the facility would conduct an investigation into all suspected cases of abuse and/or neglect, and that all incident reports would be reviewed and analyzed to rule out abuse and neglect to include review of staff involved in the resident's care for the past 24 hours prior to an incident.

Review of facility policy, "Abuse and Neglect Protocol," dated effective December 2017, revealed that facility staff, with the physician's input as needed, would investigate alleged occurrences of abuse and neglect to clarify what happened and identify possible causes.

Review of facility policy, "Accidents & Incidents," dated revised March 2019, revealed that upon discovery of an incident, facility staff would promptly initiate and document investigation into the incident. The policy further stated that for injuries of unknown origin, staff interviews and/or statements were to be obtained from previous shifts up to 24 hours in an effort to determine a potential cause and rule out potential abuse.

Review of the clinical record for Resident R113 revealed the resident was readmitted to the facility on October 15, 2019, with diagnoses including, but not limited to, left hip fracture (broken hip) with internal fixation nail (surgical procedure to repair a broken bone); Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) with behavioral disturbance (refusing care, medications, activities, and/or food at times); and osteopenia (condition that causes low bone density-weak bones).

Review of a Medicare 5-Day Minimum Data Set assessment (MDS-periodic assessment of needs) dated October 21, 2019, revealed that Resident R113 was always incontinent of bladder and bowel (inability to voluntarily pass or control urine or stool).

Review of a nursing progress note dated December 3, 2019, at 1:02 p.m., revealed Resident R113 was complaining of pain, that the resident's physician was made aware, and that the resident's physician ordered an X-ray and doppler (ultrasound-medical test using an electronic device to determine via sound waves the amount of blood flow through major arteries) of the resident's right leg. Review of a nursing progress note dated December 3, 2019, at 1:28 p.m., revealed Resident R113 continued complaining of pain in the right leg, that the nurse noted no swelling or bruising of the leg, that pain medication was administered without effectiveness, and that the resident's pain level remained a 10/10 (pain scale-10/10 indicates pain of the maximum severity). Review of a nursing progress note dated December 3, 2019, at 2:48 p.m., revealed Resident R113 refused to have the right leg X-ray and doppler, that the resident's physician was notified of the resident's refusal, and that the physician ordered staff to send the resident to an acute care hospital for evaluation. Review of a nursing progress note dated December 3, 2019, at 6:19 p.m., revealed Resident R113 was admitted to an acute care hospital with a diagnosis of hip fracture (unspecified right or left hip). Review of a nursing admission/readmission note dated December 7, 2019, at 5:59 p.m., revealed Resident R113 was readmitted to the facility from the hospital with diagnosis of right hip fracture with nail placed (surgical repair of the right hip).

Review of facility documentation dated December 9, 2019, regarding Resident R113 revealed on December 3, 2019, the resident was complaining of right leg pain, that the resident refused to have the X-ray and ultrasound (doppler) performed as ordered while at the facility, and upon transfer to the hospital, the resident was found to have a right hip fracture requiring surgical repair. The facility documentation dated December 9, 2019, revealed that it was possible that Resident R113's right hip fracture may have occurred during incontinence care. Further review of facility documentation and clinical record revealed no documented evidence that statements were obtained from staff members who cared for the resident in the 24 hour period prior to the onset of the resident's right leg pain on the 7:00 a.m. to 3:00 p.m. shift of December 3, 2019; no documentation regarding if the facility investigated this incident to rule out abuse and/or neglect during incontinence care as stated in the facility's summary of the incident; and no documentation regarding what, if any, cause was determined regarding how the resident sustained a right hip fracture on December 3, 2019, approximately two months after sustaining a left hip fracture.

Interview with the Nursing Home Administrator and Assistant Director of Nursing on January 27, 2019, at approximately 1:45 p.m. confirmed that there was no documentation that employee statements were obtained 24 hours prior to the onset of Resident R113's complaint of right leg pain and subsequent diagnosis of right hip fracture on December 3, 2019, and confirmed that this incident was not completely and thoroughly investigated to rule out possible abuse or neglect.

The facility failed to conduct a complete and thorough investigation into an incident to rule out abuse or neglect.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(1) Management
Previously cited 09/05/19, 06/27/19, 03/08/19

28 Pa. Code 201.29(c) Resident rights

28 Pa. Code 211.10(d) Resident care policies
Previously cited 03/08/19

28 Pa. Code 211.12(c) Nursing services
Previously cited 03/08/19

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 06/27/19, 04/25/19, 03/08/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 09/20/19, 06/27/19, 04/25/19, 03/08/19







 Plan of Correction - To be completed: 03/17/2020

F610
It is the practice of the facility to conduct a complete and thorough investigation for an incident to rule out abuse and/or neglect.
-Resident 113 had a complete and thorough investigation completed of the incident and ruled out abuse or neglect.
-Other residents that have incidents will have a complete and thorough investigation conducted to rule out possible abuse or neglect.
- Education will be completed by DON/Designee with staff to ensure that a complete and thorough investigation is conducted for incidents to rule out abuse or neglect.
-The DON/Designee will complete a weekly audit for 3 months to verify that a complete and thorough investigation is conducted for incidents to rule out abuse or neglect. Results of audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss need for further audits.
-To be completed by 3/17/2020.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of clinical records and facility policies, and interviews with staff, it was determined that the facility failed to follow physician's orders related to blood sugar monitoring, for one of 37 residents reviewed (Resident R86).

Findings include:

Review of facility policy, "Blood Sampling-Capillary (Finger Sticks)," dated revised September 2014, revealed that staff would follow physician's orders to notify for prescribed blood sugar level parameters and to document the results.

Review of the clinical record for Resident R86 revealed that the resident had diagnoses including, but not limited to, diabetes mellitus (DM-failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of a physician's order dated December 3, 2019, instructed staff that if the accu check (testing blood sugars) for Resident R86 was below 70 mg/dL (milligrams per deciliter) or greater than 300 mg/dL (average normal blood sugar level range is 70 mg/dL to 120 mg/dL), staff were to call the resident's physician.

Review of another physician's order, dated January 16, 2020, instructed staff to administer Humalog insulin (short acting insulin used to treat elevated blood sugar levels) subcutaneously (SQ-injection under the skin) before meals and at bedtime, based on a sliding scale (insulin dose given per blood sugar range) which specified the following: if the resident's blood sugar was 201-250 mg/dL, staff were to administer 2 units of Humalog insulin SQ; if the resident's blood sugar was 251-300 mg/dL, staff were to administer 4 units of Humalog insulin SQ; if the resident's blood sugar was 300-350 mg/dL, staff were to administer 6 units of Humalog insulin SQ; if the resident's blood sugar was 351-400 mg/dL, staff were to administer 8 units of Humalog insulin SQ. Additionally, the physician's order stated that staff were to call the physician if the resident's blood sugar was less than 70 mg/dL or greater than 400 mg/dL.

Review of the Medication Administration Record (MAR) for Resident R86 for January 2020, revealed the following documented blood sugar (BS) levels that were greater than 300 mg/dL:
January 16, 2020-BS 387 mg/dL at 11:00 a.m.; BS 399 mg/dL at 4:30 p.m.
January 17, 2020-BS 389 mg/dL at 11:00 a.m.; BS 391 mg/dL at 4:30 p.m.
January 18, 2020-BS 328 mg/dL at 11:00 a.m.; BS 386 mg/dL at 4:30 p.m.
January 19, 2020-BS 392 mg/dL at 4:30 p.m.
January 20, 2020-BS 338 mg/dL at 6:30 a.m.; 443 mg/dL at 11:00 a.m.; BS 343 mg/dL at 4:30 p.m.; BS 371 mg/dL at 8:00 p.m.
January 21, 2020-BS 313 mg/dL at 6:30 a.m.; 347 mg/dL at 11:00 a.m.; BS 348 mg/dL at 8:00 p.m.
January 22, 2020-BS 324 mg/dL at 6:30 a.m.
January 24, 2020-BS 400 mg/dL at 11:00 a.m.; BS 400 mg/dL at 4:30 p.m.
January 25, 2020-BS 389 mg/dL at 11:00 a.m.; BS 359 mg/dL at 4:30 p.m.

Review of the clinical record for Resident R86 revealed no documentation that Resident R86's physician was notified of the blood sugars over 300 mg/dL in January 2020, a total of 19 occurrences.

Interview with the Director of Nursing on January 28, 2020, at approximately 9:30 a.m., confirmed the physician's order dated December 3, 2019, instructed staff to call the physician if Resident R86's accu check was greater than 300 mg/dL; and the physician's order dated Janaury 16, 2020, instructed staff to call the physician if the accu check was greater than 400 mg/dL. Further interview with the Director of Nursing confirmed there was no documented evidence that staff clarified conflicting accu check notification orders with the resident's physician.

The facility failed to follow physician's orders regarding notification of elevated blood sugar levels.

CFR(s): 483.25 Quality of Care
Previously cited 06/27/19, 03/08/19

28 Pa. Code 211.10(c) Resident care policies
Previously cited 03/08/19

28 Pa. Code 211.12(c) Nursing services
Previously cited 03/08/19

29 Pa. Code 211.12(d)(1) Nursing services
Previously cited 06/27/19, 04/25/19, 03/08/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 09/20/19, 06/27/19, 04/25/19, 03/08/19








 Plan of Correction - To be completed: 03/17/2020

F684
It is the practice of the facility to follow physician orders related to blood sugar monitoring.
-Resident R86 had the physician order clarified to properly monitor their blood sugar levels.
-Other residents identified at risk will be monitored to ensure that physician orders are being followed appropriately for blood sugar levels.
- Education will be completed by DON/Designee with current licensed nurses to ensure that physician orders are being followed for blood sugar levels.
-The DON/Designee will complete a random weekly audit for 3 months to verify that physician orders are being followed for appropriate blood sugar levels. Results of audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss need for further audits.
-To be completed by 3/17/2020.

483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on review of clinical records and facility policies, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous (IV-tube inserted into a vein) lines for one of 37 residents reviewed (Residents R323).

Findings include:

Review of Resident R323's clinical record revealed the resident was admitted to the facility on January 7, 2020, with a diagnosis to include osteomyelitis (inflammation of the bone caused by infection) of the ankle and foot and the resident was receiving antibiotics through a PICC line (peripherally inserted central catheter).

Resident R323's physician orders included to measure arm circumference every night shift every seven day(s) measure arm circumference four inches above IV insertion (PICC line) site on admission and to measure external catheter length on admission.

Further, review of Resident R323's clinical record revealed no documented evidence the resident's arm circumference was measured on admission and no documented evidence the resident's external catheter length was measured on admission.


28 Pa. Code 211.10(c) Resident care policies
Previously cited 03/08/19

28 Pa. Code 211.12(c) Nursing services
Previously cited 03/08/19

29 Pa. Code 211.12(d)(1) Nursing services
Previously cited 06/27/19, 04/25/19, 03/08/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 09/20/19, 06/27/19, 04/25/19, 03/08/19






 Plan of Correction - To be completed: 03/17/2020

F694
It is the practice of the facility to ensure that residents received treatment and care in accordance with professional standards of practice related to intravenous lines.
-Resident R323 had their arm circumference and external catheter length measured.
-Other residents at risk will be monitored to ensure they receive treatment and care in accordance with professional standards of practice related to intravenous lines.
- Education will be completed by DON/Designee with current licensed nurses to ensure that residents receive treatment and care in accordance with professional standards of practice related to intravenous lines.
--The DON/Designee will complete a random weekly audit for 3 months to verify that residents receive treatment and care in accordance with professional standards of practice related to intravenous lines. Results of audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss need for further audits.
-To be completed by 3/17/2020.


483.40 REQUIREMENT Behavioral Health Services: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.
483.40 Behavioral health services.
Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
Observations:

Based on observation, review of clinical records and interviews with staff, it was determined that the facility failed to adequately monitor, assess, and provide the necessary and timely behavioral health care and services for residents exhibiting suicidal ideation, for one of 37 resident records reviewed (Resident R43).

Findings include:

Review of the clinical record for Resident R43 revealed the resident was readmitted to the facility on November 6, 2019, with diagnoses including, but not limited to, bilateral lower extremity (both legs) cellulitis (type of bacterial skin infection); dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability); and had a chronic (long-standing) wound on the resident's sacrum (lower back/tailbone area). Review of a nursing skilled note dated November 7, 2019, at 12:38 p.m., revealed Resident R43 speaks only Spanish but understands a little English and that, "Resident is very afraid of everything since she returned from the hospital."

Review of a social service note dated November 11, 2019, at 11:14 a.m., revealed that during an MDS (Minimum Data Set-periodic assessment of needs) interview in the presence of the resident's daughter-in-law who was translating, Resident R43 was asked if she had any suicidal ideation and she reported, "yes." The social service note added that when asked if she had a plan, Resident R43 also reported, "yes" and that she was going to, "poison herself." The social service note additionally stated that based on Resident R43's suicidal ideation statements, a crisis center was notified who recommended to have the resident evaluated at an acute care hospital, and that Resident R43 agreed to be evaluated at the hospital by a psychiatrist.

Review of a nursing progress note dated November 11, 2019, at 11:24 p.m., revealed Resident R43 returned from the hospital after evaluation of her suicidal statements and while at the hospital, the resident stated she, "does not want to kill herself but is just lonely and board [sic] at the nursing home."

Review of a facility Psychiatry Evaluation dated November 13, 2019, revealed the psychiatrist was contacted to evaluate Resident R43 after her suicidal statements and evaluation at an acute care hospital on November 11, 2019. The Psychiatry Evaluation noted that Resident R43 was, "depressed a little" due to not being able to do what she once had, and that she adamantly denied being suicidal because it was against her religion. Additionally, the psychiatrist recommended for staff to continue to administer both Remeron (antidepressant) 15 milligrams (mg) orally every night and Seroquel (antipsychotic medication used in conjunction with an antidepressant to treat depression in adults) 25 mg orally every night, as ordered by the physician, for a diagnosis of depression, and that staff should consider psychology input regarding the resident's adjustment to placement in a long term care facility.

Review of the plan of care for Resident R43 for use of antidepressant medications for a diagnosis of depression, dated initiated October 14, 2019, revealed licensed nursing staff would monitor the resident for side effects of antidepressants including, but not limited to, suicidal ideations.

Review of psychotropic (medications used to treat mood and behavioral disorders) medication reviews for Resident R43 dated November 1, 2019, December 1, 2019, and January 2, 2020, revealed the resident continued receiving Remeron 15 mg daily and Seroquel 25 mg daily; and that staff should, "consider psych consult."

Observation of Resident R43 on January 24, 2020, at approximately 10:30 a.m., during sacral wound care completed by Employee E8, wound care nurse, revealed upon successful completion of the dressing change by Employee E8, Resident R43 became teary-eyed while speaking Spanish. Resident R43 was observed to be easily redirected, consoled and comforted by Employee E8.

Further review of the clinical record revealed no documentation that Resident R43 was evaluated by a psychologist for ongoing monitoring of depression and history of suicidal ideations as recommended by the psychiatrist on November 13, 2019, and as recommended by monthly psychotropic medication reviews dated November 1, 2019, December 1, 2019, and January 2, 2020.

Interview with the Director of Nursing on January 28, 2020, at approximately 1:15 p.m. confirmed there was no documentation that Resident R43, a resident who had expressed suicidal ideations and was on medication for depression with a documented side effect of suicidal ideations, was evaluated by psychology services as recommended.

The facility failed to provide the necessary behavioral health care and services to attain or maintain Resident R43's highest practicable physical and psychosocial well-being.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(1) Management
Previously cited 09/05/19, 06/27/19, 03/08/19

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

28 Pa. Code 211.12(c) Nursing services
Previously cited 03/08/19

28 Pa. Code 211.12(d)(3)(5) Nursing services
Previously cited 09/20/19, 06/27/19, 04/25/19, 03/08/19




 Plan of Correction - To be completed: 03/17/2020

F740
It is the practice of the facility to adequately monitor, assess, and provide the necessary and timely behavioral health care and services to maintain their highest practicable physical and psychosocial well-being.
-Resident R43 was seen by psychology services as recommended.
-Other residents identified at risk will be monitored to ensure that the proper behavioral health care services are provided.
- Education will be completed by DON/Designee with current licensed nurses to ensure that residents receive the proper behavioral health care services as recommended.
--The DON/Designee will complete a random weekly audit for 3 months to verify that residents receive the proper behavioral health care services as recommended. Results of audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss need for further audits.
-To be completed by 3/17/2020.

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

483.45(h) Storage of Drugs and Biologicals

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

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on observation and staff interview, it was determined that the facility failed to store a tuberculin vial according to professional standards of practice on one of five nursing units (St. Edwards nursing unit).

Findings include:

Observation on January 27, 2020, at 9:50 a.m. of the St. Edwards nursing unit's medication cart revealed an opened undated one ml Tuberculin vial, which was stored on the medication cart. Review of the manufacturer instructions stated that the Tuberculin vial was to discard after 30 days after opening and to refrigerate the medication.

Interview on January 27, 2020, at 10:00 a.m., with licensed nursing staff, Employee E7, where Employee E7 confirmed the opened undated one ml Tuberculin vial was stored on the cart, where she confirmed the manufacturer instructions for the Tuberculin vial stated to discard after 30 days after opening and to refrigerate the medication.

The facility failed to store a tuberculin vial in accordance to professional standards of practice.


28 Pa. Code 211.9 (a) (1) (2) (i) Pharmacy services
Previously cited 3/8/19

28 Pa. Code 211.12(d) (1) (3) (5) Nursing services
Previously cited 9/20/19, 6/27/19, 4/25/19, 3/8/19





 Plan of Correction - To be completed: 03/17/2020

F761
It is the practice of the facility to store a tuberculin vial according to professional standards of practice.
-The tuberculin vial was disposed of from the cart.
-Other tuberculin vials will be monitored to ensure proper storage according to professional standards of practice.
- Education will be completed by DON/Designee with current licensed nurses to ensure that tuberculin vials are stored in accordance with professional standards of practice.
-The DON/Designee will complete a random weekly audit for 3 months to verify that tuberculin vials are stored in accordance with professional standards of practice. Results of audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss need for further audits.
-To be completed by 3/17/2020.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80(d) Influenza and pneumococcal immunizations
483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.
Observations:

Based on review of facility policy, clinical record review, and interview with staff, it was determined that the facility failed to ensure that a pneumococcal immunization was offered to five of five sampled residents reviewed (Residents R27, R158, R135, R51, R123).

Findings include:

A review of facility policy "Pneumococcal Vaccine," dated December 2018, which revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia / pneumococcal infections.

A review of the clinical record revealed Resident R27 was admitted to the facility on December 3, 2018. There was no documentation available for review to indicate if the resident had been offered or assessed to receive the pneumococcal vaccine.

A review of the clinical record revealed Resident R158 was admitted to the facility on June 11, 2018. There was no documentation available for review to indicate if the resident had been offered or assessed to receive the pneumococcal vaccine.

A review of the clinical record revealed Resident R135 was admitted to the facility on June 16, 2018. There was no documentation available for review to indicate if the resident had been offered or assessed to receive the pneumococcal vaccine.

A review of the clinical record revealed Resident R51 was admitted to the facility on January 29, 2015. There was no documentation available for review to indicate if the resident had been offered or assessed to receive the pneumococcal vaccine.

A review of the clinical record revealed Resident R123 was admitted to the facility on December 20, 2017. There was no documentation available for review to indicate if the resident had been offered or assessed to receive the revaccination of the pneumococcal vaccine.

Interview on January 28, 2020, at 10:15 a.m. with Employee E6, Infection Control Preventionist, where she confirmed that there was no documentation to indicate the above mentioned resident's had been offered or assessed to receive the pneumococcal vaccine.

The facility failed to ensure that the pneumococcal immunization was offered to Residents R27, R158, R135, R51, R123.


28 Pa. Code 211.9(a)(1) Pharmacy services
Previously cited 06/27/19, 03/08/19

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 06/27/19, 03/08/19

28 Pa. Code 211.12(d)(3) Nursing services
Previously cited 06/27/19, 03/08/19





 Plan of Correction - To be completed: 03/17/2020

F883
It is the practice of the facility to offer pneumococcal immunization to the residents.
-Residents R27, R158, R135, R51 and R123 were offered or accessed for pneumococcal immunization.
-Other residents at risk will be offered or accessed for pneumococcal immunization.
- Education will be completed by DON/Designee with current licensed nurses to ensure that pneumococcal immunization is offered to the residents.
--The DON/Designee will complete a random weekly audit for 3 months to verify that pneumococcal immunization is offered to the residents. Results of audits will be discussed and reviewed at the facility QAPI meeting to ensure compliance. QAPI committee members will review to discuss need for further audits.
-To be completed by 3/17/2020.



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