Pennsylvania Department of Health
WARREN MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WARREN MANOR
Inspection Results For:

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WARREN MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance Survey completed May 24, 2024, it was determined that Warren Manor was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

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.

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Plan of Correction - To be completed: 07/15/2024

The four identified resident care plans (R99, R106, R31 and R85) were immediately updated to reflect correct Code Status and wound vac therapy.
A house wide audit of care plans for resident code status and wound vacuums will be completed to verify accuracy of the current care plan and ensure interventions are resident specific.
Licensed nursing staff will be educated by the Director of Nursing on 6/7/24 on the importance of accuracy of interventions and treatments in care plans.
The Interdisciplinary Team or designee will audit 5 resident care plans daily for accuracy of code status and wound vacuums for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on review of manufacturer's instructions and clinical records, observations, and staff interviews, it was determined that the facility failed to prevent the potential for cross contamination during the provision of wound care and urinary catheter care for one resident (Resident R85), and during medication administration.

Findings include:

Review of manufacturer's instructions for the Nisus pump wound vacuum indicated that the pump should be kept in the black carrying case provided, and in a clean environment.

Resident R85's clinical record revealed an original admission date of 8/23/23, with diagnoses that included flaccid neuropathic bladder (nerves to the bladder are interrupted and cause the bladder to become underactive), kidney failure, stage four (full thickness loss of skin) pressure ulcer at the base of the spine, and malnutrition.

Resident R85's clinical record revealed physician orders dated 1/08/24, to maintain an indwelling foley catheter (thin tube inserted into the bladder to drain urine); 2/06/24, to provide enhanced barrier precautions while the foley catheter and wound care are present; and 4/16/24, to apply a wound vacuum to his/her wound at the base of the spine three times per week.

Observation on 5/21/24, at 2:40 p.m. revealed Resident R85 laying in bed with his/her foley catheter bag (device used to collect the urine from the catheter) and tubing laying on the bedroom floor, and the collection canister of the wound vacuum and it's tubing also laying on the floor. The black carrying case for the vacuum pump was laying on the bedside stand.

During an interview at that time, Registered Nurse Employee E2 and Licensed Practical Nurse (LPN) Employee E3 confirmed that the foley catheter urine collection bag and tubing, and wound vacuum collection canister and tubing should not be laying on the bedroom floor.

Observation of medication administration on 5/22/24, at 8:24 a.m. revealed that LPN Employee E5 transferred individual resident pills/tablets into a clear plastic medication cup and then placed his/her ungloved finger on the pills/tablets to hold them in the cup as he/she poured one pill/tablet at a time into clear plastic envelopes for crushing.

During an interview at that time, LPN Employee E5 confirmed that he/she should not have touched the resident's pills with their bare hand.

During an interview on 5/23/24, at 10:15 a.m. the Director of Nursing (DON) confirmed that the urine collection bag/tubing and the vacuum canister/tubing should not be on the floor, and also that there is no policy.

During an interview on 5/23/24, at 11:15 a.m. the DON confirmed that LPN Employee E5 should not have touched the pills with his/her ungloved hand, and also that there is no policy.

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

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

Plan of Correction - To be completed: 07/15/2024

The foley catheters/tubing and wound vac pump/tubing for R85 were immediately placed off the floor.
A house wide audit was completed to ensure compliance of having foley catheter bags/tubing and wound vac pumps/tubing off the floor.
All license nursing staff immediately received education from Director of Nursing regarding administration of medications and the utilization of gloves if needing to touch medications.
All licensed nursing staff immediately educated From Director of Nursing on infection control procedures regarding wound vac and foley catheter placement.
The Infection Prevention Nurse or nursing designee will audit infection control procedures related to foley catheter bags and tubing; and wound vac pumps and tubing daily for one week, weekly for one month, and monthly thereafter.
The Infection Prevention Nurse or designee will audit infection control procedures related to medication administration by completing medication administration audits daily for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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

Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to label multi-dose insulin pens, (medication to treat elevated blood sugar levels) with the date it was opened in one of two medication carts (C Hall), failed to label a multi-dose vial of tuberculin solution (used to test for the disease tuberculosis) with the date it was opened in one of one medication storage rooms, and failed to permanently affix a locked narcotic storage container in the medication refrigerator in one of one medication rooms to prevent unauthorized access to resident specific medications for one resident (Resident R70).

Findings include:

A facility policy dated 12/19/23, entitled "Administering Drugs" indicated that "Medications are to be administered at the time they are prepared ...Only the nurse who prepares the medication may administer it. That same nurse is then responsible for recording the administration in the resident's medication administration record at the time it is given."

A facility policy entitled "Vials and Ampules of Injectable Medications" dated 12/19/23, indicated that the date opened is recorded by the first person to use each multi-dose vial and vials expire 28 days after initial use, unless otherwise indicated by the manufacturer.

Observation of Resident R70's room on 5/22/24, at 9:00 a.m. revealed a medication cup filled with multiple unknown medications sitting on the resident's bedside tray table, Resident R70 was sound asleep, and the Licensed Practical Nurse (LPN) Employee E1 was down the hallway assisting other residents.

During an interview on 5/22/24, at that time the LPN Employee E1 confirmed that Resident R70's medications should not have been left alone in the room for the resident and he/she should have ensured Resident R70 took the mediation prior to leaving the room.

Observation on 5/23/24, at 2:00 p.m. of C Hall medication cart storage revealed a multi-dose insulin pen dated opened 4/15/24, and expired 5/12/24, and a multi-dose insulin pen dated opened 4/22/24, and expired 5/19/24.

Observation of the refrigerator in the facility medication storage room revealed an opened, undated multi-dose vial of tuberculin solution, and that the secured narcotic storge box inside the refrigerator was not permanently affixed to the inside of the refrigerator.

During an interview on 5/23/24, at 2:08 p.m. LPN Employee E4 confirmed that the multi-dose insulin pens were expired and should be discarded and that the multi-dose vial of tuberculin solution lacked an opened date and could not determine when the vial should expire.

During an interview on 5/23/24, at 2:12 p.m. the Director of Nursing confirmed that the secured narcotic box in the refrigerator was not permanently affixed to the refrigerator.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.9(a)(1) Pharmacy services

28 Pa. Code 211.9(c) Pharmacy services

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 07/15/2024

The identified expired insulin pen and unlabeled TB vial were immediately removed and properly disposed.
Resident R70 immediately arose and took medications from bedside table.
All medication carts and storage area were audited to ensure presence of expiration dates and that there were no expired meds.
The Environmental Supervisor affixed the shelf that has the secured controlled medication box adhered to the refrigerator.
All licensed nursing staff will be educated by the staff development coordinator on 6/5/24 on properly labeling medications upon opening and disposing of any expired medications per facility policy. Education will also include importance of taking medication immediately after opening medications and not leaving at bedside unattended.
The Director of Nursing or nursing designee will audit medication administration by observation, narcotic container fixation, medication carts and medication refrigerator for outdate or unlabeled medications daily for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process.

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 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(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 assure physician orders, residents' Physician Order for Life Sustaining Treatment (POLST- a legal document specifying the resident/responsible party choices regarding life-sustaining treatments), and paper charts were consistent for two of 23 residents reviewed (Residents R99 and R106).

Findings include:

The facility policy entitled "Advanced Directives Policy - PA" dated 12/19/23, indicated that "The physician's order should also be noted on the resident's plan of care and on the inside of the resident's clinical record."

Resident R99's clinical record revealed an admission date of 1/25/24, with diagnoses including dysphagia (difficulty swallowing), hypertension (high blood pressure), and cerebral infarction (stroke).

Resident R99's physician orders dated 4/12/24, revealed an order for Do Not Resuscitate (Allow Natural Death) - DNR.

Resident R99's clinical record revealed a POLST dated 4/16/24, that revealed Resident R99 requested Do Not Resuscitate (DNR), Comfort Measures Only.

Resident R99's paper chart revealed a sticker on the cover and on the face sheet to Resuscitate (provide CPR [cardiopulmonary resuscitation-emergency life-saving procedure that is done when breathing or a heartbeat has stopped and when performed immediately can double or triple chances of survival after cardiac arrest])- Full Code.

During an interview on 5/22/24, at 1:30 p.m. the Director of Nursing, confirmed Resident R99's physician's orders, POLST, and paper chart were not consistent with each other.

Resident R106's clinical record revealed and admission date of 4/17/24, with diagnoses including fractured right hip, high blood pressure, and anxiety.

Resident R106's physician order dated 5/13/24, revealed an order for DNR - Limited interventions, antibiotics as needed and no artificial feeding.

Resident R106's clinical record revealed a POLST dated 5/15/24, that revealed DNR, limited interventions, antibiotics as needed, intravenous (IV) fluids if needed, and no artificial feeding.

Resident R 106's paper chart revealed a sticker on the cover and on the face sheet to Resuscitate - Full Code.

During an interview on 05/22/24, at 2:02 p.m. the Registered Nurse Assessment Coordinator, confirmed Resident R106's physician's orders, POLST, and paper chart were not consistent with each other.

28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(a) Resident rights

28 Pa. Code 211.10(c) Resident care policies

Plan of Correction - To be completed: 07/15/2024

The two identified resident charts (R99 and R106) were immediately corrected by removing the code status stickers from the paper chart.
All code status stickers were removed from all the charts.
A house wide audit was conducted to verify the Electronic Medical Record, and paper chart code status was accurate.
Medical Records and licensed charge nurses were educated by the Director of Nursing on 5/30/24 on the discontinuation of code status stickers being utilized, where to look for code status, and admission process for code status.
Medical Records or designee will audit 5 facility charts for code status accuracy on Electronic Medical Record and paper chart daily for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on review of facility documents and clinical records, observations, and staff interviews, it was determined that the facility failed to ensure that wound treatments provided were consistent with physician orders to promote healing for one of three residents reviewed for wound care (Resident R31) and failed to ensure staff competencies related to wound care were performed annually.

Findings include:

A facility document entitled "Skills Competency Checklist- Aseptic Dressing Technique" indicated the Competency Performance Criteria included "Physician's order verified for aseptic dressing change" and "perform treatment per physician's order."

Resident R31's clinical record revealed an admission date of 10/20/23, with diagnoses that included stage four pressure ulcers (full thickness loss of skin) to the left and right buttocks, bacterial infection of the bone, and Methicillin-resistant Staphylococcus aureus (MRSA- infection caused by a type of staph bacteria that becomes resistant to many of the antibiotics used to treat ordinary staph infections).

Resident R31's clinical record revealed a physician's order dated 5/19/24, to apply a wound vacuum to his/her wounds on the left buttock and right hip pressure ulcers three times per week. A physician's order dated 5/15/24, revealed to cleanse and apply Vashe moistened gauze to the left hip wound and cover with a dry dressing.

Observation of wound care on 5/22/24, at 12:55 p.m. revealed the soiled wound vacuum dressing was removed from the left hip and a soiled Vashe moistened dressing was removed from the left buttock.

During an interview at that time, Registered Nurse Employee E6 and Licensed Practical Nurse Employee E5 confirmed that the left hip dressing and the left buttock dressings were reversed and not in compliance with physician's orders.

During an interview on 5/23/24, at 9:45 a.m. the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to complete wound care as ordered by the physician and failed to ensure competencies related to the provision of wound care were conducted annually.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 211.10(d) Resident care policies

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

Plan of Correction - To be completed: 07/15/2024

The dressing on R31 was removed from the incorrect site immediately, and new dressing was applied as per physician orders.
A house wide audit was completed to verify accuracy of placement on all current wound vacs in facility.
All licensed nursing staff will be educated by pharmacy on 6/13/24 on wound vac dressing application per physician orders.
The Infection Prevention Nurse or nursing designee will audit all wound vac dressing applications for accuracy against physician orders daily for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 23 residents reviewed (Resident R71).

Findings include:

A facility policy entitled "Comprehensive Care Plan," dated 12/19/23, indicated that the facility will develop a comprehensive person centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

Resident R71's clinical record revealed an admission date of 2/7/22, with diagnoses that included dementia (disease that affects the brains ability to think, remember, and function normally), high blood pressure, and anxiety.

Resident R71's clinical record revealed a physician's order dated 10/27/23, for a secure care band (a bracelet worn by resident to alert staff when resident is near or attempts to exit the facility) to be worn with placement verified every shift and function verified every day.

The clinical record lacked evidence that a care plan had been developed to address Resident R71's risk for elopement and use of secure care band.

During an interview on 5/22/24, at 3:12 p.m. the Registered Nurse Assessment Coordinator confirmed that a care plan had not been developed to address Resident R71's risk for elopement and use of a secure care band.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 07/15/2024

Care plan for R71 was immediately updated to reflect correct utilization of a secure care device.
A house wide audit of care plans for residents with secure care devices will be completed to verify accuracy of the current care plan and ensure interventions are resident specific.
Licensed nursing staff will be educated by the Director of Nursing on 6/7/24 on importance of accuracy of correct interventions and treatments in care plans.
The Interdisciplinary Team or designee will audit 5 resident care plans daily for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process.

483.20(g) REQUIREMENT Accuracy of Assessments:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Plan of Correction - To be completed: 07/15/2024

The MDS assessments identified for R12, R71, R21, and R86 were immediately corrected.
Registered Nurse Assessment Coordinator has completed a house wide audit on all residents with secure care devices, catheters and C-Paps to ensure MDS assessments accuracy.
Registered Nurse Assessment Coordinator will be educated by the staff development coordinator on 6/4/24 to verbally verify nursing staff documentation when identifying possible inaccuracy and make appropriate changes to reflect the accurate information within the MDS assessment.
The interdisciplinary team or designee will audit resident 5 MDS assessments for accuracy of secure care device, catheter and C-Pap coding daily for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on review of closed records and staff interview, it was determined that the facility failed to ensure that a discharge summary (a recapitulation or summary of the residents stay and course of treatment in the facility) was completed for one of three discharged residents reviewed (Closed Record Resident CR111).

Findings include:

Resident CR111's clinical record revealed an admission date of 2/6/24, with diagnoses that included chronic obstructive pulmonary disease (a lung disease that causes difficulty breathing), anemia, and peripheral vascular disease (disorder that causes blood vessels to narrow affecting blood flow).

Resident CR111's progress notes dated 3/2/24, revealed that Resident CR111 left facility against medical advice (AMA).

Resident CR111's closed clinical record lacked evidence of a discharge summary of Resident CR111's stay.

During an interview on 5/24/24, at approximately 11:15 a.m. Nursing Home Administrator confirmed that the closed record for CR111 did not have a discharge summary included in the clinical record as required.

Plan of Correction - To be completed: 07/15/2024

Medical records will be educated by the DON on 5/30/24 regarding all required documents required to close the record.
Medical Records will audit all closed charts for the month of May for discharge summary.
A closed chart check list was developed to be utilized while closing the record. This checklist will be utilized with every closed record to ensure any missing documents are brought to the attention of Director of Nursing/Administrator to ensure timely retrieval of documents prior to closing the record.
Medical Records or designee will audit all closed records for accuracy daily for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process

§ 211.9(j.1) (1) - (5) LICENSURE Pharmacy services.:

(j.1) The facility shall have written policies and procedures for the disposition of medications that address all of the following:
(1) Timely and safe identification and removal of medications for disposition.
(2) Identification of storage methods for medications awaiting final disposition.
(3) Control and accountability of medications awaiting final disposition consistent with standards of practice.
(4) Documentation of actual disposition of medications to include the name of the individual disposing of the medication, the name of the resident, the name of the medication, the strength of the medication, the prescription number if applicable, the quantity of medication and the date of disposition.
(5) A method of disposition to prevent diversion or accidental exposure consistent with applicable Federal and State requirements, local ordinances and standards of practice.

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to document the type and quantity of medication disposition for one of three closed records reviewed (Closed Record Residents CR111).

Findings include:

A facility policy entitled "Discharge Medication" dated 12/19/23, revealed that the nurse is responsible for entering the following information on the medication destruction record or medication administration record in the resident's chart: date, prescriptions number if present, name and strength of medication, and quantity or amount.

Resident CR111's clinical record revealed an admission date of 2/6/24, with diagnoses that included chronic obstructive pulmonary disease (a lung disease that causes difficulty breathing), anemia, and peripheral vascular disease (disorder that causes blood vessels to narrow affecting blood flow).

Review of facility provided information revealed Resident CR111 left the facility on 3/2/24, against medical advice (AMA).

The clinical record lacked documentation of the type and quantity of medication disposition for Resident CR111 at the time he/she left the facility AMA.

During an interview on 5/24/24, at approximately 11:15 a.m. Nursing Home Administrator confirmed that the facility failed to properly document disposition of medications for Resident CR111.

Plan of Correction - To be completed: 07/15/2024

The Director of Nursing will educate all licensed nursing staff by 6/14/24 on the disposition of medications at discharge including type and quantity of medications.
Medical Records will audit all closed charts for the month of May for disposition of medication record.
A closed chart check list developed to be utilized while closing the record. This checklist will be utilized with every closed record to ensure any missing documents are brought to the attention of Director of Nursing/Administrator to ensure timely retrieval of documents prior to closing the record.
Medical Records or designee will audit all closed records for accuracy daily for one week, weekly for one month, and monthly thereafter.
Audit findings will be reviewed through the QAPI process.

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