Nursing Investigation Results -

Pennsylvania Department of Health
MEADOWCREST HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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MEADOWCREST HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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MEADOWCREST HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure and Civil Rights Compliance Survey and an Abbreviated Survey in response to a complaint completed on January 29, 2020, it was determined that Meadowcrest Healthcare 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 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


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

483.45(h) Storage of Drugs and Biologicals

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

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

Based on review of a facility specific document and facility policy, observations and staff interviews, it was determined that the facility failed to make certain that the procedure for over-the-counter medications was followed during medication administration on two of two nursing units ( Fawn Lane and Garden Lane nursing units).

Findings include:

The facility was granted a permanent exception on November 25, 2013, as related to their over-the counter medications. The exception noted that the facility utilized a list that detailed the names of all residents who were prescribed over-the counter medications, the list was received twice a weekly from the pharmacy and listed the resident names and specified over-the-counter medications they received and the nurse would review and update the list for accuracy daily during medication pass.

The facility policy "House-supplied (Floor Stock) Medications" dated 11/22/19, indicated that the facility utilized a list of residents ordered other-the-counter medications.

During an observation of a medication pass on the Fawn Lane nursing unit on 1/27/20, at 7:35 a.m. Licensed Practical Nurse (LPN) Employee E7 dispensed the following over-the-medication, checked the over-the-counter medication list for Resident R15 and resident was not on the list for the medication then LPN Employee E7 administered medication to Resident R15 :
-Iron (supplement) 325 milligram tablet

During interviews on 1/27/20, at 8:00 a.m. LPN Employee E3 confirmed that the facility had an exception as related to the over-the-counter medications and that the facility failed to make certain that the procedure for over-the-counter medications was followed by the nurses during medication administration.

During an observation of a medication pass on the Garden Lane nursing unit on 1/28/20, at 7:35 a.m. LPN Employee E3 dispensed the following over-the-medications, did not reconcile with the over-the-counter medication list and administered them to Resident R17:
-Senna (stool softener) two 8.6 milligram (mg) tablets
-Docusate Sodium (stool softener) 100 mg tablet
-Multiple vitamin one tablet

During an observation of a medication pass on the Garden Lane nursing unit on 1/28/20, at 7:55 a.m. LPN Employee E3 dispensed the following over-the-counter medications, did not reconcile with the over-the-counter medication list and adminstered them to Resident R11:
-Aspirin 81 mg tablet
-Calcium plus Vitamin D3 600 mg / 400 international units (IU) one tablet
-Vitamin B12 two 500 microgram tablets
-Vitamin D3 2000 IU tablet.

During interviews on 1/28/20, at 8:05 a.m. and at 8:10 a.m. LPN Employee E3 and the Director of Nursing confirmed that the facility had an exception as related to the over-the-counter medications and that the facility failed
to make certain that the procedure for over-the-counter medications was followed by the nurses during medication administration.

28 Pa. Code: 211.9(h)(k) Pharmacy services.

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




 Plan of Correction - To be completed: 03/10/2020

#0761
1. Resident #15 Iron (supplement) 325milligram has been added to the over the counter medication list. Resident's #11 and #17 medication list was up to date. Nurse staff has been inserviced to reconcile residents with over the counter medication list.
2. The over the counter medication list has been updated and available to nurses to ensure the procedure is followed during medication administration.
3. The Director of Nursing/designee in-serviced current licensed nurses on the procedure of the over the counter medication list to included adding residents name and new orders for the over the counter medications to the list and reconcile with the over the counter medication list prior to medication administration.
4. The Director of Nursing/designee will complete audits x 3 weeks and then monthly x3 of new orders of over the counter medications during morning clinical meeting to ensure resident and medication has been added to the over the counter medication list. The Director of Nursing will complete 2 medication passes weekly x3 weeks then monthly x3 with licensed nurses to ensure nurses are reconciling with the over the counter medication list. The audits will be reviewed by the facility's QAPI committee monthly x3 months for further recommendations.

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 observations and resident, family and staff interviews, it was determined that the facility failed to maintain a homelike environment on one of two nursing units (Garden Lane nursing unit).

Findings include:

During observations on the Garden Lane nursing unit on 1/27/20, from 9:10 a.m. to 11:45 a.m. the following was observed in the resident room 10 there was a leg rest with padding on the seat of a visitor chair.

During an observation on the Garden Lane nursing unit on 1/27/20, at 11:35 a.m. the closet in room 4 had clumps of dust in the corner and under the laundry basket.

During an interview on 1/27/20, at 11:35 a.m. Resident Family Member RF32 reported "They never clean the floor in there (closet)."

During observations on the Garden Lane nursing unit on 1/28/20, from 8:00 a.m. to 11:15 a.m the following was observed:
-In room 10 there was a padded foot rest and a padded splint on the seat of the visitor chair.
-In the closets in rooms 4, 3, 7 and 10 there was debris on the floor which included clumps of dust, plastic thermometer covers and staples.

During interviews on 1/28/20, at 11:00 a.m., 11:15 a.m. and at 11:45 a.m. Housekeeping Employee E4 and Registered Nurse (RN) Employee E1 confirmed the items stored on the chairs in resident rooms 8 and 10 and/or the debris in the closets of resident rooms 3, 4, and 7 on the Garden Lane nursing unit and that the facility failed to create a clean, homelike environment for the residents.

During interviews on 1/28/20, at 5:00 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain a homelike environment on the Garden Lane nursing unit.

28 Pa. Code: 207.2 Administrator's responsibility.




 Plan of Correction - To be completed: 03/10/2020

#0584
1. Resident rooms 8 and 10 items stored on chairs were removed. Resident's room's 3, 4, 7, and 10 debris in the closets were cleaned to promote a homelike environment.
2. The Housekeeping Supervisor completed an initial audit of resident's rooms on January 31, 2020 to identify any other closets needing cleaned and for personal items in visitor chairs.
3. The Housekeeping Supervisor has in-serviced current housekeeping staff of proper cleaning of resident's rooms to include cleaning of debris in closets. The Director of Nursing/Designee has in-serviced current direct care staff on proper storage of resident's items to include not being placed on visitor's chairs.
4. The Housekeeping Supervisor will audit 5 resident rooms and closets twice weekly x3 weeks and then monthly x3 to ensure no debris in closets and proper cleaning techniques were completed to maintain a home like environment. The Director of Nursing/designee will monitor 5 resident rooms twice weekly x3 weeks then monthly x3 to ensure no personal items are placed on visitor chairs to maintain a home like environment. Outcomes of audits will be reported to the facility QAPI committee monthly x3 months for further review and recommendations.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:
Based on review of manufacturer specifications, policy, clinical record, observations and staff interviews,
it was determined that the facility made a significant medication error by administering a medication contrary to manufacturer specifications for one of seven residents (Resident R11).

Findings include:

The manufacturer specifications for Zafirlukast (medication to treat asthma) instructed to give the medication on an empty stomach, one hour before or two hours after meals.

The facility policy "Administering Medications" dated 8/22/19, instructed the nurse to administer medications in a safe, timely manner in accordance with the orders and prescribed times unless otherwise specified which included before and after meal orders.

The Admission Record indicated that Resident R11 was admitted to the facility on 11/1/19, with diagnoses that included heart disease, myasthenia gravis (neuromuscular disorder) and chronic obstructive pulmonary disease (COPD- a persistent obstruction of the airways).

A physician order dated 11/1/19, indicated that Resident R11 was ordered Zafirlukast 20 milligrams (mg) by mouth two times a day.

During an observation of a medication pass on 1/28/20, at 7:55 a.m. Licensed Practical Nurse (LPN) Employee E3 dispensed a 20mg tablet of Zafirlukast from the blister pack. The blister pack was labeled "Take medication on an empty stomach - 1 hour before or 2-3 hours after meals and take this medication exactly as directed."

During an observation on 1/28/20, at 7:57 a.m. LPN Employee E3 entered the resident's room and administered the Zafirlukast to Resident R11; Resident R11 was half way done eating the breakfast meal.

During an interview on 1/28/20, at 8:05 a.m. LPN Employee E3 confirmed not administering the Zafirlukast to Resident R11 on an empty stomach.

During an interview on 1/28/20, at 8:10 a.m. the Director of Nursing confirmed that the facility failed to prevent a significant medication error when Zafirlukast was not administered to Resident R11 as per manufacturer specifications.

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

28 Pa. Code: 211/12(d)(1)(3)(5) Nursing services.
Previously cited 12/6/18.



 Plan of Correction - To be completed: 03/10/2020

#0760
1. Resident #11's Physician was notified of not following manufacturer guidelines of medication. Resident #11's medication of Zafirlukast time of administration has been changed according to manufacturer's guidelines and Physician order.
2. The Director of Nursing/designee completed an initial audit on January 31, 2020 to identify any other current residents receiving Zafirlukast to ensure administered according to manufacturer's guideline.
3. The Director of Nursing/designee has in-serviced current licensed nurses on the facility's medication administration policy to include following manufacturer's guidelines and following the directions of medication administration.
4. The Director of Nursing/designee will audit new admissions medication regime during morning clinical meeting x3 weeks and then monthly x3 to ensure if on Zafirlukast it is administered according to manufacturer's guidelines. The audits will be reviewed by the facility's QAPI committee monthly x3 months for further recommendations.

483.60(d)(6) REQUIREMENT Drinks Avail to Meet Needs/Prefs/Hydration: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(6) Drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration.
Observations:
Based on clinical record review, observation and family and staff interviews, it was determined that the facility to make certain that the physician ordered consistency of fluids was provided to one of four residents reviewed (Resident R32).

Findings include:

The Admission Record indicated that Resident R32 was admitted to the facility with diagnoses that included diabetes, depression and schizoaffective disorder (combination schizophrenia and mood disorder). The Minimum Data Set (MDS - periodic assessment of care needs) dated 6/13/19, included additional diagnoses of dysphagia (difficulty swallowing).

A current physician order originally dated 6/18/19, indicated there Resident R32 was ordered a "mechanical soft, ground texture diet with nectar consistency liquids."

During an observation of the lunch meal on 1/27/20, at 12:05 p.m. there was a four-ounces carton of milk on Resident R32's tray. The resident's meal ticket was clearly marked for "Nectar-thick liquids."

During an interview on 1/27/20, at 12:05 p.m. Resident Family Member RF32 "Is this nectar thick? My husband could have choked to death."

During interviews on 1/29/20, at 8:10 a.m. and at 1:30 p.m. the Director of Nursing, Dietary Manager Employee E5 and Registered Dietitian Employee E6 confirmed that Resident R32 had difficulty swallowing and that the facility failed to make certain that the physician ordered consistency of fluids was provided to Resident R32.

28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited 12/6/18.

28 Pa. Code: 211.12(d)(1)(5) Nursing services.
Previously cited 12/6/18.



 Plan of Correction - To be completed: 03/10/2020

#0807
1. The regular consistently milk was removed from the R32's meal tray. There have been no further occurrence of resident # 32 being served the wrong consistency of liquids.
2. The Facility's Dietary Manager has completed an initial audit to identify residents with physician orders requiring other consistency of liquids than regular consistency.
3. The facility's Dietary Manager has in-serviced Dietary Department on tray assembly according to resident's meal ticket.
4. The facility's Dietary Manager will audit 5 meal trays during tray line assembly twice weekly x3 weeks and then monthly x3 months to ensure residents receiving consistency of liquids per physician order. Outcomes of audits will be reported to the facility QAPI committee monthly x3 months for further review and recommendations.

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

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

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

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

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

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

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:
Based on review of facility policy, observations and staff interviews it was determined that the facility failed to follow proper infection control procedures during blood glucose monitoring for one of one residents reviewed (Resident R35) and failed to administer medications in a sanitary manner for two of seven resident reviewed (Resident R29 and R140) which created the potential for cross-contamination for the residents.

Findings include:

Review of facility policy "Personal Protective Equipment - Using Gloves" dated 8/22/19, indicated to wash hands after removing gloves.

Review of facility policy "Handwashing/Hand Hygiene- Applying and Removing Gloves" dated 8/22/19, indicated that hand washing is the next step in the process after gloves are removed.

During an observation on 1/27/20, at 10:58 a.m. of a blood glucose check in which Licensed Practical Nurse (LPN) Employee E7 entered Resident R35's room, preformed a blood glucose reading, removed gloves, with ungloved hands pushed Resident R35 wheelchair to room door, opened door and continued to push Resident R35 down the hallway toward dining room failing to perform hand washing after removal of gloves. LPN Employee E7 was carrying the blood glucose meter in hand as pushing resident in wheelchair.

During an interview on 1/27/20, at 11:10 p.m. LPN Employee E7 confirmed that proper infection control procedures were not followed after the blood glucose by not performing hand washing after the removal of gloves created the potential for cross contamination.

During an observation on 1/27/20, at 11:14 a.m. LPN Employee E7 prepared an insulin injection for Resident R29 at the nurses station in the hallway. With an uncapped needle LPN Employee E7 walked down the hall into Resident R29's room and administered the injection and then went back to the medication cart at the nurses station to dispose of the needle and syringe.

During an interview on 1/27/20, at 11:20 a.m. LPN Employee E7 confirmed that by walking with an uncapped needle proper infection control procedures were not followed which created the potential for cross contamination.

During an observation of a medication administration on 1/28/20, at 8:06 a.m Registered Nurse (RN) Employee E8 popped all pills in medicine cup for Resident R140 and realized that one of the pills was not ordered. RN Employee E8 removed the pill that was not ordered with a finger and administrated all other pills to Resident R140.

During an interview on 1/28/20, at 8:15 a.m. RN Employee E8 confirmed that by removing the pill with a finger medications were not administrated in a sanitary manner to Resident R140 which created the potential for cross contamination.

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

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



 Plan of Correction - To be completed: 03/10/2020

#0880
1. Resident's #35, #29, and #140 had no adverse reactions related to Employee E7 and E8 not following proper infection control procedures.
2. The Director of Nursing has completed medication administration competencies on February with licensed nurses to ensure proper infection control measures are maintained.
3. The Director of Nursing/designee will in-service current licensed nurses on facility's Personal Protective Equipment-Using Gloves and Handwashing/Hand Hygiene- Applying and Removing Gloves Policies to include infection control measures with medication administration, glucometer testing, and insulin injections.
4. The Director of Nursing/Designee will complete 2 medication administration competencies/audits weekly x3 weeks and then monthly x3 to ensure infection control measures are maintained during medication administration, Glucometer testing, and insulin administration. Outcomes of the competencies/audits will be reported to the facility QAPI committee monthly x3 months for further review and recommendations.


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