Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-YORK SOUTH
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MANORCARE HEALTH SERVICES-YORK SOUTH
Inspection Results For:

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MANORCARE HEALTH SERVICES-YORK SOUTH - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure, Civil Rights survey, and one complaint survey, completed on September 19, 2019, at Manor Care Health Services-York South, it was determined that the facility was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.







 Plan of Correction:


483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Observations:



Based on clinical record review and staff interview it was determined that the facility failed to ensure each resident who experiences a significant change is comprehensively assessed within 14 days for one of 32 residents reviewed (Resident 45).

Findings Include:

Review of Resident 45's September 2019, physician orders revealed diagnoses including vascular dementia and hypertension (elevated blood pressure).

Further review of Resident 45's physician orders revealed one dated June 11, 2019, reading "Admit to [hospice provider name] to eval [evaluation] and treat for Alzheimer's Disease with Late Onset... for life expectancy of 6 months or less."

Review of Resident 45's clinical record revealed a Significant Change Minimum Data Set (MDS- a tool used to assess all care areas specific to the resident), dated July 11, 2019.

An interview, on September 19, 2019, at 11:12 AM, with the Nursing Home Administrator, confirmed a significant change MDS was completed in July 2019, as staff responsible for completing the MDS were not aware Resident 45 was admitted to hospice services on June 11, 2019.

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














 Plan of Correction - To be completed: 10/23/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken, or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been or will be corrected by the dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. This plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.

1. Resident 45's MDS ARD 7-11-19 was set after identifying resident as a significant change related to hospice admission 6-11-19. Resident 45 suffered no ill effects.
2. A review of current residents on hospice will be assessed to ensure an MDS was set with ARD within 14 days of admission to hospice services.
3. The MDS coordinators were educated on setting the ARD after a resident enrolls in Hospice care.
4. MDS Coordinators or designee will conduct an audit on all residents on Hospice care weekly to assure all hospice residents have a timely comprehensive assessment after enrolling in hospice care. Audits will be weekly for 12 weeks. QAA committee will track and trend audits and determine the need for further audits.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure an accurate assessment for one of five resident records reviewed for unnecessary medications (Resident 16).

Findings include:

Review of Resident 16's clinical record on September 17, 2019, at approximately 11:00 AM revealed diagnoses including hypertension (elevated/high blood pressure), and major depressive disorder (mental health disorder characterized by chronic low mood, loss of interest in pleasurable activities, sleep pattern disturbances, and other symptoms).

Review of Resident 16's physician orders on September 17, 2019, at approximately 11:00 AM, revealed a physician order for phenobarbital (nonselective central nervous system (CNS) depressants that are primarily used as sedative-hypnotics) 15 milligrams (mg - metric unit of measure) by mouth in the afternoon and 32.4 mg by mouth two times a day; both doses for seizures (neurological disorder of the brain).

Review of Resident 16's quarterly Minimum Data Set (MDS - assessment tool utilized to identify a residents' physical, emotional and psychosocial needs), dated July 15, 2019, revealed that section N: Medications; Subsection: N0410D Medications received: Hypnotics was coded to reflect Resident 16 did not receive a hypnotic medication.

Review of Resident 16's Medication Administration Record (MAR - documentation tool used to record when a resident is administered a medication), and prior physician orders, revealed that Resident 16 had a scheduled daily dose of phenobarbital medication since June 23, 2017.

During a staff interview on September 18, 2019, at approximately 2:00 PM, the Director of Nursing provided guidance from the facility's contracted pharmacy. Review of the facility document titled, "MDS 3.0 Section N: Medications," last revised April 2013, identified phenobarbital as, "should only be coded as a hypnotic if is being used for sleep (not if being used for seizures, etc)."

Review of Centers for Medicare & Medicaid Services' "Long-Term Care Facility Resident Assessment Instrument 3.0," (instructions and directions for the assessment and completion of the MDS form), dated October 2018, revealed that the instructions for section N0410A-H:; of N: Medications Received, stated, "Code [record/document] medications according to the pharmacological classification, not how they [the medications] are being used."

During a staff interview on September 19, 2019, at approximately 10:45 AM, Director of Nursing revealed that the facility was following guidance from the consultant pharmacy and was unaware of a change in the MDS coding instructions to code a medication per the classification and not use of the medication.

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




 Plan of Correction - To be completed: 10/23/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken, or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been or will be corrected by the dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. This plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.

1 .Resident 16's MDS has been modified on section N0410D to reflect accurate coding for hypnotic medications. Resident suffered no ill effects from MDS coding.
2. Any resident who receives hypnotic medications have the potential to be affected. All residents currently receiving hypnotic medications their MDS will be audited to ensure accuracy of section N0410D.
3. The MDS Coordinators have been educated on accurately coding section N0410D on the MDS.
4. MDS Coordinators or designee will conduct an audit of 5 completed MDS assessments weekly to ensure accuracy of section N0410D for hypnotics. Audit will be weekly for 4 weeks then monthly for 2 months. QAA committee will track and trend audits and determine the need for further audits.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on review of test tray results and resident and staff interviews, it was determined that the facility failed to serve foods at palatable temperatures. (800 dining room).

Findings included:

According to the federal regulation 483.60(i)(2) Food safety requirements-the definition of "Danger Zone",
found under the definition section, is food and liquid temperatures above 41 degrees Fahrenheit (measurements of temperatures) and below 135 degrees Fahrenheit that allows rapid growth of pathogenic microorganisms that can cause foodborne illness.

During an interview with Resident 21 and Resident 128 on September 17, 2019, at approximately 10:00 AM stated that the hot food is sometimes cold and the cold food is sometimes served warm.

The food cart was delivered to 800 hall dining room on September 17, 2019, at approximately 8:15 AM and last tray taken out of food cart was at approximately 8:30 AM. The Food Service Director tested the temperatures of test tray food items revealing the following unpalatable food beverage temperature:
Milk (4 ounce carton) - 49.9 degrees Fahrenheit.

The Tray Assessment Form indicated that a Satisfactory Temperature Range should be 41 - 45 degrees Fahrenheit.

Interview with Food Service Director and Administrator on September 17, 2019, at approximately 8:35 AM and September 18, 2019 at approximately 11:05 am confirmed that the milk temperature should be within
41 - 45 degrees Fahrenheit.

28 Pa. Code: 201.29(j) Resident rights
Previously cited 08/16/2018

28 Pa. Code: 211.6(c) Dietary services






 Plan of Correction - To be completed: 10/23/2019

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken, or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been or will be corrected by the dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. This plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.
1. No resident suffered any ill effects from the temperature of the carton of milk.
2. Test trays will be conducted on one day for every meal on every unit to check the temperature of the milk. Resident #128 and #21 will be interviewed again related to the temperature of the cold food.
3. Food Service Staff will be educated on methods to maintain food and drinks at a safe and appetizing temperature.
4. Food Service Director or designee will complete test trays 3x's a week for 4 weeks and then monthly for 2 months. Random residents will be interviewed related to the temperatures of the cold food 3X's a week for 4 weeks and then monthly for 2 months. QAA committee will track and trend audits and determine the need for further audits.



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