Nursing Investigation Results -

Pennsylvania Department of Health
GROVE AT NORTH HUNTINGDON, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GROVE AT NORTH HUNTINGDON, THE
Inspection Results For:

There are  130 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
GROVE AT NORTH HUNTINGDON, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on December 6, 2019, it was determined that The Grove at North Huntingdon 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:


483.25(k) REQUIREMENT Pain Management:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure proper pain management for three of 13 residents reviewed (Residents 3, 8, 12).

Findings include:

The facility's policy regarding pain management, dated October 4, 2019, indicated that prescribed medications were to be administered in accordance with physician's orders.

Physician's orders for Resident 8, dated August 15, 2019, included an order for the resident to receive one and a half 5 milligram (mg) tablets of Oxycodone (a narcotic pain medication) every six hours as needed for pain rating of 7-10 (on a scale of 1-10 where 10 is the worst pain).

Resident 8's Medication Administration Record (MAR) for November 2019 revealed that staff administered as-needed Oxycodone for pain ratings that were less than 7 on November 7, 8, 9 (two times), 10, 12, 15, 16, 17, 18, 19, 21, 23 and 24, 2019.

There was no corresponding documentation in Resident 8's clinical record, including on the MAR or in the nursing notes, regarding any non-medication pain interventions that were attempted prior to administering Oxycodone on the above days, and no documented evidence the physician was notified that the resident was experiencing pain that was rated as less than 7 and did not have an order for these pain ratings.

Interview with the Director of Nursing on November 25, 2019, at 2:40 p.m. confirmed that Oxycodone was administered to Resident 8 for pain ratings that were less than 7, which was not in accordance with the physician's order, and there was no documented evidence the physician was notified. She also confirmed that there were no additional pain management interventions documented prior to administering Oxycodone.


A diagnosis record for Resident 3, dated October 14, 2019, revealed that the resident had diagnoses that included a right artificial knee and diabetic neuropathy (nerve damage caused by diabetes). Physician's orders, dated October 14, 2019, at 10:06 p.m. included an order for the resident to receive one 5 mg tablet of Oxycodone every four hours as needed for mild pain, and two 5 mg tablets of Oxycodone for moderate pain. There was also an order for the resident to receive 650 mg of Tylenol (over-the-counter pain medication) every six hours as needed for pain.

A physician's medication prescription for Oxycodone indicated that it was "faxed" to the pharmacy on October 14, 2019, at 7:48 p.m.

A nursing note for Resident 3, dated October 14, 2019, at 7:00 p.m. indicated that the resident was demanding that she be given her pain medication "despite the explanation of the process to obtain narcotics."

There was no documented evidence that an assessment of Resident 3's pain was completed at that time, and no documented evidence that any non-medication interventions were offered for pain relief or that Tylenol was offered.

Interview with the Director of Nursing on November 26, 2019, at 10:42 a.m. confirmed that there was no documented assessment that Resident 3's pain was assessed at the time she requested pain medication on October 24, 2019, at 7:00 p.m., and no documented evidence that any non-medication interventions and/or Tylenol were offered for pain relief.


A diagnosis record for Resident 12, dated November 15, 2019, revealed that the resident had diagnoses that included osteomyelitis of the vertebra (infection in the spine), post laminectomy (surgery that removes part of the vertebral bone) with intraspinal abscess (swollen area in your tissues that contains a build-up of pus). Physician's orders, dated November 15, 2019, included an order for the resident to receive 15 mg of Oxycodone every four hours as needed for breakthrough pain rated as 7-10.

Resident 12's MAR's for November 2019 revealed that staff administered 15 mg of Oxycodone for pain that was rated as a 4 on November 16 at 2:51 p.m, and November 17 at 11:36 a.m.

Interview with the Director of Nursing on November 26, 2019, at 1:16 p.m. confirmed that Resident 12's physician's order for Oxycodone should have been followed.

42 CFR 483.25(k) Pain Management.
Previously cited 10/8/19.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 10/8/19.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 10/8/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/8/19.




 Plan of Correction - To be completed: 01/08/2020

There were no negative outcomes from the concerns identified.
Resident 3 was discharged from the facility. The Physician for resident 12 was notified that the resident had received Oxycodone on several days outside of parameters. No new orders were received. The Physician for resident 8 was notified the the resident received Oxycodone on several days outside of parameters. No new orders received. The Director of Nursing or Designee will re-educate licensed nursing staff including agency and new hires on the facility policy and procedure for pain management. The Director of Nursing or Designee will perform an audit 2 times a week for 2 weeks and weekly for 2 weeks, and then monthly for 3 months. The results of these audits will be reported to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of facility policies, manufacturer's instructions, meal schedules, residents' clinical records and information received from the facility, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for three of 13 residents reviewed (Residents 3, 5, 6).

Findings include:

The facility's medication administration policy, dated October 4, 2019, indicated that medications were to be administered in accordance with physician's written orders, medications ordered for before and after meals were to be administered precisely as ordered, and that documentation of medication administration was to be done immediately after the administration and/or refusal of the medication.

Manufacturer's instructions for aspart insulin (also known as Novolog - a fast-acting insulin used to lower blood sugar levels quickly), dated March 2008, indicated that it was to be administered 5 to 10 minutes before meals. The manufacturer's instructions for glargine (also known as Lantus - a long-acting insulin used to lower blood sugar levels over time), dated November 2019, indicated that it was to be administered at the same time each day.

A diagnosis record for Resident 5, dated November 7, 2019, revealed that the resident had diagnoses that included diabetes (disease that affects blood sugar control) and renal (kidney) failure that required dialysis (mechanical process of removing excess water and toxins from the blood when the kidneys are not functioning properly).

Physician's orders for Resident 5, dated July 1, 2019, included orders for the resident to receive aspart insulin (fast-acting) coverage based on a sliding scale (the amount of insulin administered is based on the results of a fingerstick blood sugar test). The sliding scale aspart insulin coverage was to start with a blood sugar level of 131 milligrams per deciliter (mg/dL), was to be given subcutaneously (injected under the skin) before meals and at bedtime, and may be given at meal times after dialysis on Monday and Friday. Physician's orders dated October 30, 2019, included an order for 13 units of glargine insulin (long-acting) to be given subcutaneously at bedtime (scheduled for 9:00 p.m. on the Medication Administration Record).

The facility's meal schedule for Resident 5's nursing unit indicated that meals were served at 7:50 a.m., 12:45 p.m. and 5:45 p.m.

Resident 5's Medication Administration Records (MAR) for October and November 2019 revealed that the breakfast dose of aspart insulin (scheduled for 7:50 a.m.) was not given 5-10 minutes before the meal on October 3 at 8:43 a.m., October 7 at 8:33 a.m., October 13 at 8:20 a.m., October 15 at 8:25 a.m., October 16 at 8:43 a.m., October 17 at 8:59 a.m., October 19 at 8:35 a.m., October 20 at 8:25 a.m., October 22 at 8:42 a.m., October 24 at 8:29 a.m., October 29 8:25 a.m., October 30 at 8:37 a.m., November 5 at 10:34 a.m., November 6 at 8:29 a.m., November 7 at 8:04 a.m., November 14 at 8:29 a.m., November 16 at 8:32 a.m., November 19 at 7:24 a.m., November 20 at 8:12 a.m., November 24 at 8:40 a.m., and November 26 at 8:27 a.m.

Resident 5's MAR's for October and November 2019 revealed that the lunch dose of aspart insulin (scheduled for 12:35 p.m.) was not given 5-10 minutes before the meal on October 6 at 12:50 p.m., October 19 at 1:00 p.m., October 12 at 11:48 a.m., October 19 at 1:00 p.m., October 20 at 1:09 p.m., October 22 at 1:38 p.m., October 29 at 3:02 p.m., November 4 at 1:20 p.m., November 9 at 11:48 a.m., November 10 at 2:15 p.m., November 14 at 11:50 a.m., November 19 at 12:58 p.m., November 21 at 1:09 p.m., November 24 at 1:09 p.m. and November 26 at 11:44 a.m.

Resident 5's MAR's for October and November 2019 revealed that the supper dose of aspart insulin (scheduled for 5:45 p.m.) was not given 5-10 minutes before the meal on October 1 at 8:13 p.m., October 2 at 6:36 p.m., October 3 at 6:55 p.m., October 4 at 7:09 p.m., October 6 at 6:35 p.m., October 8 at 6:54 p.m., October 10 at 4:54 p.m., October 11 at 4:53 p.m., October 20 at 5:07 p.m., October 21 at 5:04 p.m., October 27 at 4:48 p.m., October 30 at 8:42 p.m., October 31 at 4:49 p.m., November 1 at 6:41 p.m., November 2 at 4:55 p.m., November 4 at 6:08 p.m., November 6 at 8:00 p.m. November 7 at 4:50 p.m., November 8, 11:53 p.m., November 9 at 4:45 p.m., November 10 at 5:11 p.m., November 11 at 6:19 p.m., November 12 at 4:56 p.m., November 14 at 4:49 p.m., November 18 at 8:18 p.m., November 20 at 4:56 p.m., November 21 at 6:05 p.m., November 22 at 7:38 p.m., November 23 at 4:49 p.m., November 24 at 5:07 p.m., and November 25 at 6:26 p.m.

There were also three episodes documented on Resident 5's MAR for November 2019 where the supper insulin and bedtime insulin doses were signed out as given at the same time or very near each other. On November 6, the 5:45 p.m. dose of aspart insulin was documented as given at 8:00 p.m., the bedtime dose of aspart insulin was given at 8:06 p.m., and the glargine insulin ordered for 9:00 p.m. was given at 8:07 p.m. On November 8, the 5:45 p.m. dose of Aspart insulin was given at 10:53 p.m. and the 9:00 p.m. doses of the aspart and glargine insulins were given at 10:54 p.m. On November 22, the 5:45 p.m. dose of aspart insulin was given at 7:38 p.m. and the 9:00 p.m. doses of aspart and glargine insulins were given at 8:05 p.m. There was no documented evidence regarding why the insulin doses were not given according to physican's orders.

Interview with the Director of Nursing on November 26, 2019, at 3:15 p.m. confirmed that Resident 5 was to receive her fast-acting insulin at the time of her meals and did not receive it as ordered by the physician on multiple dates and times. She was not aware of why the insulin doses were not given as ordered and/or were given too close to the next dose, unless staff just documented it that way but gave it correctly.

Current physician's orders for Resident 5, dated October 2019, included orders for the resident to receive 13 units of Levemir Solution (insulin) at bedtime, one 15 milligram (mg) tablet of mirtazapine (antidepressant) at bedtime, one 50 mg capsule of Vistaril (antianxiety medication) at bedtime, one and a half 5 mg tablets (7.5 mg) of Haldol (treats psychotic disorders) twice daily, a 4 percent Lidocaine patch (topical pain relief) to the lower back every 12 hours for pain, a 40 mg tablet of Protonix (treats stomach problems) twice daily, a 300 mg tablet of Seroquel (treats mental/mood disorders) two times daily, three 250 mg tablets of Depakote (an anticonvulsant that is also used to treat the manic symptoms of bipolar disorder) every eight hours, one 400 mg capsule of Neurontin (an anticonvulsant that is also used to treat nerve pain) every eight hours, and sliding scale aspart insulin subcutaneously before meals and at bedtime.

Resident 5's MAR for October 2019 revealed that she was scheduled to receive these medications at 9:00 p.m. daily but did not receive them on October 14, 2019, and these medications were all marked as "refused."

An interview with Resident 5 on November 25, 2019, at 2:45 p.m. revealed that on October 14, 2019, a nurse refused to give her the bedtime medications, and she did not receive the medications until later, after she called the police to explain. The resident was not aware of why the nurse refused to give her the medications, and she denied refusing to take them.

Interviews with Licensed Practical Nurse 1 on December 3, 2019, at 10:25 a.m. and December 5, 2019, at 12:39 p.m. revealed that she was the nurse covering Resident 5's hall during the evening shift (3:00 p.m. to 11:00 p.m.) on October 14, 2019. Because Resident 5 had a history of physical aggression toward her, and refused to have care provided by her, she was not to be assigned to administer medications to the resident, and the registered nurse supervisor was to administer the medications. On the evening of October 14, 2019, neither she nor the supervisor (Registered Nurse 2) administered bedtime medications to Resident 5. She and the supervisor had a conversation in which it was decided that they "did not want to wake a sleeping bear" so the resident's medications were not administered by the end of her shift. She marked the medications as "refused" in order to close out her medication records; however, the resident did not actually refuse to take the medications.

Interviews with Registered Nurse Supervisor 2 on November 27, 2019, at 11:08 a.m. and December 5, 2019, at 3:30 p.m. confirmed that she was in charge during the evening shift on October 14, 2019. She stated that she was not aware that Resident 5 did not receive her 9:00 p.m. medications that evening, did not know if the resident called the police, and was not aware of any problems with the resident's behavior that night. She stated that does not automatically give Resident 5 her medications unless asked to do so, and she did not recall being asked to administer the resident's medications that evening and did not know why they were not given.

Interview with Registered Nurse 3 on November 27, 2019, at 9:37 a.m. revealed that she worked the night shift (11:00 p.m. to 7:00 a.m.) on October 14, 2019. At the beginning of the shift, Resident 5 told her that she did not receive her 9:00 p.m. medications. She found the medications in the top drawer of the medication cart and administered them to the resident at 12:34 a.m. on October 15, 2019. She thought this was the night that the resident called the police, but she thought the resident called the police to tell them that she did not get her shower. Staff from the previous evening shift did not report to her that Resident 5 did not receive her 9:00 p.m. medications.

Interview with the Director of Nursing on November 26, 2019, at 3:15 p.m. confirmed that Resident 5 did not receive her medications at 9:00 p.m. on October 14, 2019, and she was not aware if the resident called the police that evening.


Manufacturer's instructions for Novolog (insulin aspart - a fast-acting insulin), dated November 2019, revealed that it was to be administered 5 to 10 minutes before meals.

The facility's current meal schedule for the A wing (Rooms 44-56) indicated that breakfast was to be served at 7:20 a.m., lunch at 12:00 p.m., and supper at 5:00 p.m.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated August 29, 2019, revealed that the resident had diagnoses that included diabetes and received insulin. Physician's orders, dated October 16, 2019, included an order for the resident to receive 10 units of Novolog insulin subcutaneously before meals.

Resident 6's MAR's for October and November 2019 revealed that the breakfast dose of Novolog insulin (scheduled for 7:40 a.m.) was not given 5 to 10 minutes before the meal on October 24 at 9:20 a.m., October 26 at 8:17 a.m., October 27 at 9:23 a.m., October 29 at 8:17 a.m., October 30 at 10:23 a.m., November 5 at 8:36 a.m., November 7 at 8:47 a.m., November 8 at 10:36 a.m., November 18 at 8:05 a.m., November 21 at 8:36 a.m., and November 24 at 8:42 a.m.

Resident 6's MAR's for November 2019 revealed that the lunch dose of Novolog insulin (scheduled for 12:35 p.m.) was not given 5 to 10 minutes before the meal on November 2 at 1:38 p.m., November 8 at 1:42 p.m., and November 18 at 1:37 p.m.

Interview with the Director of Nursing on November 26, 2019, at 1:31 p.m. confirmed that staff did not administer Resident 6's Novolog insulin prior to the meals and in accordance with physician's orders and manufacturer's instructions on the above dates/times.


A diagnosis record for Resident 3, dated October 14, 2019, revealed that the resident had diagnoses that included diabetes. Physician's orders, dated October 15, 2019, included orders for the resident to receive Humalog insulin (fast-acting) coverage based on a sliding scale. The sliding scale for Humalog insulin coverage was to start with a blood sugar level of 131 mg/dL, and was to be given subcutaneously before meals and at bedtime. There was also an order for the resident to receive 5 units of Humalog insulin subcutaneously before meals

The facility's meal schedule for Resident 3's nursing unit indicated that meals were served at 7:10 a.m., 12:10 p.m. and 5:10 p.m.

Resident 3's MAR for October 2019 revealed that breakfast doses of Humalog insulin (scheduled for 7:50 a.m.) were not administered before the meal on October 5 at 7:44 a.m., October 16 at 9:00 a.m., October 17 at 8:09 a.m. and October 18 at 8:07 a.m.

Resident 3's MAR's for October 2019 revealed that lunch doses of Humalog insulin (scheduled for 12:45 p.m.) were not administered before the meal on October 15 at 12:40 p.m. and October 16 at 12:56 p.m.

Resident 3's MAR's for October 2019 revealed that supper doses of Humalog insulin (scheduled for 6:00 p.m.) were not administered before the meal on October 15 at 6:01 p.m., October 16 at 5:42 p.m. and October 17 at 6:16 p.m.

Interview with the Director of Nursing on November 26, 2019, at 10:42 p.m. confirmed that staff should administer Humalog insulin to Resident 3 before meals, as ordered by the physician.

A nursing note for Resident 3, dated October 15, 2019, revealed that the resident arrived at the facility on October 14, 2019, at 5:21 p.m. Physician orders, dated October 14, 2019, at 8:00 p.m. included an order for the resident to receive 18 units of Basaglar kwickpen insulin (long-acting insulin) at bedtime, to be started on October 14, 2019.

There was no documented evidence that staff administered Basaglar kwickpen insulin to Resident 3 at bedtime on October 14, 2019, as ordered by the physician.

Interview with the Director of Nursing on November 26, 2019, at 10:42 a.m. confirmed that Resident 3 did not receive Basaglar insulin at bedtime on October 14, 2019.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 10/8/19.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 10/8/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/8/19.





 Plan of Correction - To be completed: 01/08/2020

There were no negative outcomes with the concerns identified for any of the residents. Resident 5 doctor was notified that the Novolog insulin was not administered 5-10 minutes before meals as ordered on multiple occasions and that the residents bedtime medswere not given on October 14 as ordered, no new orders were received. The doctor for resident 6 was notified that the Novolg insulin was not administered 5-10 minutes before meals as ordered on multiple occasions, no new orders received. Resident 3 was discharged from the facility. House surveillance to ensure medications are administered as ordered. The Director of Nursing or Designee will re-educate licensed nursing staff including agency and new hires on administering medications on the facility policy and procedure for administering medications per doctors orders. The education provided to licensed nursing staff will include the consequences of failing to follow physician's orders, such as disciplinary action, termination, and/or a referral to the state board of nursing. The director of nursing or designee will complete 3 medication pass competencies weekly for four weeks and then monthly for three months to validate medications are being administered per doctors orders. The results will be taken to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:


Based on clinical record reviews and staff interview, it was determined that the facility failed to accommodate residents' preferences regarding showers for one of 13 residents reviewed (Resident 4).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated November 6, 2019, revealed that the resident was alert and dependent on staff for bathing. The resident's care plan, dated May 3, 2019, revealed that he required assistance with care tasks and preferred to have a shower.

Resident 4's shower records for September 2019 revealed that he received a bed bath instead of a scheduled shower on October 6, 13, 16 and 30 and November 6, 2019. A nursing note dated November 10, 2019, indicated that the resident "demanded to have a shower."

On the above dates, there was no documented evidence regarding why a bed bath was given instead of a shower, and no documented evidence that the resident refused a shower.

Interview with Nurse Aide 4 on November 26, 2019, at 12:20 p.m. revealed that she documented the bed baths on October 6, 13, 16 and 30, and November 6, 2019, as "late entries" on November 26, 2019, and she did not recall if the resident refused any showers.

Interview with the Director of Nursing on November 26, 2019, at 12:30 p.m. revealed that she was unaware that the above documented bed baths were "late entries" completed on November 26, 2019, and that there were no documented reasons regarding why showers were not provided as scheduled for Resident 4.

28 Pa. Code 201.29(j) Resident rights.
Previously cited 10/8/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/8/19.





 Plan of Correction - To be completed: 01/08/2020

The facility will ensure that residents' preferences regarding showers are accommodate including resident 4. Facility staff interviews resident to obtain shower preference. Once obtained they are added to the shower schedule and it is part of the Certified Nursing Assistant assignment sheet that is disctributed daily. Showers completed and/or refused are documented using Point of Care electronic health record system.
The Director of Nursing or Designee will re-educate nursing staff including new hires and agency staff on the facility policy and procedure for accommodating residents' preferences regarding showers.
The Director of Nursing or Designee will perform an audit 2 times a week for 2 weeks , and weekly for 2 weeks , then monthly for 3 months to ensure residents' preferences for showers are being accommodated. The results of these audits will be reported to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of facility policies, clinical records, and investigation reports, as well as staff interviews, it was determined that the facility failed to ensure that one of 13 residents reviewed (Resident 1) was free from non-consensual sexual contact by Resident 7.

Findings include:

The facility's policy regarding abuse, dated October 4, 2019, revealed that each resident had the right to be free from abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. Residents were not to be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated September 23, 2019, revealed that the resident had severe cognitive impairment, that he sometimes understood others and was sometimes understood by others, had no behaviors, was able to ambulate (walk) on the unit with limited assistance, was able to propel in his wheelchair with extensive assistance, and had diagnoses that included dementia (a decline in mental ability severe enough to interfere with daily life). The resident's care plan, dated February 18, 2019, included issues with grabbing at females, holding hands, trying to pull female staff into bed with him, making inappropriate remarks, and sexual behaviors toward female residents, and included interventions of administering medications as ordered, avoiding types of conversation that could encourage or initiate inappropriate behaviors, distracting him if possible, determining the root cause and documenting it, determining what triggered the behaviors, and fifteen-minute checks as indicated.

Nursing notes for Resident 7, dated October 11, 2018, at 5:42 p.m. revealed that the resident was found grabbing the breast of another resident. The residents were separated and his behaviors were to be monitored. There was no documented evidence that following the incident involving another resident on October 11, 2018, that Resident 7's care plan was updated/revised to include interventions to prevent him from having non-consensual sexual contact with female residents.

Nursing notes for Resident 7, dated February 17, 2019, at 2:50 p.m. revealed that the resident was being sexually inappropriate with staff, grabbing at them and trying to pull them into bed. Resident 7 was sitting by a female resident, the female resident's family member started to push her towards her room, and Resident 7 became irate and started swinging at the other resident's family member. A nursing note, dated March 7, 2019, at 2:24 p.m. revealed that Resident 7 was grabbing staff in the crotch and breasts. The resident was re-directed several times, started to swing at staff during care, and medication was administered after failed attempts to redirect the resident.

A quarterly MDS assessment for Resident 1, dated November 5, 2019, revealed that the resident was severely cognitively impaired; was rarely understood; could rarely understand; had short and long-term memory loss; required extensive assistance from staff for transfers, dressing and locomotion with a wheelchair; and had diagnoses that included dementia.

Information reported by the facility on November 16, 2019, revealed that at approximately 4:30 p.m. Resident 13 was yelling from the dining room for staff to go there. Resident 13 told staff that Resident 7 had his hands up Resident 1's shirt and that is why she yelled for help.

A written statement from Resident 13, dated November 16, 2019, revealed that she was going into the dining room when she saw Resident 7 with both of his hands up Resident 1's shirt, touching and groping her breasts.

Following this incident, there was still no documented evidence that interventions were developed and initiated to prevent Resident 7 from having non-consensual sexual contact with other residents.

Interview with the Director of Nursing on November 26, 2019, at 10:33 a.m. revealed that she was not aware of the incident involving Resident 7 on October 11, 2018, and she confirmed that there was nothing in place to prevent Resident 7 from having non-consensual sexual contact with other residents.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 10/8/19.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 10/8/19.

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

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 10/8/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/8/19.








 Plan of Correction - To be completed: 01/08/2020

There were no negative outcomes with the concerns identified.
Resident 7 had new care plan inventions and medications were evaluated and changes made by Physician as appropriate.
The Director of Nursing or Designee will re-educate nursing staff including agency and new hires on the facility policy and procedure for abuse, staff eduction will include identifying and reporting any observed or reported allegations of non-consensual sexual contact between residents.
The Director of Nursing or Designee will perform an audit weekly for 4 weeks and then monthly for 3 months. The results of these audits will be reported to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
483.40(b)(1) REQUIREMENT Treatment/Srvcs Mental/Psychoscial Concerns: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(b) Based on the comprehensive assessment of a resident, the facility must ensure that-
483.40(b)(1)
A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services to correct the problem for one of 13 residents reviewed (Resident 6).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated August 29, 2019, revealed that the resident was alert and oriented, could be understood and could understand others, had verbal behaviors, rejected care, and had diagnoses that included anxiety (a feeling of worry, nervousness, or unease). The resident's care plan, dated October 14, 2019, included that staff were to give the resident her anti-anxiety medication as ordered by the physician.

Physician's orders for Resident 6, dated October 10, 2019, included an order for the resident to receive 0.25 milligrams (mg) of alprazolam (an anti-anxiety medication) every 24 hours as needed for anxiety. A nursing note for Resident 6, dated October 10, 2019, at 4:50 p.m. revealed that a new prescription for 0.25 mg of alprazolam was received and faxed to the pharmacy. A pharmacy delivery sheet, dated October 11, 2019, at 2:17 a.m. revealed that the pharmacy delivered seven 0.25 mg tablets of alprazolam for Resident 6.

A nursing note, dated October 11, 2019, at 11:59 a.m. revealed that Resident 6 was displaying hostile behavior and asking for a nerve pill (thought to be gabapentin - used to treat seizures and nerve pain). The resident approached staff aggressively, was yelling, and wheeled herself back to her room. At 12:45 p.m. Resident 6 asked for a nerve pill, the nurse gave the prescribed gabapentin, and the resident yelled and stated that the nurse was an idiot and she wanted a nerve pill. The resident was told that there was no order for a nerve pill, but there was one for Ambien (medication used to help sleep). The resident yelled, "Everyone is a liar and everyone lies." At 3:40 p.m. the resident continued to request a nerve pill; however, the nursing note incorrectly indicated that there was no active order in the computer system for an anti-anxiety medication. A licensed practical nurse reported that the pharmacy delivered Xanax (alprazolam) and it was in the narcotic drawer, but upon investigation there was no order in the resident's chart. The pharmacy was called and indicated that a prescription for alprazolam was received the previous day in the afternoon.

There was no documented evidence that alprazolam was administered to Resident 1 until October 15, 2019.

An interview with the Director of Nursing on December 4, 2019, at 11:37 a.m. confirmed that Resident 1 should have received 0.25 mg of alprazolam on October 11, 2019, at 11:59 a.m. when she requested it. She indicated that there was no reason why she should not have received it.

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

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 10/8/19.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/8/19.





 Plan of Correction - To be completed: 01/08/2020

There were no negative outcomes with the concern identified. The doctor for resident 6 was notified that the resident did not receive her Alprazolam on October 11, 2019 per order. No new orders received. House surveillance to ensure residents who display or diagnosed with mental disorder or psychological adjustment disorder, or history of trauma/ post traumatic disorder are receiving appropriate treatment and services. The Director of nursing or Designee will re-educate the licensed nursing staff including agency and new hires on the facility policy and procedure for providing the appropriate treatment and services for residents who display or are diagnosed with mental disorder. The Director of Nursing or Designee will perform audits 2 times a week for 2 weeks then weekly for 2 weeks and the monthly for 3 months. The results of these audits will be reported to the monthly Quality Assurance and performance Improvement Committee for review and frequency of audits.
483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:


Based on clinical record reviews and staff interviews, it was determinied that the facility failed to ensure that pain medications were obtained timely for one of 13 residents reviewed (Resident 12).

Findings include:

A diagnosis record for Resident 12, dated November 15, 2019, revealed that the resident had diagnoses that included osteomyelitis of the vertebra (infection in the spine), post laminectomy (surgery that removes part of the vertebral bone) with intraspinal abscess (swollen area in your tissues that contains a build-up of pus). Physician's orders, dated November 15, 2019, at 9:48 p.m. included an order for the resident to receive two 15 milligram (mg) tablets of extended release Oxycodone (a narcotic pain medication) every 12 hours for pain control.

A nursing note for Resident 12, dated November 16, 2019, indicated that the pharmacy was notified to have the medication "stat out" (sent immediately) and the facility was informed that it would be sent out in the morning after the pharmacy opened. A phone call to pharmacy in the a.m. indicated that the medication would be "stat out" that a.m.

However, Resident 12's Medication Administration Record (MAR) for November 2019 revealed that the first dose of extended release Oxycodone was not administered until November 17, 2019, at 9:00 p.m. (two days after it was ordered), and there was no documented evidence of any further attempts by nursing staff to obtain the medication between the a.m. of November 16 and the p.m. of November 17, 2019.

Interview with the Director of Nursing on November 26, 2019, at 1:16 p.m. confirmed that there was a delay in obtaining Resident 12's pain medication.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 10/8/19.




 Plan of Correction - To be completed: 01/08/2020

There were no negative outcomes from the concern identified. The doctor of resident 12 was notified that the resident did not receive Oxycodone Er that was ordered on November 15 until 9 PM November 17, no new orders were received. No other residents were identied as affected. The facility will ensure that pain medications are obtained from the pharmacy timely. There was not an emergency system that the particular medication could have been obtained from and administered until it arrived from the pharmacy. The Director of Nursing or Designee will re-educate the licensed nursing staff including agency and new hires on the facility policy and procedure for obtaining pain medication from the pharmacy timely. An Audit will be completed by the Director of Nursing or Designee 2 times weekly for 2 weeks then weekly for 2 weeks and then monthly for 3 months.
The results of these audits will be reported at the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medication for two of 13 residents reviewed (Residents 3, 12).

Findings include:

The facility's policy regarding controlled medication (drugs with the potential to be abused), dated October 4, 2019, indicated that controlled medications were to be handled and stored properly, and that there was to be an inventory of the controlled substances. The licensed nurse was to document on the record when a medication was administered.

Physician's orders for Resident 3, dated October 14, 2019, included an order for the resident to receive one 5 milligram (mg) tablet of Oxycodone (a controlled narcotic pain medication) every four hours for mild pain, and two 5 mg tablets every four hours as needed for moderate pain.

Resident 3's controlled medication record (a form for staff to account for each dose of a controlled medication) indicated that on November 17, 2019, at 1:00 a.m., staff signed out two 5 mg tablets of Oxycodone to administer to the resident. However, the resident's Medication Administration Record indicated that only one 5 mg tablet was administered at that time.


Physician's orders for Resident 12, dated November 15, 2019, included an order for the resident to receive 15 mg of Oxycodone every four hours as needed for pain.

Resident 12's controlled medication record for for November 2019 indicated that staff signed out 15 mg doses of Oxycodone to administer to the resident on November 17 at 3:40 p.m., November 19 at 7:30 p.m., and November 20 at 6:00 a.m. However, there was no documented evidence, including on the MAR and in the nursing notes, that the doses of Oxycodone were administered to the resident at those times.

Interview with the Director of Nursing on November 26, 2019, at 1:16 p.m. confirmed that staff were to document the administration of controlled medications on the residents' MAR's, and the administration of Oxycodone to Residents 3 and 12 on the above dates/times was not documented.

42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.
Previously cited 10/8/19.

28 Pa. Code 211.9(a)(1) Pharmacy services.
Previously cited 10/8/19.

28 Pa. Code 211.12(d)(1)Nursing services.
Previously cited 10/8/19.




 Plan of Correction - To be completed: 01/08/2020

The facility will ensure the f the accountability of controlled medications. Other controlled medication records were reviewed with the medication administration records and no other areas of concern were identified. The Director of Nursing or Designee will re-educate licensed nursing staff including agency and new hires on the facility policy and procedure for maintaining accountability for controlled medications. The Director of Nursing or Designee will complete an audit 2 times a week for 2 weeks then weekly for 2 weeks and then monthly for 3 months. The education provided to the licensed staff, including new and agency staff including the consequences of failure to account for controlled medications including disciplinary action, termination, and/or a referral to the state board of nursing. The results of these audits will be taken to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits,
211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:


Based on review of nursing schedules, and staffing and payroll information provided by the facility, it was determined that the facility failed to provide 2.7 hours of direct resident care for each resident during two of 21 days (24-hour periods) reviewed.

Findings include:

Nursing time schedules and staffing information provided by the facility, dated October 13 through 19, 2019; October 27 through 2, 2019; and November 10 through 16, 2019, revealed that the facility provided only 2.59 hours of direct resident care on November 1, 2019, and 2.35 hours of direct resident care on November 2, 2019.




 Plan of Correction - To be completed: 01/08/2020

The facility will maintain the minimum 2.7 hours direct nursing care for each resident. The facility will monitor nursing hours five times a week (including weekends and holidays). This audit will include all licensed nurses and nurse aides, to validate we are maintaining the minimum required 2.7 hours for each resident, and adjusting with call offs and changes in census. Daily hours are reviewed by the Nursing Home Administrator and Director of Nursing and reviewed prior to next day schedule posting. The Nursing Home Administrator or Designee will re-educate Department Managers, Scheduler and Registered Nurse Supervisor on calculating and maintaining required 2.7 Nursing hours and notifying Nursing Home Administrator and or Director of Nursing if hours are not being maintained due to call offs or change in census. The Nursing Home Administrator or Designee will complete an audit 5 times a week for 4 weeks then weekly for 4 weeks, then monthly for 3 months to validate required nursing hours are met. The results of these audits will be reported to the monthly Quality Performance Improvement Committee for review, recommendations and frequency of audits.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port