Nursing Investigation Results -

Pennsylvania Department of Health
WESLEY ENHANCED LIVING PENNYPACK PARK
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WESLEY ENHANCED LIVING PENNYPACK PARK
Inspection Results For:

There are  69 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.
WESLEY ENHANCED LIVING PENNYPACK PARK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey and State Licensure Survey, completed on February 24, 2020, it was determined that Wesley Enhanced Living Pennypack Park, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations, related to the health portion of the survey process.




































 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
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 clinical record, facility documentation, and staff interview, it was determined the facility failed to timely identify and increase interventions to prevent the development of a pressure ulcer for Resident R68 who was identified as a low risk for skin breakdown and with an increase in incontinence, resulting in actual harm to Resident R68 developing a sacral Stage III pressure ulcer for one of 47 clinical records reviewed. (Resident R68)

Findings include:

Review of Resident R68's February 2020 physician's order indicated the following diagnoses, Parkinson disease, (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), pathological fracture, (a bone fracture caused by weakness of the bone structure that leads to decrease mechanical resistance to normal mechanical loads), history of falling, difficulty walking and muscle weakness.

Review of facility documentation, titled, "Braden Scale for Predicting Pressure Sore Risk", dated April 29, 2019, indicated, Resident R68, was identified as a low risk for developing a pressure ulcer.

Review of Resident R68's "Bowel and Bladder Assessment", dated April 29, 2019, revealed that the resident was frequently incontinent of bowel and bladder and required the use of an incontent brief. Continued review of this assessment indicated, that Resident R68, required "Extensive assist, requires frequent supervision/assistance." Section 4 of the Bowel and Bladder Assessment form, related to appropriate program based on the resident's functional abilities related to incontinence care, noted that Resident R68 should be kept clean and dry, use incontinence product and barrier cream as needed. It was also indicated that Resident R68 walked occasionally during the day, but for very short distances, with or without assistance. The resident spent the majority of each shift in bed or chair.

Review of an Annual MDS, (Minimum Data Set - periodic assessment of needs), dated April 29, 2019, indicated under section G, Functional Status, that Resident R68 requires extensive assistance with one person for physical assistance for activities of daily living, such as dressing, bed mobility, transfering, walking, toilet use and personal hygiene.

Review of Resident R68's care plan related to frequently incontinent, revised, Janaury 1, 2020, indicated, on June 1, 2015, the following measure was added "To offer routine toileting, (every two hours), and provide incontinence care as needed."

Continued review of Resident R68's care plan revealed an intervention to "Observe skin areas when ADL care given. Report any redness or skin breakdown to nurse. Follow up with treatment protocol as needed."

An interview with Employee E3, Licensed Nurse on February 21, 2020, at 11:20 a.m. confirmed Resident R68 was care planed to prevent skin breakdown, related to incontinent of bladder and bowel and impaired physical mobility.

Review of facility documenation, related to Resident R68's bladder/bowel episodes, since last skin assessment completed on June 18, 2019, indicated that Resident R68 was not provided routine toileting, every two hours, from the last skin assessment, as indicated as a preventive approach in the resident's care plan. Further review of the bladder/bowel documenation indicated that Resident R68 experienced between six to seven episodes of urinary incontinence a day.

Review of facility documenation, titled, "Weekly Skin Review," from May 14, 2019 through June 18, 2019 indicated that Resident R68's skin was examined and found to be intact.

Review of nursing progress note dated June 21, 2019, at 10:00 a.m. indicated that the resident was "seen on wound rounds today for sacrum, 1.3 centimeters (cm), x 1.5 centimeters, x 0.1, centimeters, with 50% granulation, (new connective tissue and small microscopic blood vessels that form on the surfaces of a wound during the healing process. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size), and 50% slough, (non - viable yellow, tan, gray, green or brown tissues, usually moist, can be soft, string, and mucinous in texture), with serious/erythema to periwound, new treatment- santyl and CDD (cover with dry dressing) daily."

An interview with Employee E3, Licensed Nurse, on February 24, 2020, at 10:30 a.m. confirmed that Resident R68 was identified to have a facility acquired stage III pressure ulcer to sacrum.

An interview with Director of Nursing and Employee E3, Licensed Nurse, on February 24, 2020, at 12:00 p.m., revealed at the time Resident R68 was found to have the stage III pressure ulcer to sacrum (ulcer involving full thickness of skin loss, exposing tissue), the resident was noted to have an increase in incontinent episodes and health concerns related to a family members personal health concerns.
Further during an interview with Director of Nursing and Employee E3, it was indicated that Resident R68's Stage III pressure ulcer required debridement (the removal of damaged tissue from a wound) by the wound consultant.

Continued review of Resident R68's clinical record revealed a wound consultant report, dated June 21, 2019, which confirmed "sacral wound of less than 3 days."
The report further indicated "wound #1 sacral is an acute Stage 3 pressure injury pressure ulcer.. initial wound encounter measurements are 1.3 cm ( length x 1.5 c.m. width x 0.1 depth, with an area of 1.95 sq (square) cm and a volume of 0.195 cubic cm. no tunneling has been noted... There is a scant amount of serous drainage (watery, clear fluid) noted which has no odor. The patient reports a wound pain of level 1/10. wound bed has with 50% slough and 50% granulation."

Review of the most recent wound consultant report dated February 14, 2020, noted that the resident's stage III sacral pressure ulcer measuring "0.2cm x 0.2 with no measurable depth with an area of 0.4sq cm. no tunneling has been noted... There was no drainage noted. The patient reports a wound pain of level 0/10. The wound is improving."

The facility failed to timely identify and increase interventions to prevent the development of a pressure ulcer for Resident R68 who was identified as a low risk for skin breakdown and with an increase in incontinence, resulting in actual harm to Resident R68 developing a sacral Stage III pressure ulcer.


Treatment/Services to Prevent/Heal Pressure Ulcer
CFR 483.25(b)(1)(i)(ii)

28 Pa Code 201.14(a) Management

28 Pa Code 201.18(b)(1) Management

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

28 Pa Code 211.11(d) Resident care plan

28 Pa Code 211.10(c) Resident care policies

29 Pa Code 211.10(d) Resident care policies

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

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










 Plan of Correction - To be completed: 03/31/2020

The facility does and shall ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers, unless the individual resident's clinical condition demonstrates that they were unavoidable. Further, the facility does and shall ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and new ulcers from developing.

R68's wound continues to heal. Residents with a low risk for skin breakdown care plans will be reviewed to ensure appropriate pressure relieving measures are in place; updates to equipment and care plans will be completed as deemed appropriate. Non-professional staff will be educated on the accuracy of documentation related to all ADLs, including incontinence care. All nursing staff will be educated on the prevention of and early detection of pressure ulcers.

Monitoring of documentation on a random basis will be conducted; and, monitoring of residents pressure relieving interventions will be conducted on a random basis with findings report to the CQI Committee for a period of time deemed appropriate by the CQI Committee.

Monitor: RNACs, Unit Managers, DON

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on resident and staff interview, observation, and review of facility documenation, it was determined that the facility failed to accommodate the need of a resident related to replacing a mattress for one of 5 residents interviewed (Resident R59).

Findings include:

During a group meeting with five alert and oriented residents, (Residents R18, R20, R38, R59 and R85), on February 20, 2020, at 11:30 a.m. it was indicated by Resident R59, that her bed mattress was not comfortable and was having a difficult time sleeping at night.

Review of the Resident Council Meeting minutes dated January 8, 2020, revealed that once again Resident R59 stated "having a hard time sleeping with her bed." "She was wondering if maintenance could have a look at it and maybe change the bed for her."

Review of Resident Council minutes from February 12, 2020, indicated in both set of minutes that Resident R59 related to staff present at the meeting "Having a hard time sleeping with her mattress." "She was wondering if maintenance could look at it and maybe change the mattress for her."

An observation of Resident R59's mattress on February 20, 2020, at 2:00 p.m. in the presence of the Nursing Home Adminstrator, Employee E8, Maintenace Director, and Resident R59, it was observed that Resident R59, had a thick blue knitted blanket, folded in half, placed on top of the bottom sheet and Resident R59 indicated that the blanket was placed on the mattress where it was not comfortable to her. At the time of the observation the mattress was found to be sunken in at the place where the blanket was placed.

An interview with Employee E9, Central Supply Coordinator, on February 21, 2020, at 10:15 a.m. could not indicate a date of the last time Resident R59's mattress was changed.

An interview with Employee E7, Activities Coordinator, on February 24, 2020, indicated that she forwarded Resident R59's concerns about mattress that were brought up during the February 12, 2020's resident council meeting to Employee E8, Maintenace Director on February 18, 2020, via an email to be looked into. Employee E7, also indicated, that Resident R59's mattress concerns from Resident Council meeting on, January 8, 2020, were forwarded on January 22, 2020, to Employee E8.

An interview with Employee E8, Maintenace Director on February 24, 2020, at 11:50 a.m. confirmed that Resident R59's mattress was not changed, until February 20, 2020, upon observation of the mattress, with Nursing Home Adminstrator, surveyor and Resident R59.

The facility failed to accommodate the needs of and preferences of Resident R59 related to replacing a mattress.

28 Pa. Code 201.29(j) Resident rights

28 Pa. Code 207.2(a) Administrator's responsibility










 Plan of Correction - To be completed: 03/31/2020

The facility does and shall reasonably accommodate resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Resident R59's mattress was changed on 02.20.2020. All resident mattresses will be assessed and will be replaced as deemed necessary. The facility will review, and change if deemed appropriate, its process for communication of resident council concerns and those concerns will be tracked for completion/closure and reported to the CQI Committee for monitoring for a period of time deemed appropriate by the CQI Committee.

Monitor: Social Service Manager, Activities Director, Unit Managers, DON

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 observation and staff interview, it was determined that the facility failed to maintain dining room table menus in a sanitary condition for three of three dining rooms (Second floor)

Findings include:

During the initial observation of the lunch meal, on February 19, 2020, at 11:45 a.m. in each of the three of three dining rooms for the second floor nursing unit, it was observed that each of the resident dining tables had a 8.5 inches by 11 inches menu book, that were black in color and opened like a book. Closer observation of each of the menus, revealed that the front and back covers, were heavily soiled with dried on food debris.

Further observations of the lunch meals, on the remaining days of the survey, February 20, 21 and 24, 2020, at various times, revealed that the heavily soiled black colored menu books on each resident table remained heavily soiled with dried on food debris.

An interview with Employee E12, Dietary Aide, on Feburary 24, 2020, at 12:10 p.m., indicated the black menu books, contain the menus for the day and the always available menu, for residents to review meal options.

At the time of the interview with Employee 12, an observation was made of all the menu books on the resident dining tables, in the three of three dining rooms for the second floor. It was confirmed by Employee E12, that all the menu books that were on the dining tables were heavily coated with dried on food debris.

28 Pa. Code 207.2(a) Administrator's responsibility



 Plan of Correction - To be completed: 03/31/2020

The facility does and shall provide a community that is safe clean, comfortable and homelike, including receiving treatment and supports for daily living safely.

All dining room table menus have been cleaned and have been incorporated in the daily process for cleaning to ensure sanitary conditions. Findings and on-going monitoring of table menus will be reported to the CQI Committee for a period of time deemed appropriate by the CQI Committee.

Monitor: HC Dining Room Manager, General Manager Dining, Unit Managers, DON

Completion: March 31, 2020

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

Based on clinical record review and staff interviews, it was determined that the facility failed to develop a comprehensive care plan for one of 47 residents reviewed regarding constipation. (Resident R84)

Findings include:

A review of Resident R84's clinical record revealed that the resident was admitted to the facility on April 2, 2019, with a diagnosis including but not limited to a gastrointestinal hemorrhage (GI bleed).

A review Resident R84 November 2019 Medication Administration Record (MAR) , revealed a physician's order dated August 29, 2019, for Oxycodone HCl, 10 milligrams, (a narcotic used to treat moderate to severe pain-it can cause constipation, nausea and vomiting) one tablet by mouth every 12 hours as needed for pain.

Further review of November 2019's MAR revealed that the resident received Oxycodone 10 milligrams, 16 days out of 30 days in November 2019. A review of December 2019 MAR revealed that the resident received Oxycodone 10 milligrams, 13 times in the month of December 2019. A review of the January 2020 MAR, revealed that the resident received Oxycodone 10 milligrams, five times in the beginning of January 2020.

The resident was sent to the hospital from the facility on January 26, 2020, for chest pain and coughing. The resident returned to the facility on January 30, 2020.

A review of the physician's progress note dated February 4, 2020, revealed that the resident was recently treated for pneumonia with increasing cough and epigastric abdominal pain. "ct (cat scan)abdomen reported dilated colonic loops, in keeping with ileus pattern. Findings in keeping with constipation and fecal impaction.... GI (Gastrointestinal) was consulted for fecal impaction on ct, was placed on bowel regimen with good results. Advanced to cardiac diet. General surgery was consulted for abdominal distension and fecal impaction likely related to constipation. They recommended no surgical intervention."

A review of the residents' care plan revealed no evidence that a care plan had been developed to address the risk of developing constipation while on a narcotic medication.

It was confirmed in an interview with licensed nursing staff, Employee E3, on February 24, 2020, at 9:15 a.m. that the resident did not have a comprehensive person centered care plan for receiving a narcotic which can cause constipation.

The facility failed to develop a comprehensive care plan for a resident on a narcotic that can cause constipation.

28 Pa. Code 211.11(c) Resident care plan

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









 Plan of Correction - To be completed: 03/31/2020

The facility does and shall develop comprehensive care plans for each resident.

R84, and all residents receiving a narcotic, which can cause constipation, will have their care plans reviewed to ensure they are comprehensive and include the standing bowel regimen and any other interventions deemed necessary by the physician. All new narcotic orders will be reviewed, physician consulted for additional orders outside of the standing bowel regimen and care plans reviewed for accuracy. Monitoring/random review of care plans will be conducted with findings reported to the CQI Committee for a period of time deemed appropriate by the CQI Committee.

Monitor: RNACs, Unit Managers, DON

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

Based on clinical record review, review of facility documentation and staff interviews, it was determined that the facility failed to update and revise a care plan for one of 15 resident reviewed for falls. (Resident R44)

Findings include:

A review of Resident R44's clinical record reveal that the resident was admitted to the facility on October 24, 2017, with a diagnosis including but not limited to stroke (damage to the brain from an interruption of its blood supply), muscle weakness and abnormalities of gait and mobility.

A review of facility documentation dated December 30, 2019, revealed that the resident was found on the floor in the television room at 11:00 a.m. The resident was last seen sitting in a chair in the television room. The resident stated he was trying to get up. The resident did not sustain any injuries as a result of the fall. The facility indicated that to prevent another fall the resident was to be place at table for group activities.

A review of facility documentation dated January 25, 2020, at 5:20 p.m. revealed that the resident was brought to the dinning room for dinner and placed at his table, while waiting for dinner he slipped out of the wheelchair and and landed on his left side. The resident was noted with a 3 centimeter by 1 centimeter skin tear to his left elbow and a 2 centimeter by 1.5 centimeter skin tear to his mid back. The resident stated that he was fixing himself in the wheelchair. The facility indicated that to prevent another fall the resident was to participate in a toileting schedule.

A review of facility documentation dated February 7, 2020 at 9:45 a.m. the resident was found on the floor in his room. The resident's bed was noted in the high position and the call bell was not on. The resident stated that he was trying to get into bed. There were no injuries sustained by the resident. The facility indicated that in an effort to prevent another fall the resident was to be brought to a common area for direct supervision.

Review of Resident R44's fall care plan revealed that the resident's care plan was last revised revised August 26, 2019. The resident's fall care plan was not updated with the interventions as indicated to placed the resident at a table for group activities, the development of a toileting schedule and to bring the resident to a common area for direct supervision.


The facility failed to update and revise Resident R44's care plan for falls.

28 Pa. Code 211.11 (d) Resident care plans.

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








 Plan of Correction - To be completed: 03/31/2020

The facility does and shall update and revise care plans.

R44 and all residents with falls in the last 90 days care plans will be reviewed and updated as deemed appropriate. RNACs will be re-educated on all documents to review, post fall, to ensure all interventions are identified in the care plan. Facility will assess process for updating/revising care plans and make changes to the process as deemed appropriate. Monitoring of random charts for care plan revisions will be conducted. Monitoring/random review of care plans will be conducted with findings reported to the CQI Committee for a period of time deemed appropriate by the CQI Committee.

Monitor: RNACs, Unit Managers, DON

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to obtain/or follow a physician's orders related to the use of a dietary supplement for one of 47 residents reviewed (Resident R85).

Findings include:

Review of R85's clinical record revealed a Nutrition note dated February 7, 2020, revealed that Resident R85 had a significant weight loss in the last six months. The resident had a history of weight loss/gain cycles since admission. The resident's food intakes, varied at times, from 25 - 50%. The resident agreed to receiving a Magic Cup (fortified nutritional snack - with added calories) twice a day.

Review of Resident R85's physician orders dated February 7, 2020, revealed a physician order for the resident to receive a Magic cup, (fortified nutritional supplement - with added calories), two times a day for weight loss.

Review of Resident R85's February 2020 Medication Administration Record (MAR) revealed no documented evidence that Resident R85 received the Magic Cup on February 12, 13, 16, 17, 18, 19, 20, 2020, as ordered by the physician.

Review of nursing progress notes for each of these dates indicated, "Magic Cup not available."

An interview with Employee E11, Food Service Director, on February 24, 2020, at 9:50 a.m. indicated, that Magic Cup supplemented was available. Review of nutritional supplement order form revealed that Magic Cup was ordered and received as needed for residents.

Observation of the 2nd floor food pantry refrigerator, with Employee E11 on February 24, 2020, at 10:10 a.m. revealed that Magic Cups were readily available.

An interview with Employee E3, Licensed nurse, confirmed that there was no evidence that the Magic Cup had been provided to the resident on February 12-20, 2020, as ordered.

The facility failed to ensure that one resident received their nutritional supplement as ordered.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

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

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













 Plan of Correction - To be completed: 03/31/2020

The facility does and shall obtain/or follow physician orders related to the use of dietary supplements.

R85 and other residents with orders for supplements are receiving them as ordered. Review of the process for ordering and delivery will be reviewed and modified as deemed appropriate and necessary. Monitoring/random review of inventory and order compliance will be conducted with findings reported to the CQI Committee for a period of time deemed appropriate by the CQI Committee.

Monitor: HC Dining Manager, General Manager Dining, Unit Managers, DON

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on clinical record review, review of facility documentation and staff interviews, it was determined that the facility failed to provide adequate supervision to two of 39 residents reviewed. (Resident R44 and R56)

Findings include:

A review of Resident R44's clinical record reveal that the resident was admitted to the facility on October 24, 2017, with diagnose,including but not limited to, stroke (damage to the brain from an interruption of its blood supply),
muscle weakness and abnormalities of gait and mobility.

A review of Resident R44's care plan,"risk for falls due to a stroke", dated revised August 26, 2019, revealed that the following approaches were initiated and created in 2017: prompt response to request for assistance, encourage the resident to call for staff assistance, ensure pathways are clutter free, bed in low position and instruct resident in safety measures.

A review of facility documentation revealed that the resident has had six falls since December 4, 2019. Further
review of facility documentation dated December 4, 2019, revealed that the resident was found on the floor in his room at 5:45 a.m. He stated that he rolled out of bed. He asked to be put back into bed. No injuries noted. The
call bell was not on. Continued review of facility documentation revealed that the facility would encourage the resident to ring bell for assistance and provide incontinence care. Interventions already in place to prevent further falls are: frequent reminders to use call bell, ensure pathways are free of clutter and dry, call bell in reach and bed in low position, to prevent further falls

A review of facility documentation dated December 27, 2019, revealed that the resident was again found lying on the floor in his room at 9:55 a.m. The resident stated that he was trying to get out of bed to the wheelchair and slid out of bed. The call bed was not on. No injuries noted. Actions the facility will take to prevent another fall: have resident get involved in group activities. Interventions already in place: encourage the resident to call for assistance, call bell with in reach, pathways free of clutter, bed in low position and non skid footwear.

A review of facility documentation dated December 30, 2019, revealed that the resident was found on the floor, a third time, in the television room at 11:00 a.m. The resident was last seen sitting in a chair in the television room. The resident stated I was trying to get up. No injuries noted. Action the facility will take to prevent another fall: the resident will be placed at table for group activities. Interventions already in place to prevent falls: encourage resident to call for staff, call bell within reach, pathways free of clutter, bed in low position and non skid footwear.

A review of facility documentation dated January 25, 2020, at 5:20 p.m. revealed that the resident was brought to the dinning room for dinner and placed at his table, while waiting for dinner he slipped out of the wheelchair and landed on his left side. The resident was noted with a 3 centimeter by 1 centimeter skin tear to his left elbow and a 2 centimeter by 1.5 centimeter skin tear to his mid back. The resident stated that I was fixing myself in the wheelchair. Action the facility will take to prevent another fall: toileting schedule, remind the resident to avoid standing without assistance, remove from stimulation, involve in activities, review of medication, call for assistance and call bell with in reach. Interventions that are already in place: remind the resident to call for assistance, keep call bell within reach, pathways clutter free, nonskid footwear, low bed, do not leave unattended in the bathroom.

A review of facility documentation dated February 7, 2020 at 9:45 a.m. revealed that the resident was found on the floor in his room. The bed was in the high position. The call bell was not on. The resident stated that he was trying to get into bed. No injuries. Action that the facility will take to prevent another fall: bring the resident to common area for direct supervision. Intervention that are already in place: encourage resident to call for assistance, call bell within reach, non skid footwear, pathways free of clutter.

A review of facility documentation dated February 20, 2020, at 9:15 a.m revealed that the resident was sitting in his wheelchair in the dining room. The resident attempted to push himself back in his wheelchair but instead slid out of his wheelchair. The resident landed on his buttocks. No injuries noted. Action the facility will take to prevent another fall: non skid footwear and instruct the resident on safety measures. Interventions already in place encourage the resident to ask for assistance, call bell with in reach and ensure pathways are clutter free.

Review of the clinical record for Resident R56 revealed that the resident was admitted to the facility on October 16, 2012, with diagnoses including, but not limited to, coronary artery disease (narrowing of the blood vessels which supply the heart with blood and oxygen), diabetes type II (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

Interview with Resident R56 on February 20, 2020 at 12:51 PM. revealed that the resident had washed and dressed herself. The resident also stated that she can transfer herself and walk by herself by pushing her wheelchair. When asked about how she injured her finger, the resident said she does no know why the finger is "crooked". Resident stated she did not hit her hand and no one hit her hand. Resident stated she is able to function with hand and it does not bother her.

Interview with Employee E5, nurse aide, on February 20, 2020 at 1:15 PM revealed that the nurse aides wash, dress, shower and toilet the resident. The resident can not transfer herself or walk independently. The nurse aide must provide assistance.

Observation of Resident R56 on February 21, 2020 at breakfast between 8:15 and 9:00AM. Resident moved from table in dining room to bed room by propelling herself in the wheelchair with her feet while sitting on the edge of the seat.

Review of documentation submitted by the facility dated 7, 2019, revealed that on June 5, 2019 at 5PM, the resident reported that her 4th finger of left hand hurt. Initial assessment determined that the digit was discolored and swollen however, the resident was able to move her fingers. On June 6, 2019 the swelling spread to the 5th digit and the resident could not bend the finger. An x-ray revealed that the resident had a fracture of the 4th finger. The finger was splinted. On June 10, 2019 the resident was placed on every 30 minutes safety checks around the clock. The safety checks continued until September 23, 2019. Subsequent to the injury that occurred on June 5, 20119, the resident had three injuries of unknown origin and two unwitnessed falls. Two of the incidents of unknown injuries occurred while the resident was on 30 minute safety checks.

Review of documentation submitted by the facility dated June 27, 2019 at 6:15 AM revealed that a nurse aide had
noticed that the resident had three bruises to the left side of the back while assisting the resident with a transfer from
the wheelchair to the toilet. Follow up: bruises were not noted prior to this time.

Review of the "24 hour observation-Q 30 minutes" safety check documentation revealed that there was no documentation that the thirty minute checks had been completed on June 27, 2019. Documentation for June 23, 2019 to June 29, 2019 indicated the location of the resident on the nursing unit without any details about the resident's activity or behavior.

Review of documentation submitted by the facility dated September 6, 2019 at 4:50 PM revealed that a nurse aide noticed that the resident had a bruise on her right buttock while showering the resident.

Review of the "24 hour observation-Q 30 minutes" safety check documentation dated September 2, 2019 to September 6, 2019 indicated the resident location without details about resident's activity or behavior. Staff reported that they had no knowledge of how the incidents occurred.

Review of documentation submitted by the facility dated October 24, 2019 at 6:55 AM revealed that a nurse aide found the resident, in her room lying on the floor in urine. Follow up: resident wanted to go to the bathroom and attempted to urinate in the trash can but fell to to the floor and voided on the floor. Care plan reviewed. No further interventions in place.

Review of documentation submitted by the facility dated December 15, 2019 at 12:19 AM revealed that a nurse
aide found the resident in her room lying on the floor. The resident stated she was trying to get out of bed. The resident was incontinent of urine. Documentation further indicated that Immediate action taken: staff will monitor incontinence/toileting pattern for possible specific plan.

Review of documentation submitted by the facility dated January 2, 2020 at 5 PM revealed that a nurse aide noticed that the resident had a bruise on the right forearm and a bruise under the left breast. The resident stated that she bumped it on the dresser. Follow up: self inflicted injury. No further interventions required.

The facility failed to ensure that two residents with a history of repeated falls and injuries were provided with adequate supervision to prevent further falls and injuries.

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

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

















 Plan of Correction - To be completed: 03/31/2020

The facility does and shall ensure the environment remains as free of accident hazards as possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

Residents 44 and 56 and all residents, with falls and injuries in the last 90 days, care plans will be reviewed to ensure the appropriate interventions are in place to help reduce the risk of falls/falls/injuries and updated as deemed appropriate, including increased supervision. RNACs will be re-educated on all documents to review, post fall, to ensure all interventions are identified in the care plan. Facility will assess process for updating/revising care plans and make changes to the process as deemed appropriate. Monitoring of random charts for care plan revisions will be conducted. Monitoring/random review of care plans will be conducted with findings reported to the CQI Committee for a period of time deemed appropriate by the CQI Committee.

Monitor: RNACs, Unit Managers, DON

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to document adequate indications for the frequent use of an antianxiety medication for one of 47 clinical records reviewed. (Resident R44)

Findings include:

A review of Resident R44's clinical record reveal that the resident was admitted to the facility on October 24, 2017, with a diagnosis including but not limited to stroke (damage to the brain from an interruption of its blood supply) and muscle weakness.

A review of physician's orders dated October 31, 2019, revealed an order for Ativan 0.5 milligrams (mg)one tablet by mouth every 12 hours as needed for agitation, (an antianxiety medication- used to relieve anxiety.) A review of Resident R44's November 2019's Medication Administration (MAR) record revealed that the resident received Ativan 0.5 milligrams every day in November 2019 except on the 20th, 27th and 29th. Further review of this MAR revealed that the resident received Ativan 0.5 milligrams twice on the 6th,7th,10th, 16th, 23rd and 25th.

A review of the MAR for December 2019, revealed that the resident received Ativan 0.5 mg every day in December 2019, except the 24th and the 26th. The resident received Ativan 0.5 mg twice a day on the 19th and 22nd.

A review of the MAR for January 2020, revealed that the resident received Ativan 0.5 mg every day in January except January 1st, 2nd, and 3rd and January 6th to the 12th.

A review of the MAR for February 2020, revealed that the resident received Ativan 0.5 mg every day in February except the 4th and the 18th.

A review of nurse's notes that corresponded with the above dates revealed no documented evidence related to the resident experiencing anxiety /or agitation symptoms requiring the administration of an anti-anxiety medication. Further, there was no documented evidence of non-pharmacological interventions attempted prior to the administration of the anti-anxiety medication Ativan.

Interview with licensed nursing staff, Employee E3, on February 24, 2020 at 10:00 a.m. confirmed that there were no nurse's notes to state what the anxiety/agitation symptoms were experienced by the resident and no non-pharmacological interventions noted.

The facility failed to indicate the reason for frequent use of an as needed antianxiety medication for Resident R44.

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

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

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









 Plan of Correction - To be completed: 03/31/2020

The facility does and shall ensure each resident's drug regimen is free from unnecessary drugs, in excessive doses, duration, without adequate monitoring or in the presence of adverse consequences which indicate dose reduction or discontinuation.

Resident 44 and all residents receiving anti-anxiety medications be reviewed to ensure documentation indicates continued use is necessary and appropriate actions, as deemed necessary, will be implemented. Professional and non-professional nursing staff will be educated on the need to continually/consistently document behaviors associated with medication order and the need for non-pharmacologic interventions prior to administration of as needed medication.

Monitoring of orders and documentation of random charts will be conducted. Findings will be reported to the CQI Committee for a period of time deemed appropriate by the CQI Committee.

Monitor: Consulting Pharmacist, Unit Managers, DON


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 observation, staff interview and review of facility policy, it was determined that the facility failed to failed to properly store a three compartment soiled linen cart on one of two nursing units (Second floor) and failed to ensure that aseptic technique was maintained during wound care for one of two residents observed with wound treatments. (Resident R72).

Findings include:

Review of the policy "Dressing Change" (effective date: January 1, 2009). General Infection Control Guidelines indicated to: observe (standard) universal precautions or other infection control standards as approved by appropriate facility. Wash hands before and after all procedures. Wear gloves when necessary. Dispose of disposable equipment appropriately. Dispose of infectious materials appropriately.
The procedure specify ... place plastic bag near foot of bed to receive soiled dressing, put on pair of clean gloves, remove soiled dressing and discard in plastic bag, remove gloves and discard in plastic bag

Review of Resident R72's clinical record revealed that the resident was admitted to facility on March 1, 2019 with the diagnoses included, but not limited to, heart failure (excessive body/lung fluid caused by weakened heart muscles), diabetes (failure of the body to produce insulin to enable sugar to pass from blood stream to cells for nourishment) and a pressure ulcer of the sacrum.

Observation of wound care and dressing change to was conducted on February 11, 2020 at approximately 11:00 a.m. with licensed nursing staff, Employee E4.
Employee E4 indicated that the resident had a dressing on his chest that she would change in addition to the sacrum ulcer. Employee E4 proceeded to place dressing supplies on the resident' bed side table without prior cleaning or establishing a clean field before placing clean supplies on the bed side table.

Continue observation of the wound treatment revealed that Employee E4 did not wash hands prior to opening the sterile dressing package. Employee E4 proceeded washed hands and don gloves prior to removing the soiled dressing from the right chest. After removing the soiled dressing, Employee E4 was observed removing one gloved over the soiled dressing then removing the other gloved over the other soiled glove. The soiled gloves were placed on the bedside table with the clean supplies. Employee E4 repeated the same process of removing and discarding soiled items 3 times before leaving the room to obtain a red trash bag. The red trash bag was not opened and utilize at the time; instead it was placed on top of the soiled items that were on the bedside table. Employee E4 was not observed to wash hands upon returning to the room. Employee E4 proceeded to don gloves, opened a sterile dressing package then removed her gloves. The gloves were then placed on the bedside table. Employee E4 washed hand and don gloves and removed the soiled dressing from the sacrum. After removing the soiled dressing, the nurse repeated the process of placing soiled items on the bedside table 3 times. When the entire wound care and dressing change to the sacrum was completed, the nurse gather all soiled items and placed items in a red bag.

The facility failed to ensure that aseptic technique was maintained during wound care to Resident R72.


Observation of the Second floor central bathroom, on February 20, 2020, at 1:30 p.m. in the presence of the Nursing Home Adminstrator and Employee E8, Maintenace Director, revealed a three sectional side by side soiled linen cart was stored in a shower room with in the central bathroom. Further observation of the soiled linen cart revealed that each of the three sections contained soiled linens. At the time of the observation, the Nursing Home Adminstrator, confirmed that the soiled linen cart was not properly stored.


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

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

28 Pa. Code 201.14(a) Responsibility of licensee

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









 Plan of Correction - To be completed: 03/31/2020

The facility does and shall maintain an infection prevention and control program that includes, at a minimum, a program designed to provide a safe, sanitary and comfortable environment; and, to help prevent the development and transmission of communicable diseases and infections. R72 did not experience a negative outcome.

E4 has been re-educated on the aseptic technique required for wound care; and, re-education of all professional nurses will be provided. Professional nurse competencies will be monitored with education as needed based on performance, on an on-going basis. Immediate interventions/education will be provided as deemed necessary. Findings of competencies will be reported to the CQI Committee for a period deemed appropriate by the CQI Committee.

The facility addressed the linen cart immediately and initiated education with nursing staff, which was completed. On-going monitoring will be implemented and findings will be reported to the CQI Committee for a period deemed appropriate by the CQI Committee.

Monitoring: Unit Managers, DON


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