Nursing Investigation Results -

Pennsylvania Department of Health
FRIENDSHIP VILLAGE OF SOUTH HILLS
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FRIENDSHIP VILLAGE OF SOUTH HILLS
Inspection Results For:

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FRIENDSHIP VILLAGE OF SOUTH HILLS - 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 November 24, 2021, it was determined that Friendship Village of South Hills, 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.

































































 Plan of Correction:


483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to investigate incidents of possible abuse and neglect for two of four residents (Residents R32, and R309).

Findings include:

The facility policy "Resident Abuse/Neglect/Exploitation and Reporting Requirements" dated 2/2/21, indicated each resident has the right to be free from abuse, neglect, exploitation, corporal punishment, and involuntary seclusion. This policy includes verbal, physical, and mental abuse. Mental abuse is defined as willful infliction of mental suffering by a person in a position of trust with the elder, and includes humiliation, harassment, threats of punishment, and instilling fear in the resident. Neglect is defined as failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress, and includes failure to assist in personal hygiene and failure to provide medical health needs for the resident.

The facility policy "Accidents and Incidents - Investigating and Reporting" dated 2/2/21, indicated that the nurse supervisor or department director shall promptly initiate and document investigation of the accident or incident, and will include the following data: date and time it took place, nature of injury/illness, circumstances, witness statements, inured person's statement, any corrective action taken, and other pertinent information as needed or required. Per this policy, the person conducting the investigation will: interview the person making the report, interview any witnesses to the incident, notify the resident's attending physician, interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, and interview other residents to whom the accused employee provides care or services.

A review of the clinical record revealed Resident R32 was re-admitted to the facility on 10/12/21, with diagnoses that included Alzheimer's Disease, dementia, depression, and a history of falls.

A review of facility documentation failed to reveal a complete investigation into an incident on 11/14/21, when Resident R32 removed a bottle of medication from an unlocked treatment cart drawer, emptied the bottle into his hand, and swallowed the pills before a staff member could stop him.

A review of facility documents revealed Nurse Aide Employee E9 witnessed Resident R32 take the bottle from the treatment cart, open the bottle, empty the medication into his hand, and swallow the pills before she could stop him. NA Employee E9 estimated the number of pills to be between 30 and 50.

Further review of facility documentation revealed the previously opened bottle of over-the-counter medication, Aspirin 81 milligrams, initially contained 36 pills. The exact number of pills consumed was unknown.

During an interview on 11/24/21, at 12:50 p.m. Licensed Nurse (LN) Employee E5 revealed that she was not Resident R32's nurse on 11/14/21, but responded to the incident when NA Employee E9 notified her of the occurrence. LN Employee E5 did not witness the incident but stated that another bottle of medication, multi-vitamins, was found in the treatment cart following the incident. LN Employee E5 did provide a witness statement and stated that sometimes the treatment cart was left unsecured because multiple agency nurses worked at the facility and needed access to its contents.

During a telephone interview on 11/24/21, at 1:00 p.m. LN Employee E6 stated she had worked on the date of the incident but was not interviewed or asked for a witness statement. LN Employee E6 stated that she was ultimately responsible for the treatment cart keys on 11/14/21, and confirmed the treatment cart was unlocked. LN Employee E6 stated the treatment cart keys were kept in an unsecured drawer at the nurse's station.

The admission record indicated that Resident R309 was admitted to the facility on 11/10/21, with diagnoses that included Crohn's Disease (causes inflammation of your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss), unsteadiness on feet, and high blood pressure.

A review of facility documentation failed to reveal a complete investigation into an incident on 11/17/21, when Resident R309 reported to staff she was told by Nurse Aid (NA) Employee E10 she could not use the bathroom between 9:30 p.m. and 12:00 a.m., and at 12:00 a.m. was told she was not allowed out of bed until 5:30 a.m.

During an interview on 11/23/21, at 10:50 a.m. Social Services Employee E3 confirmed Resident R309 was the only resident interviewed in the incident.

Review of facility documentation revealed LN Employee E3 worked the shift during the incident on 11/17/21, and had direct contact with Resident R309.

During a telephone interview on 11/24/21, at 11:00 a.m. LN Employee E3 stated she worked during the shift of the incident on 11/14/21 and had the nurse aids that were involved write a statement before the end of their shift. LN Employee E3 stated she talked to Resident R309 during her shift, but she did not write a witness statement, and was not asked to complete a statement.

Review of facility documentation revealed LN Employee E4 worked the shift during the incident on 11/17/21 with Resident R309.

During a telephone interview on 11/24/21, at 12:10 p.m. LN Employee E4 stated she could not recall the resident, was unable to recall Resident R309's name, and was unable to recall an incident occurring on 11/17/21, involving Resident R309. LN Employee E4 stated she was not asked for a witness statement.

During an interview on 11/23/21, at 10:50 a.m. Social Services Employee E2 confirmed that no other residents or staff were interviewed in the incident with Resident R309 even when the roommate corroborated the events of 11/17/21.

During an interview on 11/23/21, at 11:15 a.m. the Nursing Home Administrator confirmed the facility did not complete a full investigation into the incidents involving Residents R32 and R309, and confirmed the facility did not conduct a thorough investigation into the allegations, including not interviewing all possible witnesses, did not interview other staff members who had contact with the resident, did not interview the resident's roommate, or other residents to whom the accused employee provides care or services.

28 Pa. Code: 201.14 (a)(c)(e) Responsibility of licensee.

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


 Plan of Correction - To be completed: 01/05/2022

Health Center investigations of the incident related to R32 and R309 have been submitted via ERS and PB22 on 11/15 and 11/18. A look back at previous incidents will be performed to ascertain completed investigations were complete. All incidents will be thoroughly investigated to include statements from any witnesses, team members, residents and all other pertinent information required for the completion of the investigation by the DON. NHA will educate DON and all nursing team members on the Accidents and Incidents - Investigation and Reporting policy. All investigations will audited to meet the policy requirements weekly for 4 weeks. Audits will be taken to QAPI for review.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on facility policy, observations and interviews, it was determined that the facility failed to ensure that over the counter (OTC) medications were properly stored and labeled on two of three nursing units (Dogwood and Pinewood Nursing Units), and failed to date multi-dose OTC medication bottles in one of three medication carts (Pinewood).

Findings include:

Review of the facility "House Stock Items" policy last reviewed on 2/2/21, indicated that the facility should ensure that house stock medications are stored in original manufacturer's container. The medication name, strength, expiration date and lot number should be visible. The facility must ensure that stock medications are stored under proper conditions in accordance with Applicable law and the State Operations Manual.

During an observation on 11/22/21, at 10:40 a.m. the Pinewood medication cart OTC medications did not include resident names indicating which resident receives the medications from each bottle, and the following OTC medication was observed open without a date of opening:

Loratadine oral solution 10 milligrams (mg)
Preservision supplement
Melatonin 1 mg
Melatonin 3 mg
Melatonin 5 mg
Miralax laxative

During an interview on 11/21/21, at 10:45 a.m. Licensed Nurse Employee E7 confirmed that the OTC medications were open and not dated and the resident names were not on each bottle and the facility does not have a list or any means of knowing the expiration date and lot number of medications provided to each resident requiring OTC medications.

During an observation on 11/22/21, at 11:10 a.m. the Dogwood medication cart over the counter(OTC) medications did not include resident names indicating which residents receive the medications from each bottle.

During an interview on 11/21/21, at 11:10 a.m. Licensed Practical Nurse Employee E16 confirmed that the resident names were not on each bottle and the facility does not have a list or any means of knowing the expiration date and lot number of medications provided to each resident requiring OTC medications.

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

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





 Plan of Correction - To be completed: 01/05/2022

OTC in Dogwood and Pinewood medication carts will be labeled with resident's names and dated when opened. OTC bottles will have expiration date and lot numbers visible. Whole house audit of residents on OTC will be completed in order to ensure proper labeling of OTC in medication cart. DON or designee will educate licensed staff on the House stock items policy. OTC in the medication cart will be audited weekly for 4 weeks to ensure OTC are correctly labeled and dated and stored in the original manufacturer's containers. Audits will be taken to QAPI for review.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 review of facility policy, facility documents, clinical records and staff interviews, it was determined that the facility failed to investigate, evaluate the incidents and accidents that occurred and implement interventions to decrease the hazards and/or risks and monitor the effectiveness of those interventions, and failed to properly secure medications in a locked compartment for (Resident R2, R7, R32)

Findings include:

A review of the facility "Elopement, Unsupervised Absence, Hazardous Wandering and Missing Residents" policy dated 2/2/21, indicated Lifespace Communities will implement procedures that strive to identify, prevent and respond to resident elopement attempts.

A review of the facility "General Dose Preparation and Medication Administration" policy dated 2/2/21, indicated facility staff should not leave medications or chemicals unattended, and facility should ensure that medication carts are always locked when out of sight or unattended.

A review of the facility "Storage and Expiration of Medications, Biologicals, Syringes, and Needles" policy dated 2/2/21, indicated that all medications and biological's are stored separately and in a secure location that is inaccessible by residents and visitors

A review of the facility "House Stock Items" policy dated 2/2/21, indicated the facility will ensure that over-the-counter stock medications are stored in a secure area.

A review of the clinical record face sheet revealed that resident R32 was admitted to the facility 3/24/21 with diagnosis that included Dementia which is a chronic disorder of the mental processes caused by brain disease.

A review of facility reported documents indicated that the resident had eloped 4/18/21.

During an interview on 11/28/21, at 12:27 p.m. the Nursing Home Administrator (NHA) confirmed that the facility could not provide the investigation of the elopement incident that occurred on 4/18/21 for Resident R22.

During an observation on 11/23/21, at 9:58 a.m. an alarm was heard, above the Resident lounge a light was illuminated going from red to white. Observation into the lounge revealed the outside door to be open and gaping. Staff continued to walk past the light. Once SA entered room, Social Worker(SW) Employee E2 followed and stated " Oh, I think Maintenance was in here", when asked she indicated he was checking the alarms. SA indicated that the Maintenance Director was in the conference room with the SA team. The SW Employee E2 then closed the door. When asked if anyone was outside, SW Employee E2 then re-opened the door and looked outside and closed door and said " No". At this time the SA went and had the Maintenance Director Employee E12 walk thorough the area. Outside tow gates exiting the premises were locked. A door entering back into the building at the second Resident lounge was open, no alarm sounded when entering. The Maintance Director Employee E12 stated " This should not be open", when entering. In this lounge was a female resident with a wanderguard on her ankle. SA turned around and was able to exit the door back outside. At this time, SA asked Maintenance Director Employee E12 to get a wanderguard to check all exits. During this observation, the door exiting though the ambulance exit and the main exit, the exit doors did not lock when wanderguard approached as the other doors did.

During an interview on 11/22/21, at 10:45 a.m. Maintenance Director Employee E12 confirmed that the exit doors should lock upon the approach of the wanderguard and the resident lounge doors in either case should not be unsecured. The facility failed to make certain the interventions to maintain the safety of residents requiring elopement monitoring an supervision are functioning properly.

Review of the clinical record indicated that Resident R7 had been admitted to the facility on 5/28/21, with diagnoses which included dementia, a stroke, history of falls, Parkinson's Disease ( Disease which affects the nervous system which affects movement and causes tremors, loss of balance), and depression. The resident and his spouse live on campus in one of the apartments. An MDS (Minimum Data Set- a periodic assessment of resident care need) indicated the diagnoses remained current.

Review of facility documents dated 7/28/21, indicated that Resident R7 had eloped from the facility. The document indicated that after a visit with his spouse, the resident exited the building with his rollator and walked to his apartment. His wife called the facility and made them aware that he was with her.

During an interview on 11/23/21, at 11:30 a.m. the Nursing Home Administrator confirmed that a full investigation as to how Resident R7 exited the building, documentation of staff interviews, resident interview was not completed.

Review of the clinical record indicated that Resident R48 had been admitted to the facility on 2/14/20, with diagnoses which inlcuded lung disease, anxiety disorder, and cancer of the cervix. Additional diagnosis dated 6/8/20 indicated falls, (/14/20 additional diagnoses added were tremors, hearing loss and poor vision. On 2/9/21, dementia was added as a diagnosis. An MDS indicated the diagnoses remained current. Resident R48 was a high risk for elopement and had a wanderguard placed.

Review of the clinical record indicated that Resident R48 had behaviors of slapping herself in the face, biting herself and stating she wanted to die. The facility did have Psychiatry following resident. Resident R48 had been known to exit seek according to documentation.

Review of the clinical record indicated that on 11/13/21, at 10;05 p.m., Resident R48 did not have a wanderguard on. The note indicated that Resident R48 had "cut it off". A wanderguard was placed on her ankle while she was sleeping.

During an interview on 11/23/21, at 12:45 p.m. the Nursing Home Administrator confirmed that an incident report and full investigation as to how the wanderguard had been removed, why a resident with suicidal ideations would have been given anything to cut off a wanderguard had not been completed.

A review of the clinical record revealed Resident R32 was re-admitted to the facility on 10/12/21, with diagnoses that included Alzheimer's, dementia, depression, and history of falls.

A review of Resident R32's care plan dated 10/20/21, indicated history of suicidal and homicidal ideations.

A review of a physician order revealed Resident R32 was admitted to hospice (special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care) services on 11/15/21.

A review of a facility witness statement dated 11/14/21, Nurse Aide (NA) Employee E9 witnessed Resident R32 remove a bottle of medication (Aspirin 81 milligrams) from a drawer in the treatment cart, empty the bottle in his hand, and place the handful of medication in his mouth and swallow them before she could stop him.

During a telephone interview on 11/24/21, at 1:00 p.m. Licensed Nurse (LN) Employee E6 indicated the treatment cart is stationed at the nurses station, unlocked and unattended on 11/14/21, stating the keys to the treatment cart are stored in an unsecured drawer at the nurses station, assessable to all staff. LN Employee E6 was unable to tell why the medication was in the treatment cart instead of the medication cart. LN Employee E6 confirmed the treatment cart should be secured and medication should be stored in the treatment cart.

During a telephone interview on 11/24/21, at 1:15 p.m. NA Employee E9 confirmed she witnessed Resident R32 take the handful of medication but was unable to get to him prior to him placing them in his mouth.

During an interview on 11/24/21, at 1:35 p.m. the NHA confirmed the treatment cart is to be secured when unattended and medications are not to be stored in the treatment cart..


28 Pa. Code 201.14(a)Responsibility of licensee
28 Pa. Code 211.10(d)resident care polices



 Plan of Correction - To be completed: 01/05/2022

R7 and R22 have wanderguards in place. A prescheduled upgrade of the Wanderguard systems hardware in the health center was completed on 11/29. All residents with wanderguard orders were audited for an order of Q shift checks for placement and all were current. Whole house elopement assessment will be completed on all residents to ensure accuracy and appropriateness of interventions. Maintenance will inspect all exit/entrance points with a wanderguard system for correct functioning. DON or designee will educate all health center team members on elopement, unsupervised absence, hazardous wandering and missing residents policy. Elopement assessments will be audited weekly for 4 weeks and wanderguard door checks weekly for 4 weeks. Audits will be taken to QAPI for review.
R48 nail clippers have been removed from her room. No other residents have been identified to be at risk for injury related to nail clippers. Whole house BIMS to be completed and those identified high risk will be reviewed for cognitive impairment related to accidents. DON or designee to educate nursing team members on Accidents and Incidents policy. BIMS will be audited weekly for 4 weeks to identify high risk residents with cognitive impairment for accidents. Audits will be taken to QAPI for review.
R32 did not experience any adverse effects from the ingestion of Aspirin and all appropriate parties were notified. Whole house audit of all treatment carts will be completed to ensure no medications are stored. DON or designee will educate licensed staff on General Dose preparation and medication administration, storage and expiration of medications, biologicals, syringes and needles, and house stock items policies. Treatment cart audit will be completed to ensure its locked and no medications are stored it in weekly for 4 weeks. Audits will be taken to QAPI for review.



483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:
Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for seven of seven residents (Resident R4, R16, R30, R31, R32, R308, and R309).

Findings include:

A review of the facility "Admission Agreement" indicated upon admission the facility will inquire of the resident or responsible party about the existence of any written Advanced Directive, the facility will maintain a copy and make it available to necessary caregivers when decisions about care must be made.

A review of the clinical record indicated Resident R4 was re-admitted to the facility on 1/23/20, with diagnoses that included high blood pressure, and a history of falls.

A review of the clinical record failed to reveal an advanced directive or documentation that Resident R4 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R16 was re-admitted to the facility on 3/9/21, with diagnoses that included high blood pressure, anxiety, and diabetes.

A review of the clinical record failed to reveal an Advanced Directive or documentation that Resident R16 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R30 was re-admitted to the facility on 10/21/20, with diagnoses that included dementia, and muscle weakness.

A review of the clinical record failed to reveal an Advanced Directive or documentation that Resident R30 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R31 was re-admitted to the facility on 4/16/21, with diagnoses that included repeated falls, depression, and high blood pressure.

A review of the clinical record failed to reveal an Advanced Directive or documentation that Resident R31 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R32 was re-admitted to the facility on 10/12/21, with diagnoses that included depression, dementia, and a history of falls.

A review of the clinical record failed to reveal an Advanced Directive or documentation that Resident R32 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R308 was re-admitted to the facility on 11/12/21, with diagnoses that included history of falls, and muscle weakness.

A review of the clinical record failed to reveal an Advanced Directive or documentation that Resident R308 was given the opportunity to formulate an Advanced Directive.

A review of the clinical record indicated Resident R309 was admitted to the facility on 11/10/21, with diagnoses that included muscle weakness, and high blood pressure.

A review of the clinical record failed to reveal an Advanced Directive or documentation that Resident R309 was given the opportunity to formulate an Advanced Directive.

During an interview on 11/23/21, at 2:00 p.m. the Social Services Employee E2 confirmed that the clinical record did not include documentation that residents were afforded an opportunity to formulate an Advance Directive (POA or Living Will) for Resident's R4, R16, R30, R31, R32, R308, and R309.


28 Pa. Code: 201.29(b)(d)(j) Resident rights.


 Plan of Correction - To be completed: 01/05/2022

Preparation and/or execution of this plan of correction does not constitute admission or agreement by this provider of the truth of the facts alleged or conclusions set forth in the statement of insufficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and/or state law.


R4, R16, R30, R31, R32, R308, and R309 will have advanced directives reviewed and documented. A whole house review of all residents will be completed focusing on documentation of advance directives. The Administrator will educate Social Services and Admission on obtaining advanced directives upon admission, readmission, including updates and this will be documented in the medical record. NHA will complete an audit of all documentation of advance directives for all new admissions and readmissions weekly for 4 weeks. The audits will be taken to QAPI for review.

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, documents, clinical records, and staff interviews it was determined that the facility failed to make certain a resident was free from abuse and neglect for one of one resident reviewed (Resident R309).

Findings include:

The facility's policy "Resident Abuse/Neglect/Exploitation and Reporting Requirements" dated 2/2/21, defined verbal abuse as any use of oral, written, or gestured language to residents, regardless of their age, ability to comprehend or disability. The policy further defines mental abuse as the willful infliction of mental suffering by a person in a position of trust with the elder, including humiliation, threats of punishment, humiliation, and intimidation.

The facility's policy "Resident Rights" dated 2/2/21, indicated each resident shall be treated with consideration, respect, and full recognition of their dignity including treatment of personal and social needs, and each resident shall be free from mental, and emotional abuse or neglect.

The admission record indicated that Resident R309 was admitted to the facility on 11/10/21, with diagnoses that included Crohn's Disease (causes inflammation of your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss), unsteadiness on feet, and high blood pressure.

During an interview on 11/23/21, at 11:00 a.m. Resident R309 stated "last week a nurse aide came in my room and announced that I was not allowed to use the bathroom between 9:30 p.m. and 12:00 a.m. and again from 12:30 a.m. to 5:30 a.m.", and stated Nurse Aid (NA) Employee E10 placed a wheelchair in front of the bathroom door so she could not get into the bathroom. Resident R309 was visibly upset about this action. Resident R309 further stated she did report this incident to staff that night and the next day.

A review of the admission Minimum Data Set (MDS - standardized assessment tool for all residents of long-term care facilities) dated 11/16/21, Section C: Cognitive Patterns, Question C0500 BIMS Summary Score (The BIMS is a brief screener that aids in detecting cognitive impairment.) indicated Resident R309 scored 13 out of a possible 15 on the BIMS assessment indicated she was cognitively intact (no evidence for dementia or thought impairment). Section G: Functional Status, Question G0110: Activities of Daily Living indicated Resident R309 required limited assistance with bed mobility, transfers, walking in room, dressing, eating, toilet use, and personal hygiene.

Review of Resident R309's care plan indicated a risk for falls related to impaired mobility, and impaired physical mobility related to weakness.

A review of the clinical record failed to reveal documentation of Resident R309 being toileted on 11/17/21 or 11/18/21.

Review of the clinical record dated 11/16/21, revealed a progress note indicating Resident R309 had bloody loose stool in her brief from Crohn's Disease. A physician progress note dated 11/19/21, indicated Resident R309 reported diarrhea.

A review of NA Employee E10's witness statement dated 11/17/21, revealed NA Employee E10 considered Resident R309 very demanding and derogatory, and stated she did not want the assignment of taking care of Resident R309's room.

A review of NA Employee E11's witness statement dated 11/17/21, revealed NA Employee E11 considered Resident 309 demanding and stated that Resident R309 was taken to the bathroom on multiple occasions.

A review of Social Services Employee E2's witness statement dated 11/18/21, indicated she spoke with Resident R309 and her roommate, Resident R310, corroborated her statement.

A review of the clinical record revealed Resident R310 was admitted to the facility on 11/9/21, with diagnoses that included left arm fracture, depression, anxiety, and history of falls. A review of the admission MDS dated 11/15/21, indicated Resident R310's BIMS score was 15, indicating no cognitive or memory impairment.

During an interview on 11/23/21, at 10:50 a.m. Social Services Employee E2 revealed that she initially interviewed Resident R309 after hearing of the incident and confirmed that no other interviews were conducted with other residents or staff.

During a telephone interview on 11/24/21, at 11:00 a.m. Licensed Nurse (LN) Employee E3 indicated NA Employee E10 told her Resident R309 wanted to go to the bathroom every hour so she went back to talk with Resident R309 at an unknown time and Resident R309 did not make a complaint at that time. LN Employee E3 revealed the facility did not ask her for a witness statement at any time.

During a telephone interview on 11/24/21, at 12:10 p.m. LN Employee E4 indicated she did not know Resident R309, Resident R309's name did not "ring a bell", LN Employee E4 would have to look at her schedule to see if she worked that night and was unable to recall her assignment on the night of 11/17/21.

A review of the facility provided event timeline investigation indicated NA Employee E10 was suspended pending investigation from 11/18/21 to 11/21/11 and returned to work at the facility on 11/23/21.

Review of facility documentation on 11/23/21, revealed NA Employee E10 had reviewed and signed the abuse and resident rights policies.

During an interview on 11/24/21, at 1:00 p.m. the Social Services Employee E2 confirmed that the facility failed to make certain a resident was free from verbal abuse for one resident (Resident R309).

28 Pa. Code 201.14(a) Responsibility of licensee.

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

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

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.

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


 Plan of Correction - To be completed: 01/05/2022

R309 was discharged from the health center on 11/26/21. A look back of previous concerns will be performed to rule out any abuse or neglect that may have been missed. Whole house audit will be conducted of all residents to evaluate they are free from abuse, neglect and exploitation of resident property. A look back will performed Social worker or designee will educate all health center team members on the abuse policy and procedure. Social services will interview 5 residents a week to ensure they are free from abuse, neglect and exploitation of resident property weekly for 4 weeks. Audits will be taken to QAPI for review.
483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on review of facility clinical records, observations and staff interview, it was determined that the facility failed to make certain that resident assessments were accurate for two of eight residents (Resident R4 and R16).

Findings include:

A review of the Resident Assessment Instrument (RAI) Manual (provides instructions and guidelines for completing a Minimum Data Set Section (MDS-periodic assessment of care needs) dated October 2019, Section O: Special Treatments, Procedures, and Programs; Question O 0100K: Hospice Care indicates residents identified as being in a hospice (special model of care for patients who are in the late phase of an incurable illness and wish to receive end-of-life care)program for terminally ill persons.

A review of the clinical record indicated that Resident R4 was re-admitted to the facility on 1/23/20, with diagnoses that included history of falls, and high blood pressure.

A review of a physician's order dated 5/13/21, indicated Resident R4 was admitted to hospice services. Further review of the clinical record indicated Resident R4 continues to receive hospice care.

A review of the significant change MDS dated 6/24/21, revealed Resident R4 was coded as receiving hospice services. A review of MDS dated 8/19/21, failed to indicate Resident R4 was receiving hospice services.

A review of the clinical record indicated that Resident R16 was re-admitted to the facility on 3/9/21, with diagnoses that included diabetes, anxiety, and depression.

A review of a physician's order dated 3/24/21, indicated Resident R16 was admitted to hospice services. Further review of the clinical record indicated Resident R16 continues to receive hospice care.

A review of the modification of admission MDS dated 3/15/21, revealed Resident R16 was not coded as receiving hospice services until 9/10/21.

During an interview on 11/23/21, at 2:00 p.m. Admissions Employee E8 confirmed the facility did not correctly assess Residents R4 and R16 for hospice services in a timely manner.

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




 Plan of Correction - To be completed: 01/05/2022

The MDS for R4 and R16 reflects hospice services. Modification MDS were submitted and accepted. RNAC completed a whole house audit of all current hospice residents to compare the start of care date, date of the order, and MDS coding. Director of Clinical Reimbursement or designee will educate RNAC on MDS accuracy policy and DON or designee to educate licensed nurses on the hospice service policy. RNAC will audit MDS accuracy related to hospice services for all current residents monthly for a quarter to ensure all hospice residents are reviewed. Audits will be taken to QAPI for review.
483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
483.70(o) Hospice services.
483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in 418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at 483.24.
Observations:

Based on review of facility policy, and facility documents and clinical records and staff interview, it was determined that the facility failed to make certain that hospice documentation was maintained in the clinical record for one of eight residents (Resident 42)

Findings include:

A review of the faciltiy "Hospice Services" policy dated 2/12/21, indicated the steps to engage hospice services while in the Health Center.

The clinical record indicated Resident R42 was admitted to the facility on 3/26/17, with diagnosis that included Alzheimers Disease(progressive mental deterioration) and Dementia(chronic disorder of processes caused by brain disease).

The clinical record record revealed a physican order dated 10/19/20 for a consult with Kindred Hospice.

Review of Resident R42 care plan revealed that Hospice was initated on 11/4/20.

The November 2021 recapitulation of physician order indicated the Resident R42 wasn't admitted to Kindred Hospice till 3/24/2.

During an interview on 11/23/21, at 1:30 p.m. Employee E8 confirmed that Resident R42 was receiving hospice services and her clinical record did not include a hospice order till 4 months later in March 2021.

28 Pa. Code 201.18(b)(1)(e)(1) Management
28 Pa. Code 211.5(h) Clinical records
28 Pa. Code 211.12(d)(1)(3)Nursing Services







 Plan of Correction - To be completed: 01/05/2022

R42 has a current order for hospice services. Whole house audit of all current residents receiving hospice services will be conducted by RNAC to ensure that hospice orders are appearing on the monthly recapitulation orders. DON or designee will educate licensed staff on the hospice service policy to include ensuring a physician order for services. Audits of hospice orders to reflect hospice service start date will be completed weekly for 4 weeks. Audits will be taken to QAPI for review.
483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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(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)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on review of facility policy, infection control documentation and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program that included protocols for antibiotic use and the tracking/reporting of antibiotic resistance for six of 12 months (November 2020 to April 2021).

Findings include:

Review of the facility policy "Infection Prevention and Control Program" dated 2/2/21, indicated the facility would include monitoring the use of antibiotics, monitoring of resistance patterns, reports on the number of antibiotics prescribed, monitoring of antibiotic resistance patterns and pharmacy consultant reviews of antibiotic usage data.

Review of infection control documentation failed to reveal any antibiotic stewardship monitoring having been completed for six of 12 months (November 2020 to April 2021).

During an interview on 11/23/21, at 11:10 a.m. the Nursing Home Administrator confirmed the facility antibiotic stewardship were missing from November 2020 to April 2021.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 201.18(b)(3) Management.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(c) Nursing services.
28 Pa. Code 211.12(d)(3) Nursing services.



 Plan of Correction - To be completed: 01/05/2022

The antibiotic stewardship program is current as of May 2021. DON or designee will educate infection control preventionist on the Antibiotic Stewardship reporting requirements. The DON will audit the antibiotic stewardship monitoring documentation for the 3 months. Review will be taken to QAPI for review.
483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training: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.
483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12.

483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

483.95(c)(3) Dementia management and resident abuse prevention.
Observations:
Based on review of facility policy, staff personnel records and staff interviews it was determined that the facility failed to provide newly hired staff with resident abuse training for one out of six personnel records (Agency Licensed Practical Nurse Employee E19).

Findings include:

The facility "Resident abuse identification and reporting suspicion of a crime" policy, last reviewed on 2/2/21, indicated that the facility has an obligation to prevent abuse, neglect and exploitation of our residents, and to establish procedures for identifying such situations and reporting the incidents to the proper authorities. All staff members will be trained on this policy and procedure. This policy will be reviewed by all newly hired team members in the new hire packet and a copy will be signed and place in the team member's file.


The facility "Orientation and training" policy last reviewed on 2/2/21, indicted that the facility is committed to providing the best customer service and hospitality to the residents. The orientation and training program for all new team members will include an introduction to the facility culture and facility policies, community-specific policies and procedures, department specific information and web-based training. All new team members will begin working a day that the culture program is being presented. The training will be scheduled by the human resource department. All team members will have a general orientation to their community and department. Training modules will be assigned to each team member to complete in the on-line training program within 30 days of employment.

Review of Agency Licensed Practical Nurse (LPN) Employee E19 employee record indicated she was hired at the facility on 11/16/21.

During an interview on 11/23/21, at 11:40 a.m. Agency Licensed Practical Nurse (LPN) Employee E19 stated she had started working at the facility four days ago.

During an interview on 11/24/21, at 9:29 a.m. the Human Resource assistant Employee E20 confirmed that the facility failed to provide a newly hired staff personnel with resident abuse training prior to working with residents as required.




28 Pa Code: 201.14 (a ) Responsibility of licensee

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

28 Pa Code: 201.20 (a )(c ) Staff development







 Plan of Correction - To be completed: 01/05/2022

Agency E19 will receive education on the Abuse and Neglect policy and procedure. Whole house audit of team members and contracted service staff will be conducted for proof of abuse education. DON or designee will educate the nursing scheduler and HR on obtaining abuse training for new contracted service staff prior to them starting. New contracted service staffing file will be audited to proof of abuse training weekly for 4 weeks. Audits will be taken to QAPI for review.
201.20(b) LICENSURE Staff development.:State only Deficiency.
(b) An employe shall receive appropriate orientation to the facility, its policies and to the position and duties. The orientation shall include training on the prevention of resident abuse and the reporting of the abuse.
Observations:
Based on review of facility policy, staff personnel records and staff interview it was determined that the facility failed to provide staff orientation to newly hired employees for two out of six staff personnel records (Contracted Registered Dietitian Employee E18 and Licensed Practical Nurse (LPN) Employee E19).

Findings include:

The facility "Orientation and training" policy last reviewed on 2/2/21, indicted that the facility is committed to providing the best customer service and hospitality to the residents. The orientation and training program for all new team members will include an introduction to the facility culture and facility policies, community-specific policies and procedures, department specific information and web-based training. All new team members will begin working a day that the culture program is being presented. The training will be scheduled by the human resource department. All team members will have a general orientation to their community and department. Training modules will be assigned to each team member to complete in the on-line training program within 30 days of employment.

Review of Contracted Registered Dietitian Employee E18 employee record indicated she was hired at the facility on 11/8/21.

Review of Licensed Practical Nurse (LPN) Employee E19 employee record indicated she was hired at the facility on 11/16/21.

Review of staff personnel records for Contracted Registered Dietitian Employee E18 and Licensed Practical Nurse (LPN) Employee E19 did not include a general orientation to the facility.

During an interview on 11/23/21, at 11:40 a.m. Licensed Practical Nurse (LPN) Employee E19 stated she had started working at the facility four days ago.

During an interview on 11/23/21, at 11:43 a.m. Contracted Registered Dietitian Employee E18 stated she had started working at the facility two weeks ago.

During an interview on 11/24/21, at 9:29 a.m. the Human Resource assistant Employee E20 confirmed that the facility failed to provide staff orientation to newly hired employees.






 Plan of Correction - To be completed: 01/05/2022

E18 and E19 will receive facility orientation. Whole house audit will be conducted to ensure orientation was complete for hires health center team members and contracted service staff. DON or designee will educate the nursing scheduler and HR on obtaining facility orientation for new health center and contracted service staff. New staff and contracted service staffing file will be audited to proof of facility orientation weekly for 4 weeks. Audits will be taken to QAPI for review.
201.20(c) LICENSURE Staff development.:State only Deficiency.
(c) There shall be at least annual inservice training which includes at least infection prevention and control, fire prevention and safety, accident prevention, disaster preparedness, resident confidential information, resident psychosocial needs, restorative nursing techniques and resident rights, including personal property rights, privacy, preservation of dignity and the prevention and reporting of resident abuse.
Observations:
Based on review of facility policy, staff personnel records and staff interview it was determined that the facility failed to provide annual in-service training on emergency disaster preparedness and fire prevention for three out of ten staff personnel records ( Nurse aide Employee E14, LPN Employee E15, and LPN Employee E16).

Findings include:

The facility "Staff development" policy, last reviewed on 2/2/21, indicated that the facility will develop an annual education plan. The plan will include all required training that will satisfy federal and state regulations.

The facility "Fire plan" policy last reviewed on 2/2/21, indicated that the fire plan defines a priority sequence of action for all employees. All employees are trained to rescue, activate alarm, contain fire, and extinguish/evacuate (RACE).

Review of Nurse aide Employee E14 personnel record indicated she was hired on 8/22/13.

Review of Licensed Practical Nurse (LPN) Employee E15 personnel record indicated she was hired on 8/25/20.

Review of Licensed Practical Nurse (LPN) Employee E16 personnel record indicated she was hired on 7/1/15.

Review of Nurse aide Nurse aide Employee E14 and LPN Employee E15 records did not include annual fire prevention and emergency disaster preparedness training.

Review of LPN Employee E16 personnel record did not include annual fire prevention training.

During an interview on 11/24/21, at 8:45 a.m. the Human Resource assistant Employee E20 confirmed that the facility failed to provide annual in-service training on disaster preparedness and fire prevention for three out of ten staff personnel records as required.




 Plan of Correction - To be completed: 01/05/2022

E14, E15, and E16 will receive annual inservice training on emergency disaster preparedness and fire prevention through the Relias training program. Whole house of current health center team members will be conducted to ensure all training is up to date. NHA or designee will educate HR and department heads on Staff development policy. Audits of annual staff education of emergency disaster preparedness and fire prevention will be conducted to ensure annual inservice requirements are scheduled and met through Relias training program weekly for 4 weeks. Audits will be taken to QAPI for review.
209.8(b) LICENSURE Fire Drills.:State only Deficiency.
(b) A written report shall be maintained of each fire drill which includes date, time required for evacuation or relocation, number of residents evacuated or moved to another location and number of personnel participating in a fire drill.
Observations:
Based on review of facility policy, review of 12 months of fire drill documentation, and staff interview it was determined that the facility failed to document staff that participated in four out of 12 fires drills (October 2020, Nov 2020, February 2021, and May 2021) and failed to complete fire drills for one out of 12 months (October 2021).

Findings include:

The facility "Fire plan" last reviewed on 2/2/21, indicated that the fire plan defines a priority sequence of action for all employees. All employees are trained to rescue, activate alarm, contain fire, and extinguish/evacuate (RACE).

Review of fire drills documentation for October 2020, Nov 2020, February 2021, and May 2021 did not include the names of staff participating in the fire drills.

Further review of fire drills did not include a fire drill for the month of October 2021.

During an interview on 11/23/21, at 9:58 a.m. the Maintenance supervisor Employee E12 confirmed that the facility failed to document staff that participated in four out of 12 fires drills and failed to complete fire drills for one out of 12 months as required.



 Plan of Correction - To be completed: 01/05/2022

Fire drill will occur monthly and signatures of all participants will be obtained. NHA or designee will educate maintenance on the facility fire plan including frequency and participation requirements. Monthly audit will be done to ensure fire drills occur and signatures are obtained x 3 months. Drills will be taken to QAPI for review for the next 3 months.

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