Nursing Investigation Results -

Pennsylvania Department of Health
CLIVEDEN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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CLIVEDEN NURSING AND REHABILITATION CENTER
Inspection Results For:

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CLIVEDEN NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint completed on November 30, 2021, it was determined that Cliveden Nursing and Rehabilitation Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.



 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on review of clinical records, and review of facility policies and procedures, it was determined that the facility failed to promptly notify a resident's representative following an emergency hospital transfer for one of four residents reviewed (Resident R1).

Findings include:

Review of facility policy titled, "When any of the following instances occurs, the resident's responsible party or guardian will be notified, -The resident is transferred to the hospital emergency room and/or admitted for care. The nurse must document the name of the person notified, the date and the time in the nurse's note. Any pertinent comments made by this person should be documented. If official notification has not occurred by the end of a shift the next shift will continue to try to reach the family and the resident will be placed on the 24-hour report. The resident will remain on report until official notification occurs and is documented in the nurses note."

A review of Resident's R1's Minimum Data Set (MDS- periodic review of care needs) dated September 16, 2021 revealed that the resident had a BIMS (Brief Interview for Mental Status-a screening assessment to aid in in determining cognitive impairment) score of 12 which indicated that the resident had moderatly impaired cognitive status.

Review of clinical record revealed that Resident's mother was listed as primary resident contact, following resident and his aunt.

Review of nursing notes for Resident R1 stated September 27, 2021 revealed that the resident was transferred to the hospital via 911 emergency transport for a change in condition.

Review of clinical record for Resident R1 dated September 27, 2021 revealed no evidence that the staff contacted resident representative or attempted to contact resident representative to notify emergency hospital transfer for Resident R1. The clinical record also did not include a reason for not contacting the resident representative for the shift or the following shift.

Review of nursing note dated September 28, 2021 revealed that the resident representative was contacted via phone and was upset about the lack of notification about Resident R1's hospital transfer.

28 Pa. Code: 211.5(f)(g) Clinical records.

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





 Plan of Correction - To be completed: 01/12/2022

Plan of Correction for F tag 0580
Step 1. .... Resident R1 was transferred to the hospital and has not returned to the facility.
Step 2......An audit was conducted for all residents who were transferred to the hospital to verify responsible party notification was completed.
Step 3.... Licensed Nursing staff have been reeducated on the importance of notifying the responsible party for any resident transferred to the hospital.
Step 4....... DON/Designee will audit residents' records to confirm notification of the responsible party for any resident transferred to the hospital. Audits will be conducted weekly X 4 weeks, Biweekly X 2 and Monthly X 2. Results of audits will be submitted to QAPI committee for review.
Completion date is 1/12/2022.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on the review of clinical records, observations and staff interviews, it was determined that the facility failed to provide services necessary to prevent complications related to the use an indwelling urinary catheter for two of four residents reviewed (Resident R1 and Resident R2)

Findings include:

Review of a facility policy entitled; "Care and Maintenance of Foley Catheter" (is a thin, flexible tube placed in the bladder to drain urine), dated December 9, 2003, revealed that "Gently cleanse the external meatus with soap and water, with am (morning) and pm (evening) care and prn as needed including outside of the catheter."

Review of guidelines provided by CDC ( The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States.) available at https://www.cdc.gov/infection/guidelines/cauti/recommendations.html revealed that " III. Proper Techniques for Urinary Catheter Maintenance: Maintain unobstructed urine flow.
1.Keep the catheter and collecting tube free from kinking. (Category IB)
2.Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate"

Review of clinical record for Resident R1 dated September 11, 2021 revealed that the nurse was called to room by resident with a complaint of " not able to urinate" resident requested a " foley urinary catheter." Resident was noted with abdominal distension and abdomen hard on palpation. Physician was notified and a foley urinary catheter was inserted. An initial urine output of 500 ml of urine and continued drainage of 600 ml of urine was documented.

Review of Resident R1's September 2021 physician orders and Treatment Administration Record (TAR) revealed no evidence that the facility obtained a physician order for the care of urinary catheter from September 11, 2021 to September 14, 2021. There was no documented evidence that the routine urinary foley care was provided for Resident R1 from September 11, 2021 to September 14, 2021.

Further review of physician orders for Resident R1 dated September 15, 2021 revealed that an order was obtained for "Foley catheter care every shift".

Review of TAR for the month of September 2021 revealed no documented evidence that the urinary foley catheter care was provided on the following nursing shifts: Night shift on September 16, 17, 18, 19, 21 and 22.
Day shift on September 19, 23 and 24.

Interview with Director of Nursing, Employee E2, on November 30, 2021 at 3:00 p.m. stated staff was expected obtain a physician order for care of urinary catheter every shift and document the completion in the TAR. Employee E2 confirmed that Resident R1's clinical record did not include a physician order for the care of urinary catheter from September 11, 2021 to September 14, 2021 and there was no documented evidence that the foley care was provided every for Resident R1 from September 11, 2021 to September 14, 2021. Employee E2 also confirmed that the there was no documented evidence that the foley catheter care was provided consistently from September 15, 2021 to September 27, 2021

Observation of Resident R2 on November 30, 2021 at 11:48 a.m. revealed that the resident had a urinary catheter device connected to a urinary drainage bag. The resident was observed in supine position (lying horizontally with the face and torso facing up). It was also observed that the urinary drainage bag was touching the floor matt.

Interview with the Nursing Assistant, Employee E5, on July 11, 2021 at November 30, 2021 at 11:48 a.m. confirmed that the drainage bag was above touching the floor.


28 Pa. Code 211.12 (c) Nursing Services

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

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





 Plan of Correction - To be completed: 01/12/2022

Plan of Correction for F tag 0690
Step 1. .... Resident R1 was transferred to the hospital and has not returned to the facility. Resident R2's urinary drainage bag was properly repositioned so that it was not touching the floor.
Step 2.... An audit was completed for all residents with Foley, to verify that the physician's orders included catheter care. All resident with Foley's were assessed to ensure drainage bags were not touching the floor.
Step 3.... Reeducated Licensed Nursing staff on the requirement for physician orders for catheter care for all residents with a Foley. Nursing staff were educated on keeping the Foley catheter bag from touching the floor.
Step 4....... DON/ Designee will audit Foley catheter care orders and proper placement of Foley bag weekly X 4 weeks, Biweekly X 2 and Monthly X 2. Results of audits will be submitted to QAPI committee for review.
Completion date is 1/12/2022.


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