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:

There are  127 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.
CLIVEDEN NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey and Civil Rights Compliance Survey, and an Abbreviated survey in response to two complaints completed on January 17, 2020, it was determined that Cliveden Nursing & Rehabilitation Center, 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:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observations, interviews with staff, and a review of facility policies, it was determined that the facility did not ensure that food was stored in accordance with professional standards for food service safety.

Findings include:

A review of facility policy "food storage," dated January 17, 2019, revealed that leftover food is used within five days or discarded.

Observation on January 14, 2020, at 9:25 a.m. revealed leftover cooked rice in a refrigerator in the facility's main kitchen that was dated January 6, 2020, and was beyond the five day use date.

Observation on January 16, 2020, at 12:05 p.m. of the facility's emergency food storage area revealed the following: six 430 ounce pouches of tuna fish marked best if used by August 16, 2019, and six harvest pudding cans weighing six pounds each marked best if used by October 2017.

Interview on January 16, 2020, at 12:10 p.m. with Employee E6, Dietary Director, where he confirmed the above mentioned findings.

The facility failed to store food in accordance with professional standards for food service safety.


28 Pa. Code 201.18(b)(3) Management
Previously cited 07/31/19

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited 07/31/19

28 Pa. Code 211.6(c) Dietary services






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

Dietary staff discarded the rice and tuna fish which were kept past expiration.
Other food items were viewed to ensure that there was no other expired food in the kitchen.
Dietary staff educated on the facility policy related to food storage and the proper time frame for discarding expired food to ensure that the problem does not reoccur. Dates will be checked daily prior to kitchen closing.
Food Service Director/ Assistant or designee will audit food storage daily x 3 months to ensure that there is no expired food in storage area or refrigerator. Results of audit to be presented to Administrator at QAPI monthly to ensure ongoing compliance.

483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning 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.
483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Observations:


Based on the interview with resident and staff, review of clinical records and facility policies, it was determined that facility failed to ensure that resident or resident representative were afforded the opportunity to participate in their care planning process for one resident of 34 residents reviewed. (Resident R148)

Findings include:

Review of the facility policy, "Person Centered Care Planning", dated October 2019 revealed "The social worker/designee will invite residents/responsible parties to the care conferences. Accommodations will be made as needed to enable resident/responsible party participation i.e., time/date change, phone conference, etc." Further review of the policy revealed that "A schedule will be prepared by the Registered Nurse Assessment Coordinator for each resident for the completion of the assessments and person-centered comprehensive care plans within the required time frame. The review can be for initial, quarterly, annual and significant change reasons. All assessments and care plan updates must be completed prior to the care plan review."

Review of the clinical record for Resident R148 revealed that the resident was admitted to the facility on April 11, 2019 with diagnosis including but not limited to chronic obstructive pulmonary disorder (a group of lung disease that block the airflow and make it difficult to breathe) and major depressive disorder. Review of Minimum Data Set (MDS-periodic assessment of resident care needs) assessement for dated December 30, 2019 revealed that the resident's cognitive skills for daily decision making was intact.

Interview with the Resident R148 on January 15, 2020 at approximately 9:33 a.m. stated he was not invited and/or included for his care plan meetings and he was not aware that he could participate in his care plan meetings.
Review of the clinical record for Resident R148 revealed no evidence that the resident or resident responsible party were invited for the care plan meetings.

Interview with the social worker, Employee E12 on January 17, 2020 at approximately 10:30 a.m. confirmed that, there was no evidence in the clinical record or facility record that the resident or resident responsible party were invited for the care plan meeting.

The facility failed to ensure that Resident R148 was afforded the opportunity to participate in their care planning process.

28 Pa. Code 211.11(c) Resident care plan

28 Pa. Code 211.11(e) Resident care plan
Previously cited 07/31/19








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

Resident R148 care conference was held, resident and responsible party invited and participated on Jan 30th.
Care Conference Schedule for all other residents audited to ensure that a care conference invite was sent to resident and responsible party and that care conference is held.
Social Services educated by Administrator and Regional Nurse Manager to follow the care conference schedule and send invites to resident and responsible party at least 1 week prior to the meeting. If no answer is received a follow up phone call will be made and documented.
Medical Records or designee will audit the care conference schedule weekly x 3 months to ensure that resident and responsible parties are invited to care conferences. Results of the audit will be reported at QAPI monthly to the Administrator to ensure ongoing compliance.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

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 interview with facility staff and review of facility documentation, it was determined that the facility failed to notify an incident sustained by a resident while on leave of absence resulting in a fracture to the State Department of Health for one of 34 residents reviewed. (Resident R148).

Findings include:

Review of Resident R148's nursing notes dated December 12, 2019 at 10:22 p.m. revealed that the resident went over to his daughter's house and argued with her over some missing money from his bank. Daughter stated to the facility staff that the resident grabbed a kitchen knife and attacked her, which resulted him to fall with his leg twisted. Resident R148 was transported to the hospital via Emergency Medical Services 9-1-1 from his daughter's house.

Review social service note for Resident R148 dated, December 20, 2019 at 4:00 p.m. revealed that the social worker spoke to resident's daughter about the argument about the missing money from his bank. She stated the resident pulled a hammer and covered it with a bag and tried to swing at her which resulted in resident falling. The daughter also stated that resident's brother, who is the resident's Power of Attorney), witnessed the incident and did not do anything while the incident occurred.

Review of the progress note for Resident R148 dated, December 13, 2019 at 10:59 p.m. revealed that the resident was admitted to the hospital with the diagnosis of right femur fracture.

Interview with Nursing Home Administrator, on January 16, 2020 at approximately 11:00 a.m. confirmed that the facility did not report to the State Department of Health Resident R148's injury while on leave of absence from the facility on December 12, 2019 to Pennsylvania Department of Health as required.

The facility failed to report an incident sustained by Resident R148 while on leave of absence which resulted in a right femur fracture to the Pennsylvania Department of Health.


42 CFR 483.12(c)(1) Reporting alleged violations
Previously cited 7/31/19

201.14. (c) Responsibility of licensee.
Previously cited 7/31/19

201.18(b)(3) Management










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

Event report for incident involving resident R148 was submitted to dept of health
Other facility incidents for last 30 days reviewed and audited to determine if they should also be submitted to Department of health event reporting site.
Administration and Department Head team/ Supervisors in serviced Regional Nurse Manager on code 483.12(c)(1)(4) Reporting of alleged violations to ensure understanding of the policy. Each facility incident will be reviewed daily to determine whether or not it warrants an event report to DOH.
Administrator or designee will audit facility incident reports weekly x 3 months to ensure that proper reporting occurs. Results of the audit will be reported at QAPI monthly to ensure ongoing compliance.

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 observations, staff interviews, and a review of clinical records, it was determined that the facility failed to obtain, follow, and or clarify physician's orders regarding wound care for two of 34 residents reviewed. (Residents R62 and R415)

Findings include:

Review of facility policy, "Wound Prevention & Maintenance Guidelines," dated last revised "12/12" revealed that the resident would be assessed for skin integrity by the licensed nurse on readmission to the facility; that the licensed nurse would document in the Nursing Admission Assessment the skin condition for the resident; and that all dressings applied to resident would be labeled with date, time and initials of the nurse who performed the treatment.

Review of Resident R 62's clinical record revealed the resident was admitted to the facility on April 26, 2018, and the resident's diagnosis included malignant neoplasm (cancerous tumor) of right lower limb.

Review of January 2020 physician's orders for wound care for Resident R62's right heel revealed that an order for the application of a skin protectant- no-sting barrier to peri-wound daily.

Observation conducated on January 17, 2020, at 10:00 a.m. of wound care treatment to Resident R 62 revealed licensed nursing staff, Employee E3, did not apply the skin protectant- no-sting barrier to the peri-wound on the resident's right heel as indicated per the physician's orders.


Review of the clinical record for Resident R415 revealed the resident was readmitted to the facility on January 10, 2020, with diagnoses including, but not limited to, recent abdominal surgery and urinary incontinence (inability to voluntarily pass or hold urine).

Review of the Admission Nursing Evaluation dated January 10, 2020, indicated Resident R415 was noted with an abdominal surgical incision.

Review of faciilty documentation in the clinical record for Resident R415, dated January 10, 2020, revealed the resident was noted with the abdominal surgical incision as indicated in the Admission Nursing Evaluation, along with a wound located on the resident's sacrum (low back area).

Observation during dressing change of Resident R415's sacral wound on January 16, 2020, at approximately 10:15 a.m., with Employee E9, Licensed Practical Nurse, revealed that along with the documented sacral wound and abdominal wound, there was a white gauze dressing observed that was affixed to the resident's right ischial area (hip/upper thigh area) that was unlabeled, undated and uninitialed. Observed on the resdient's lower back area was an opaque flexible dressing applied directly over the spine which was unlabeled, undated and uninitialed. Additionally, there was a white gauze dressing covered with transparent tape that was affixed to the resident's right clavicle area (collarbone) that was also unlabeled, undated and uninitialed.

Further observation of Resident R415's skin was conducted on January 16, 2020, at approximately 10:30 a.m., in the presence of Employee E10, Wound Care Nurse, and licensed nursing staff, Employee E11. Interview with Employee E10 at the time of the observation revealed Employee E10 had changed Resident R415's sacral dressing the previous day (January 15, 2020), and stated at that time, the resident did not have a dressing in place on the right ischial area, but did have the dressings in place on the spine and the right clavicle and stated, "[Resident R415] had those dressings [spine and right clavicle] when he came back from the hospital."

Further review of the clinical record for Resident R415 revealed no physician's orders for dressings to the right ischial area, lower back area, and right clavicle areas.

Interview with Employee E11 on January 16, 2020, at approximately 11:00 a.m. confirmed there were no physician's orders for dressings to be applied to Resident R415's right ischial area, lower back area, and right clavicle areas.

The facility failed to follow and obtain physician orders regarding wound care.

CFR(s): 483.25 Quality of Care
Previously cited 07/31/19

28 Pa. Code 211.10(d) Resident care policies
Previously cited 07/31/19

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 07/31/19

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 07/31/19








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

Employee applied the skin protectant to resident R62's right heel. Dressings on Resident R415's lower back and right clavicle where removed. no skin breakdown was present in those areas therefore no order were necessary. A Physicians Order was obtained for R Ischial area skin impairment.
Facility has completed skin assessments on current residents to ensure that dressings observed have physician orders and are signed and dated.
Nursing Staff to be in serviced ADON or designee on the following Treatment Orders and ensuring that orders are received for any dressing that are utilized. ADON or designee will review during weekly wound rounds.
Director of Nursing, Unit Manager or designee will audit TAR's weekly x 3 months to ensure that treatments are administered according to physicians orders. Treatment administration observations will be conducted by the ADON/ Designee weekly x 3 months. Results of audit to be reported to Administrator at QAPI monthly to ensure ongoing compliance.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on a review of clinical records and staff interviews, it was determined that the facility failed to ensure that residents with limited range of motion received appropriate treatment and services for one of 34 residents reviewed (Resident R62).

Findings include:

Review of Resident R62's clinical record revealed the resident was admitted to the facility on April 26, 2018, and the resident's diagnosis included cerebral infarction (an area of necrotic tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain).

Resident R62's clinical record revealed a physical therapy referral to restorative nursing program for transfers and active range of motion (AROM) which included the following: AROM x 30 repetitions to bilateral lower extremities and transfer supine to and from sitting position 5x with bedrails for assistance.

Review of Resident R62's clinical record revealed no documented evidence that the restorative nursing program had been initiated.

Interview on January 16, 2020, at 10:20 a.m. with Employee E4, Rehabilitation Director, where he confirmed the above mentioned restorative program was referred back in March 25, 2019, when the resident's physical therapy sessions were discontinued and he confirmed that the same restorative program would be the same one utilized to the present date.

Interview with the administrator on January 17, 2020, at 9:00 a.m. where he confirmed there was no documented evidence Resident R62's restorative program had been initiated as outlined from Rehabilitation.


28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
Previously cited 7/31/19

28 Pa. Code 201.18(b)(2) Management
Previously cited 7/31/19

28 Pa. Code 211.10(d) Resident care policies
Previously cited 7/31/19
























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

Resident R62 was evaluated by Physical Therapy and continues to receive therapy treatment.
Facility has reviewed recommendations for Restorative Nursing Program and also the Functional Maintenance Program to ensure that current residents who have a recommendation for RNP are receiving it.
Therapy staff educated by Administrator or designee on the proper order content for Restorative Nursing Programs. Therapy will only write for Restorative Nursing Program and communicate with the RNP coordinator.
RNAC or designee will audit the RNP program recommendations weekly x 3 months to ensure that anyone who had an RNP recommendation did indeed have the program initiated. Results of the audit to be reported to Administrator at QAPI monthly to ensure ongoing compliance.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

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

Based on review of facility documentation and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable and at appetizing temperatures, for nine of nine residents interviewed (Residents R15, R50, R88, R90, R95, R104, R109, R122 and R159).

Findings include:

During the initial tour of the third floor nursing unit on January 14, 2020, at 10:15 a.m. Resident R104 communicated to the surveyor that the food tray brought to his room was served cold when the food was supposed to be served hot and on January 14, 2020, at 10:40 a.m. Resident R109 also indicated that the food tray brought to her room was cold.

During a group interview conducted on January 15, 2020, at approximately 11:15 a.m., with of seven alert and oriented residents (Residents R15, R50, R88, R90, R95, R122, R159) revealed that the food served by the facility to residents who chose to eat in their rooms was "always cold, especially on Saturdays and Sundays."

Review of Resident Menu Review Committee meeting minutes revealed on "12/19 [December 2019]," in response to the question of food temperatures ("Are the hot foods hot and the cold foods cold?"), the response from six residents (identified on the minutes by first name only) at the Menu Review Committee was, "yes except on weekends," and that, "nursing takes too long to pass food trays." Further review of the Menu Review Committee meeting minutes for December 2019 revealed the facility's action to be taken was to review tray times with nursing staff.

Review of Resident Menu Review Committee meeting minutes revealed on January 7, 2020, in response to the question of food temperatures, the response from 14 residents (no names identified on the minutes and no documentation of a resident list) at the Menu Review Committee was, "trays sit long on flr [floor] on weekends." Further review of the Menu Review Committee meeting minutes for January 7, 2020, revealed the facility's action to be taken was to work with nursing to move trays quicker on weekends.

Interview with Employee E6, Dietary Director on January 17, 2020, at 11:30 a.m. revealed that the facility's process for serving meals to residents who eat in their rooms was dietary staff would prepare and send the trays up to each nursing unit in a food cart, and then it was the nursing staff's responsibility to check each tray for accuracy and then serve the tray to each resident from the food cart. Further interview with Employee E6 on January 17, 2020, at 11:30 a.m. confirmed there was no documented evidence that dining staff reviewed the resident's food delivery concerns with nursing staff, or that any monitoring of food temperatures on Saturdays and Sundays was conducted by dietary staff in December 2019, and January 2020.

The facility failed to maintain appetizing and palatable food temperatures.

28 Pa. Code 201.18(b)(3) Management
Previously cited 07/31/19

28 Pa. Code 201.18(e)(1) Management
Previously cited 07/31/19

28 Pa. Code 211.6(c) Dietary services










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

Residents who stated they received cold food was offered for their food to be reheated or a new hot plate.
Current resident's trays will be tested to ensure that food temperatures were hot and food palatable. Special attention to be given to Saturdays and Sundays as cited in the 2567.
Dietary staff educated by Food Service Director to ensure that the hotplates are in use on the weekends. Nursing staff educated on the timely delivery of trays to ensure that food is delivered hot and palatable.
Food Service Director or designee will audit test tray temperatures 3 times x week for 3 months particularly on Saturdays and Sundays at the point of service on the floors to ensure that hot food temperatures are within acceptable range. Results of audit will be presented to Administrator at QAPI monthly to ensure ongoing compliance.

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:

Based on observations, clinical record review and staff interviews, it was determined that the facility failed to provide residents with assistive feeding equipment for one of 34 residents reviewed (Residents R48).

Findings include:

Review of Resident R48's clincial record revealed diagnoses including, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dysphagia (difficulty swallowing foods or liquids), glaucoma (group of eye conditions that damage the optic nerve, often caused by an abnormally high pressure in your eye), cataracts (clouding of the lens in your eye), and diabetes mellitus (a disease that affects the way the body processes blood sugar (glucose)).

Review of the nutritional assessment dated November 13, 2019, revealed an order for a good grip, built up spoon with all meals.

Observation on January 14, 2020, at 12:45 p.m. of Resident R 48 during the lunch meal service revealed the resident was attempting to eat her lunch with a disposable plastic spoon and not a good grip built up spoon as ordered by the physician.

Observations of Resident R48 on January 15, 2020 during the lunch meal revealed Resident 48 did not have a good grip, built up spoon. The resident was observed eating the lunch meal with a plastic, disposable spoon. Resident R48 was also observed picking up her fruit from a bowl with her fingers.

Interview on January 14, 2020, at 12:50 p.m. with Employee E5, Registered Dietician, where she confirmed the resident was ordered a good grip built up spoon and she confirmed the resident was eating with a plastic disposable spoon at the time of the observation.


The facility failed to provide Resident R48 with assistive feeding equipment.

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 07/31/19

28 Pa Code 211.12(d)(5) Nursing services
Previously cited 7/31/2019









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

Resident R48 was given the proper assistive feeding equipment a built up spoon.
Current residents with orders for feeding equipment reviewed to ensure that they have the proper utensils.
Dietary staff and nursing staff educated by Food Service Director or designee on the importance of residents having the proper equipment and checking the tray ticket to ensure that we follow the order for assistive feeding equipment to ensure that the problem does not reoccur.
Dietician and or designee will audit at least 3x a week x 3 months to ensure that the proper assistive feeding equipment is in use for residents with that order. Results of audit to be presented to Administrator at QAPI monthly x3 to ensure ongoing compliance.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:

Based on review of facility staffing documentation and interviews with staff, it was determined that the facility failed to meet the minimum number of direct nursing care hours per resident in each 24-hour period, for one of 21 days reviewed. (Augsut 31, 2019)

Findings include:

Review of nursing staffing schedules for three non-consecutive weeks provided by the facility from August 26, 2019 through September 1, 2019; November 25, 2019 through December 1, 2019; and January 10-16, 2020, revealed that on August 31, 2019, the facility's per patient day was 2.59 nursing hours per resident which was below the minimum 2.7 per patient care hours.

Interview with Employee E7, Staffing Coordinator, on January 17, 2020, at approximately 9:35 a.m. confirmed the facility's staffing on August 31, 2019, was 2.59 nursing hours per resident.

The facility failed to meet the State minimum of 2.7 nursing hours per resident for one of 21 days reviewed.










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

Staffing schedules will be reviewed 6 weeks in advance to anticipate coverage for vacations, vacancies and anticipated call outs. Staff will be scheduled in advance to ensure that the facility meets the state minimum of 2.7 nursing hours per resident.
Staffing will also be reviewed daily to ensure the number of hours are met. The facility staffing coordinator will call in PRN staff, agency, and/or nursing administration in order to have the appropriate number of hours coverage.
Staffing Scheduler and nursing supervisors educated on state minimum staffing levels and measures to maintain required staffing levels.
Director of nursing will audit ppd weekly x 3 months to ensure that staffing is meeting the state minimum requirements. Results of audit to be reported monthly at QAPI to Administrator to ensure ongoing compliance.


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