Nursing Investigation Results -

Pennsylvania Department of Health
OIL CITY HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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OIL CITY HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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OIL CITY HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on January 30, 2020, it was determined that Oil City Healthcare 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.


 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 but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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(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, review of facility policies and staff interviews, it was determined that the facility failed to maintain infection control practices in the kitchen during food service in the main kitchen.

Findings include:

The "Hand Washing" policy, dated 11/19/19, revealed "each employee will wash his or her hands to eliminate visible dirt and reduce the bacterial load...(j) after handling or removing trash, (k) anytime hands are soiled..."

Observations on 1/27/20, from 12:00 p.m. to 12:30 p.m. revealed that the Dietary Manager and the Cook both touched the lid of the garbage can and proceeded to put on gloves without first washing their hands. At the time of the observations, the Dietary Manager confirmed that hands should be washed before putting on gloves.

28 PA Code 211.6(f) Dietary services















 Plan of Correction - To be completed: 03/24/2020

No residents were affected.
The Director of Education/ Infection Control Coordinator will educate all dietary staff on "Hand Washing" policy.
The Director of Education/Infection Control Coordinator will randomly audit dietary staff for hand washing two times a week for one week, one time a week for two weeks and then once a month for one month.
Results of the audits will be reported to the Quality Assessment and Assurance Committee monthly for two months for further review and recommendations.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on observations, review of clinical records and staff interviews, it was determined that the facility failed to update skin/pressure ulcer, activities of daily living, and fall care plans for four of 23 residents reviewed (Residents R12, R32, R35 and R53).

Findings include:

Resident R12's clinical record revealed an admission date of 10/16/19, with diagnoses that included diabetes, heart failure, high blood pressure and a right hip fracture.

The "Wound Evaluation Flow Sheet" form dated 1/02/20, revealed that Resident R12 had developed an open area on the right outer ankle.

There was no documented evidence that the skin care plan had been updated to include the identified new open area for Resident R12.


Resident R35's clinical record revealed an admission date of 7/02/19, with diagnoses that included heart failure, anxiety and a left hip contusion and fracture.

The "Wound Evaluation Flow Sheet" form dated 12/12/19, revealed that Resident R35 had developed an open area on the left heel.

There was no documented evidence that the skin care plan had been updated to include the identified new open area for Resident R35.

During an interview on 1/29/20, at 2:00 p.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed that skin care plans for Residents R12 and R35 had not been updated to reflect the new open areas.


Resident R32's clinical record revealed an admission date of 12/27/18, with diagnoses that included stroke, high blood pressure, seizures, and weakness.

Resident R32's clinical record revealed a physician's order dated 10/28/19, for an abductor wedge (device to keep legs apart) between knees and splint to left knee when he/she is in bed and up in his/her chair. A physician's order dated 11/07/19, for a left lateral body support in his/her wheelchair, and foot buddy (foot rest device) to high-back wheelchair at all times, and a physician's order dated 11/08/19, to use a Sara lift (a type of mechanical lift used to assist people who are able to partially support themselves for transferring from one surface to another) for all transfers.

Resident R32's care plans did not identify the use of the interventions of the abductor wedge, left knee splint, left lateral body support, foot buddy, high-back wheel chair, and Sara lift.

Observation on 1/27/20, at 3:05 p.m. of Resident R32 sitting up in his/her wheel chair with the left lateral body support, left knee splint, and knee wedge in place.

During an interview on 1/29/20, at 12:00 p.m. the RNAC confirmed that Resident R32's care plans were not updated to include the above interventions.


Resident R53's clinical record revealed an admission date of 6/10/19, with diagnoses that included diabetes and was dependant on renal dialysis.

A physician order, originally dated 1/21/20, revealed that Resident R53 was ordered contact isolation (precautions to assist in the containment of an infection) for an infection.

Resident R53's care plans lacked evidence to indicate that the physician ordered isolation precautions were on the care plans.

During an interview on 1/30/20, at 1:37 p.m. the Director of Nursing confirmed that Resident R53's care plan was not updated to include the contact isolation precautions ordered by the physician.

28 PA Code 211.5(f) Clinical records
Previously Cited 12/07/18

28 PA Code 211.12(d)(1)(3)(5) Nursing services
Previously Cited 12/07/18















 Plan of Correction - To be completed: 03/24/2020

Residents R12, R32, R35, and R53 suffered no negative outcomes. Resident R12 skin care plan was updated, R35 skin care plan updated, R32 activities of daily living care plan updated and R53 isolation order has since been discontinued.
An audit of all residents with pressure ulcers, adaptive equipment and falls will be reviewed by the Resident Assessment Coordinator to ensure the accuracy of interventions and will be revised as needed.
The Resident Assessment Coordinator will be in-serviced by the Director of Nursing or/designee on updating care plans timely to accurately reflect resident interventions.
The Resident Assessment Coordinator will update care plans each business day during morning start up meeting with any new orders/change in condition to accurately reflect interventions. The Director of Nursing or/designee will monitor care plans for accuracy each business day for one week, twice a week for two weeks, then once a month for one month. The results will be reported to the Quality Assessment and Assurance Committee monthly for two months.

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 review of facility policies and staff and resident interviews, it was determined that the facility failed to include the resident in the care plan interdisciplinary meetings for one of 23 residents (Resident R21).

Findings include:

The "Care Plans, Comprehensive Person-centered" policy, dated 11/19/19, revealed that " (1) the Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident and (5) the resident will be informed of his or her right to participate in his or her treatment and (6) an explanation will be included in the residents medical record if the participation of the resident and his/her resident representative for developing the resident's care plan is determined to not be practicable."

The Annual Minimum Data Set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care needs), dated 11/12/19, revealed that Resident R21 was alert and oriented.

During an interview on 1/28/20, at 9:57 a.m. Resident R21 disclosed that he/she did not think they were invited to a care plan meeting.

There was no evidence to show that Resident R21 was invited to the care plan meetings.

During an interview on 1/30/20, at 10:45 a.m. the Social Worker (SW) identified that Resident R21's family does not attend the meetings, therefore Resident R21 was not asked to attend. The SW additionally confirmed that he/she was the only member of the IDT who attended Resident R21's meeting.

28 PA Code 211.11(e) Resident care plan










 Plan of Correction - To be completed: 03/24/2020

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

Resident R21 suffered no negative outcomes.
The Social Service Director will invite/ include individual residents to his/her care plan meetings.
The Social Service Director will have the resident sign the care plan meeting sign-in sheet for either, refusal to attend, or for verification of his/her attendance as evidence to show his/her invitation to care plan meetings.
The Director of Nursing/Designee will audit the care plan sign-in sheets to ensure that residents were invited to care plan meeting, one time a week for three weeks and conclude with once a month for one month. The results of the audit will be reported to the Quality Assessment and Assurance for review and recommendations.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to document the monitoring of oxygen saturation (measurable balance of oxygen in the blood) while ordered oxygen for one of 23 residents (Resident R35).

Findings include:

The "Admission Record" revealed that Resident R35 was admitted to the facility on 7/02/19, with diagnoses that included heart failure, pneumonia and stomach problems.

A physician order, originally dated 7/02/19, identified to check oxygen (O2) saturation levels every shift.

Resident R35's January 2020 "Treatment Administration Record" (TAR) revealed that O2 saturation levels to be checked every shift were not documented for 13 of 87 opportunities from 1/01/20, through 1/29/20.

During an interview on 1/30/20, at 9:56 a.m. the Director of Nursing confirmed that Resident R35's oxygen saturation levels were not all documented on the January 2020 TAR.

28 PA Code 211.5(f) Clinical records
Previously cited 12/07/18

28 PA Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 12/07/18






 Plan of Correction - To be completed: 03/24/2020

Resident R35 suffered no negative outcomes.
The Clinical Director of Education will educate all nursing staff on the documentation of monitoring of oxygen saturation in the "Treatment Administration Record".
The Assistant Director of Nursing/designee will audit all residents with orders for oxygen saturation each business day for one week, twice a week for two weeks, then once a month for one month.
The Assistant Director of Nursing/designee will report the results of the audit to the Quality Assessment and Assurance Committee for the review and recommendations.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a comprehensive care plan for dialysis services was developed for two of 23 residents reviewed (Residents R53 and R60).

Findings include:

An admission Minimum Data Set (MDS-a federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessment for Resident R53, dated April 29, 2019, revealed diagnoses that included kidney failure requiring hemodialysis (a process of cleaning the blood of a person whose kidneys are not working normally).

There was no comprehensive care plan regarding care and services for dialysis services for Resident R53.


Resident R60's admission MDS dated December 21, 2019, revealed diagnoses that included kidney failure requiring hemodialysis.

There was no comprehensive care plan regarding care and services for dialysis services for Resident R60.

During an interview on 1/29/20, at 2:00 p.m. the Registered Nurse Assessment Coordinator confirmed that Residents R53 and R60 did not have comprehensive care plans developed regarding their dialysis services.

28 PA Code 211.11(d) Resident care plan







 Plan of Correction - To be completed: 03/24/2020

Resident R53 and R60 suffered no negative outcomes. Resident R53 and R60 comprehensive care plan regarding care and services for dialysis was developed.
An audit of all current residents receiving dialysis will be reviewed by the Resident Assessment Coordinator to ensure the comprehensive care plans for dialysis were developed.
The Resident Assessment Coordinator will be in-serviced by the Director of Nursing or/designee on timely development of comprehensive care plans for dialysis services.
The Resident Assessment Coordinator will review all new admissions for dialysis services and develop a comprehensive care plan after completion of the comprehensive assessment. The Director of Nursing/Designee will monitor the development of dialysis care plans each business day for one week, twice a week for two weeks, the once a month for one month. The results will be reported to the Quality Assessment and Assurance Committee monthly for two months.

483.20(g) REQUIREMENT Accuracy of Assessments:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care needs) assessments accurately reflected the discharge status of two of 23 residents reviewed (Residents R69 and Closed Record [CR] Resident R83).

Findings include:

The admission MDS, dated 10/30/19, revealed that Resident R69 was admitted to the facility on 10/23/19, and the Discharge Assessment-return not anticipated, Section A2100, dated 12/14/19, revealed that Resident R69 was discharged to an acute hospital.

A nurses note, dated 12/14/19, by Registered Nurse Employee E1 revealed Resident R69 was "discharged home with wife and son."

During an interview on 1/30/20, at 9:45 a.m., the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident R69's discharge MDS was coded incorrectly.


Resident CR83's clinical record revealed an admission date of 11/12/19, and documentation identifed a discharge date of 12/05/19, and went home with his/her spouse.

Resident CR83's discharge MDS dated 12/02/19, Section A2100 indicated that he/she was discharged on 12/05/19, to the acute care hospital.

During an interview on 1/30/20, at 9:45 a.m. the RNAC confirmed that Section A2100 of the discharge MDS dated 12/02/19, was coded incorrectly for Resident CR83.

483.20(g) Previously cited deficiency 12/07/18

28 PA Code 211.5(f) Clinical records
Previously Cited 12/07/18

28 PA Code 211.12(d)(5) Nursing services







 Plan of Correction - To be completed: 03/24/2020

I hereby acknowledge the CMS 2567-A, issued to OIL CITY HEALTHCARE AND REHABILITATION CENTER for the survey ending 01/30/2020, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

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