Nursing Investigation Results -

Pennsylvania Department of Health
GREEN RIDGE CARE CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GREEN RIDGE CARE CENTER
Inspection Results For:

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GREEN RIDGE CARE 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 February 12, 2020, it was determined that Green Ridge Care Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.25 REQUIREMENT Quality of Care:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§ 483.25 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 select facility policy and clinical record review and resident and staff interview, it was determined that the facility failed to follow a physician ordered bowel protocol, facility policy and the resident's care plan to promote adequate bowel activity, which resulted in increased pain and discomfort and diagnosed fecal impaction for one resident out of 19 sampled (Resident 81).

Findings include:

A review of the clinical record revealed that Resident 81 was admitted to the facility on September 7, 2018, with diagnoses to include constipation (according to the American Academy of Family Physicians primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week) and gastroparesis (a condition in which the stomach's motility slows down or doesn't work at all which in turn, prevents the stomach from emptying completely).

A review of the facility policy entitled "Bowel tracking Protocol" last reviewed by the facility January 2020, revealed that it is facility policy to record and monitor each resident's bowel movement to prevent impaction's (a hard mass of stool that gets stuck in the colon or rectum that can't be pushed out). A Bowel Movement Worksheet is maintained by staff and tracked according to size and if no bowel movement, staff are instructed to enter 0. Further review of the policy revealed if a resident has not had a bowel movement by the third day, nursing will implement the bowel protocol.


Review of the resident's care plan initiated on November 29, 2018, to address at risk for constipation related to decreased mobility, medication use and chronic constipation related to diabetic gastroparesis called for interventions to include: administer medications as ordered, resident to have a BM at least every three days, bowel protocol per prn (as needed) orders, monitor constipation and causes, record each bowel movement and assess pattern of bowel movements.

Medications and preventative measures ordered on February 15, 2019, for bowel management protocols included the following: Milk of Magnesia (a laxative given for constipation) 30 ml as needed for constipation on Day 2 if no bowel movement on 3 p.m. to 11 p.m. shift, Prune Juice as needed on Day 2 if no bowel movement on 7 a.m. to 3 p.m. shift, (a saline laxative inserted in the rectum to produce a bowel movement) 7-19 gm as needed for constipation on Day 5 if no bowel movement by 2 p.m.

A quarterly MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 18, 2019, revealed that Resident 81 was cognitively intact, required extensive assistance of staff for toileting, was always incontinent of bowel and had a history of constipation.

A review of physician orders dated for December 24, 2019, revealed that the resident was to receive Miralax (a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements and to treat occasional constipation or irregular bowel movements) 17 grams by mouth every day for constipation and Colace (a stool softener used to treat or prevent constipation, and to reduce pain or rectal damage caused by hard stools or by straining during bowel movements) 100 mg by mouth daily twice a day for constipation.

A review of Resident 81's December 2019, "Bowel Movement Record" revealed that the documentation indicated that the resident did not have a bowel movement for five days, from December 8, 2019, 7 a.m. to 3 p.m. shift to December 13, 2019, 3 p.m. to 11 p.m. shift.

A review of the resident's January 2020, "Bowel Movement Record" revealed that the documentation indicated that the resident did not have a bowel movement for eight days, from January 5, 2020, 3 p.m. to 11 p.m. shift to January 12, 2020, 11 p.m. to 7 a.m. shift.

A review of Resident 81's December 2019 and January 2020, Medication Administration Records (MAR), revealed that staff failed to followed the facility's bowel protocol and offer or administer the Prune Juice, Milk of Magnesia, Bisacodyl Suppository or Fleet Enema.

Further review of the January 2020, MAR revealed that Resident 81 refused the Miralax solution on January1, 2, 3, 6, 7 and 12, 2020.

There was no documented evidence that staff had implemented any bowel protocol measures when the resident had no bowel movements for more than three days according to facility policy, physician orders for Resident 81 and the resident's care plan.

During interviews with Resident 81, on February 10, 2020, at approximately 11:06 a.m. and on February 12, 2020, at approximately 10:55 a.m., the resident stated that "I had more pain down there (pointing to lower stomach) than usual and I told them, but they didn't do anything, then I went out to the hospital back in January of this year."

Review of a nursing progress note dated January 3, 2020, at 11:34 p.m. revealed that the resident had multiple loose stools with no other complaints.

Review of nursing progress notes dated January 12, 2020, at 1:22 p.m., revealed that the resident complained of nausea and was vomiting. The resident was sent to the ER for evaluation on that date and subsequently admitted.

On January 19, 2020, at 6:27 p.m., nursing documented that the resident was readmitted back to the facility on this date at 6:20 p.m. following a hospitalization.

Review of the hospital history and physical (H & P) dated January 12, 2020, revealed that resident was examined amid complaints of nausea and vomiting. The report indicated the resident had experienced dark brown vomitus and abdominal pain. While in the emergency department, the resident had a small bowel movement. Further review of the H&P revealed results from a CT Scan (computerized tomography - a diagnostic x-ray which produces different images, in more detailed, in the body) that identified a small bowel mal-rotation (a condition usually congenital \ involving the rotation and settling of the intestines). The scan also noted a mild to moderate fecal loading (the appearance of gas and fecal \ matter) of the colon and a more moderate fecal loading of the rectosigmoid (the portion of the colon that is located near the end of the large intestine) and correlate for fecal impaction (a solid, immobile bulk of feces that develops in the rectum as a result of chronic constipation).

Review of the hospital Consultation Report dated January 13, 2020, revealed the resident presented to the ER with abdominal pain, positive distention and 3-4 episodes of dark colored vomitus. Further review of the report indicated the resident reported having abdominal fullness and crampy pain since the past 7 to 10 days, progressively worsening. The resident also reported the pain at its worse as 7 out of 10, throughout the abdomen, but more pronounced over the epigastric region. Treatment plans while hospitalized included taking Miralax twice a day to facilitate more bowel movement to relieve the loading, and ordering Fleet Enemas daily.

Review of a physican's readmission progress note dated January 21, 2020, revealed that the resident had been readmitted from the hospital after admission for nausea and vomiting and was eventually diagnosed as fecal impaction.

During an interview on February 12, 2020, at approximately 10:19 a.m, the Director of Nursing and Corporate Registered Nurse confirmed that the physicians orders for the prescribed bowel protocols to promote adequate bowel activity were not followed by nursing staff for Resident 81 prior to the resident's hospitalization for treatment of a fecal impaction.

28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services
Previously cited 3/15/19

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

28 Pa. Code 211.11(d)(e) Resident care plan































 Plan of Correction - To be completed: 03/10/2020

Resident 81 bowel movement record / medications were evaluated by nurse practitioner.

To identify other residents that have the potential to be affected, the DON / designee will review documentation for the last 72 hours to ensure those residents that have not had a bowel movement have the bowel protocol implemented.

To prevent this from reoccurring, the DON / designee completed education with nursing staff on the bowel policy / facility bowel protocol and documentation of bowel movements.

To monitor and maintain ongoing compliance, the DON / designee will audit daily to ensure facility bowel protocol is being followed for 4 weeks, then monthly X 2 to ensure proper compliance. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. Date of compliance March 10, 2020


483.40(b)(3) REQUIREMENT Treatment/Service for Dementia: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.
§483.40(b)(3) A resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.
Observations:

Based on a review of select facility policy and clinical records, observation, resident and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address the dementia-related behavioral symptoms displayed by one resident out of three residents sampled with this care area (Resident 77).

Findings include:


A review of the clinical record revealed that Resident 77 was admitted to the facility on February 19, 2016, with diagnoses to include dementia. A quarterly Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated January 22, 2020, revealed that Resident 77 was severely cognitively impaired, with a BIMS score (brief interview for mental status- a tool to assess cognitive function) of 1 ( a score of 0-7 indicates severe cognitive impairment), required staff assistance with daily living activities, including ambulation and transfers and had wandering behaviors. The resident resided in room 303.

Current physician orders dated February 2020 included Seroquel (an antipsychotic medication) 25 mg by mouth in the AM and 50 mg at bedtime. A review of the corresponding behavior monitoring flow records dated September 2019 through February 2020 revealed that the targeted behaviors for the use of the Seroquel was "fighting."

A facility investigation report dated August 2, 2019, at 1:44 AM revealed that Resident 77 was found lying on the floor of her room next to her bed. The report indicated that "resident declines non-skid socks. The resident stated at the time of the fall that "I have to go to the pot." The facility's investigative report did not indicate the last time this resident was toileted to identify potential contributing factors and plan preventative care accordingly.

An investigative report dated August 12, 2019, at 9:31 PM indicated that Resident 77 was found lying on the floor in her room. The report indicated that her chair alarm did not sound to alert staff to unassisted transfers. The immediate intervention put into place after the fall was to apply a new alarm box to her wheelchair and for a therapy screen.

An investigation reported dated September 19, 2019, at 11:20 AM Resident 77 was found lying on her back in her bathroom. Her wheelchair alarm was sounding. The resident had wandered into her bathroom. The immediate intervention put into place at the time of the fall was to alarm the resident's bathroom door to alert staff of this resident's need for assistance.

A review of facility investigation reports dated October 20, 2019, at 9 PM revealed that Resident 77 was found on the floor in the middle of the 100 hallway between rooms 109 and 106. Corresponding nursing documentation dated October 20, 2019, at 10:15 PM revealed that at approximately 9 PM Resident 77 had an unwitnessed fall from her wheelchair in the 100 hallway. The nurse aide responded to Resident 77's chair alarm sounding. The resident was wearing both shoes and the brakes on her wheelchair were locked. Resident 77 was at the nurses station 5 minutes prior to the incident, as she propels independently in her wheelchair throughout the facility easily. The facility placed the resident on every 15 minute checks until post fall review meeting on Monday morning.

A facility investigative report dated October 27, 2019, at 1:23 PM revealed that Resident 77 was in another resident's room, room 300, when a nursing staff member went in to assist Resident 77 out of that room. Resident 77 became combative and reached out to the wooden assist rail near the wall and threw herself on the floor. The noted intervention was to place dycem ( a non skid material often placed under a wheelchair cushion to prevent sliding out of the chair). The facility's investigation continued to state that Resident 77 was confused and combative at the time of the incident.

A review of an employee witness statement dated October 27, 2019, (no time indicated) from Employee 4 (LPN) revealed that the employee stated "I was walking in the 300 hallway when I observed Resident 77 in room 300 shouting obscenities at the resident who resides at the door side of the room (Resident 77 resides in room 303). Immediately following removal from the room, Resident 77 reached for the wooden assist rail, lining the wall near room 300 and threw herself onto the floor, landing on her bottom." The immediate intervention to prevent future falls was to place dycem on top of and underneath the resident's wheelchair cushion.

A review of nursing documentation dated December 23, 2019, at 1:47 PM revealed that Resident 77 took an angel figurine and threw it at her roommate, hitting her in the legs. The facility conducted no further investigation into this incident to identify potential precipitating factors to the altercation.

A review of the every 15 minute checks conducted by the facility dated December 1, 2019 through December 23, 2019, revealed that the checks were consistenly conducted according to this incomplete documentation.

A review of a facility investigation report and nursing documentation dated January 5, 2020, at 6:45 AM revealed that Resident 77 was found in the main, resident bath/shower room, on the floor. The resident was found in the toilet area of the room with the left side of her head against the wall. When asked what happened, she said "mama come to me, mama please come to me." The resident unable to provide a description of the incident due to diagnosis of advanced Alzheimers disease. The floor was observed to be wet as the resident had become incontinent. No injuries were noted from this incident.

A review of the resident's resident care plan for this resident's problem of diagnosis of dementia with behavioral disturbances: combative with staff-punching, kicking, wandering in/out of other resident rooms, taking items out of other resident rooms. The care plan noted incidents, which had occurred on October 7, 2019, during which the resident punched another resident in the face and February 10, 2020, when the resident sustained a self-inflicted skin tear to her right elbow, as she was hitting her arm against doorways in the 300 hallway. The care plan goal was that the resident will remain free of signs and symptoms of distress and anxiety. The planned interventions included that if the resident is being disruptive to others, remove resident from the situation and attempt to calm her down, if she does not care to leave the room, offer to help her with what she is doing and then begin talking to her and then work towards leaving the room. If she enters a room nicely and politely, ask her to leave or ask her to come with you.

During an interview February 11, 2020, at approximately 1:30 PM Resident 36, a cognitively intact resident residing on the 100 hallway, stated that there is a stop sign across her bedroom doorway because Resident 77 constantly comes into her room uninvited. Resident 36 stated that the facility's nursing staff told her Resident 77 doesn't know any better and it is safer for her to not to yell at Resident 77 to leave her room, but just to wait for her to leave. Resident 36 stated that Resident 77 takes things from her room. She further stated that daily Resident 77 goes to the exit door located next to her bedroom door and bangs on the door and yells.
Resident 36 stated that she has been placing her bedside table in front of her closed bedroom door in an attempt to keep Resident 77 from entering the room at night. She stated that about 2 weeks ago, at 2:30 AM Resident 77 was in her room and touched her attempting to wake her up. Resident 36 was very upset over this incident and said that she told staff about Resident 77's behavior "many times."

An observation on February 11, 2020, at approximately 1:45 PM revealed that Resident 77 was observed in her wheelchair at the nurses station. The resident was yelling and appeared anxious. A nursing staff member brought Resident 77 to the main activity room to participate in the ongoing activity. Resident 77 was placed in the room behind a row of residents participating in the activity. Resident 77 was yelling and screaming. Employee 9 (activity aide) then removed Resident 77 from the activity room and left her in the hallway outside the main dining room by herself.

During an interview on February 11, 2020, at approximately 2:30 PM the Nursing Home Administrator confirmed that the activity aide should not have placed Resident 77 by herself in the hallway.

A review of the resident's monthly behavior monitoring revealed that the facility had not identified wandering and/or intrusive wandering as a targeted behavior. Nursing documentation dated November 2019 through February 2020 indicated that Resident 77 displayed wandering behaviors almost daily.

The facility failed to demonstrate the development and implementation of an individualized activities program including attempts to provide meaningful interaction, resident specific diversional activities and resident preferred individualized activities as approaches to deter the resident's intrusive wandering behavior.

The facility further failed to demonstrate the development and implementation of a person-centered, individualized plan designed to address, manage and/or mitigate the resident's dementia-related behavioral symptoms. The care plan developed by the facility in response to the resident's behavioral symptoms, included how to follow-up to the resident's intrusive wandering behavior (by retrieving other's belongings, checking the resident's room), but did not include the resident's specific preferences, past habits, personal history and/or daily routines that may be incorporated into meaningful and/or diversional activities for the resident.

There was no indication that the facility had developed and implemented individualized, non-pharmacological interventions to address the resident's intrusive wandering and unsafe dementia related behaviors to promote the quality of life of residents residing in the facility, Resident 77's highest practical level of psychosocial well-being and safety.

During an interview on February 12, 2020, at approximately 11 AM the Director of Nursing confirmed that the current care plan to address Resident 77's dementia related behavior was ineffective in modifying the resident's behaviors.



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

28 Pa Code 211.11(d) Resident care plan



























 Plan of Correction - To be completed: 03/10/2020

Resident 77 has been re-evaluated for the appropriate programs to individualize person-centered care.

To identify other resident with the potential to be affected, The DON / designee completed an audit on residents with dementia and severely cognitive impairment to ensure these residents have an individualized person centered care plan. Corrections will be made as needed.

To prevent this from reoccurring, the DON / designee completed education with staff on dementia and the importance of having an individualized person centered care plan to meet the needs of residents.

To monitor and maintain ongoing compliance the DON / designee will complete an audit 3X a weekly X4 weeks, then monthly X 2 to ensure the individualized person centered care plans are followed for those residents identified with dementia, severely impaired. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Date of compliance March 10, 2020


483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
§483.80(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 a review of facility's infection control policies and procedures and staff interview, it was determined that the facility failed to develop and implement an antibiotic stewardship program and failed to follow their procedure for antibiotic use for two residents (Resident 46 and 76) out of 19 sampled residents.

Findings include:

Review of the facility policy entitled "Antibiotic Stewardship Program Policy" last reviewed by the facility on July 19, 2019, revealed that the facility's infection prevention and control committee "will meet monthly to oversee the surveillance, investigation of, reporting, control, and prevention of infections within the facility; as well as monitoring/tracking of antibiotic prescribing, use, and resistance in order to promote a culture of optimal antibiotic use within the facility. Antibiotic stewardship will focus on improving antibiotic use by avoiding unnecessary or inappropriate antibiotics. The antibiotic stewardship program will be reviewed on an annual basis and as needed."

The antibiotic stewardship policy addressed the steps to be taken to promote antibiotic stewardship. However, the facility was unable to provide documented evidence that the program was operational and implemented into a functioning system to monitor the use of antibiotics.

During an interview with Employee 1 (Infection Control-Registered Nurse) on February 12, 2020, at 12:58 PM, Employee 1, stated that Resident 46 was prescribed Macrobid (an antibiotic) 100 mg, twice a day for 10 days, on December 20, 2019. The antibiotic was administered to the resident for five days. On December 25, 2019, the medication was discontinued, as the infection was resistance to the antibiotic, as per the culture and sensitivity results. Cipro (an antibiotic) 250 mg was ordered on December 25, 2019, twice a day for seven days. Employee 1, confirmed the antibiotic Macrobid should not have been administered until the laboratory results were reviewed.

During an interview with Employee 1 and the Regional Director of Clinical Services on February 12, 2020, at 12:58 PM, it was confirmed the facility failed to implement an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance.


483.80 (a)(3) Infection prevention and control program
Previously cited 3/15/19

28 Pa. Code 211.12 (c) Nursing services
Previously cited 3/15/19

28 Pa. Code 211.10(a)(d) Resident care policies
Previously cited 3/15/19









 Plan of Correction - To be completed: 03/10/2020

Resident 46 and 75 received no negative outcomes.

To identify other residents with the potential to be affected, the DON / Designee
Completed an audit of all antibiotics ordered to ensure they meet criteria. Negative findings will be corrected.

To prevent this from reoccurring, the DON /designee educated licensed staff and
Physicians on the antibiotic stewardship program.

To prevent this from reoccurring, the DON / designee will audit al antibiotic
orders 5X weekly, X 4 weeks and weekly X 2 months to ensure proper
documentation and testing is completed. The results of the audits will be forwarded to the
facility QAPI meeting for further review and recommendations.

Date of Compliance March 10, 2020

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on observations, staff interview and review of the facility's Infection Control Transmission Based Precautions policy, it was determined the facility failed to provide care in an environment that respects each resident's personal dignity and privacy as evidenced by random observations of four residents (Residents 17, 285, 135 and 59).

Findings included:

Review of the facility's policy entitled "Infection Control Transmission Based Precautions" last reviewed by the facility January 2020, indicated the facility's procedure for residents with infections will have a sign placed on the door frame of the resident's room indicating that visitors should stop at nurses station before entering.

During the initial tour of the facility on February 9, 2020, between 8:00 AM and 8:45 AM in room 300-D (Resident 17), 205-D (Resident 285) and 512-D (Resident 59) observations were made of signs on the resident's door frames which read, "contact precautions, gloves, gown, hand hygiene, supplies in cart below, see nurse with any questions."

An observation of room 518-D (Resident 135) revealed a sign at the residents door frame which read droplet precautions "maintain space more than three feet, mask, gowns, eye protection, see nurse with any questions."

During an interview on February 12, 2020, at 12:10 PM the Nursing Home Administrator confirmed that the signage should have directed visitors to the nurses station and should not have identified the specific precautionary procedures and PPE (personal protective equipment) required.



28 Pa Code 211.12 (c)(d)(1)(5) Nursing services
previously cited 3/15/19

28 Pa Code 201.29(j) Resident rights
previously cited 3/15/19








 Plan of Correction - To be completed: 03/10/2020

Preparation and submission of this Plan of Correction does not constitute an admission of or agreement with, it is required by State and Federal law. It is executed and implemented as a means to continuously improve the quality of care to comply with state and federal requirements.

Signs were removed and replaced with a sign stating "See Nurse" for Resident 17, Resident 285, Resident 59, and Resident 135.

To identify other residents that have the potential to be affected, the Don/designee completed an audit of resident door entrances to ensure proper signage. Negative findings will be addressed.

To prevent this from recurring, the DON / designee completed education with staff to ensure proper signage is in place.

To monitor and maintain ongoing compliance the DON / designee will complete audits 2X weekly X4 weeks, then monthly X 2 to ensure proper signage at door entrance. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

Date of compliance March 10, 2020


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

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

Based on observation, review of clinical records and select facility policy and procedures and resident and staff interviews it was determined that the facility failed to maintain an environment free of potential accident hazards by failing to secure medications to prevent resident access/misuse/mishandling

Findings include:


Review of policy and procedure entitled "General dose preparation and Medication Preparation," dated as reviewed by the facility January 2020, revealed, "Facility staff should only prepare medications for resident at a time and faciity staff should not eave medications or chemicals unattended and facility staff should ensure medication carts are always locked when out of site or unattended."

Observations on February 12, 2020, at 9:05 AM on the 400 hallway toward the 500 hallway, a medication cart was observed positioned along the right side of the hallway wall. There was no nurse and/or facility staff observed with the medication cart, although residents were present in the area. Continued observation revealed a syringe filled with approximately 40 units of insulin and 30 cc medication cup filled with approximately 15 cc to 20 cc of a dark colored red liquid. The medications were accessible to any mobile resident in the corridor/vicinity of the medication cart.

Observation revealed that Employee 2, a licensed practical nurse (LPN), was observed in resident Room 402 with his back towards the medication cart, which was across the hallway not in his line of vision. While standing a several feet away from the medication cart it remained unattended while the LPN remained in Room 402 administering medications to a resident.

Employee 3 (RN) was observed to walk by this surveyor, stop at the medication cart and dispose of the unattended filled insulin syringe and liquid medication. Employee 3 (RN) then placed the cart in front of the doorway of the room in which Employee 2 (LPN) was administering medications, placing the cart in his line of vision.

Interview with the NHA on February 12, 2020, at 1:30 PM confirmed that medications should not be left unattended on top of a medication cart.


28 Pa. Code 211.10 (d) Resident care policies

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














 Plan of Correction - To be completed: 03/10/2020

Employee 22 was educated on keeping all meds and med cart locked to ensure the safety of Residents.

To identify other potential accident hazards, all medication carts and med rooms were checked to ensure they were secured, negative findings will be corrected.

To prevent this from reoccurring, the DON / designee completed education on medication storage.

To monitor and maintain ongoing compliance the DON / designee will complete audits 5X weekly X4 weeks, then monthly X 2 to ensure all medication carts and rooms are secured.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Date of compliance March 10, 2020


483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

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

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

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

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

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

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


Based on a review of clinical records and manufacturer drug information and staff interview, it was determined the facility failed to clinically justify the necessity of antibiotic usage for one (Resident 76) out of 19 sampled.

Findings include:

A clinical record review revealed that Resident 76 was admitted to the facility on December 20, 2016, with diagnoses to include diabetes (elevated blood sugar), urinary retention (inability to empty bladder completely or partially of urine) and cerebral palsy (disorder affecting movement and muscle tone or posture).

A review of a quarterly minimum data set (MDS) assessment (Minimum Data Set assessment -a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 4, 2019, revealed that the resident's cognition was intact, that she required some assistance for activities of daily living (bathing dressing, toileting, etc) and had a foley catheter (a flexible tube that passes through the urethra and into the bladder to drain urine).

Nursing documentation dated Janaury 2, 2020, at 3:21 p.m revealed that the resident was confused saying random things. The CRNP (certified registered nurse practioner) ordered a a urinalysis and culture and sensitivity (a test to determine what type of micro-organism \ is found in the urine that causes an infection and the right medicine for treating the infection). At 5:17 p.m. on January 2, 2020, revealed that a nurse documented that the lab results were faxed and called to the provider and an order was obtained to begin Cipro (an antibiotic that fights bacterial infections) 250 mg twice a day for 5 days for a urinary tract infection (UTI).

A review of the final lab results report dated January 3, 2020, revealed that the culture and sensitivety report was received and suggested multiple flora (inability to determine if results are negative or positive of infection based on lack of bacterial identification) contamination or colonization (presence of bacteria on a body surface without causing illness in the person).

A review of the resident's Janaury 2020 medication administration record (MAR) revealed that Resident 76 received ten doses of the Cipro from Janaury 3, 2020, through Janaury 7, 2019.

Nursing documentation dated Janaury 21, 2020, at 12:57 p.m revealed that the resident was
lethargic, but responding easily to verbal stimuli earlier in shift, but later in shift was not. The CRNP ordered a urinalysis and culture and sensitivity. On January 21, 2020, at 3:14 p.m. a nurse documented that an order was obtained from the CRNP to begin Levaquin (an antibiotic that fights bacterial infections) 750 mg IV (delivery of fluid directly into a vein) every other day times three days for a UTI.

A review of the final lab results report dated January 23, 2020, revealed the culture and sensitivety report was received and again suggested multiple flora contamination or colonization.

A review of the resident's Janaury 2020 MAR revealed that Resident 76 received three doses of the Levaquin from Janaury 23, 2020 through Janaury 27, 2019.

During an interview May 16, 2019 at approximately 11:56 a.m., the Director of Nursing and Corporate Registered Nurse confirmed that the antibiotics were administered without identifying the micro-organism and that the source of the contamination (either at the facility or the laboratory) was not verified and/or considered prior to starting an identified antibiotic medication for a urinary tract infection.


28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
Previously cited 3/15/19

28 Pa. Code 211.9 (k) Pharmacy services.
Previously cited 3/15/19

28 Pa. Code 211.2(a) Physician services.
Previously cited 3/15/19

28 Pa. Code 211.5(f)(g) Clinical records.
Previously cited 3/15/19

28 Pa. Code 211.10(a) Resident care policies








































 Plan of Correction - To be completed: 03/10/2020

Resident 76 had no adverse reaction to the antibiotic.

To identify other residents that have the potential to be affected, the DON / designee competed an audit of antibiotics ordered to ensure proper documentation usage. Negative findings will be corrected.

To prevent this from reoccurring, the DON / designee completed with education with licensed staff and physicians regarding appropriate antibiotic usage and documentation required.

To monitor and maintain ongoing compliance the Director of Nursing / designee will complete an audit 5X a week X4 weeks, then monthly X 2 to ensure all antibiotics ordered have appropriate testing and documentation. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.


Date of compliance March 10, 2020




483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs: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)(3) Food prepared in a form designed to meet individual needs.
Observations:



Based on observation, clinical record review and staff and resident interview, it was determined that the facility failed to provide food in a form that meets a resident's individual assessed needs for one of 19 residents sampled (Resident 50).

Findings include:


Clinical record review revealed that Resident 50 was admitted to the facility on November 11, 2019, with diagnosis to include diabetes.

A significant change minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 13, 2019, revealed that the resident was moderately, cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status - a tool to assess cognitive status, a score of 8-12 indicates moderate cognitive impairment). It was noted that the resident held food in her mouth or cheeks and had no teeth.

A review of the resident's current physician orders and plan of care, initially dated November 12, 2019, revealed that the resident had a physician order for a ground, low concentrated sweets, no added salt diet.

Observations on February 9, 2020, at approximately 9 AM, 10 AM, 11 AM and 11:45 AM revealed that Resident 50 was in bed. Her upper and lower dentures were observed in a denture cup on her bedside table.

Further observations on February 9, 2020, 12 PM through 1:30 PM revealed that Resident 50 was seated in a wheelchair in the dining room. Observations revealed that the resident's dentures remained in the denture cup located on her bedside table in the resident's room. Observation revealed that the resident was served a regular formed hamburger on a bun. Observation revealed that the resident appeared to be having difficulties chewing the hamburger in the form served. Continued observation at 1:30 PM revealed that this resident was still attempting to eat the hamburger. At this time, al the other residents dining in this dining room for the lunch meal and completed their meal and left the dining room.

During an interview conducted on February 9, 2020, at approximately 2 PM revealed that the resident stated that staff did not put her dentures in her mouth that morning and confirmed that it was difficult for her to chew the hamburger served to her at the lunch meal.

During an interview on February 10, 2020, at approximately 10 AM the Director of Nursing confirmed that Resident 50 did not receive the correct diet consistency at the lunch meal on February 9, 2020, and that staff failed to ensure that the resident's dentures were in place to facilitate chewing.


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













 Plan of Correction - To be completed: 03/10/2020

Resident 50 had no negative outcomes and will be monitored daily at meals to ensure she has her dentures in place.

To identify other residents that have the potential to be affected, the DON / designee competed an audit to ensure all diets served were matching diet orders. Negative findings will be corrected.

To identify other resident that have the potential to be affected, the DON / designee completed an audit to identify all residents that have dentures are currently wearing them. Negative findings will be addressed

To prevent this from reoccurring, the DON / designee provided education to nursing staff and dietary to ensure diets given to residents match physician orders and to ensure all residents dentures are in place during meals.

To monitor and maintain ongoing compliance the DON / designee will complete an audit for one meal 5X a weekly X4 weeks, then monthly X 2 to ensure diet delivered matches physician order. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

To monitor and maintain ongoing compliance the DON / designee will complete an audit 5X weekly X 4 weeks, then monthly X 2 to ensure residents dentures are in place. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Date of compliance March 10, 2020


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, a review of clinical records and staff and resident interviews it was determined that the facility failed to provide adaptive eating equipment as prescribed for one resident out of 19 sampled (Resident 50).

Findings included:

A review of the clinical record revealed that Resident 50 was admitted to the facility on November 11, 2019, with diagnoses to include diabetes.

A significant change minimum data set assessment (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 13, 2019, revealed that the resident was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status - a tool to assess cognitive function, a score of 8-12 indicates moderate impairment). It was also noted that the resident held food in her mouth or cheeks and had no teeth.

The resident had a current physician order, initially dated November 26, 2019, for the use of a plate guard (built-up sides on a plate to assist in self-feeding) at all meals.

During an observation February 9, 2020, at 12 PM and again February 10, 2020 at 12 PM at the lunch meal it was observed that Resident 50's meal was served on a regular plate and the resident was not provided the plate guard as ordered.

During an interview on February 11, 2020, at approximately 10 AM the facility's consultant Dietitian confirmed that Resident 50 should have been using the lip guard plate at the observed meals and had not been provided the adaptive eating utensil ordered by the physician.



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





 Plan of Correction - To be completed: 03/10/2020


Resident 50 had no adverse effects from not receiving plate guard during meals.

To identify other residents that have the potential to effected, the DON / designee completed an audit of assistive devices to ensure all residents ordered have received them with meals. Corrections will be made as needed.

To prevent this from reoccurring, the DON / designee completed education with staff on adaptive eating devices are given as ordered.

To monitor and maintain ongoing compliance the DON / designee will complete audits 3X weekly X4 weeks, then monthly X 2 to ensure all adaptive eating devises are present as ordered. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Date of compliance March 10, 2020


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observation and staff interview, it was determined that the facility failed to maintain infection control practices for one of 19 sampled residents ( Resident 50).

Findings include:


During an observation on February 9, 2020, at approximately 11 AM, Resident 50 was observed in bed. The resident's urinary foley catheter bag and tubing were observed positioned directly on the floor.

An additional observation on February 9, 2020, at approximately 11:45 AM revealed Resident 50 was seated in a wheelchair in the dining room. Observation in the resident's room at 11:50 AM on February 9, 2020, that the resident's oxygen tubing including the nasal canula were observed directly on the floor and the oxygen concentrator was running. Continued observation revealed that staff placed the resident back to bed at approximately 2 PM on February 9, 2020. Employee 6, a nurse aide, was observed to pick the oxygen tubing and nasal canula off the floor and placed the nasal cannula into Resient 50's nose. The oxygen concentrator had not been turned off and was resumed delivering oxygen therapy to the resident.

During an interview February 11, 2020 at approximately 10 an, the Director of Nursing confirmed the above observed breaks in infection control practices.


483.80 (a)(2) Infection control
previously cited 3/15/19


28 Pa. Code 2311.12 (c)(d)(1)(3)(5) Nursing services
previously cited 3/15/19





 Plan of Correction - To be completed: 03/10/2020

Resident 50 had no adverse reaction.

To identify other residents with the potential to be affected, the DON / designee completed an audit to ensure all residents with oxygen tubing and foley catheters are properly positioned. Negative findings will be corrected.

To prevent this from reoccurring, the DON / designee completed education with staff to ensure they understand the IC prevention and control policy.

To monitor and maintain ongoing compliance the DON / designee will complete audits 3X weekly X4 weeks, then monthly X 2 to ensure oxygen and foley catheters are properly positioned. The DON / designee will compete 4 staff interview weekly X 4 then monthly X 2 to ensure they understand infection control practices. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Date of compliance March 10, 2020


§ 205.31 LICENSURE Storage.:State only Deficiency.
General storage space shall be provided for storage of supplies, furniture, equipment, residents' possessions and the like. Space provided for this purpose shall be commensurate with the needs of the nursing facility, but may not be less than 10 square feet per bed.
Observations:

Based on observation, resident and staff interviews and review of facility documentation and grievances lodged with the facility, it was determined that the facility failed to provide adequate space for storage of resident belongings, equipment and furniture.

Findings include:

A review of a grievance submitted by Resident 72 revealed that the facility had informed the resident that she was unable to store her personal belongings in the facility's storage room because the room was full of wheelchairs. The facility's resolution was for her to purchase a tote and the facility will place it in storage.

A review of a Resident/Family Grievance Form completed by Resident 72 on November 26, 2019, during a Resident Council Meeting, revealed that the resident voiced a complaint that the facility had informed her that she cannot store her personal belongings in the facility's resident storage area because the storage room was filled with wheelchairs.

The documentation of the facility's follow up to Resident 72's grievance was dated November 27, 2019, by the facility Social Services Director. The results were noted as, "she (Resident 72) will purchase a large tote to put seasonal items in to be placed in the storage room."

During an interview conducted on February 12, 2020, at approximately 11:30 AM Resident 72 stated the facility's Social Services Director told her that there was no room in the resident storage room to put her extra personal belongings. The resident stated she had purchased two large plastic totes and placed some of her belongings in them and they are currently in the bottom of her closet in her room. The resident stated that she was unable to place her personal belongings in the resident storage area as of the time of the interview.

An observation was made at that time of the resident's closet in her room. Two plastic totes were on the bottom of her closet with many other additional personal items, including clothing on top of the totes. There was very little free space available in this resident's closet.

A tour of the 200 hallway resident storage room revealed that the room contained resident personal items, wheelchairs and resident equipment. The activity department also stored decorations and activity equipment in this area. A room, located between the 400 hall and 500 hallway, was also utilized for resident storage and measured 112 square feet. This room contained mostly resident personal belongings.

At the time of the survey ending February 12, 2020, the facility housed 95 residents and required a total of 950 square feet of storage.

A review of correspondence from the Department of Health, Division of Safety Inspection dated December 28, 2012, revealed that DSI approved the conversion of the facility's secured storage room to be changed into a medical records room. This change resulted in a reduction of 231 square feet of resident storage space with 1308 square feet of storage space remaining.

According to the facility plan of correction dated May 19, 2015, the plan indicated that the facility's secured storage area on the 500 hall and the larger secured storage area on the 200 hall have been converted back to resident storage. With those changes, the facility had 648 square feet of available resident storage. The facility indicated that it will convert its garage to have 305 feet allocated solely for resident storage. This area will accommodate those items that are safe for outdoor storage.

Observations on February 12, 2020, revealed that the facility currently utilized the storage room at the end of the 200 hall, which measured 536 square feet. This room contained resident personal items, wheelchairs and resident equipment. The activity department also stored decorations and activity equipment in this area. A room, located between the 400 hall and 500 hallway was also utilized for resident storage this room measured 112 square feet this room contained mostly resident personal belongings. The total square footage of available storage space was only 648 square feet within the facility.

Interview with the director of maintenance on February 12, 2020, revealed that the garage, which was previously allocated for storage was no longer utilized for storage of resident belongings and equipment. The director of maintenance stated that the garage was now used as a maintenance office and utilized for maintenance storage, resulting in a loss of 305 square feet of storage space previously allocated to resident storage.

A review of facility correspondence dated October 2, 2012, and initial licensure information revealed that the facility initially the following areas were identifed as resident/facility secured storage:

Resident secured storage A (new wing) 112 square feet (no longer available)

Resident secured storage B (new wing) 231 square feet (changed to medical records room)

Resident secured storage C (existing wing) 536 square feet

Garage 660 square feet

Total 1539 square feet

Following the December 28, 2012, DSI approval for the reduction of 231 square feet of resident storage to be changed into medical records, leaving 1308 square feet of storage remaining, the facility failed to maintain sufficient storage space for supplies, furniture, equipment and residents' possessions.







 Plan of Correction - To be completed: 03/10/2020

Resident 72 has been able to store her things in the storage area at the facility.

Storage areas were cleaned out and made room for resident things. The facility is purchasing a large shed to make the storage space needed available.

To prevent this from reoccurring, the DON / designee completed education with staff on how and where resident things can be stored and a storage shed will be delivered and installed approximately May 18,2020.

To monitor and maintain ongoing compliance, the DON / designee will audit weekly for X 4 weeks and monthly X 2the storage areas to make room for resident items until the storage shed has arrived.

Date of Compliance March 10, 2020

§ 209.3(a) LICENSURE Smoking.:State only Deficiency.
(a) Policies regarding smoking shall be adopted. The policies shall include provisions for the protection of the rights of the nonsmoking residents. The smoking policies shall be posted in a conspicuous place and in a legible format so that they may be easily read by residents, visitors and staff.
Observations:

Based on observation and staff interviews, it was determined that the facility staff failed to post the smoking policy in a conspicuous place and in a legible format that could be easily read by residents, visitors and staff.

Findings include:

During an observation on February 9, 2020, at 9:00 AM, the facility's smoking policy, including provisions for the protection of the rights of non-smoking residents, was not posted in the facility and was not accessible to residents, staff and visitors.

While touring the facility with the Nursing Home Administrator on February 10, 2020, at 1:40 PM, the NHA confirmed that the facility failed to post the smoking policy.









 Plan of Correction - To be completed: 03/10/2020

The smoking policy was posted the by the nurse's station.

To prevent this from reoccurring, the DON / designee completed education with staff on the posting of smoking signs.

To monitor and maintain ongoing compliance, the DON / designee will audit weekly for X 4 weeks and monthly X 2 that the smoking signs are in place.
The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

Date of Compliance March 10, 2020


§ 211.9(g) LICENSURE Pharmacy services.:State only Deficiency.
(g) If over-the-counter drugs are maintained in the facility, they shall bear the original label and shall have the name of the resident on the label of the container. The charge nurse may record a resident's name on the nonprescription label. The use of nonprescription drugs shall be limited by quantity and category according to the needs of the resident. Facility policies shall indicate the procedure for handling and billing of nonprescription drugs.
Observations:

Based on observation, staff interview and review of a facility exception request and policy and procedure, it was determined that the facility failed to compile a current listing of all residents utilizing house stock medications including one resident observed during the medication administration (Resident 61).

Findings include:

Observation of the medication administration to Resident 61 on February 11, 2020, at 9:00 AM revealed that Resident 61 had physician orders for Iron Tablets and Aspirin. Employee 5, LPN administered house stock medications, iron tablets and aspirin to Resident 61.

Observation of the house stock bottles for the above medications revealed that Resident's 61's name did not appear on the labels. Employee 5 (LPN) provided a stock medication list which was contained on the medication cart in a binder. However, this listing had not been updated since October 2019 and did not contain current resident names and listing of stock medications for all residents currently residing in the facility receiving house stock medications.

An observation of the medication cart on the 300 hallway on February 11, 2020, revealed that the cart also contained a stock medication listing. This listing also had not been updated since October 2019, which was verified by Employee 4 (LPN), at the time of this observation.

Interview with the nursing home administrator on February 26, 2015, at 11:30 a.m., confirmed that the names of the residents receiving house stock medications were not present on the medication label and there was no list contained on the medication cart.


A review of the state exception granted to the facility by the department dated March 2, 2105 indicated the facility was granted and exception and the faciltiy implemented the policy entitled Labeling of Stock Medications.

The policy indicated;

A list of OTC (over the counter) medications will be kept in the front of each MAR (medication administration record). The list will be generated by the DON/Designee and will include the nursing unit, the OTC medication and the names of the residents on that unit who are ordered on that OTC medication.

It is the responsibility of the nursing staff to update the list of residents using stock OTC medications with admissions, readmissions and discharges. The list is also to be updated if there are any new changes, or discontinued OTC medication orders fir the residents in a timely manner.

The DON/Designee will review the lists/labels weekly and make any changes deemed necessary. The changeover nurse will check and edit the list against current physician orders for stock OTC medications before placing the lists in the MAR's on a monthly basis.

The facility failed to maintain current lists of stock medications for resident use at the time of this survey ending February 12, 2020.







 Plan of Correction - To be completed: 03/10/2020

List of over the counter medications were immediately added to each narcotic administration record on each unit.

To identify areas with the potential to be affected an audit was completed by the RN supervisor to ensure over the counter medication lists were located in each narcotic administration record pm each unit.

To prevent this from recurring the DON re—educated the licensed staff on the need for and location of the over the counter medication list for each unit.

To monitor and maintain ongoing compliance the ADON/designee will monitor the location of each over the counter medication list on each unit 3x a week for 4 weeks then weekly x 2 months to ensure compliance. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

Date of Compliance March 10, 2020


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