Nursing Investigation Results -

Pennsylvania Department of Health
LITTLE SISTERS OF THE POOR
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LITTLE SISTERS OF THE POOR
Inspection Results For:

There are  33 surveys for this facility. Please select a date to view the survey results.

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LITTLE SISTERS OF THE POOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey, completed on December 13, 2019, it was determined that Little Sisters of the Poor, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:
Based on observations, clinical record review and staff interview, it was determined that the facility failed to identify potential restraint for one of three residents, (Resident R18).

Findings include:

Resident R18 was admitted on 4/1/19, with diagnoses of dementia, anxiety disorder and muscle weakness. The quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated 10/11/19, indicated these diagnoses remained current.

Observation of the first floor, Sacred Heart, lounge area on 12/11/19, at 1:10 p.m. revealed Resident R18 calling out for help repeatedly and standing up in front of a recliner chair, holding onto the top of a backward facing wheelchair that was a few inches in front of her.

During an interview on 12/11/19, at 1:17 PM Nurse Aide (NA) Employee E2 stated that R18 wandered and was a fall risk, the staff placed her wheelchair backwards in front of her while she was sitting in the recliner, to prevent her from getting up.

During an interview on 12/13/19, at 2:34 p.m. the Director of Nursing confirmed that the facility failed to identify blocking Resident R18's ability to ambulate with a wheelchair was a potential restraint.

Pa. Code 201.14(a) Responsibility of Licensee.
Previously cited 1/12/18

Pa. Code 211.10(d) Resident Care Policies.
Previously cited 1/12/18 and 8/1/19

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


 Plan of Correction - To be completed: 01/10/2020

Resident R 18 utilizes a chair alarm in her recliner. She is a fall risk. She stands up frequently when her legs hurt to stretch them. Staff will be educated that her wheel chair will not be placed in front of her back wards, as it can be considered a potential restraint by 01/10/2020. She is currently in Physical therapy until 1/6/2020 and then will be picked up by Restorative therapy.

Resident's who are a fall risk utilize bed,chair alarms, floor mats on an individual basis. They are engaged in activities and one to one interactions. They are evaluated by Physical and Occupational therapy upon admission, quarterly and when there is a change in their mobility/condition. After they are finished with skilled therapy a Restorative therapy program is put into place. Fall risk assessment are done annually and when their is a change in their mobility/ condition.

The DON will audit Residents who are a fall risk for potential restraints and educate staff as indicated and report to Quality Assurance Committee monthly x3 and 100 % compliance
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 observations, clinical record review and staff interview, it was revealed that the facility failed to assess residents for the placement of beds against the wall for two of two residents (Resident R7 and Resident R10).

Findings include:

During an observation on 12/11/19, at 12:50 p.m. it was revealed that Resident R10 bed was flush against the wall, limiting the ability to exit one side of the bed.

During an observation on 12/12/19, at 12:06 p.m. it was revealed that Resident R7 was in bed with the side of the bed flush against the wall, limiting the ability to exit one side of the bed.

A review of the clinical record indicated Resident R10 was admitted to the facility on 10/16/14, with diagnoses of pain in right hip, muscle weakness, and spinal stenosis. The quarterly MDS (Minimum Data Set - a periodic assessment of resident needs) dated 10/3/19, indicated these diagnoses remained current.

A review of the clinical record for Resident R10 did not include an assessment for safety or to determine if the bed placement was a restraint. The clinical record also failed to include a physician's order to place the resident's bed against the wall, inhibiting the ability of the resident to get out of the bed from either side.

A review of the clinical record indicated Resident R7 was admitted to the facility on 9/6/19, with diagnoses that included spinal stenosis (progressive narrowing of the opening in the spinal canal), legal blindness, and anxiety.

A review of the clinical records for Resident R7 and R10 did not include an assessment for safety or to determine if the placement of the bed against the wall was a restraint. The clinical record also failed to include a physician's order to place the resident's bed against the wall, inhibiting the ability of the resident to get out of the bed from either side.

During an interview 12/13/19, 2:35 p.m. Director of Nursing confirmed that Resident R7 and R10 did not have an assessment ot determine the safety of bed placement against the wall.

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

28 Pa. Code: 211.12(d)(1)(5) Nursing services.
Previously cited 1/12/18 and 8/1/19.




 Plan of Correction - To be completed: 01/17/2020

The Bed Safety Policy was updated to include that "Bed may be placed against the wall, not as a restraint but to enhance the room size and the Resident's safe mobility. A physician's order will be obtained for bed placement against the wall." Care plans and orders will be updated to include bed placement against the wall for Resident R 10 and R 7 and for any other Residents who have their beds against the wall. At care plan meetings, the DON will audit where the bed is placed and that the necessary documentation in place. This information will be reported to the CQI committee monthly x 3 and with 100 % compliance. All new admissions will be have the necessary documentation in place if their bed is against the wall. This will be audited by the DON and reported to CQI monthly x3. Nurses will be educated on bed placement documentation on January 16, 2020
483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that alternate interventions were attempted prior to the administration of psychotropic medications for one of five residents (Resident R28).

Findings include:

Review of the clinical record indicated Resident R28 was admitted to the facility on 11/20/15, with major depressive disorder and anxiety disorder. The Minimum Data Set (MDS - a periodic assessment of needs) dated 11/5/19, indicated these diagnoses remained current.

Review of Resident R28's physician recapitulation orders dated 1/30/19, revealed an order for Lorazepam (Ativan - an antianxiety medication) Tablet 0.5mg Give 1 tablet by mouth as needed for anxiety twice daily.

Review of Resident R28's progress notes for eMAR (electronic Medication Administration Record) note text revealed the following:
6/2/19, at 08:47: Crying during am care. Ate breakfast in room. Ativan given as per order. Ativan was effective and came out to lunch.
7/10/19, at 22:16 : Became very upset after supper, yelling at NA (Nurse Aide), threatening to throw BM at her. Medicated with Ativan and given PM care.
10/31/19, at 22:23: Talking about how everything is her daughter-in-law's fault. Refused supper. Given Ativan at HS.
11/8/19, at 14:25 : Very anxious this AM. Talking about "the Boat" other delusions/hallucinations. Medicated with Ativan 9:30 am.

Review of Resident R28 clinical record revealed that no non-pharmacological interventions were attempted prior to the administration of the PRN ativan.

During an interview on 12/13/19, at 2:30 p.m. Director of Nursing confirmed that the facility failed to attempt non-pharmacological interventions prior to administering the PRN antianxiety medication to Resident R28.

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

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

28 Pa. code 211.12(d)(1)(5)Nursing services.
Previously cited 1/12/18 and 8/1/19.


 Plan of Correction - To be completed: 01/17/2020

Nurses were verbally re educated on documenting all interventions tried prior to administering PRN Psychotropic Drugs for Resident R2. All nurses will be re educated on intervention and documentation for prn psychotropic drugs on January 16, 2020. e.g. food, drink, bathroom, one to one interaction, leave alone and come back.
The DON will audit prn usage of all prn psychotropic drugs weekly x 4 for documentation, then q 2 weeks x 4 or until 100 % compliance. She will discuss with the nurses involved with lack of documentation on a individual basis. Reports will be given to Quality Assurance Committee monthly x 3.

The consultant Pharmacist does monthly drug reviews and indicates the need for drug reductions. The attending Physician addresses the drug reviews to determine if dose reduction is indicated or clinically contraindicated.
All prn psychoactive medications will be reviewed by the DON for documentation that the Physician states that the prn order is appropriate and least restrictive for their diagnosis to extend beyond the 14 days with their rationale. This will be reported monthly to the Quality Assurance Committee x 6 or until 100 % compliance
201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:
Based on review of facility documents and staff interview, it was determined that the facility failed to comply with the following requirement of MCARE Act 403(a)(1), for two of four quarterly Infection Control Committee meetings as required (August and November 2019).

Findings include:

MCARE Act, Section 403(a)(1), 40 P.S. 1303.403(a)(1) - Infection Control Plan, states:
(a) Development and compliance - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for improving the health and safety of patients and health care workers and shall include:
(1) A multidisciplinary committee including representatives from each of the following, if applicable to the specific health care facility:
(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii) Administration representatives that could include the chief executive officer, the chief financial officer or the nursing home administrator.
(iii) Laboratory personnel.
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) Members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility or ambulatory surgical facility.

A review of the facility quarterly Infection Control Committee sign-in sheets for calendar year 2019, revealed the August and November quarterly Infection Control Committee meetings did not include the required laboratory personnel team member.

During an interview on 12/13/19, at 10:00 a.m. the Director of Nursing and Assistant Director of Nursing confirmed that the facility was unable to provide evidence that the required lab personnel team member attended two of the four quarterly meetings as required.








 Plan of Correction - To be completed: 02/10/2020

The next Infection Control meeting is set for February 10,2020. The sign in sheet has a designated line for each of the 9 multidisciplinary members as required by Act 52. The ADON will co ordinate with the Medical Director for the dates of the meetings and notify all the members. If a committee member is unable to attend physically, they will participate via phone. The ADON will report the presence of each member by auditing the signing sheet. She will report to the Quality Assurance Committee q 3 months x
one year.

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