Nursing Investigation Results -

Pennsylvania Department of Health
HOLLIDAYSBURG VETERANS' HOME
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HOLLIDAYSBURG VETERANS' HOME
Inspection Results For:

There are  118 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
HOLLIDAYSBURG VETERANS' HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on November 22, 2019, it was determined that Hollidaysburg Veterans Home 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:


483.25(k) REQUIREMENT Pain Management: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.
483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to perform a thorough pain assessment and offer non-pharmacological interventions for pain relief for one of 88 residents reviewed (Resident 37).

Findings include:

The facility's policy regarding pain management, dated March 22, 2019, revealed that pain observation documentation was to include characteristics of the resident's pain intensity, pattern, location and radiation, frequency, timing and duration, along with verbal and non-verbal signs and symptoms of pain. Licensed nurses were to document both pharmacological (medicines) and non-pharmacological interventions, and the effectiveness of pain management in the nursing progress notes.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated August 27, 2019, indicated that the resident was able to be understood, could understand, required limited to extensive assistance from staff for daily care tasks, had frequent complaints of moderate pain, and received "as needed" pain medicine. The resident's care plan, dated September 5, 2019, revealed that the resident had a history of pain related to fractures, and staff were to assess and document pain characteristics such as quality, severity, location, onset, duration and precipitating and relieving factors.

Physician's orders for Resident 37, dated June 1, 2019, included orders for the resident to receive 20 milliliters (ml) of liquid Tylenol (160 milligrams per 5 ml) to be administered by mouth for headache, mild discomfort, or a fever of 101 degrees Farenheit lasting greater than 24 hours. Physician's orders dated August 21, 2019, included orders for one 5/325 milligram (mg) tablet of Norco (an opioid pain medication) to be administered every four hours as needed for pain.

Resident 37's nursing notes and Medication Administration Records (MAR's) for September, October and November 2019 revealed that on the following dates and times, the resident had complaints of pain in various locations, and staff administered Norco:

September 2 at 5:18 p.m.
September 3 at 5:07 p.m.
September 5 at 11:20 a.m.
September 6 at 8:20 a.m.
September 10 at 8:10 a.m.
September 15 at 7:45 a.m.
September 18 at 8:16 a.m.
September 26 at 7:54 a.m.
September 28 at 8:03 a.m.
September 29 at 7:39 a.m.
October 1 at 8:02 a.m.
October 3 at 9:10a.m.
October 4 at 9:10 a.m.
October 9 at 10:15 a.m. and 6:20 p.m.
October 14 at 1:06 p.m.
October 22 at 9:10 a.m. and 5:10 p.m.
October 23 at 8:30 a.m.
October 24 at 7:50 a.m.
October 26 at 8:16 a.m.
October 28 at 8:40 a.m.
October 31 at 8:10 a.m.
November 1 at 8:02 a.m.
November 4 at 11:30 a.m.
November 6 at 8:06 a.m.
November 7 at 6:20 a.m.
November 9 at 8:06 p.m.
November 13 at 8:35 a.m.
November 14 at 8:16 a.m.
November 15 at 8:12 a.m.
November 18 at 8:08 a.m.
November 19 at 8:12 a.m.
November 21 at 8:28 a.m.

There was no documented evidence in the resident's clinical record that staff assessed the resident's complaints of pain, including characteristics of the pain such as intensity, pattern, and radiation, frequency, timing and duration, along with verbal and non-verbal signs and symptoms of pain, nor did staff document any attempts at non-pharmacological interventions prior to medicating the resident with Norco.

Interview with Licensed Practical Nurse 9 on November 21, 2019, at 2:03 p.m. revealed that she was very familiar with Resident 37 and was assigned to give him medications on most days she worked. She confirmed that the physician's orders for Norco did not include parameters for what type or level of pain to administer it for, versus giving the Tylenol. She indicated that if the resident complained of a headache she would give him Tylenol, and she administered Norco for back pain.

Interview with Registered Nurse Supervisor 8 on November 22, 2019, at 11:50 a.m. confirmed that there was no documented evidence that staff assessed Resident 37's above complaints of pain, and no documented evidence that staff attempted non-pharmacological interventions prior to medicating the resident with Norco.

Interview with the Director of Nursing on November 25, 2019, at 1:40 p.m. confirmed that staff should be following the facility's pain management policy regarding documentation of pain assessments and non-pharmacological interventions.

42 CFR 483.25(k) Pain Management.
Previously cited 10/25/18.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 3/28/19, 10/25/18.






 Plan of Correction - To be completed: 01/07/2020

Resident 37 was assessed for pain and the care plan was updated to include non-pharmacological interventions for pain relief. Unit licensed staff were educated on performing a thorough pain assessment.

An audit of residents who trigger in the Minimum Data Set for pain will be conducted to ensure a thorough pain assessment has been completed and non-pharmacological interventions for pain relief were in place on the care plan.

The Pain Management Policy was updated to include: Non-pharmacological interventions should be attempted prior to administering any pain medication. Non-narcotic pain medication should be administered first and effectiveness evaluated unless severe pain is identified, requiring narcotic medication. The Medication Administration Policy was updated to include Licensed staff (Registered Nurses (RNs)/Licensed Practical Nurses (LPNs)will assess/evaluate for and document in the progress notes characteristics of the pain such as intensity, pattern, and radiation, frequency, timing and duration, along with verbal and non-verbal signs and symptoms of pain, as well as non-pharmacological interventions prior to medicating residents. Licensed staff (RNs/LPNs)will be educated on the policy changes.

Random quality reviews of progress notes regarding pain assessments and non-pharmacological interventions for pain relief will be conducted by the Registered Nurse Supervisors to ensure that non-pharmacological interventions were attempted prior to administering any pain medication.
This review will be conducted daily for four weeks, weekly for four weeks, then bi-weekly for one month. Results will be reported at regularly scheduled quality improvement meetings.


483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficient practices.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending October 25, 2018, and March 28, 2019, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending November 22, 2019, identified repeated deficiencies related to professional standards of nursing practice, accident hazards, and pain management.

The facility's plans of correction for deficiencies regarding failures to ensure that professional standards of practice were followed, cited during the surveys ending October 25, 2018, and March 28, 2019, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding professional standards of practice.

The facility's plan of correction for a deficiency regarding ensuring that the resident environment was free from accident hazards, cited during the survey ending October 25, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding accident hazards.

The facility's plan of correction for a deficiency regarding pain management, cited during the survey ending October 25, 2018, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F697, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding pain management.

Refer to F658, F689, F697.

42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities.
Previously cited 10/25/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 10/25/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 10/25/18.






 Plan of Correction - To be completed: 01/07/2020

All current outstanding deficiencies are being reviewed at monthly Quality Improvement Meetings.

Quality Improvement meetings are held monthly to ensure quality care is being delivered to the residents that reside at the facility.
Audit tools have been created to specifically target the deficient practice that took place as well as an added section for comments on performance improvement on the audit form to be later reviewed by the Quality Improvement Committee. The Quality Assurance Performance Improvement committee utilizes a root cause analysis among other approaches to problem solving.


Quality Assurance Coordinator or designee will review outstanding deficiency audits to ensure compliance. Findings of the reviews will be reported to the Quality Improvement Committee for recommendations or resolution at its regularly scheduled meeting until substantial compliance for results, areas of improvement and/or continuation of audits.



483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12 Freedom from Abuse, Neglect, and Exploitation
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)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from mental abuse for one of 88 residents reviewed (Resident 166).

Findings include:

The facility's abuse policy, dated March 22, 2018, indicated that the facility prohibited abuse, and staff were to abstain from taking part in any act of resident abuse, including engaging in behaviors that unnecessarily increased the level of unpleasantness to a resident. Mental abuse included the use of verbal or nonverbal conduct that causes or has the potential to cause the resident to experience humiliation, shame or degradation.

A comprehensive annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 166, dated January 16, 2019, indicated that the resident was cognitively impaired and required extensive assistance from staff for daily care tasks, including eating.

Facility investigation documents revealed that on March 4, 2019, Dietary Aide 3 reported an allegation of abuse to her supervisor. She gave a physical description of Nurse Aide 4 and indicated that she witnessed the nurse aide interact inappropriately with Resident 166 during the lunch meal on March 3, 2019, by prompting the resident to repeat vulgar/sexual statements, and that staff then laughed at the resident.

A written statement from Dietary Aide 3, dated March 7, 2019, revealed that she gave an accurate physical description of Nurse Aide 4 and indicated that during the lunch meal on March 3, 2019, she observed the nurse aide prompting Resident 166 to say vulgar statements, and then other staff laughed when the resident said what the nurse aide told him to say.

A written statement from Licensed Practical Nurse 5, dated March 14, 2019, revealed that during the lunch meal on March 3, 2019, she witnessed Nurse Aide 4 ask Resident 166 to say an inappropriate sexual statement, which the resident said, and then other staff laughed at the resident.

An interview with the Director of Nursing on November 22, 2019, at 1:20 p.m. confirmed that Nurse Aide 4 mentally abused Resident 166 on March 3, 2019, by having the cognitively impaired resident repeat inappropriate statements.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 10/25/18.

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

28 Pa. Code 201.18(e)(1) Management
Previously cited 10/25/18.

28 Pa. Code 201.29(j) Resident rights
Previously cited 10/25/18.

28 Pa. Code 211.12(d)(5) Nursing services
Previously cited 3/28/19, 10/25/18.




 Plan of Correction - To be completed: 01/07/2020

Resident 166 was interviewed and had no recollection of the incident and demonstrated no lasting effects.

There were no other cases of mental abuse reported. The perpetrator is no longer employed at the facility.

All staff will be trained on the Facility Abuse policy which will include competency testing to ensure understanding of the definition of mental abuse. Facility staff are trained during orientation and annually regarding prevention of abuse, the consequences of abuse and/or not reporting abuse timely.

Random quality reviews of dining room staff will be conducted by the Registered Nurse Supervisors to ensure that appropriate interactions are occurring. This review will be conducted daily for four weeks, weekly for four weeks, then bi-weekly for one month. Results will be reported at regularly scheduled quality improvement meetings.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on review of policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that allegations of abuse were reported immediately to the Nursing Home Administrator for one of 88 residents reviewed (Resident 166).

Findings include:

The facility's abuse policy, dated March 22, 2018, indicated that the facility prohibited abuse, and staff were to abstain from taking part in any act of resident abuse, including engaging in behaviors that unnecessarily increased the level of unpleasantness to a resident. Mental abuse included the use of verbal or nonverbal conduct that causes or has the potential to cause the resident to experience humiliation, shame or degradation. The policy included that staff were to immediately report any knowledge of a possible alleged violation to the supervisor, and if a supervisor was not immediately available, to notify the Commandant or designee. Staff were to always err on the side of reporting if they were unsure.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 166, dated January 16, 2019, indicated that the resident was cognitively impaired and required extensive assistance from staff for daily care tasks, including eating.

Facility investigation documents revealed that on March 4, 2019, Dietary Aide 3 reported an allegation of abuse to her supervisor. She gave a physical description of Nurse Aide 4 and indicated that she witnessed the nurse aide interact inappropriately with Resident 166 during the lunch meal on March 3, 2019, by prompting the resident to repeat vulgar statements, and that staff then laughed at the resident.

Dietary Aide 3 failed to report the allegation involving mental abuse of Resident 166 within two hours.

Investigation documents revealed that Dietary Aide 3's supervisor asked her to complete a witness statement on March 4, 2019, but the dietary aide did not complete the statement that day and abruptly went home. She did not work on March 5, 2019; did not complete a statement when she returned to work on March 6, 2019; and did not complete a statement until March 7, 2019. There was no documented evidence that the dietary supervisor notified the Nursing Home Administrator about the allegation of abuse until after Dietary Aide 3's statement was obtained on March 7, 2019, which was four days after the event occurred.

An interview with the Director of Nursing on November 22, 2019, at 1:20 p.m. confirmed that Nurse Aide 4 mentally abused Resident 166 on March 3, 2019, by having the cognitively impaired resident repeat inappropriate statements, and Dietary Aide 3 did not report the allegation to her supervisor until the next day. The dietary supervisor then failed to report the allegation to administration until after Dietary Aide 3 completed a written statement on March 7, 2019. The Director of Nursing confirmed that Dietary Aide 3 should have reported what she witnessed right away, and the dietary supervisor should have had the dietary aide fill out a witness statement right away and then reported the allegation to administration right away.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 10/25/18.

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

28 Pa. Code 201.18(e)(1) Management.
Previously cited 10/25/18.

28 Pa. Code 201.29(a) Resident rights.








 Plan of Correction - To be completed: 01/07/2020

Resident 166 was interviewed and had no recollection of the incident and demonstrated no lasting effects.

There was one allegation of abuse reported which was reported timely.

All staff will be trained on the Facility Abuse policy which will include competency testing to ensure understanding of timely reporting

Random quality reviews of allegations of abuse will be conducted by the Quality Assurance Department to ensure that timely reporting has occurred. This review will be conducted daily for four weeks, weekly for four weeks, then bi-weekly for one month. Results will be reported at regularly scheduled quality improvement meetings.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of the Pennsylvania Nursing Practice Act, facility policies and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a registered nurse completed a thorough assessment after a medical device was found dislodged for one of 88 residents reviewed (Resident 108).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

The facility's policy concerning midline catheters (a catheter approximately three to eight inches long inserted through the skin and into a vein in the upper arm to administer antibiotic therapy lasting two to four weeks), dated March 22, 2019, indicated that when performing dressing changes or administering medications via the midline catheter, staff were to measure the length of the catheter to determine if migration has occurred and inspect the insertion site for redness, swelling and drainage. The policy indicated that midline catheters were not to be removed at the facility and residents were to be sent to the hospital for removal; however, the policy did not include what staff were to do in the event of an accidental removal of the midline catheter.

Physician's orders for Resident 108, dated March 4, 2019, included an order for the resident to receive 1000 milligrams (mg) of intravenous (IV - administered directly into a vein) Vancomycin (an antibiotic) to be administered via the midline catheter every eight hours. The resident's Medication Administration Records (MAR's) indicated that the resident received IV Vancomycin from March 4 through 10, 2019.

A nursing note dated March 10, 2019, at 9:37 p.m. revealed that the registered nurse went to flush Resident 108's midline catheter and it was no longer in place. The resident stated that he did not know it was out and was not sure when or how it came out.

There was no documented evidence in Resident 108's clinical record regarding the condition of the midline site or the length or condition of the catheter (whether or not the catheter was intact or had been broken).

Interview with Registered Nurse Supervisor 8 on November 22, 2019, at 11:50 a.m. confirmed that the note written on March 10, 2019, concerning the midline catheter should have contained a thorough assessment and description of the midline site and the condition in which the catheter was found.

42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 3/28/19, 10/25/18.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 3/28/19, 10/25/18.




 Plan of Correction - To be completed: 01/07/2020

Resident 108 was sent to the hospital for evaluation and Peripherally Inserted Central Catheter (PICC) line placement. A PICC line is a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. It is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs.

An audit was conducted of residents with a midline or PICC to ensure thorough assessment after a medical device was found dislodged.

The PICC or Midline Catheters Policy was revised to state: in the event of accidental dislodgement of PICC or Midline catheters pressure will be applied, site and catheter will be assessed, and the physician will be notified. Licensed nursing staff will be educated by the Registered Nurse Instructors regarding policy updates.

Random quality reviews of residents with a midline or PICC will be conducted by the Registered Nurse Supervisor to ensure that midline or PICC are assessed for positioning, signs of infection, drainage or potential for dislodgement. This review will be conducted daily for four weeks, weekly for four weeks, then bi-weekly for one month. Results will be reported at regularly scheduled quality improvement meetings.


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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that fall prevention interventions were in place as care planned for one of 88 residents reviewed (Resident 47).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 47, dated August 28, 2019, revealed that the resident was cognitively impaired; required assistance from staff for daily care tasks, including bed mobility and transfers; and used a wheelchair for mobility. The resident's care plan, dated September 5, 2019, indicated that he was at risk for falls related to poor safety awareness and purposeful movement of his hips in the wheelchair. The resident's care plan, dated September 5, 2019, indicated that Dycem (a non-slip material) was to be placed between the resident and the mechanical lift sling (heavy-duty fabric sling attached to a mechanical lift and used to transfer a resident), and the resident and the ROHO (a pressure relief) cushion.

Observations of Resident 47 on November 24, 2019, at 10:35 a.m. revealed that Nurse Aides 1 and 2 used a mechanical lift to transfer the resident. During the transfer, there was no Dycem in place between the resident and the lift sling, and when placed in his wheelchair, there was no Dycem between the resident and the ROHO cushion.

Interviews with Nurse Aides 1 and 2 on November 22, 2019, at 10:40 a.m. confirmed that there was no Dycem in place between Resident 47 and the mechanical lift sling, and between the resident and the ROHO cushion.

Interview with the Director of Nursing on November 22, 2019, at 1:47 p.m. confirmed that Resident 47's Dycem should have been in place as care planned.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 10/25/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 3/28/19, 10/25/18.


 Plan of Correction - To be completed: 01/07/2020

Dycem was applied as per care plan for Resident 47. Staff involved were re-educated on placement of Dycem for resident 47. An occupational therapy evaluation was obtained for the resident to assess wheelchair positioning and transfers.

An audit of residents who transfer via lift sling and also require Dycem was conducted to ensure placement per care plan.

The Fall Prevention policy will be updated to include that nursing staff will review the resident profile to ensure that fall prevention interventions were in place as care planned. Nursing staff will be educated by the Registered Nurse Instructors regarding policy updates.

Random quality reviews of residents who transfer via lift sling and also require Dycem will be conducted by the Registered Nurse Supervisors to ensure that fall prevention interventions were in place as care planned. This review will be conducted daily for four weeks, weekly for four weeks, then bi-weekly for one month. Results will be reported at regularly scheduled quality improvement meetings.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:


Based on review of manufacturer's instructions, facility policies and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain essential resident care equipment in a safe manner for one of 88 residents reviewed (Resident 63).

Findings include:

A safety inspection checklist in the manufacturer's directions for the Invacare Perfecto 2 Oxygen Concentrator (an electrical machine that concentrates oxygen from the air), dated August 2, 2016, indicated that the cabinet filter (located on the back of the machine) was to be cleaned to avoid damage to the internal components. The concentrator was not to be operated with a dirty filter, and for safe usage, the cabinet filter was to be checked and cleaned during each inspection.

The facility's policy regarding oxygen administration, dated January 19, 2019, indicated that external filters on oxygen concentrators were to be cleaned on a weekly basis and replaced if necessary by the adaptive equipment department.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated September 4, 2019, indicated that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, and used oxygen therapy. Current physician's orders included an order for the resident to receive continuous oxygen via nasal cannula (tubes that deliver oxygen into the nostrils) at a flow rate of 2 liters per minute for a medical diagnosis of chronic obstructive pulmonary disease (COPD - a lung disease that interferes with normal breathing).

Observations in Resident 63's room on November 19, 2019, at 10:18 a.m.; November 20, 2019, at 5:12 p.m.; and November 21, 2019, at 12:00 p.m. revealed that the cabinet filter on the resident's oxygen concentrator had an accumulation of removable dust and lint on it.

An interview with Adaptive Equipment Employee 6 on November 22, 2019, at 1:15 p.m. revealed that oxygen concentrator filters were to be cleaned weekly.

There was no documented evidence that Resident 63's oxygen concentrator filters were cleaned on a weekly basis.

Interview with Housekeeping Supervisor 7 on November 22, 2019, at 1:19 p.m. confirmed that Resident 33's oxygen concentrator was dirty and needed cleaned.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 10/25/18.

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

28 Pa. Code 201.18(b)(3) Management.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 10/25/18.

28 Pa. Code 207.2(a) Administrator's responsibility.





 Plan of Correction - To be completed: 01/07/2020

Invacare Perfecto 2 Oxygen Concentrator filter for resident 63 was cleaned and inspected.

All other external concentrator filters in the facility were replaced.

The Oxygen Administration Policy was updated to include external oxygen concentrator filters will be replaced every six months and as needed per manufacturer's recommendations.

Random quality reviews of external oxygen concentrator filters will be conducted by the Maintenance Department or designee to ensure that maintenance of oxygen concentrator filters was performed and documented. This review will be conducted daily for four weeks, weekly for four weeks, then bi-weekly for one month. Results will be reported at regularly scheduled quality improvement meetings.



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