Nursing Investigation Results -

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

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
HILLVIEW HEALTHCARE AND REHABILITATION CENTER
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.
HILLVIEW HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint and incident survey completed on January 23, 2020, it was determined that Hillview Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.














 Plan of Correction:


483.25 REQUIREMENT Quality of Care:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that speech therapy recommendations were followed for one of 12 residents reviewed (Resident 1), creating a situation in which the resident's safety was in Immediate Jeopardy related to the resident aspirating and dying.

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 25, 2019, indicated that the resident was cognitively impaired and required supervision and set-up help for eating. Physician's orders, dated December 5, 2019, included an order for the resident to receive a controlled carbohydrate diet, pureed texture, with thin (regular) consistency liquids, and pleasure foods with supervision recommended.

A speech therapy discharge summary for Resident 1, dated December 18, 2019, indicated that the resident had been on a mechanical soft diet and she was trialed (downgraded) to a pureed diet to ensure her safety and tolerance of her diet. With the mechanical diet she was observed to have impulsive rate, unsafe amounts of large bites, and had reduced chewing; therefore, she was changed to a pureed diet with pleasure foods. The recommendations were that during her oral intake to alternate liquids and solids, rate modification, bolus size modifications and general swallowing techniques.

A nursing note for Resident 1, dated December 21, 2019, revealed that a nurse aide noticed a change in the resident's condition. The resident was observed to have a skin color change from yellow to ashen (grey tone to the skin). The nurse aide indicated that the resident was eating peanut butter crackers; therefore, the nurse began the Heimlich maneuver with nothing expectorated and cardiopulmonary resuscitation (CPR) was initiated. A nursing note dated December 21, 2019, at 6:44 a.m. revealed that the resident was transferred to the hospital for evaluation.

Resident 1's death certificate, dated December 21, 2019, indicated that her primary cause of death was aspiration (inhaling a foreign material or food into the lungs) and the interval from onset to death was "minutes."

Interview with Licensed Practical Nurse 1 on January 22, 2020, at 7:50 p.m. revealed that on December 21, 2019, she gave Resident 1 regular peanut butter crackers. She indicated that she was not aware of the resident's diet order, nor the speech recommendations to alternate liquids and solids, rate modification, bolus size modifications and general swallowing techniques.

Interview with Nurse Aide 3 on January 23, 2020, at 3:18 p.m. revealed that the nurse gave the resident a packet of peanut butter crackers and she fed herself the whole pack. He was with Resident 1 while she ate the peanut butter crackers on December 21, 2019, and she did not have anything to drink while she ate them. He was not aware of the resident's diet or that the resident had speech therapy recommendations for eating and swallowing.

Interview with Registered Nurse 2 on January 22, 2020, at 8:15 p.m. revealed that the speech therapy recommendations for Resident 1 should have been communicated to the physician to obtain an order, and then the resident's care plan should have been updated with the recommendations so that all staff were aware.

On January 22, 2020, at 11:19 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses, licensed practical nurses and nurse aides not knowing how to locate a resident's ordered diet, what consistencies the residents could be served, and what speech therapy recommendations were to be followed when giving residents food.

The facility submitted and implemented an immediate plan to ensure resident safety by reviewing speech therapy recommendations and providing them to administrative nursing staff, who were to ensure that physician's orders were obtained and placed on the medical record; ensuring that residents' kardex and care plans were updated; providing education to nursing staff regarding where to find a resident's diet consistency; how to access the residents' kardex, which contains diet orders; what snacks are safe for residents based on their specific diets; and posting signs at each nursing station regarding what snacks are safe for each diet consistency.

The Immediate Jeopardy was lifted on January 23, 2020, at 7:30 p.m. when it was confirmed that speech therapy's recommendations were reviewed, physician's orders were obtained, and this information was placed on residents' kardex and care plan; that over 90 percent of the nursing staff received education regarding how to access diet orders, kardex and care plans, with the remaining staff scheduled to receive the education prior to the start of their next shift; and that the facility posted signs at each nursing station regarding what snacks were safe for each diet consistency.

42 CFR 483.25 Quality of Care
Previously cited 8/13/19.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 12/17/19, 8/29/19, 8/13/19, 5/2/19, 6/29/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/17/19, 8/29/19, 8/13/19, 5/2/19, 10/22/18, 9/18/18, 6/29/18.








 Plan of Correction - To be completed: 02/20/2020

Resident 1 expired on December 21, 2019.

Licensed Practical Nurse was educated on how to access kardex and care plan to determine residents diet on December 23, 2019.

Post the event on December 21, 2019 the facility initiated a plan on December 23, 2019 to address residents care plan and kardex indication of resident's diets and textures. Audit of current residents was completed to validate that the current physician orders matched the care plan and kardex and where needed updates were made on the care plan/kardex. This was completed by the Director of Nursing and Assistant Director of Nursing in conjunction with therapy and dietary.

Education was initiated for nurses and nursing assistants on how to access point click care (facility electronic medical record) to identify resident's diet/texture of resident diet on December 23, 2019. This education included diet types, what a staff member can and cannot give to a resident on a modified diet and how to locate the information.

A copy of an approved snack list based on diet and texture was developed and placed on the nursing unit for reference on January 17, 2020. Random audits were completed to ensure diet orders match the care plan and kardex. Facility dietician and speech therapist will complete review and assure listing is accurate and current on a monthly basis.

On January 22, 2020 when the jeopardy was called the facility submitted a plan which included the steps that were completed in December as well as speech therapy and dietary development of safe food choices that are within the resident's diet restrictions. The listing of "Always available foods" based on diet restrictions education was initiated on January 23, 2020 and posted on each nursing unit on January 23, 2020. The snack and always available choices will be maintained and monitored by the facility dietician. Therapy representative will attend morning clinical meeting for resident updates and/or changes needing additional services.

The Immediate Jeopardy was lifted on January 23, 2020 when it was confirmed that speech therapy recommendations were reviewed, physician orders were obtained, present on kardex and careplans; that over 90 percent of nursing staff received education regarding how to access diet orders, kardex and care plans with the remaining staff scheduled to receive education prior to the start of their next shift.

The facility nursing staff will be receiving training by a Department of Health approved vendor on F684 42CFR 483.25 Quality of Care related to swallowing precautions and strategies that includes each staff member's specific responsibilities for knowing and implementing all physician-ordered and/or care-planned interventions. LW Consulting will be completing the Directed In-servicing training.

The Director of Nursing/designee will complete random review of care plans of 5 residents, 5 times per week for 1 month, weekly for 1 month then monthly for 1 month to validate that appropriate diet/texture is noted on care plan and kardex.

The Dietician/designee will complete review of postings at nursing station on facility snacks/always available menu items per texture. This audit will be conducted weekly for 3 months.

Results of audits will be reviewed with the Quality Assurance Performance Improvement Committee monthly for possible recommended changes until compliance is met.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper preventive maintenance was performed for five of five suction machines in the facility.

Findings include:

The facility's policy regarding suctioning the upper airway, dated September 1, 2019, indicated that for preparing to use the suction equipment, staff were to determine that the equipment was generating appropriate negative air pressure (suction). Lower negative pressure was to be used with older residents whose oral mucosa was fragile. The portable suction devices were to have negative pressure set at 10-15 millimeters of mercury (mmHg). The facility's policy did not include any information regarding maintaining and monitoring the suction machines for proper function.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 25, 2019, indicated that the resident was cognitively impaired and required supervision and set-up help for eating. Physician's orders, dated December 5, 2019, included an order for the resident to receive a controlled carbohydrate diet, pureed texture, with thin (regular) consistency liquids, and pleasure foods with supervision recommended.

A nursing note for Resident 1, dated December 21, 2019, revealed that a nurse aide noticed a change in the resident's condition. The resident was observed to have a skin color change from yellow to ashen (grey tone to the skin). The nurse aide indicated that the resident was eating peanut butter crackers; therefore, the nurse began the Heimlich maneuver with nothing expectorated and cardiopulmonary resuscitation (CPR) was initiated. A nursing note dated December 21, 2019, at 6:44 a.m. revealed that the resident was transferred to the hospital for evaluation.

Interview with Licensed Practical Nurse 1 on January 22, 2020, at 7:50 p.m. revealed that during the incident on December 21, 2019, she attempted to suction Resident 1, obtained a small amount of phlegm (mucous), and then the machine would not suction any further.

Interview with Licensed Practical Nurse 4 on January 22, 2020, at 7:11 p.m. revealed that during the incident on December 21, 2019, when the first suction machine quit working, she grabbed and set up a second suction machine; however, no suction was generated after set-up.

Observations of the B-wing suction machine (#AS14112) on January 22, 2020, at 8:15 p.m. revealed that Licensed Practical Nurse 7 set the machine up and it did not function. A "date of service" on the side of the machine was 2007.

Observations of three suction machines in a storage room on A-wing on January 22, 2020, at 8:20 p.m. revealed that the machines had a layer of dust on them. Licensed Practical Nurse 7 set up the machines, and two machines (#ASO2077 and #ASO2086) appeared to function; however, the side of each machine was marked that it was last serviced in 2007. The third machine did not function and did not have a number on it.

Observations of the C-wing suction machine (#ASO2085) on January 22, 2020, at 8:26 p.m. revealed that the machine had a layer of dust on it. Licensed Practical Nurse 7 set the machine up and it did not function. A date of service on the side of the machine was 2007.

Interview with Registered Nurse 8 on January 20, 2020, at 8:05 p.m. revealed that she does not check the function of the suction machines on crash carts, only that the necessary supplies are present.

Interview with Licensed Practical Nurse 7 on January 22, 2020, at 8:09 p.m. revealed that she used to check the crash carts and that the necessary supplies were present, but she only checked motor function on the suction machines and not that there was suction present because that would require a new package of tubing to be opened each time a machine was checked.

Interview with the Director of Nursing on January 22, 2020, at 9:10 p.m. confirmed that there were no service logs or manufacturer's instructions for the facility's suction machines. She contacted a maintenance staff member and he had no idea where the information could be because the machines were so old.

On January 22, 2020, at 11:19 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to staff not being able to quickly access a functioning suction machine for emergency use.

The facility submitted an immediate action plan to ensure resident safety by removing the suction machines from service and contacting a local durable medical equipment company on January 23, 2020, at 1:00 a.m., to deliver two suction machines. At the time the machines were delivered, registered and licensed practical nurses in the building were to receive education regarding how to set the machines up and use them, with a return demonstration. All other nurses were to receive this education starting on January 23, 2020, and continuing until 100 percent of the nurses were educated.

The Immediate Jeopardy was lifted on January 23, 2020, at 7:30 p.m. when it was confirmed that the facility entered into a contract with a local medical supply company for a total of five suction machines, along with a monthly service agreement for the machines; it was confirmed that five suction machines were delivered, two during the night shift on January 23, 2020, and three additional machines during the day shift on January 23, 2020; and it was confirmed that 100 percent of registered and licensed practical nurses received education regarding the use of the suction machines.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/17/19, 8/29/19, 5/2/19, 6/29/18.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 12/17/19, 5/2/19.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 12/17/19, 5/2/19, 6/29/18.





 Plan of Correction - To be completed: 02/20/2020

The facility removed from service, then disposed, of suction machines in-house.

On January 22. 2020 the facility obtained 2 suction machines from Dick's Homecare, Inc., as well as an agreement for preventative maintenance/service for the machines.

Crash cart checklist was updated to reflect the checking of the functioning of the suction machines on the crash carts. Crash cart will be checked daily for functioning equipment. The facility Maintenance Director will maintain manufacturer's instruction on facility equipment with oversight from the Administrator. Staff education was initiated with the licensed staff (RN, LPN) on January 22, 2020 on proper use of suction machine and a return demonstration of proper use of suction machine to include checking for appropriate suctioning. On January 24, 202 100% of nursing staff were educated on proper

Directed in-service will be provided by a Department of Health approved vendor on February 12, 2020 for F908 42 CFR 483.90(d)(2) on Essential Equipment, Safe Operating Condition - For each old and new piece of equipment of any type, all facility staff must receive training related to reviewing the manufacturer's instructions and identifying the maintenance schedule required or recommended by the manufacturer and the facility' s systems for ensuring that the maintenance schedule is followed.

Administrator/designee will monitor the preventative maintenance of the suction machines as well as the functioning of the suction machines 5 times per week for 1 month then 3 times per week for 1 month then weekly for 1 month.

Director of nursing will audit the crash cart checklist 5 times per week for 1 month then 3 times per week for 1 month then weekly for 1 month and complete a return demonstration of 2 nurses per week for 3 months to validate proper use of suction machine.

Results of audits will be reviewed with the Quality Assurance Performance Improvement Committee by the administrator for recommendations for any systematic changes needed to ensure compliance.



483.60(d)(3) REQUIREMENT Food in Form to Meet Individual Needs:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for diet consistency were followed for one of 12 residents reviewed (Resident 1), creating a situation in which the resident's safety was in Immediate Jeopardy related to being given regular consistency food, aspirating, and dying.

Findings include:

The facility's policy regarding therapeutic diets, dated December 1, 2019, indicated that a therapeutic diet included an altered consistency diet, that it must be prescribed by the attending physician, and that a resident's snacks should be compatible with the therapeutic diet.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 25, 2019, indicated that the resident was cognitively impaired and required supervision and set-up help for eating. Physician's orders, dated December 5, 2019, included an order for the resident to receive a controlled carbohydrate diet, pureed texture (foods that have been mechanically altered and do not have to be chewed), with thin (regular) consistency liquids, and pleasure foods with supervision recommended.

A speech therapy discharge summary for Resident 1, dated December 18, 2019, indicated that the resident had been on a mechanical soft diet and she was trialed (downgraded) to a pureed diet to ensure her safety and tolerance of her diet. With the mechanical diet she was observed to have impulsive rate, unsafe amounts of large bites, and had reduced chewing; therefore, she was changed to a pureed diet with pleasure foods. The recommendations were that during her oral intake to alternate liquids and solids, rate modification, bolus size modifications and general swallowing techniques.

A nursing note for Resident 1, dated December 21, 2019, revealed that a nurse aide noticed a change in the resident's condition. The resident was observed to have a skin color change from yellow to ashen (grey tone to the skin). The nurse aide indicated that the resident was eating peanut butter crackers; therefore, the nurse began the Heimlich maneuver with nothing expectorated and cardiopulmonary resuscitation (CPR) was initiated. A nursing note dated December 21, 2019, at 6:44 a.m. revealed that the resident was transferred to the hospital for evaluation.

Interview with Licensed Practical Nurse 1 on January 22, 2020, at 7:50 p.m. revealed that on December 21, 2019, she gave regular crackers with peanut butter to Resident 1 because she heard that others gave peanut butter crackers to the resident for a snack because she liked them. She stated that she was unaware of the resident's actual diet order until after the incident.

The facility's undated investigation statement for Licensed Practical Nurse 4, and an interview with Licensed Practical Nurse 4 on January 22, 2020, at 7:11 p.m., revealed that during CPR performed on Resident 1 on December 21, 2019, she documented what was occurring, and the documentation indicated that emergency medical services (EMS) noted to her that "the airway establishment was complicated by what appeared to be peanut butter."

Interview with Nurse Aide 3 on January 23, 2020, at 3:18 p.m. revealed that he was assigned to do one-to-one observation of Resident 1 on December 21, 2019, and the resident wanted a snack. The nurse gave her a packet of peanut butter crackers and she fed herself the whole pack. The nurse aide indicated that he was not aware of the resident's diet order. After eating the crackers, the resident became unresponsive.

Resident 1's death certificate, dated December 21, 2019, indicated that her primary cause of death was aspiration (inhaling a foreign material or food into the lungs) and the interval from onset to death was "minutes."

Interview with the Director of Nursing on January 22, 2020, at 5:59 p.m. revealed that the facility did not have any guidelines for staff regarding what "pleasure foods" were, and that nursing staff were to check residents' diet orders when giving snacks.

On January 22, 2020, at 11:19 p.m. the Nursing Home Administrator was informed that the health and safety of residents were in Immediate Jeopardy due to registered nurses, licensed practical nurses and nurse aides not knowing how to locate a resident's ordered diet or what consistencies the residents could be served.

The facility submitted and implemented an immediate plan to ensure resident safety by completing an audit for all residents to ensure that their ordered diet, kardex and care plans matched; providing education to nursing staff regarding where to find a resident's diet consistency; how to access the residents' kardex (which contains diet orders); what snacks are safe for residents based on their specific diets; and posting signs at each nursing station regarding what snacks are safe for each diet consistency.

The Immediate Jeopardy was lifted on January 23, 2020, at 7:30 p.m. when it was confirmed that an audit was completed for all residents; that over 90 percent of the nursing staff received the education, with the remaining staff scheduled to receive the education prior to the start of their next shift; and that the facility posted signs at each nursing station regarding what snacks were safe for each diet consistency.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 12/17/19, 8/29/19, 5/2/19, 6/29/18.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 12/17/19, 5/2/19.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 12/17/19, 5/2/19, 6/29/18.

28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 12/17/19, 8/29/19, 8/13/19, 5/2/19, 6/29/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/17/19, 8/29/19, 8/13/19, 5/2/19, 10/22/18, 9/18/18, 6/29/18.






 Plan of Correction - To be completed: 02/20/2020

Resident #1 expired on December 21, 2019

Licensed Practical Nurse was educated on how to access kardex and care plan to determine residents diet on December 23, 2019.

Post the event on December 21, 2019 the facility initiated a plan on December 23, 2019 to address residents care plan and kardex indication of resident's diets and texture. Audit of current resident was completed to validate that the current physician orders matched the care plan and kardex and where needed updates were made on the care plan/kardex. This was completed by the Director of Nursing and Assistant Director OF Nursing. In conjunction with therapy and. Dietary.

Residents on a "Special Liberalized diet" such as comfort foods or pleasure foods were monitored to ensure that they were still appropriate and if not were discontinued.

Education was initiated for licensed nurses and nursing assistants on how to access point click care (facility electronic medical record) to identify resident's diet/texture of resident's diet on December 23, 2019. This education included diet types, what a staff member can and cannot give to a resident on a modified diet and how to locate the information.

A copy of Approved snack list based on diet and texture was developed and placed on the nursing unit for reference on January 17, 2020.

Random audits were completed to ensure diet orders match the care plan and kardex.

On January 22, 2020 when the jeopardy was called the facility submitted a plan to include the steps that were completed in December as well as speech therapy and dietary developed safe food choices that are within the resident's diet restrictions. Listing of "Always available" food based on diet restrictions education was initiated on January 23. 2020 and posted on each unit on January 23, 2020. The snack and always available choices will be maintained and monitored by the dietician.

An ongoing audit speech therapy recommendations will be reviewed and provided to nursing administration to obtain the physician order and ensure that it is placed in the medical record (care plan/kardex). Nursing is responsible for review of recommendation with the physician for approval. Therapy representative will attend morning clinical meeting for review of resident updates and/or changes needing additional services.

At the time of the exit on January 23, 2020 90% of staff have been educated on how to access care plan/kardex and the "Always Available" food list.

Directed in-service will be conducted by a Department of Health vendor on February 12, 2020 for F tag F805 42 CFR 483.60(d)(3) Food in Form to Meet Individual Needs - All staff involved in serving residents food and drink, and in assisting residents to eat and drink, must receive training related to ensuring that appropriate and correct food and drink consistencies are served and/or provided. The training must include information regarding the facility's systems for ordering, care planning, assessing and monitoring correct diet consistencies, and when and how to access the resident' s diet order

Audits of new speech therapy recommendations and diet orders present on care plan and kardex will be completed by the Director of Nursing/designee. This audit will be performed 5 times per week for 1 month then 3 times week for 1 month and weekly for 1 month.

Results of audits will be reviewed by the Director of Nursing with the Quality Assurance and Performance Improvement committee for any systematic changes.


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.21(b)(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 and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for "pleasure foods" were clarified for one of 12 residents reviewed (Resident 1).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, and was responsible for assessing human responses and plans, implementing nursing care, and analyzing/comparing data with the norm in determining care needs.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 25, 2019, indicated that the resident was cognitively impaired and required supervision and set-up help for eating. Physician's orders, dated December 5, 2019, included an order for the resident to receive a controlled carbohydrate diet, pureed texture, with thin (regular) consistency liquids, and pleasure foods with supervision recommended.

A speech therapy discharge summary for Resident 1, dated December 18, 2019, indicated that the resident had been on a mechanical soft diet and she was trialed (downgraded) to a pureed diet to ensure her safety and tolerance of her diet. With the mechanical diet she was observed to have impulsive rate, unsafe amounts of large bites, and had reduced chewing; therefore, she was changed to a pureed diet with pleasure foods.

A nursing note, dated December 21, 2019, indicated that a nurse aide noticed a change in the resident's condition. The resident was observed to have a skin color change from yellow to ashen (grey color to the skin). The nurse aide indicated that the resident was eating peanut butter crackers; therefore, the nurse began the Heimlich maneuver with nothing expectorated and cardiopulmonary resuscitation (CPR) was initiated. A nursing note dated December 21, 2019, at 6:44 a.m. revealed that the resident was transferred to the hospital for evaluation.

Interview with Licensed Practical Nurse 1 on January 22, 2020, at 7:50 p.m. revealed that on December 21, 2019, she provided crackers with peanut butter to Resident 1 because she heard that others gave her the snack of peanut butter crackers and that she liked them. She stated that she was unaware of the resident's diet being pureed until after the incident.

There was no documented evidence that nursing staff clarified what "pleasure foods" Resident 1 was permitted to have and if the consistency of the resident's "pleasure foods" was to be pureed.

Interview with the Director of Nursing on January 22, 2020, at 5:59 p.m. revealed that there were no guidelines available for nursing staff regarding what consistency "pleasure foods" were to be.

A list of residents' diets, dated January 23, 2020, revealed that there were 43 residents with physician's orders that stated the resident may have two unrestricted meals per month; however, the facility did not have a policy regarding what consistency an unrestricted meal should be or how the resident should be supervised while eating an unrestricted meal.

Interview with the Director of Nursing on January 23, 2020, at 2:45 p.m. confirmed that there were no policies or guidelines for staff regarding what an "unrestricted meal" was.

42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 12/17/19, 8/13/19, 6/29/18.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/17/19, 8/13/19, 5/2/19, 6/29/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/17/19, 8/29/19, 8/13/19, 5/2/19, 10/22/18, 9/18/18, 6/29/18.







 Plan of Correction - To be completed: 02/20/2020

Resident #1 expired on December 21, 2019

The 43 residents that had orders for 2 unrestricted meals per week have been reviewed and discontinued and care plans updated as appropriate.

Education was completed with the staff that provide foods/fluids for the residents on appropriate foods based on the consistency diet they are ordered and how to clarify unclear order.

Education was completed starting on January 23, 2020Changes in diet orders to include any unclear orders will be reviewed by the interdisciplinary team in the facility clinical morning meeting.

Facility will complete random review of care plans of 5 residents 5 times per week for 1 month, weekly for 1 month and monthly for 1 month to validate that appropriate diet/texture is noted on care plan and kardex by the Director of Nursing/designee.

Results of audits will be reviewed with the Quality Assurance Performance Improvement committee by the Director of nursing/designee monthly for possible recommended changes until compliance is met.


483.70 REQUIREMENT Administration: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.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:


Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure resident safety.

Findings include:

The job description for the NHA, dated October 3, 2011, indicated that the NHA was to direct and oversee the day-to-day operations of the facility, to ensure that care was maintained at all times in accordance with current state and federal standards, and implement and enforce policies and procedures.

The job description for the DON, dated October 3, 2011, indicated that the DON was to manage the overall operations of the nursing department in accordance with regulatory standards, and have the knowledge of professional nursing theory and practice to provide resident care.

The deficiencies cited under the Code of Federal Regulatory Groups for Long Term Care, 483.25 Quality of Care (F684), 483.25(d)(3) Food in Form to Meet Individual Needs (F805) and 483.90(d)(2) Essential Equipment, Safe Operating Condition (F908) revealed that the NHA and DON failed to fulfill their essential job duties for ensuring the safety of residents and adherence to regulatory guidelines.

Refer to F684, F805, F908.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 12/17/19, 8/29/19, 5/2/19, 6/29/18.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 12/17/19, 5/2/19.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 12/17/19, 5/2/19, 6/29/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 12/17/19, 8/29/19, 8/13/19, 5/2/19, 10/22/18, 9/18/18, 6/29/18.










 Plan of Correction - To be completed: 02/20/2020

The facility Market Vice President of Operations will review with the facility Nursing Home Administrator and Director of Nursing their job descriptions which outline their responsibility for effective management of the facility and to ensure resident safety.

The Administrator and Director of Nursing will participate in daily clinical meeting and walking rounds to monitor the resident environment and delivery of resident care and services. The Nursing Home Administrator will round weekly with the Maintenance Director.

The Market Vice President of Operations/designee will meet with the Nursing Home Administrator and Director of Nursing weekly to discuss facility operations.

Results of audits will be reviewed with the Quality Assurance Performance Improvement Committee by the Director of Nursing/designee monthly for 3 months or until substantial compliance is met.




51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:


Based on review of clinical records and facility investigation documents, as well as staff interviews, it was determined that the facility failed to report an event that seriously compromised resident safety and resulted in death due to unusual circumstances to the Department of Health for one of 12 residents reviewed (Resident 1).

Findings include:

Physician's orders for Resident 1, dated December 5, 2019, included an order for the resident to receive a controlled carbohydrate diet, pureed texture (foods that have been mechanically altered and do not have to be chewed), with thin (regular) consistency liquids, and pleasure foods with supervision recommended.

A nursing note for Resident 1, dated December 21, 2019, revealed that a nurse aide noticed a change in the resident's condition. The resident was observed to have a skin color change from yellow to ashen (grey tone to the skin). The nurse aide indicated that the resident was eating peanut butter crackers; therefore, the nurse began the Heimlich maneuver with nothing expectorated, and cardiopulmonary resuscitation (CPR) was initiated. A nursing note dated December 21, 2019, at 6:44 a.m. revealed that the resident was transferred to the hospital for evaluation.

Resident 1's death certificate, dated December 21, 2019, indicated that her primary cause of death was aspiration (inhaling a foreign material or food into the lungs) and the interval from onset to death was "minutes."

There was no documented evidence that Resident 1's incident of December 21, 2019, was reported to the Department of Health.

An interview with the Director of Nursing on January 22, 2020, at 10:14 p.m. confirmed that the incident was not reported to the Department of Health.

28 Pa. Code 201.14(c)(e) Responsibility of the licensee.




 Plan of Correction - To be completed: 02/20/2020

Resident #1 expired on December 21, 2019

The facility department managers will be educated by the Market Director of Clinical Operations on events that should be reported to the state under State code 51.3 (g) (1-14). A listing of reportable event categories for the Department of Health will be utilized in clinical meeting for reference with event reviews. This reference will also be maintained at the nursing station.

Market President and the market director of clinical operations will audit events during routine facility visits to validate that events were reported to the state agency as per the regulation.

Audits will be reviewed with the Quality Assurance and Performance Committee by the administrator for recommendations/needs.


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