Pennsylvania Department of Health
ELAN SKILLED NURSING AND REHAB, A JEWISH SENIOR LIFE COMMUNI
Patient Care Inspection Results

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ELAN SKILLED NURSING AND REHAB, A JEWISH SENIOR LIFE COMMUNI
Inspection Results For:

There are  87 surveys for this facility. Please select a date to view the survey results.

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ELAN SKILLED NURSING AND REHAB, A JEWISH SENIOR LIFE COMMUNI - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on February 16, 2024, it was determined that the Elan Skilled Nursing and Rehab, A Jewish Senior Life Community, 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:


483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
483.24(c) Activities.
483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on observation, a review of clinical records and activities programming and participation records, and resident and staff interviews, it was determined that the facility failed to provide an ongoing program of activities designed to meet the needs, interests and functional abilities of residents including two of 25 sampled residents (Residents 83 and 117).


Findings include:


Review of Resident 117's clinical record revealed that the resident was admitted to the facility on November 16, 2023, with diagnoses that included major depressive disorder ([MDD] persistently low or depressed mood) and stage four sacral ulcer (a severe wound that extends past het skin and subcutaneous tissue, exposing muscle and bone).

Review of an initial activities assessment dated November 21, 2023, revealed that the resident enjoyed listening to oldies music and watching cooking shows on the television.

Review of the resident's care plan dated November 21, 2023, revealed that the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. Approaches planned were to offer encouragement of ongoing family involvement, activities that the resident enjoys, and providing the resident with an activities calendar and weekly menu, and to notify the resident of any changes to the calendar of activities. The resident's care plan did not identify the resident's specific preferences for activities programming that she enjoys.

Review of the resident's activity participation titled "Documentation Survey Report v2" for January 2024 and February 2024, failed to reveal that the resident had been offered or participated in the activities the resident preferred. The participation documentation listed cognitive group, self-directed activities, and sensory stimulation and did not identify the specific programming or the resident's response to the activities.

Observation of Resident 117 on February 14, 2024, at 1:42 PM, revealed that the resident was lying in bed. The resident was observed throughout the day on February 15, 2024, in her room and observed at 1:00 PM, lying in her bed. There was no observable evidence that the resident was provided with supplies/resources for independent/self-directed preferred activities.

An interview with Resident 117 on February 14, 2024, at 2:21 PM revealed she does not attend group activities due spending most of her time in bed. She stated that when she sits for a long period of time it causes her pain due to her sacral wound. She stated there are activities offered but as a group, "so I usually do not go." When asked if there are activities individualized to her preferences, she said "no, just the group."

Review of Resident 83's clinical record revealed that the resident was admitted to the facility on November 17, 2023, with diagnoses that included macular degeneration (deterioration of the retinal macular causing blurring and leading to vision loss) and hemiplegia/hemiparesis (weakness caused by brain damage leading to paralysis on one side of the body) due to left cerebrovascular accident ([CVA] when blood flow to a part of the brain is stopped by blockage or the rupture of a blood vessel).

Review of an initial activities assessment dated November 26, 2023, revealed that the resident enjoys music by Elvis, arts and crafts, pet and patio visits and prefers to watch the evening news on the television.

Review of the resident's care plan dated November 26, 2023, revealed that the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to physical limitations. Approaches were to offer encouragement of ongoing family involvement, her activity preferences, to encourage the resident to participate in group activities allowable with COVID-19 restrictions, provide individual activities related to their personal preferences to Face Time, Skype, and Google Duo visits are being offered as family and resident desire.

Review of the resident's activity participation titled "Documentation Survey Report v2" for January 2024 and February 2024, failed to reveal that the resident had been offered or participated in the activities the resident preferred. The participation documentation listed cognitive group, self-directed activities, and sensory stimulation and did not identify the specific programming or the resident's response to the activities.

Review of a nurses progress note dated February 5, 2024 at 10:06 AM revealed that the resident tested positive for COVID-19 and isolation droplet precautions were initiated.

Observation of Resident 83 on February 14, 2018, at 1:22 PM, revealed that the resident was sitting on the bed in the resident's room with the television on. The resident was observed throughout the day on February 15, 2024, in her room, and observed at 1:00 PM, sitting on the bed in her room. There was no observable evidence that the facility provided the resident with supplies/resources for independent/self-directed preferred activities.

An interview with Resident 83 on February 14, 2021, at 1:20 PM revealed that the resident stated the activities in the facility "are not good here" and that she has problems with her vision that prevents her from participating in some of the activities they have. The resident stated that she has been under isolation/droplet precautions since February 5, 2024, due to testing positive to COVID-19. The resident stated that she is lonely because her roommate had to change rooms due to the COVID infection, and she has no one to talk to and the facility has not provided her with any activities during this time.

An interview with Employee 1, Life Enrichment Director, on February 15, 2024, at 10:00 AM revealed that the "Documentation Survey Report v2" was the only documentation used for tracking residents' activity participation and confirmed that the activity participation failed to clearly reflect the activities offered to the residents and their response to those activities. Additionally, there was no indication of the activity programming for residents who prefer not to attend group activities and prefer one to one or self-directed activities of preference.

During an interview on February 16, 2024, at approximately 11:30 AM, with the Assistant Nursing Home Administrator (ANHA) confirmed the lack of ongoing program of activities in the facility to meet the needs, interests, preferences, and cognitive and physical abilities of residents who are dependent on staff and those under isolation precautions.


28 Pa. Code 201.29 (a) Resident Rights

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




 Plan of Correction - To be completed: 04/15/2024

F-0679
Elements detailing how the facility will correct the deficiency as it relates to the individual residents. Resident 117's care plan was updated to include her specific preferences for activities.
Resident 117 was provided with independent activities of her preference.
Resident 83 was provided with supplies/resources for independent/self-directed, preferred activities while in her room as per her plan of care listed preferences.
Indicate how the facility will act to protect residents in similar situations. An audit of care plans for residents who primarily remain in their rooms will be completed by the Director of Life Enrichment or designee for being specific with the resident's preferences for activities programming. The care plans not in compliance will be updated with specific preferences.
The measures the facility will take or the system it will alter to ensure that the problem does not recur. The Administrator or designee will educate the Director of Life Enrichment and the staff of the department of the requirements of this regulation.
The process to track the resident's activity participation, the response to the activities for participants, and the refusal of residents who were encouraged to attend will be reviewed and revised as needed by the Administrator with the Director of Life Enrichment.
A separate activities calendar will be developed for one-to-one or self-directed activities.
How the facility plans to monitor its performance to make sure that solutions are sustained.
From 3/1/24 through 4/14/24, the Life Enrichment Director or designee will audit 100% of new resident records where the resident is identified as preferring one-to-one or self-directed activities of preference. Auditing will include:
- Assuring identified residents have been provided with supplies/resources required for independent/self-directed preferred activities.
- That the resident has been offered or participated in the specific activities they prefer.
- And the resident response to the programming his documented.
The results of the audits will be reviewed in the monthly Quality Assurance Performance Improvement meetings

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on review of select facility policy and controlled drug shift count records, observation, and staff interviews, it was determined that the facility failed to implement procedures for reconciling and accounting for the use and administration of controlled drugs on three of five medication carts reviewed (3rd high, 3rd low, and 2nd).

Finding include:

A review of facility policy "Controlled Medication" last reviewed by the facility February 5, 2024, indicated that the policy is to ensure appropriate management and accounting of all controlled medications. All controlled medications will be counted by the on-coming and off-going licensed nurse at the change of each shift. After verification of the accuracy of the controlled substance count, both nurses will sign the Narcotic and Controlled Drug Record on the line corresponding with the appropriate date and shift.

Observation of medication administration pass, on February 14, 2024, at approximately 8:25 AM, revealed Employee 5, Licensed Practical Nurse (LPN), was completing med pass on the 3rd floor high side medication cart. Upon review of the narcotic count records, entitled "count form", it was revealed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify completion of the counts of controlled drugs in the respective medication cart on February 11, 2024 and February 13, 2024. Interview with employee 5 (LPN), confirmed the observation and acknowledged the licensed nurse are expected to sign at change of shift.

A review of the narcotic count records, entitled "count form", on February 14, 2024, at approximately 8:38 AM, revealed Employee 6, Licensed Practical Nurse (LPN), on the 3rd floor low side medication cart. It was observed that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following dates to verify completion of the counts of controlled drugs in the respective medication cart: January 21, 2024, and February 2, 2024. Interview with employee 6 (LPN), confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift.

A review of the narcotic count records, entitled "count form", on February 14, 2024, at approximately 12:50 PM, revealed Employee 7, Licensed Practical Nurse (LPN), on the 2nd floor medication cart. It was discovered that the on-coming nurse and/or off-going nurse failed to sign the sheets during shift change on the following date to verify counts of controlled drugs in the respective medication cart: January 29, 2024. Interview with employee 7 (LPN), confirmed the observation and acknowledged the licensed nurse signatures are expected to be signed at change of shift.

Interview with the Assistant Nursing Home Administrator (Asst. NHA) on February 15, 2024, at approximately 11:10 AM, confirmed the observation, and that it is his expectation that nursing staff signs the narcotic count records, entitled "count form", at change of shift, and that the facility failed to implement procedures for accounting for the controlled drugs.



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

28 Pa. Code 211.9 (k) Pharmacy Services



 Plan of Correction - To be completed: 04/15/2024

F 0755

Elements detailing how the facility will correct the deficiency as it relates to the individual residents.
Documentation related to on-coming and off-going nurses who failed to sign the Narcotic and Controlled Drug Record forms on 01/21/2024, 01/29/2024, 02/02/2024, 02/11/2024, 02/13/2024 throughout the Facility, cannot be retroactively rectified. Narcotic counts were completed during the DOH on-site survey and controlled drugs were found to be present and accounted for.

Indicate how the facility will act to protect residents in similar situations.
100% of the active Narcotic and Controlled Drug Record forms have been reviewed in the facility. No other missing licensed nurse signatures were identified during the audit.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.
The Facility Clinical Coordinator or designee will provide re-education to licensed nurses regarding the Facility "Controlled Medication" policy to assure management and accounting of in-use controlled medications.

How the facility plans to monitor its performance to make sure that solutions are sustained.
Clinical Directors or designee(s) will review Narcotic and Controlled Drug Record forms every day shift. The DON or designee will be notified immediately with any missing signatures identified.

Facility evening and night shift RN Supervisors or designee(s) will review 100% of the Narcotic and Controlled Drug Record forms every evening and night shift. The DON or designee will be notified immediately with any missing signatures identified.

Results of the daily reviews will be reviewed by the Quality Assurance Performance Improvement committee to determine if the process is effective or requires revision.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on observation, a review of clinical records and interviews with staff it was determined that the facility failed to consistently provide a functional communication system to maintain the resident's ability to communicate for one of one residents sampled with communication needs/deficits (Resident 122).

Findings include:

A review of Resident 122's clinical record revealed that the resident was admitted to the facility on December 4, 2023, with diagnoses including dementia.

A review of Resident 122's nursing progress notes revealed a nursing note dated December 4, 2023, indicating that the resident's first language is Russian, further stating the resident's family helps her with translation.

According to the resident's admission MDS assessment (Minimum Data Set assessment-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 4, 2023, the resident was sometime able to understand others and was sometimes understood.

A review of resident's clinical record during survey ending February 16, 2024, revealed the resident's care plan initiated December 4, 2023, did not address the resident's communication deficit and primary language, other than English and corresponding interventions to maintain the resident's ability to communicate.

Interview with the Assistant Nursing Home Administrator (ANHA) February 15, 2024, at approximately 1:00 p.m. confirmed that the facility had not provided the resident with any other means of communication to facilitate continuous communication between the resident and staff at all times.

The facility failed to ensure that this resident was provided a functional communication system to effectively communicate with others in the facility at all times.


28 Pa. Code 201.29 (a) Resident rights.

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



 Plan of Correction - To be completed: 04/15/2024

Elan Skilled Nursing and Rehab (facility) submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long-term care. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.

F 0676

Elements detailing how the facility will correct the deficiency as it relates to the individual residents.
Resident #122's plan of care was updated to include the intervention, "I prefer to be called Lucy. I do understand English. Speak slowly to me. My preferred language to speak with staff is English."

Indicate how the facility will act to protect residents in similar situations.
An audit of current in-house residents was completed by the DON, ADON and Director of Human Services on 03/08/2024 to identify any resident with a first language that is not English. One capable resident was identified as having a first language of Polish. After discussion with the resident, the plan of care was updated to include his preferred language to speak with staff, as English.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.
Upon admission of residents after 03/08/2024, with the resident and responsible representative, Social Services will identify both the new resident's first language and their preferred language to interact with staff. The resident plan of care will be updated for the interdisciplinary team to act accordingly.

How the facility plans to monitor its performance to make sure that solutions are sustained.
For residents identified as English not being their first language, validation of the resident's preferred language will occur at the scheduled PATH meeting with review of the plan of care. The plan of care will be revised, as necessary.

This process will be monitored by the DON or designee to ensure the process is in place. The resident care plans for those with their first and/or preferred language other than English will be reviewed and the data examined by the Quality Assurance Performance Improvement committee monthly x three to determine if the process is effective.

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 review of clinical records, information submitted by the facility, and select facility reports and staff interviews, it was determined that the facility failed to provide necessary supervision and effective safety measures to monitor the whereabouts and activities of one out of two sampled residents with wandering behavior (Resident 108) to maintain resident safety.

Findings include:

A review of the clinical record revealed that Resident 108 was admitted to the facility on December 21, 2022, with diagnoses of Dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), macular degeneration, and osteoarthritis.


A review of Resident 108's wander/elopement risk scale (a document used to rate an individual's risk of elopement) dated March 11, 2023, revealed that the resident scored a 10, indicating that the resident was at risk for elopement/wandering.

A review of an Annual Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated October 17, 2023, revealed that the resident's cognition was severely impaired with a BIMS score (brief interview for mental status -section of MDS that assesses cognition) of 4 (a score of 0-7 indicates severely impaired cognition). The resident was independent with walking and used a wander/elopement alarm daily.

Interventions care planned to address the resident's elopement risk were to check resident's location on inter shift rounds, and check transmitter per facility policy, dated December 26, 2022, and the resident's care plan noted that "when I am wandering, please offer to me my busy box with a few favorite items (sun catcher/puzzles/water paining/word search). Radio is in my room, likes to request phone calls and offer assistance, comfort snack is coffee with sugar, dated February 24, 2023, and place photo in wanderers book, check placement of transmitter on inter shift rounds, date revised August 28, 2023."

A nursing progress note dated April 19, 2023, at approximately 2:35 PM, revealed that Resident 108 was seen on the first floor (not the floor where the resident resides). She was attempting to go through the back entrance, exit doors. Her wanderguard sounded and our receptionist notified maintenance, who redirected her around to the elevator, and escorted back to the fourth floor without incident. The resident stated she was going to her grandmother's house. MD, aware, and family currently in the building and aware. New order noted for customer service 15 - minute checks for safety.

Nursing documentation dated November 24, 2023, indicated that at 2:55 PM, the resident was found at the back door of the facility. Her transmitter did alert staff to her attempts to leave the building. Employee 2, a nurse aide, was coming on shift at the time, and saw Resident 108 at the door and escorted her back into the building. The resident's daughter, was also entering the building, and escorted her back to the unit with Employee 2. Emotional support was provided.

The resident's care plan was revised on November 25, 2023, in response to an incident on November 24, 2023, during which the resident was found attempting to leave facility, located at the front door. The goal was that the resident's safety will be maintained, and the resident will not leave the facility unattended through the next review date with the target date April 18, 2024

A review of a change in condition note dated November 24, 2023, at 4:30 PM, indicated a change in condition assessment was completed related to the resident attempted elopement out the back entrance. Found at doorway and escorted back to fourth floor. No injuries noted. and at 5:30 PM, the MD was notified of the incident. Changes and updates were made to the keyed entrance/exit codes on the unit.

A review of an incident report entitled Event of Known Origin (Other than Fall) dated November 24, 2023, at 2:55 P.M., revealed that Resident 1 had been found at the rear lobby door without injury and that the entrance/exit elevator codes had been changed, and that every 15-minute safety checks were initiated.

A review of Employee 2's witness statement dated November 24, 2023, indicated that the employee was approaching the door to enter for her shift. The employee saw the resident walk out of the 2nd set of doors to the parking lot. Resident 108 was walking with another woman along with an employee behind them. The resident was stopped at the door by Employee 2, and the resident's daughter as they were entering. Together, they escorted the resident back into the building and notified the supervisor.

A review of facility incident follow up, dated November 24, 2023, revealed that the administrator was alerted immediately, and went to the area to investigate. Employee 4 (receptionist) was on duty, thought the alarm was going off because a resident was coming in from the outside with a family member. Employee 4 (receptionist) had seen Resident 108 in the past, but thought she was with her family and did not verbally verify who she was and who was accompanying her.

The resident's code alert was tested and found to be functioning, the lobby door was tested and found to be working properly. A request for maintenance to determine if the elevator code for the 4th floor unit could be changed.
Camera footage was reviewed and showed a family member of another resident from 4th floor was leaving the building at 2:48 PM. The lobby door closed behind her. At 2:53:51 PM Resident 108 was seen at the lobby exit door and code alert bracelet worn prevented the door from opening, alarm sounded. At the same time, 2 visitors arrived at the door with Resident 108 to go out (exit), and 1 staff member Employee 3, a nurse aide, and a visitor arrived at the door to come in from the outside. Employee 4 (receptionist) went to the door and disarmed the door. Resident 108 walked through the first door with the other 2 visitors into the vestibule and stepped out to the mat at the second door going out of the vestibule at the same time another staff member, Employee 2 was walking into the door into the vestibule with the resident's daughter. Resident 108 was returned to unit without incident.

Employee 3, nurse aide and Employee 4, receptionist, stated they thought Resident 108 was going out with family as she had her coat and purse, and was speaking with the 2 visitors as they walked through the first door into the vestibule, which is why Employee 4 (receptionist) turned off the alarm system.

In response to the incident, reception staff educated, in-serviced, on their responsibility when the alarms go off, (identifying the resident, who is accompanying the resident) prior to resetting the code. All elevator codes have been changed to all elevators to the 4th floor, and all staff have been educated, in-serviced on the new codes, and to visibly observe the elevator doors close to ensure no unauthorized residents are on the elevators before walking away. Signs have been posted for staff not to share the codes with family/visitors, and for family/friends to ask, request, access from a staff member for the elevators to exit the floor.

A review of information submitted by the facility dated November 24, 2023, indicated that Resident 108 had left the nursing unit unattended, unsupervised by staff, on the elevator and proceeded to the main lobby as stated.

The Assistant Nursing Home Administrator (Asst. NHA) on February 15, 2024, stated during interview at approximately 1:10 PM, that Resident 108 had not exited the 2nd set of doors into the parking lot, but rather was in-between the inner and outer doors (the vestibule). Interview with the Asst. NHA on February 16, 2024, at approximately 10:05 AM, confirmed that staff were not aware of Resident 108 leaving the nursing unit until the resident was observed attempting to exit the facility at the lobby doors.


28 Pa. Code 201.18 (e)(2.1) Management

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






 Plan of Correction - To be completed: 04/15/2024

F 0689

Elements detailing how the facility will correct the deficiency as it relates to the individual residents.
Resident #108, as a high risk to wander, will continue implemented care planned interventions to assure necessary supervision, effective safety measures, and an environment that remains free of accident hazards.

Indicate how the facility will act to protect residents in similar situations.
A review of current in-house resident wander risk scores was completed by the DON on 3/08/2024. Facility clinical, interdisciplinary team (IDT) will review each resident, plan of care, Code Alert transmitter utilization on 03/11/2024. Resident plans of care will be appropriately updated to assure necessary supervision, effective safety measures and an environment that remains free of accident hazards, as possible, is in place per IDT review.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.
The DON or designee will monitor 100% of facility admissions from 03/11/2024 through 04/14/2024 for resident wander risk score and resident plans of care to assure necessary supervision, effective safety measures and an environment that remains free of accident hazards, as possible, is in place per facility protocol.

How the facility plans to monitor its performance to make sure that solutions are sustained.
The DON or designee will complete a quarterly audit of current in-house resident wander/risk scores. Those identified as being at high risk for wandering will be added to the At-Risk weekly meeting for full IDT review to assure necessary supervision, effective safety measures and an environment that remains free of accident hazards, as possible, is in place and reflected on the care plan per facility protocol.

Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of the audit process.

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to accurately monitor a fluid restriction prescribed to address a resident's clinical condition and maintain fluid balance and adequate hydration status for one resident receiving dialysis (Resident 54) out of 25 sampled.

Findings include:

A review of the clinical record revealed that Resident 54 was admitted to the facility on January 24, 2024, with diagnoses which included peripheral vascular disease, diabetes, and end stage kidney disease with dependence on hemodialysis.

A physician's order dated January 25, 2024, was noted for the resident to be maintained on a 1000 cc fluid restriction with the following breakdown of the fluid distribution:

7:00 AM - 3:00 PM shift nursing 240 ml.
3:00 PM - 11:00 PM shift nursing 120 ml.
11:00 PM - 7:00 AM. shift nursing 120 ml.

A total of 520 ml of fluids provided by dietary each day.

A review of the resident's January 2024 and February 2024 Documentation Survey Report failed to provide evidence of an accurate recording and/or accounting of the amount of fluids the resident consumed each day to assess compliance with physician ordered fluid restriction related to the resident's kidney disease and to meet the resident's hydration needs.

Interview with the facility's Registered Dietitian on February 15, 2024, at approximately 11 AM confirmed that the facility did not have a process in place to monitor Resident 54's total fluid consumption for compliance to the fluid restriction.

The facility was unable to confirm the amount of fluid consumed by the resident daily and if that amount of fluid consumed exceeded the physician prescribed fluid restriction or was sufficient to maintain adequate hydration. The facility was unable to provide documented evidence that this fluid restriction was maintained in accordance with physician orders.


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

28 Pa. Code 211.5(f) Medical records



 Plan of Correction - To be completed: 04/15/2024

F 0698

Elements detailing how the facility will correct the deficiency as it relates to the individual resident.
Resident #54 has been discharged from the Facility.

Indicate how the facility will act to protect residents in similar situations.
An audit of current in-house residents ordered fluid restriction was completed on 03/10/2024. Two residents were identified. Both residents had fluid volume tallies added to their electronic medication administration records (EMAR) for each of three shifts. Night shift will be responsible to tally the fluids consumed/documented over the prior 24 hours. Licensed nurse to report any excess of maximum fluid allowed over prior 24 hours to RN Supervisor.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.
Process for collecting total fluid volume intake of residents revised. Due to high risk of dehydration in the elderly, residents will have total intake documented in the medical record in the EMAR or Point of Care (POC).

Education regarding this new process will be provided by the Director of Nursing or designee.

How the facility plans to monitor its performance to make sure that solutions are sustained.
From 3/11/2024 through 04/14/2024, Dietitian or designee will audit 100% of the resident records ordered a specific fluid watch, to assure accuracy in nursing documentation of resident fluid volume consumed per shift and tallied daily.
Audit results will be reviewed by the Quality Assurance Performance Improvement Committee to determine resolution or need for continuation of the audit process.


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

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

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

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

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

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

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


Based on a review of clinical records and select facility policy, resident and staff interviews it was determined that the facility failed to ensure that resident's drug regimen was free of unnecessary antibiotic drugs for one out of five residents sampled prescribed antibiotic drugs (Resident 40).


Findings included:

A review of the facility's policy titled "Antibiotic Stewardship Plan" with a review date of August 23, 2023, states that antibiotic resistance is a major problem, it is imperative to protect agents available by judicious antimicrobial management, which improves resident outcomes and reduces the potential development of resistant infections. The guideline principles include timely and appropriate initiation of antibiotics, appropriate administration according to evidence-based practice, monitoring the effectiveness and promoting transparency and open communication.

Review of Resident 40's clinical record revealed that the resident was admitted to the facility on August 31, 2023, with diagnoses of cognitive communication deficit (impaired functioning of one or more cognitive processes) and diabetes mellitus type two ([T2DM] a condition of insufficient insulin production causing high blood sugar levels).

A clinical record titled "JH Change in Condition Evaluation" dated January 28, 2024, at 4:03 PM, revealed that "\ had a fever of 102.4 degrees Fahrenheit. All other vital signs were within normal limits, no changes were observed in her mental, functional, or behavioral status. The resident had no complaints or observations of her urinary function. The record stated that the resident was experiencing a fever and her daughter was concerned of a urinary tract infection (UTI) without any other indication. Recommendations from the provider were to obtain a urinalysis ([UA] is an analysis that includes various tests to examine the urine contents for any abnormalities that indicate a disease condition or infection), culture and sensitivity ([C & S] identifies the organisms create infections and illnesses. Sensitivity tests to identify the most effective medications to treat the illnesses or infections), and a complete blood count ([CBC]serum laboratory testing), complete metabolic panel ([CMP] serum laboratory testing), and blood cultures (serum laboratory testing), and one time of dose of Levaquin (antibiotic medication) 750 mg. Levaquin (antibiotic medication) one dose after urine sample obtained and re-evaluate after results of CBC and UA/C&S."

A review of the resident's medication administration record (MAR) for the month of January 2024, revealed that the resident received one dose of Levaquin, received on January 28, 2024.

A review of McGeer's Criteria dated January 29, 2024, revealed that the resident had a single symptom of fever and no other symptoms of a UTI and that the UTI criteria was not met to treat.

A review of laboratory test results (U/A) dated January 28, 2024, at 5:46 PM revealed an abnormal result of "small amount of esterase urine" and "WBC urine 20-29."

A review of laboratory test results (CBC) dated January 28, 2024, at 3:06 PM revealed that the patient had a slightly elevated WBC (white blood cell) count of 11.89, but not exceeding 14,000 WBC/mm to meet McGeer's Criteria for leukocytosis (higher than normal level of white blood cells in the blood).

A review of laboratory test results (blood cultures) dated February 2, 2024, at 6:02 PM revealed that there was no growth of bacteria noted.

There was no evidence of an order to obtain a urine culture and sensitivity or report of the results of a urine C & S when reviewed at the time of the survey ending February 16, 2024.

There was no physician documentation to indicate the clinical necessity of initiating antibiotic treatment with Levaquin to treat the resident's suspected urinary tract infection prior to receiving the results of a urine C&S or that a C&S was performed.

Interview with the Infection Preventionist Nurse on February 16, 2024, at 11:30 AM, confirmed that the prescribing physician did not document the supporting clinical rationale for initiating antibiotics prior to receiving the results of the culture and sensitivity results identify the most effective treatment for the resident's suspected urinary tract infection.




28 Pa. Code 211.2(d)(3)(5) Medical director

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.9 (k) Pharmacy services






 Plan of Correction - To be completed: 04/15/2024

F 0757

Elements detailing how the facility will correct the deficiency as it relates to the individual residents.
There is no way for the facility to retroactively address resident #40 physician documentation.

Indicate how the facility will act to protect residents in similar situations.
The Infection Preventionist reviewed current in-house residents utilizing antibiotics at the facility on 3/8/24. Those audited that did not meet criteria for antibiotics will be reviewed by the Infection Prevention and Control and Quality Assurance Performance Improvement committees with appropriate follow-up.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.
The Infection Preventionist or designee will re-educate licensed facility staff regarding the facility's current Antibiotic Stewardship Plan to ensure staff understanding and ability to educate physicians and extenders when interacting for resident care.

How the facility plans to monitor its performance to make sure that solutions are sustained.
The Infection Preventionist or designee will continue to review current in-house resident conditions, provider notes, and antibiotic orders at the time of care and treatment to ensure adherence with the facility antibiotic stewardship plan.

Results of the individual reviews will be reported to the Infection Prevention and Control committee and the Quality Assurance Performance Improvement committee to determine compliance.



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