Nursing Investigation Results -

Pennsylvania Department of Health
JEWISH HOME OF EASTERN PA
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
JEWISH HOME OF EASTERN PA
Inspection Results For:

There are  68 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.
JEWISH HOME OF EASTERN PA - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint Survey completed on February 28, 2020, it was determined that the Jewish Home of Eastern PA was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.







 Plan of Correction:


483.10(j)(1)-(4) REQUIREMENT Grievances: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.
483.10(j) Grievances.
483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with 483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on observations, review of select facility policy and resident interviews, it was determined that the facility failed to make information available regarding the facility's grievance/complaint process and the residents' rights to file a grievance in prominent locations on the nursing units.

Findings include:

A review of the facility's policy entitled "Grievance Policy" and the "Grievance Posting Policy" last reviewed by the facility March, 2020, indicated that it is the policy that grievances will be afforded prompt investigation and resolution by the facility administration. The policies failed to indicate where the residents or family members may obtain a grievance form.
During an interview with the Director of Social Services on February 26, 2020, at 10:00 AM, it was acknowledged that grievance postings were not placed in prominent locations on each unit of the facility and the policies failed to indicate where grievances can be obtained.

During a group interview conducted on February 25, 2020, at 1:00 PM with eight residents who regularly attend the monthly Resident Council Meetings (Residents 136, 102, 139, 86, 42, 22, 54 and 35) the residents stated that they were not aware how to file a grievance, the location of grievance forms or the identify of the facility's designated Grievance Offical. All the residents in attendance were unaware of the location of any grievance postings in the facility, which comprised of four nursing units, which detailed the facility's grievance process.

Observations conducted on the days of survey of all four nursing units, from February 25, 2020, through February 28, 2020, revealed the postings of the availability of grievance forms was written in small print posted on the back of a clipboard. The forms were difficult to read due to the size of the print and format and were not found in prominent locations for access by resident and family members. The grievance postings failed to include pertinent information regarding contacting and/or role of the local area Ombudsman.




28 Pa. Code 201.18(e)(1) Management
Previously cited 1/25/19

28 Pa. Code 201.29(a)(b)(i) Resident rights
Previously cited 1/25/19









 Plan of Correction - To be completed: 03/31/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.


Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

Information on the grievance process including, how to file a grievance, location of grievance forms and the identity of the Grievance Official will be provided to identified residents (136,102,139,86,42,22,54 and 35).


Indicate how the facility will act to protect residents in similar situations.

Information on the grievance process including, how to file a grievance, location of grievance forms and the identity of the Grievance Official will be reviewed with residents a monthly resident council meetings.



The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

Grievance policy will be reviewed and updated as needed. The grievance posting will be updated to include location of grievance forms and any additional information required. The grievance posting will be displayed in prominent locations such as the bulletin board and in close proximity to the concern boxes located on each floor. The grievance posting will be displayed in 12 pt. font or lager.

How the facility plans to monitor its performance to make sure that solutions are sustained.

Grievance posting placement will be audited for prominent placement for 3 months.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to develop and/or implement a person-centered comprehensive care plan for six out of 31 residents sampled (Residents 57, 58, 75, 88, 7 and 20).


Findings include:

A review of the clinical record revealed that Resident 88 was admitted to the facility on December 27, 2018, with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).

A review of Resident 88's current physician orders revealed an order dated December 27, 2018, for Pradaxa (anticoagulant medication) 150 mg to be taken twice a day.

A review of Resident 88's current comprehensive plan of care conducted on February 27, 2020, revealed that the facility failed to include the specific individualized interventions in response to the resident's use of anticoagulant therapy.

Interview with the Clinical Operations Executive on February 28, 2020, at approximately 1:00 p.m., confirmed the absence of a resident centered care plan addressing Resident 88's use of anticoagulant therapy.

A review of the clinical record revealed Resident 57 was admitted to the facility on December 12, 2014, with diagnoses that currently included peripheral vascular disease (poor circulation of the extremities), abnormal posture, joint stiffness, and pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin), Stage IV on the right lower back.

Review of Resident 57's clinical record revealed that the resident's current care plan noted the presence of the pressure ulcer and the approaches that included to avoid positioning the resident on back and to turn the resident side to side every 1 hour and as needed.

A review of Resident 57's repositioning log, care cards and Kardex indicated that the resident was being turned every 2 hours, and not every 1 hour, as indicated in the resident's care plan,

A review of the clinical record revealed Resident 75 was admitted to the facility on October 17, 2017, with diagnoses that included dementia with behavioral disturbances, (a disorder associated with a decline in memory of other thinking skills severe enough to reduce a person's ability to perform everyday activities), major depressive disorder (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine) and delusional disorder (fixed, false ideas and/or beliefs), .

The resident had a physician order for Haldol (an antipsychotic medication that treat certain types of mental disorder) decanoate solution, inject 75 mg IM (Intramuscular) one time a day every 28 days, dated January 18, 2019, and discontinued on January 8, 2020.

The resident had a physcian order for Haloperidol lactate concentrate, give 2.5 mg PO (By mouth) in the afternoon dated December 29, 2019 and discontinued January 3, 2020.

The resident had a physician order for Haloperidol tablet 0.5 mg, give 1 tablet PO in the afternoon dated December 11, 2019, and discontinued December 30, 2019.

The resident had a physician order for Haloperidol tablet 2 mg, give 1 tablet PO in the afternoon written on December 11, 2019, and discontinued December 30, 2019.

Review of Resident 75's Medication Administration Record for February 2020 revealed physician's orders for Haloperidol decanoate solution, inject 150 mg IM one time a day every 28 days dated February 4, 2020 and discontinued on February 19, 2020, and subsequently Haloperidol decanoate solution, inject 150 mg IM at bedtime every 28 days dated February 19, 2020,

Further review of Resident 75's clinical record revealed that the care plan did not address the resident's antipsychotic drug use, Haloperidol, and its black box warning (type of warning that appears on the package insert that a risk of serious or even life-threatening adverse effects is possible. In September 2007, the FDA released a warning that torsades de pointes [is a specific type of abnormal heart rhythm that can lead to sudden cardiac death] and and QT prolongation [heart muscle takes longer than normal to recharge between beats] might occur in patients receiving haloperidol, particularly when the drug is administered intravenously or at doses higher than recommended).

Interview with the Clinical Operations Executive on February 27, 2020 at approximately 11:30 a.m. confirmed that the Resident's 57 care plan for repositioning was not consistently implemented and that Resident 75's care plan did not include the resident's antipsychotic drug use and related risks.

A review of the clinical revealed that Resident 58 was admitted to the facility on November 27, 2017, with a diagnosis that included atrial fibrillation.

A review of Resident 58's current physician orders revealed an order dated February 14, 2020, for Pradaxa (anticoagulant medication) 75 milligrams (mg) to be taken by mouth two times a day.

A review of Resident 58's current comprehensive plan of care conducted on February 27, 2020, revealed that the facility failed to include address the resident's use of anticoagulant therapy.

Interview with the Clinical Operations Executive on February 27, 2020 at approximately 11:30 a.m. confirmed the plan of care of Resident 58 did not address the resident's anticoagulant drug therapy and related bleeding risks and/or monitoring needs.

A review of the clinical record revealed that Resident 88 was admitted to the facility on December 27, 2018, with diagnoses that included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow).

A review of the clinical record revealed that Resident 7 was admitted to the facility on April 8, 2019.

A review of an annual MDS (Minimum Data Set- an assessment completed at specific intervals to identify care issues) dated February 10, 2020 and a quarterly MDS dated November 15, 2019, indicated the resident has a history of wandering.

A review of the Resident 7's current comprehensive care plan conducted on February 26, 2020, revealed the facility failed to include interventions and approaches addressing the resident's wandering. This was confirmed by the Director of Social Services on February 27, 2020, at 10:10 AM.

A review of the clinical record revealed that Resident 20 was admitted to the facility on June 25, 2014, with diagnoses that included anxiety, dementia and depression.

During an interview with the Clinical Operations Executive on February 25, 2020 at approximately 11:38 a.m. she indicated the Resident 20 had colonization VRE of the rectum (Vancomycin-Resistant Enterococci - a type of bacteria that can cause an infection in the bloodstream; however, it other parts of the body it does not cause an infection and shows no symptoms and requires no antibiotics).

A review of Resident 20's current comprehensive plan of care conducted on February 27, 2020, revealed that the facility failed to include specific individualized precautions and/or interventions in response to the resident having colonization VRE of the rectum.

Interview with the Clinical Operations Executive on February 28, 2020, at approximately 11:35 a.m., confirmed the absence of a resident centered care plan addressing Resident 20's VRE of the rectum and specific precautions and/or interventions.




28 Pa Code 211.11(d) Resident care plan.

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












 Plan of Correction - To be completed: 04/16/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.

Elements detailing how the facility will correct the deficiency as it relates to the individual residents
By February 27, 2020, the following modifications were made to the identified residents care plans:
Resident 88 and 58's care plans were updated to include resident centered interventions regarding the use of anti-coagulants.

Resident 57's care plan and POC were updated to include repositioning every one hour as per the resident plan of care.

Resident's 75's care plan was updated to include the use of the antipsychotic drug and its black box warning.

Resident 7's care plan was updated to include interventions and approaches addressing resident's wandering.

Resident 20's care plan was revised to include individualized precautions for colonized VRE.

Indicate how the facility will act to protect residents in similar situations.

An audit of all residents receiving anticoagulants/antipsychotic medications as well as those on repositioning schedules, transmission-based precautions and wandering will be completed and care plans updated

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.


All licensed nurses will be re-educated on the need to include resident centered interventions on the plan of care and verification of consistency on interventions of those receiving anti-coagulants, anti-psychotics, wandering, requiring transmission-based precautions and orders specific to repositioning.

All licensed nurses and social workers will be re-educated on the need to include resident specific interventions re the use of antipsychotic medications as well as black box warnings in resident care plans.


How the facility plans to monitor its performance to make sure that solutions are sustained.

Random audits of all residents receiving anticoagulants will be completed for the next 30 days with the need for ongoing audits based on outcomes.

Random audits of the plan of care of residents receiving antipsychotic medications will be completed by for the next 30 days with the need for ongoing audits based on outcomes.

Random audits of the repositioning log, kardex and care plan will be completed for the next 30 days, with the need for ongoing audits based on outcomes.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:


Based on observations, a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to timely consult with the resident's physician regarding a change in condition for one of 31 sampled residents (Resident 58).

Findings include:

A review of Resident 58 clinical record revealed admission to the facility on Novemeber 27, 2017, and had a Stage IV pressure ulcer of the sacral region. The resident had an indwelling urinary foley catheter inserted to assist with wound healing.

A review of the resident's most recent quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated December 25, 2019, indicated that the resident was cognitively impaired with a BIMS score of 00 (brief interview for mental status, a tool to assess the residents' attention, orientation and ability to register and recall new information).

A review of facility policy titled "Physician Notification" with a policy review date of January 22, 2020, indicated that "A resident's physician will be notified by Clinical Director, Nursing Supervisor or Licensed Nurse in the following instances: when there is an accident that results in injury and has the potential for requiring physician intervention, if there is significant change in a resident's physical, medical, or psychosocial status, in the event of abnormal or unusual diagnostic study, if there is a need to alter a resident's treatment, for a decision to transfer or discharge a resident or on nursing assessment/judgement".

A review of interdisciplinary notes revealed an entry by a licensed practical nurse on January 12, 2020, at 2:52 p.m. noting there was hematuria (blood in the urine) in the foley collection bag.

Further review of the interdisciplinary notes revealed hematuria was noted to be present in the foley collection bag on January 12, 2020 at 9:40 p.m., January 13, 2020 at 3:05 a.m., 1:28 p.m., and 10:19 p.m., January 14, 2020 at 5:14 a.m., 3:01 p.m.

However, the physician was not made aware until January 15, 2020, at 10:56 a.m. An interdisciplinary entry dated January 15, 2020, noted a "moderate amount of hematuria noted in the resident's foley collection bag" and the resident stating "I don't feel good."

An observation of the resident on February 25, 2020, at 2:27 p.m. revealed gross hematuria noted in the foley bag.

During an interview February 28, 2020, at approximately 9:30 a.m. Employee 3, the Clinical Operations Executive confirmed that the resident had a change in condition, gross hematuria, observed on January 12, 2020, and physician was not notified until January 15, 2020.


28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing Services
previously cited: 1/25/19,9/18/19,12/30/19

28 Pa Code 211.5 (d)(f) Clinical Records
previously cited: 1/25/19



















 Plan of Correction - To be completed: 04/16/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.


Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

The physician was notified of the resident's change in condition on 1/15/2020


Indicate how the facility will act to protect residents in similar situations.

The facility will audit changes in condition for the last 14 days to assess for appropriate physician notifications of changes in condition.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

All licensed staff will be re-inserviced on the need to notify the physician timely of changes in condition per facility policy.


How the facility plans to monitor its performance to make sure that solutions are sustained.

Audits of physician notification of change in condition will be completed for the next 30 days and further audits based on need as determined by outcome.


483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of two resident out of 31 sampled (Residents 58 &105).

Findings include:

According to the RAI User's Manual, Section N0410 for Medications Received, the facility is to record the number of days a medication was received by the resident at any time during the 7-day assessment look back period.

A review of the clinical record of Resident 105 revealed physician's orders for Tramadol ( an opiate analgesic) 50 milligrams (mg), administer 0.5 tablet (25 mg) by mouth two times a day at 09:30 AM and 08:00 PM.

A review of this resident's Significant Change MDS Assessment dated January 22, 2020, Section N0410, indicated that the resident did not receive an opioid in the seven day look back.

A review of Resident 105's Medication Administration Record (MAR) revealed that the resident received Tramadol 25 mg (tramadol is classified as a centrally-acting, oral analgesic (pain drug) that contains an opioid [narcotic]) by mouth two times a day, on seven days during the seven day look back period.

A review of the clinical record of Resident 58 revealed physician's orders for Pradaxa ( an anticoagulant) 150 mg capsule, administer 1 capsule by mouth two times a day at 10:00 AM and 8:30 PM.

A review of this resident's Quarterly MDS Assessment dated December 25, 2019, Section N0410, indicated that the resident did not receive an anticoagulant in the seven day look back.

A review of Resident 58's Medication Administration Record ( MAR) revealed that the resident received Pradaxa 150 mg capsule by mouth two times a day, on the seven days during the seven day look back period.

Interview with Employee 2, the Registered Nurse MDS Assessment Coordinator (RNAC) on February 28, 2020, at approximately 10:00 a.m. confirmed that the above MDS Assessments section N0410, were inaccurate.



28 Pa. Code 211.5(g)(h) Clinical records
previously cited: 1/25/19

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
previously cited: 1/25/19, 9/18/19, 12/30/19










 Plan of Correction - To be completed: 04/06/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.



Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

On February 27, 2020, the MDS Coordinator reviewed and modified the MDSs of both residents, 58 and 105, to reflect medications received in Section N0410.


Indicate how the facility will act to protect residents in similar situations.

A random audit of 50 residents' MDS Section N0410 will be completed to verify accuracy.


The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

Senior Director of Clinical Operations will re-educate the RNACs on the need to accurately record medications received by the resident at any time during the 7day lookback period.


How the facility plans to monitor its performance to make sure that solutions are sustained.

A random audit of MDS Section N0410 will be completed for the next 30 days to verify accuracy of information documented. The need for further auditing will be based on outcomes.

483.25 REQUIREMENT Quality of Care: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 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 observation, review of clinical records and resident and staff interview it was revealed that the facility failed to provide physician ordered treatment planned to aid in the healing or prevention of skin impairments/issues for one of 31 residents reviewed (Resident 88).

Findings included:

A review of Resident 88's clinical record revealed physician's orders dated February 24, 2020, to apply Allkare (a non-water soluble formula for skin protection; skin barrier) to intact blisters on right lower extremity two times daily.

A review of the resident's February 2020 treatment administration records on February 28, 2020, revealed that the facility failed to initiate the above noted treatment as ordered. Further review of the treatment administration record revealed that the physician's order had not been transcribed onto the treatment record.

Observation of Resident 88's blistered areas on February 28, 2020, at approximately 10:55 a.m. revealed the resident's right lower extremity was wrapped with an absorbent dressing and kling (absorbent gauze roll, which stretches and conforms to the body shape). The resident stated at the time of the observation that the blisters had "popped and were leaking."

Interview with Employee 6, Licensed Practical Nurse, on February 28, 2020, at approximately 11 AM confirmed that Resident 88's right lower extremity was wrapped with an absorbent dressing and kling. Employee 6 further confirmed that the physician order for treatment to the intact blisters noted on February 24, 2020, was not carried out and the treatment had not been performed as ordered on February 24, 25, 26, 27 or 28, 2020.

A review of Resident 88's clinical record conducted on February 28, 2020, failed to reveal documented evidence that the physician was aware of the change in condition of resident's blisters as the treatment ordered was for noted for intact blisters.

Interview with Resident 88's assigned nurse, Employee 6, LPN on February 28, 2020, at approximately 11:10 Am revealed that Employee 6 was not aware that the resident's blisters were no longer intact. Employee 6 confirmed that there was no documentation in the resident's clinical record regarding the change in the resident's skin concern.

Interview with the Clinical Operations Executive on February 28, 2020, at approximately 1:30 p.m. confirmed that the facility failed to provide physician ordered treatment for Resident 88's blisters.

Refer to F842


28 Pa. Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing Services.








 Plan of Correction - To be completed: 04/16/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.

Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

Resident 88's treatment record was updated to reflect the physician ordered treatment on February 28, 2020.

Indicate how the facility will act to protect residents in similar situations.

Treatment orders will be reviewed on all residents to ensure accuracy between the physician's orders and treatment record.

The facility will audit changes in condition for the last 14 days to assess for appropriate physician notifications of changes in condition and documentation in resident record.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

Re-in servicing of all licensed nurses will be completed on the PCC process of adding new treatment orders to the treatment tab.

All licensed staff will be re-inserviced on the need to notify the physician timely of changes in condition per facility policy.


How the facility plans to monitor its performance to make sure that solutions are sustained.

Random audits of treatment orders will be completed for 30 days, with the need for continued auditing based on outcome.

Audits of physician notification of change in condition and documentation in resident record will be completed for the next 30 days, with further audits based on need as determined by outcome.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of clinical records and staff interview, it was determined that the facility failed to develop and implement interventions designed to prevent pressure sore development and prevent worsening of an existing pressure sore for one of four sampled residents (Resident 129) with pressure sores.

Findings include:

A review of the clinical record revealed that Resident 129 had diagnoses, which included unspecified dementia without behavioral disturbances.

A review of Resident 129's annual MDS Assessment (Minimum Data Set - a federally mandated standardized assessment process completed periodically to plan resident care) dated November 6, 2019, revealed that the resident required extensive assisstance of staff for transfers and bed mobility (moving to and from lying position, turning side to side and positioning body while in bed). Additionally, the assessment indicated that the resident had impairments of bilateral upper and lower extremities and was at risk of developing pressure sores.

A review of a "Braden Scale" (a tool used to determine/predict pressure sore development) dated November 6, 2019, revealed that the resident received a score of 12, indicating that the resident was at high risk for pressure sore development.

A review of the resident's care plan initiated on August 15, 2018, and revised in November 5, 2019, revealed that the resident has a potential for impairment to the skin integrity related to immobility and dementia. Interventions planned included to apply lotion daily AM and PM care, and as needed, float heels while in bed with pillow, pressure reducing mattress in bed, pummel cushion while in chair, avoid tight fitting clothes and footwear, and keep skin clean and dry.

Review of a "Open Area Record" dated November 25, 2019 at 3:14 a.m. as initial identification of the area revealed a Suspected Deep Tissue Injury (a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as "A pressure-related injury to subcutaneous tissues under intact skin. Initially, these lesions have the appearance of a deep bruise), which measured 4 centimeters (cm) in length, 3.5 cm in width, and 0 depth, no exudate.

Review of a "Pressure Ulcer Review" signed on November 25, 2019, by the facility's QA Coordinator and November 27, 2019, by Director of Nursing , indicated that a therapy evaluation for seating was requested as the resident had a foot buddy and "the area was obtained from that."

An occupational therapy evaluation conducted on December 4, 2019, indicated that the foot buddy, identified as a contributing factor to the resident's pressure ulcer on November 27, 2019, remained in place during this assessment of the resident.

Interview with Employee 4, Registered Nurse, on February 28, 2020 at approximately 9:45 a.m. indicated that the resident's pressure area on the left heel was acquired from shoes the resident's family member provided, as the sister is particular with what the resident would wear, and would not let the resident wear diabetic shoes.

Interview with Employee 5, Licensed Practical Nurse on February 28, 2020, at approximately 10:00 a.m. indicated that the pressure wound on the resident's left heel with from "ill fitting shoes."

There were no interdisciplinary progress entries noted in the resident's clinical record surrounding the finding of the SDTI on November 25, 2019.

Interview with the Director of Nursing (DON) on February 28, 2020, at approximately 10:35 a.m. when presented with conflicting information surrounding the development of a pressure sore confirmed that the facility was unable to provide clarification to the likely cause of the pressure ulcer to plan preventative care accordingly.



28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services.
Previously cited: 1/25/19,9/18/19,12/30/19

28 Pa. Code 211.5(f) Clinical records.
Previously cited: 1/25/19







































 Plan of Correction - To be completed: 04/16/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.


Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

Resident 129's mobility device was reassessed and altered on 12/17/2019 by therapy, removing use of foot buddy at that time, along with removal of tight-fitting shoes.

Indicate how the facility will act to protect residents in similar situations.

All residents with facility acquired wounds/pressure ulcers of undetermined cause for the last 30 days will be reassessed for possible contributing factors and validate that interventions initiated and documented are in place.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

All new facility acquired pressure areas will be reviewed for potential contributing factors documentation and appropriate interventions implemented as needed.

How the facility plans to monitor its performance to make sure that solutions are sustained.

Audits of all new facility acquired pressure areas will be completed for the next 30 days to assess for documented actual and potential contributing factors documentation and appropriate interventions implemented as needed.


483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to thoroughly assess and evaluate bladder function and implement individualized approaches to restore normal bladder function to the extent possible for one resident (Resident 150) out of 31 sampled residents.

Findings include:

A review of the clinical record revealed that Resident 150 had diagnoses to include chronic obstructive pulmonary disease, heart failure and hypertension.

An admission Minimum Data Set Assessment (MDS -a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated December 11, 2019, indicated that the resident was dependent on staff for activities of daily living (ADLs - the basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring and repositioning) and was occasionally incontinent of urine, always continent of bowel and was not on a toileting program.

A quarterly MDS Assessment dated February 2, 2020, indicated that the resident remained occasionally incontinent of urine, always continent of bowel and was not on a toileting program.

A review of facility policy entitled "Bowel and Bladder/ Toileting Plan Process" reviewed December 2019, revealed that it was the policy of the facility to implement measures to attain and maintain the highest level of continence for each resident as indicated based on assessment. Further review of the facility policy indicated that each resident is assessed upon admission and/ or readmission to the facility with completion of a bowel and bladder incontinence evaluation assessment, a 5-day Bowel and Bladder tracker is initiated followed by a bowel and bladder incontinence evaluation assessment. Upon completion of the evaluation assessment a toileting program is initiated if indicated.

A review of Resident 150's admission Bladder and Bowel Incontinence Evaluation dated December 6, 2019, revealed that the resident was placed on a 7-day tracker to evaluate voiding pattern. However, there was no evidence that the 7-day tracker was completed.

A review of Resident 150's Bladder and Bowel Incontinence Evaluation dated January 11, 2020, upon re-admission to the facility following a hospitalization, revealed that the resident was to be re-assessed due to re-admission and recent hospitalization. There was no documented evidence that the resident was re-assessed for toileting needs/toileting plan.

A review of Resident 150's Bladder and Bowel Incontinence Evaluation dated January 27, 2020, upon re-admission to the facility revealed that the resident was able to make needs known prior to re-admission and the plan to re-assess. There was no documented evidence that the resident was re-assessed for toileting needs/toileting plan.

A review of Resident 150's care plan that was initiated on December 6, 2019, revealed that the resident had potential for functional bladder incontinence (form of urinary incontinence in which a person is usually aware of the need to urinate, but for one or more physical or mental reasons they are unable to get to a bathroom. The loss of urine can vary, from small leakages to full emptying of the bladder) related to confusion and AKI (acute kidney injury) with planned interventions to notify nursing if incontinent during activities, the use of medium briefs and toilet upon request. Additional planned interventions included to ensure the resident has an unobstructed path to the bathroom, establish voiding patterns, clean per-area with each incontinence episode, and to monitor/ document for signs and symptoms of a urinary tract infection.

A review of the resident's personalized Kardex revealed that she was to be supervised by one staff member for toileting, the peri-area was to be cleansed with each incontinent episode, that the resident used a medium brief and that she was to be toileted upon request.

Review of information provided by the facility dated February 8, 2020, at 7:45 p.m. revealed that the resident was found on the floor in her bathroom. Further review of the documentation revealed that the resident stated she "rang the bell, but no one came. I had to go to the bathroom." The intervention after her fall without injury was the application of infrared alarms to both sides of bed and every 15-minute checks while in bed. The need for the resident to be toileted was not addressed in the facility's fall investigation and plan for prevention of future falls of a similar nature.

A review of the bowel and bladder daily tracker completed February 13, 2020, through February 17, 2020, indicated that the resident experienced three (3) episodes of urinary incontinence during the 11 p.m. to 7 a.m. shift. The evaluation was completed February 18, 2020, and indicated that the resident is continent of bladder and bowel and that she is to be toileted upon request.

A review of documentation in Resident 150's clinical record dated February 24, 2020, at 5:30 a.m., revealed that the resident was found lying in her roommate's bed with her oxygen off, her brief off and was found lying on her roommate's chair, which was soiled with urine. According to the documentation, the resident was helped back to bed, a brief was applied, and her oxygen was put back in place. There was no documentation that the resident's toileting needs were identified possible contributing factors to the incident.

Interview with the Clinical Operations Executive on February 28, 2020, at approximately 8:30 a.m. confirmed that the facility failed to timely and consistently implement an individualized toileting plan and meet this resident's toileting needs in a timely manner.



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

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








 Plan of Correction - To be completed: 04/16/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.


Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

Resident 150 was transferred to hospital on 3/9/2020, and discharged from the facility on 3/18/2020.

Indicate how the facility will act to protect residents in similar situations.

All newly admitted or re-admitted residents still residing at the JH will be reviewed for completion of B&B tracker with follow up assessments of individualized toileting needs.

All Clinical Directors will be re-educated on the process of implementing B&B trackers and follow up tracker evaluations to determine the residents individualized toileting needs.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

All Clinical Directors will be re-educated on the process of implementing B&B trackers and follow up tracker evaluations to determine the residents individualized toileting needs.


How the facility plans to monitor its performance to make sure that solutions are sustained.

Random audits of bowel and bladder tracker and tracker evaluations will be completed for the next 30 days. The need for continued auditing will be based on outcomes

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 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 narcotic shift count records and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled drug on two of eight medication carts (2nd floor high, 2nd floor low).

Finding include:

A review of the "Count Form" for the 2nd floor low side medication cart on February 26, 2020, at approximately 2:00 p.m., revealed that the on-coming nurse and/or off-going nurse failed to sign the medication sheets during various shifts on the following dates to verify counts of controlled drugs in the respective medication cart: December 9, 14, and 15, 2019, January 5, 6, 7, and 20, 2020 and on February 6, 13, 16, 17, and 25, 2020.

A review of the "Count Form" for the 2nd floor high side medication cart on February 27, 2020, at approximately 8:50 a.m., revealed that the on-coming nurse and/or off-going nurse failed to sign the medication sheets during various shifts on the following dates to verify counts of controlled drugs in the respective medication cart: December 12, 16, 23, 24, 30 and 31, 2019, January 1, 17, and 20, 2020, and on February 24 and 26, 2020.

Interview with Employee 1 (RN) on February 27, 2020, at approximately 1:30 p.m. confirmed that there were no nursing staff signatures on the dates noted above to demonstrate consistent implementation of facility procedures for promoting accurate drug records.

Interview with the Clinical Operations Executive on February 27, 2020, at approximately 1:50 p.m. confirmed that there were no nursing staff signatures on the dates noted above and confirmed the expectation that the signatures would be completed at the end of each shift for promoting accurate drug records.




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

28 Pa Code 211.9(a)(1)(k) Pharmacy services.






 Plan of Correction - To be completed: 04/06/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.


Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

Does not apply to an individual resident.

Indicate how the facility will act to protect residents in similar situations.

All licensed nurses will be re-educated on the need to document the completion of the change of shift narcotic count.

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

All licensed nurses will be re-educated on the need to document the completion of the change of shift narcotic count.

How the facility plans to monitor its performance to make sure that solutions are sustained.

Random audits of the controlled drug count form will be completed for the next 30 days with continued need based on outcomes.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on a review of clinical records, select facility policy and falls reports and staff interview it was determined that the facility failed to assure that a resident drug regimen remains free of unnecessary drugs by failing to demonstrate adequate monitoring of potential adverse consequences of psychoactive drug use for one resident out of 14 sampled who experienced falls (Resident 7).

Findings included:

Review of the facility's policy, entitled "Fall Management Program" last reviewed by the facility January 2020, indicated that the facility is committed to minimizing the risk of resident falls without compromising the mobility and functional independence of residents. Fall mitigation strategies are implemented to minimize this risk. The staff will conduct assessments and address factors that may have contributed to falls. The facility will ensure interventions are consistent with root cause to mitigate fall risk and risk of injury for the resident.

Review of Resident 7's clinical record revealed admission to the facility on April 8, 2019. According to the resident's clinical record, the resident's cognition was severely impaired and the resident wandered about the unit independently.

Review of a fall risk evaluation dated April 2019, revealed that the resident scored a 12, which indicated that the resident was at high risk for falls

Further review of the resident's clinical record during the survey ending February 28, 2020, revealed that the resident was currently receiving the antipsychotic drug Abilify 2 mg in the PM for depression (initial order dated April 11, 2019) and the antidepressant drug Lexapro 15 mg daily for depression (initial order date 4/8/2019).

The potential side effects of these psychoactive medications include dizziness, drowsiness, weakness, feeling shaky or anxious, blurred vision, feeling tired and feeling restless.

Review of the facility's fall report dated November 16, 2019, at 1:05 PM revealed that the resident was ambulating in the common area when she attempted to sit on the edge of a recliner chair, on which another resident was seated and Resident 7 fell to the floor. The intervention put into place to prevent future falls was to redirect the resident away from the recliners when other residents are in the recliners.

Review of a fall report dated December 28, 2019, at 1:50 AM, the resident was found in her bedroom, on her back, on the floor. The new interventions put in place to prevent future falls was to conduct 15 minute checks of the resident while in bed and to conduct a staff in-service to check resident's blankets and sheets to ensure that the resident does not get tangled in her bedding.

Review of a fall report dated January 18, 2020, at 11:50 AM, indicated that the resident was in the main dining room with her husband. The resident went to sit down in a chair when the chair slid out from under her. The intervention put into place to prevent future falls was for staff to assist the resident's husband when seating the resident at the dining room table.

Review of a fall report dated January 26, 2020, at 10:10 AM, revealed that the resident was attempting to sit on the edge of a recliner chair and slipped to the floor. The intervention put into place to prevent future falls was for staff to encourage the resident sit in her own chair with her baby doll.

Review of a fall report dated January 27, 2020, at 4:20 AM, revealed that the resident was sitting in the common room, when she stood up, turned, lost her balance and fell to the floor. The intervention put into place to prevent future falls was to have a therapy evaluation completed.

Review of a fall report dated February 28, 2020, at 5:15 AM, revealed that the resident was found in her room, lying on the floor. The new intervention put into place to prevent future falls was to start a bowel and bladder tracking program and contact the doctor for a psychiatric appointment.

There was no documented evidence that the facility had evaluated the potential side effects of the resident's psychoactive medication regimen as possible contributing factors to the resident's multiple falls.

According to interview with the NHA (Nursing Home Administrator) on February 28, 2020, at 11:41 AM, the facility will address residents receiving psychoactive medications to determine if medications could be a contributing factor in resident falls.

During this interview the NHA confirmed that Resident 7's medications should be reviewed as a possible contributing factor to the resident's falls and that at the time of the survey the facility was unable to provide documented evidence that the potential side effects of the resident's psychoactive drugs were being actively monitored and evaluated in relationship to the resident's multiple falls.



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

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

28 Pa. Code 211.9(k) Pharmacy services




















 Plan of Correction - To be completed: 04/16/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.

Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

Resident #7's medications were reviewed by a licensed pharmacist. Recommendations were sent with resident to appointment with consulting psychiatrist and new orders were noted on March 5, 2020.


Indicate how the facility will act to protect residents in similar situations.

Residents with 3 or more falls in the last 3 months will be evaluated by a licensed pharmacist for recommendations related to psychoactive medications contributing to falls

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

The falls management program will be reviewed and updated where necessary so that consideration will be given to medications as potential causative factor in a fall investigation.

Licensed nurses will be updated these changes and the need to consider medications as potential causative factor in a fall and how to documentation this consideration and any potential follow up required.

How the facility plans to monitor its performance to make sure that solutions are sustained.

Random audits of residents who fall and are receiving psychoactive medications will be completed for the next 30 days with the need for continued auditing based on outcomes.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on observation, staff interview and select policy review, it was determined that the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions for administration of a cytotoxic medication prescribed for one resident out of 32 sampled (Resident 148).

Findings include:

Review of the facility's policy entitled "Safe Handling of Hazardous Drugs Program" reviewed by the facility February 2020, revealed that the handling of hazardous drugs includes, but is not limited to, the receipt, storage, compounding, dispensing, administration and disposal of sterile and non-sterile products and preparations. This system includes policies and procedures to prevent the unintentional entry of hazardous drugs into the body due to handling of hazardous drugs and/ or touching contaminated surfaces. Further review of the facility policy revealed that all personnel will be trained based on their job functions including the receipt, storage, compounding, repackaging, dispensing, administering and disposing of hazard drugs and that "training will occur before the employee independently handles HDs All trained employees must sign the Hazardous Drug Risk Acknowledgement."

A review of Resident 148's current physician orders on February 27, 2020, revealed that the resident had an order dated October 1, 2018, for Letrozole (hormone-based chemotherapy medication) 2.5 mg orally one time a day for the treatment of breast cancer.

Observation of the medication label on February 27, 2020, at approximately 9:30 a.m. revealed that the medication was labeled "Cytotoxic \ Material, Handle Properly." There were no further cautionary instructions noted on the label or specifications regarding proper handling.

Clinical guidelines for Oral Cytotoxic Agent Administration indicate that the tablets must be handled in a manner which avoids skin contact and liberation of powdered agent into the air. Dispense tablets into a disposable medicine cup using a non-touch technique or gloves; avoid crushing and breaking oral cytotoxic agents; dispose of gloves and equipment as cytotoxic waste; wash hands following administration and disposal of cytotoxic agents and related waste

Interview with Employee 3, Licensed Practical Nurse, on February 27, 2020, at approximately 9:30 a.m. revealed that she understood that anyone who was pregnant should use precaution when administering the medication. Employee 3 further stated the she "assumed we should wear gloves," but was not certain of any special precautions related to administration of the medication.

Interview with the Clinical Operations Executive on February 28, 2020, at 8:00 a.m. confirmed that the medication label failed to identify the specific necessary cautionary instructions for safe handling of the medication and no staff education had been provided as noted in facility policy.


28 Pa. Code 211.9(a)(1)(k) Pharmacy services.

28 Pa Code 211.12(c) Nursing services

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









 Plan of Correction - To be completed: 04/16/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.


Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

The licensed nurse used a no-touch technique when pouring the hazardous medication.

Indicate how the facility will act to protect residents in similar situations.

All licensed nurses will be educated on the handling of hazardous drugs and be required to sign the "Hazardous Drug Risk Acknowledgement."

The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

All licensed nurses will be educated on the handling of hazardous drugs and be required to sign the "Hazardous Drug Risk Acknowledgement" upon hire.

How the facility plans to monitor its performance to make sure that solutions are sustained.

A random audit with handling observation of all hazardous drugs will be completed by the consulting pharmacist on a monthly basis for the next 30 days with the need for continued auditing based on outcomes.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:

Based on review of clinical records and select facility policy and staff interview, it was determined that the facility failed to maintain complete and accurate clinical records for one of 31 sampled residents (Resident 88).

Findings include:

A review of the facility policy entitled "Change in Condition Evaluation/ Focused Assessment Policy" dated January 1, 2020, revealed that staff are to at a minimum, the PCC (Point Click Care) Change in Condition Evaluation Focused Assessment will be initiated on a significant change in resident condition. A nurse that identifies a change in a resident's condition or identifies an event that may precipitate a change in condition or need for a change in treatment or in care planning will initiate the PCC Change in Condition Evaluation Focused Assessment. The PCC Change in Condition Evaluation Focused Assessment will assess the resident for 48 hours / 6 shifts beginning with the shift identifying the change. Based on the resident status post evaluation, the attending physician, clinical director or nursing supervisor may elect to continue the assessment, as needed.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care: Assessments, Clinical problems, Communications with other health care professionals regarding the patient and Communication with and education of the patient, family, and the patient ' s designated support person and other third parties.

A review of the clinical record revealed that on February 24, 2020, Resident 88 had developed two (2) intact fluid filled blisters on her right lower extremity. Further review of the clinical record revealed that a physician order dated February 24, 2020, for Allkare (a non-water soluble formula for skin protection; skin barrier) to intact blisters on right lower extremities two times a day was to be initiated.

A review of the February 2020 treatment administration record (TAR) for Resident 88 revealed that there was no documentation that the ordered treatment had been completed on the following dates: February 24, 25, 26, 27 or 28.

Observation of Resident 88's blistered areas on February 28, 2020, at approximately 10:55 a.m. revealed the resident's right lower extremity was wrapped with an absorbent dressing and kling (absorbent gauze roll, which stretches and conforms to the body shape). The resident stated at that time that the blisters had "popped and were leaking."

Review of the resident's clinical record conducted on February 28, 2020, failed to identify a change in the resident's skin condition or that the physician and/ or resident representative were made of aware of the change.

Interview with Employee 6, Licensed Practical Nurse, on February 28, 2020, at approximately 11:00 a.m. confirmed that Resident 88's right lower extremity was wrapped with an absorbent dressing and kling. Employee 6 further confirmed that there was no documentation in the clinical record to identify a change in the resident's skin condition or that the physician and/ or resident representative were made aware.

Interview with the Clinical Operations Executive on February 28, 2020, at approximately 1:30 p.m. confirmed that the facility failed to provide physician ordered treatment, notify the physician and/ or resident representative and document a change in Resident 88's skin condition.

Refer to F684

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

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

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







 Plan of Correction - To be completed: 04/16/2020

The Jewish Home of Eastern Pennsylvania (the "Home") 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 Home's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.


Elements detailing how the facility will correct the deficiency as it relates to the individual residents.

Resident 88's treatment record was updated to reflect the physician ordered treatment on February 28, 2020.

The nurse responsible for the omission of the treatment order on the TAR was re-educated on the process.


Indicate how the facility will act to protect residents in similar situations.

Treatment orders will be reviewed on all residents to ensure accuracy between the physician's orders and treatment record.

The facility will audit changes in condition for the last 14 days to assess for appropriate physician notifications of changes in condition and documentation in resident record.


The measures the facility will take or the system it will alter to ensure that the problem does not reoccur.

Re-inservicing of all licensed nurses will be completed on the PCC process of adding new treatment orders to the treatment tab.

All licensed staff will be re-inserviced on the need to notify the physician timely of changes in condition and document in resident record, per facility policy.

How the facility plans to monitor its performance to make sure that solutions are sustained.

Random audits of treatment orders will be completed for 30 days, with the need for continued auditing based on outcome.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port