Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT ORANGEVILLE, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
GARDENS AT ORANGEVILLE, THE
Inspection Results For:

There are  76 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.
GARDENS AT ORANGEVILLE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint survey completed on December 7, 2021, it was determined that the Gardens at Orangeville was not in compliance with the following requirements of 42 Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 a review of clinical records and select facility investigation reports and staff interviews, it was determined that the facility failed to timely review and revise a resident's fall prevention plan and provide necessary staff supervision and individualized person-centered approaches to maintain resident safety for a resident identified at risk for falls and known unsafe behaviors to prevent a fall with serious injury, a subarachnoid hemorrhage, for one resident out of 10 residents reviewed (Resident CR1).

Findings include:

A review of the Resident CR1's clinical record revealed that the resident was admitted to the facility on June 1, 2019, with heart failure, Parkinson's disease, and syncope (temporary loss of consciousness caused by a fall in blood pressure) and collapse.

A review of a Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 2, 2021, revealed that the resident's BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) was a 12, indicating that the resident was moderately cognitively impaired. The resident required limited assistance of one staff member for transfers and extensive assistance of two staff members for bed mobility.

A review of an incident/accident report dated October 2, 2021, at 2:30 a.m. indicated that the staff heard moaning coming from the resident's room. Staff responded and observed the resident lying on the floor flat on his back. The resident stated he was trying to get his Reese Cups from the closet.

According to the facility's incident/accident investigation dated October 2, 2021, the resident sustained abrasions to his right ear, right knee, and a lump and abrasion to his right back as a result of the fall. Further review of the facility's investigation revealed that the resident's call bell was not on and that the resident's bed alarm was not sounding. The report noted that the, "resident turns alarm off" and the resident had admitted to turning off his alarm prior to getting out of bed prior to the fall. The facility recommended that staff encourage the resident to get out of bed for bathing after breakfast and morning/daytime activity since he habitually sleeps throughout the day and is up at night. Further recommendations included that the nursing supervisor follow-up with the physician regarding an increase in melatonin and/or question need for new sleep aide, as appropriate. The resident was also educated with importance stressed on using call bell for assistance and not manipulating personal safety alarms.

A review of Resident CR1's physician orders dated October 2021, revealed that on October 4, 2021 the resident's melatonin was increased from 5 mg daily at bedtime to 6 mg daily at bedtime.

A review of an incident/accident report dated October 21, 2021, at 1:20 a.m. indicated that the resident was found and observed by another resident, lying on the floor in the resident's room next to his bed.

According to the facility's investigation dated October 21, 2021, the resident was attempting to reach his urinal when he slid out of bed. The investigation revealed that the resident did not use his call bell for assistance and he again turned off the bed alarm intended for personal safety. The facility again educated the resident regarding adherence with safety measures in place, relocated the bed sensor alarm box to the foot of the bed, staff to ensure urinal is at bedside, and a "low-bed" was implemented.

A review of an incident/accident report dated November 13, 2021, at 10:15 p.m. indicated that the resident had fallen in the hallway near the nurse's station, in short hall, after turning off his chair alarm and using his walker to ambulate into the hallway.

According to the facility's investigation dated November 13, 2021, Resident CR1 lost consciousness for one minute, with sonorous respirations (producing a sound when struck) and full body extension. A hematoma (a collection of blood outside of blood vessels. Most commonly, hematomas are caused by an injury) was present to his left forehead and the resident sustained a skin tear to his left elbow, earlier during the shift, while agitated.

Further review of the investigation dated November 13, 2021, revealed that prior to the resident's fall in the hallway, he had removed the alarm box from the back of the wheelchair and turned the seat alarm off. According to the documentation in the investigation, the alarm in the resident's doorway (mini motion sensor: MMS) that was functioning at 5:30 p.m. also did not function properly and the resident was described as agitated prior to the fall. Resident CR1 was transferred to the emergency room for evaluation.

Review of the Resident CR1's hospital record dated November 14, 2021, revealed that the resident was found to have a "traumatic ICH \ prompting admission to the TICU (trauma intensive care unit) along with a left frontal cephalohematoma (accumulation of blood under the scalp), and a left hip hematoma.

The resident was assessed as moderately cognitively impaired and identified at risk for falls due to impaired mobility with risks for falls due to unstable health condition, syncope and collapse, history of falls and actual falls dated September 13, 2020, November 25, 2020, April 16, 2021, April 22, 2021, April 28, 2021, August 27, 2021, September 14, 2021, October 2, 2021, October 21, 2021, and November 13, 2021 as per his care plan dated June 3, 2019. The facility planned approaches that included educating resident on importance \ remaining compliant with fall interventions, educate/offer reminders to use RW (rollator walker) with transfers and ambulation and to wear nonskid footwear at all times, keep call bell and personal belongings in resident reach at all times, and MMS in doorway of room to alert staff to resident exiting room.

There was no evidence that the facility had timely reviewed and revised the resident's safety plan and had addressed the resident's known behavior of turning off the bed and chair alarms prior to his fall on October 21, 2021. The facility was also aware of the resident's unsafe behaviors, particularly late in the 3 PM to 11 PM and 11 PM to 7 AM shifts, and had identified the resident's habit of turning off personal alarms on the bed and chair planned to prevent fall. The facility failed to review and revise the existing fall prevention and safety measures for adequacy in preventing falls and develop and implement necessary supervisory approaches and alternative measures to maintain the resident's safety and prevent another fall on November 13, 2021, resulting in serious injury.

Resident CR1 was readmitted to the facility on November 16, 2021, with diagnosis of subarachnoid hemorrhage and urinary tract infection.

According to nursing documentation dated November 16, 2021 at 2:15 p.m., the resident was verbally reminded not to transfer or ambulate independently, but to ask staff for assist, and all alarms were checked for function and working properly.

However, there was no documented evidence that additional safety interventions or supervision were implemented upon his return from the hospital.

The resident had been displaying repeated instances of unsafe behaviors, self-transfers and turning off alarms that had been implemented for resident safety, but the facility failed to timely provide necessary staff supervision and interventions, at the frequency and level required, to prevent a fall, which resulted in a subarachnoid hemorrhage.

28 Pa. Code 211.11(d) Resident care plan
Previously cited 3/6/20, 6/29/21

28 Pa. Code: 211.12(a)(c)(d)(1)(5) Nursing services
Previously cited 3/6/20, 6/29/21






 Plan of Correction - To be completed: 01/18/2022

The facility cannot retroactively correct this deficiency as resident CR1 has expired.
Falls for the last 30 days will be reviewed for appropriateness and effectiveness of fall interventions that were implemented.
Staff re-educated on fall prevention strategies, resident centered safety interventions, recognizing residents at risk and implementing appropriate interventions. Staff re-educated on fall risk scores on admissions/readmissions and implementation of appropriate fall interventions.
Falls will be reviewed daily with IDT to ensure new intervention is implemented and intervention is appropriate. New admission fall risk scores will be reviewed and interventions in place as appropriate.
Audit of 25% of falls interventions and effectiveness of interventions will be completed weekly x4 then monthly by the DON/ADON.
Results to QA for review and recommendations.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record review and staff interview it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene of residents' who need assistance with activities of daily living for two out of 10 residents reviewed. (Residents 2 and 3).

Findings include:

A review of the clinical record revealed that Resident 2 was admitted to the facility on October 5, 2019, with diagnoses to include dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).

A review of the resident's plan of care for self-care deficit initially dated October 7, 2019, revealed an intervention for the resident to receive a tub bath or shower twice a week.

A review of the resident's bathing record for August 2021 through December 2021 revealed the resident did not receive tub baths or showers twice a week as per her plan of care.

A review of the clinical record revealed that Resident 3 was admitted to the facility on October 10, 2018, with diagnoses to include dementia.

A review of the resident's plan of care for self-care deficit initially dated October 11, 2018, and revised September 3, 2019, revealed an intervention for the resident to receive a tub bath or shower twice a week.

A review of the resident's bathing record for August 2021 through December 2021 revealed no documentation the resident was provide tub baths or showers twice a week according to her plan of care.

Interview with the Nursing Home Administrator on December 7, 2021, at approximately 2:00 PM confirmed the facility failed to provide services planned to maintain adequate personal grooming and hygiene.


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

28 Pa Code 211.11(d) Resident care plan




 Plan of Correction - To be completed: 01/18/2022

Resident 2 and 3 were bathed as per their preference.
Residents plan of cares reviewed to determine bathing preference and updated as needed.
Staff re-educated on ensuring residents receive services to maintain adequate personal hygiene with ADL's.
Random audits will be completed to ensure resident is bathed per preference 2x weekly x2 weeks, then weekly x4, then monthly x2.
Results to QA for review and recommendations.

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 review of the clinical records and select facility policies and procedures, and staff interview, it was determined that the facility failed to timely consult with the physician and notify the resident's representative of significant changes in condition displayed by two residents out of 10 sampled (Resident 10 and Resident CR1).

Finding include:

A review of the facility policy entitled "Weight Assessment and Intervention" provided by the facility during the survey ending December 7, 2021, revealed that the nursing staff will measure resident weight on admission, and then weekly for two weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter or as per dietician or physician. Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the physician and dietitian.

Review of Resident 10's clinical record revealed that on September 8, 2021, the resident's weight was recorded at 199.0 pounds.

The resident's weight on October 8, 2021, had decreased to 180.0 pounds reflecting a loss of 19 pounds in one month, or 9.5% loss of body weight in one month. There was no evidence that a reweight was obtained to confirm the 19 pound weight loss or that the physician and dietitian were made aware of significant weight loss.

Resident 10 was not weighed again until October 14, 2021, and weighed 179.0 pounds, a loss another pound, a significant weight loss of 10% body weight over the last month. .

A dietary progress note dated October 15, 2021 at 10:01 a.m. indicated that Resident 10 had a significant weight loss of 10% over the last month.

There was no documented evidence that the resident's significant weight loss was identified and/or addressed by the facility prior to October 15, 2021.

There was no documented evidence that the physician and the resident's representative had been notified of the resident's significant weight loss until October 18, 2021.

The facility failed to implement their "Weight Assessment and Intervention" policy as indicated by not obtaining a reweight to confirm weight loss or notifying the dietician and physician of a significant weight loss.

A review of the facility policy entitled "Change in a Resident's Condition or Status" provided by the facility on December 7, 2021, revealed the facility shall promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Further review revealed that the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident physical/emotional/mental condition. A "significant change" of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

Review of Resident CR1's clinical record revealed documentation dated November 7, 2021 at 2:06 p.m. that the resident was difficult to arouse for noon medication administration. Nursing documentation further indicated that the resident had slight swelling noted to lower lip, speech was thick and garbled. There was also swelling noted to lower legs and feet, his weight was 156 pounds, and he was noted to be confused. Reassurance was provided and the registered nurse supervisor was made aware of the findings.

Documentation dated November 7, 2021, at 3:13 p.m. revealed that the resident's sister had called the facility and reported to staff that she had been talking with the resident and during the call the resident told her that he needed help. According to the nursing documentation, resident was noted to +2 edema in his lower legs, did not appear to be in acute distress, and a "note" was left for the nurse practitioner.

On November 8, 2021, at 6:44 p.m. nursing noted that the resident was yelling out for help and making accusations that his wife was trying to kill him.

It was not until 8:14 p.m. on November 8, 2021, according to documentation in the clinical record that a physician was notified of the observed changes in the resident's condition. Orders were received for blood work and a urinalysis with culture and sensitivity. The lab specimens were picked up November 9, 2021.

On November 11, 2021, nursing noted that the resident remained in bed most of the day and was difficult to arouse and continued to have edema (swelling) of his bilateral lower extremities. Culture and sensitivity results received November 13, 2021, which revealed that the resident had a urinary tract infection and required treatment with antibiotic therapy.

There was no evidence that the facility promptly notified Resident CR1's physician of the changes in condition that were initially identified on November 7, 2021, delaying the resident's treatment for a urinary tract infection.


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



 Plan of Correction - To be completed: 01/18/2022

Resident 10's significant weight loss from October was updated to the physician and the responsible party. Resident CR1 change in condition was updated to the physician and family on 11/8/21.
Residents will be reviewed for a significant weight loss in the last 30 days and an update will be provided to MD and family/responsible party if not completed. All current residents will have documentation reviewed for the last two weeks to ensure physician notification has been completed for any change in condition.
Licensed staff re-educated on updating MD and family/RP of any significant weight losses, "Weight Assessment and Intervention" policy for re-weights and physician notification needed for any change in condition.
All significant weight changes will be reviewed by the Registered Dietician/DON weekly to assure MD and family/RP notification are present. All documentation will be reviewed daily by the DON/ADON and the IDT, to ensure the physician has been updated to any change in the residents condition.
An audit of 25 % of weights will be completed weekly x4, then monthly to ensure notification of significant weight losses are reported to the MD and responsible party. An audit of 25% of residents will be completed weekly for 4 weeks then monthly by the DON/ADON to ensure timely notification has been made to the MD with any residents change in condition.
Results to QA for review and recommendations.

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 review of select facility policies and clinical records and interviews with staff, it was determined the facility failed to provide nursing services consistent with professional standards of practice by failing to ensure that one resident received timely and necessary services for a change in condition out of 10 sampled residents (Resident CR1).

Findings include:

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

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the LPN (licensed practical nurse) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place.

A review of the facility policy entitled "Change in a Resident's Condition or Status" provided by the facility on December 7, 2021, revealed the facility shall promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental condition and/or status. Further review revealed that the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident physical/emotional/mental condition. A "significant change" of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

A review of the clinical record revealed that Resident CR1 was admitted to the facility on June 1, 2019, and had diagnoses that include Parkinson's disease, heart failure, and diabetes.

A Quarterly Minimum Data Set Assessment (MDS - a federally mandated assessment of a resident's abilities and care needs) dated September 3, 2021, revealed that the resident was moderately cognitively impaired and required supervision (oversight, encouragement, or cueing) for meals, no physical assistance required. Further review revealed that the resident had not displayed any hallucinations or delusions, and had not exhibited physical, verbal, or other behaviors towards others.

Review of Resident CR1's clinical record revealed documentation dated November 7, 2021 at 2:06 p.m. that the resident was difficult to arouse for noon medications. Documentation further indicated that the resident had slight swelling noted to lower lip, speech was thick and garbled. There was also swelling noted to lower legs and feet, his weight was 156 pounds, and he was noted to be confused. Reassurance was provided and the registered nurse supervisor was made aware of the findings.

Documentation dated November 7, 2021, at 3:13 p.m. revealed that the resident's sister had called the facility, that she had been talking with the resident when he told her that he needed help. According to the documentation, resident was noted to have +2 edema (swelling) in his lower legs, did not appear to be in acute distress, and a "note" was left for the nurse practitioner.

There was no documented evidence that the nurse supervisor assessed the resident on November 7, 2021.

On November 8, 2021, at 6:44 p.m. the resident was noted to be yelling out for help and making accusations that his wife was trying to kill him. It wasn't until 8:14 p.m. according to documentation in the clinical record that a physician was notified of the observed changes in the resident's condition and orders were received for blood work and a urinalysis with culture and sensitivity, which was not picked up by the lab until November 9, 2021.

Documentation date November 10, 2021 revealed that the resident was not meeting restorative nursing program ambulation goal due to decreased endurance and generalized weakness, skin was pale, "lipoatrophy" (loss of fat) of the cheeks noted, and decreased appetite as evidenced by 0% consumption of breakfast and 50% of lunch. The resident also required to be fed his lunch by staff which was an additional change for Resident CR1.

On November 11, 2021, documentation indicated that the resident remained in bed most of the day and was difficult to arouse and continued to have edema (swelling) of his bilateral lower extremities.

Culture and sensitivity results of the urine specimen collected on November 9, 2021 were received November 13, 2021 which revealed that the resident had a urinary tract infection and required treatment with antibiotic therapy.

There was no evidence that the facility promptly notified Resident CR1's physician of the changes in condition that were identified on November 7, 2021. As a result of the failure of the facility's licensed and professional nursing staff to provide care consistent with professional standards of practice and failure to implement facility policy, treatment of the resident's urinary tract infection was delayed.

Refer: F580

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

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


 Plan of Correction - To be completed: 01/18/2022

Resident CR1 change in condition was updated to the physician and family on 11/8/21.
Residents will have documentation reviewed for the last two weeks to ensure physician notification has been completed for any change in condition and follow up treatment is implemented as ordered by the physician as needed.
Licensed staff re-educated on updating MD and family/RP of any change in condition and follow up treatment as ordered. Re-education also provided on The Professional and Vocational Standards as per the State Board of Nursing functions of the RN and LPN.
All documentation will be reviewed daily by the DON/ADON and the IDT, to ensure the physician has been updated to any change in the residents condition.
25% of residents will be audited weekly for 4 weeks then monthly by the DON/ADON to ensure timely notification has been made to the MD with any residents change in condition and as per physician, will implement further treatment orders as prescribed.
Results to QA for review and recommendations.

483.35(b)(1)-(3) REQUIREMENT RN 8 Hrs/7 days/Wk, Full Time DON: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.
§483.35(b) Registered nurse
§483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

§483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis.

§483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.
Observations:

Based on nursing time schedules and staff interview, it was determined that the facility failed to ensure the consistent services of a full-time Director of Nursing in the facility.

Findings include:

A review of the Director of Nursing (DON) time clock entries revealed that during the week of November 22, 2021 through November 26, 2021, the Director of Nursing worked 41.75 hours for the week. The average daily occupancy - resident census during that week was 83 residents.

Further review of nursing schedules revealed of those 41.75 hours, the Director of Nursing worked as the Registered Nurse Supervisor on the nursing unit for 16 hours. The Director of Nursing only worked 25.75 hours as the DON, failing to work a minimum of 35 hours a week performing the duties of the Director of Nursing.

A review of the Director of Nursing time clock entries revealed during the week of November 29, 2021 through December 3, 2021, the Director of Nursing worked 42.5 hours for the week.
The average daily occupancy - resident census during that week was 83 residents.

Further review of nursing schedules revealed of those 42.5 hours the Director of Nursing worked as the Registered Nurse Supervisor on the nursing unit for 12 hours. The Director of Nursing only worked 30.5 hours as the DON, failing to work a minimum 35 hours a week as the Director of Nursing .

During an interview December 7, 2021, at approximately 2:00 PM the Nursing Home Administrator (NHA) stated the Director of Nursing was working as a Nursing Supervisor on the nursing units as noted above and confirmed that the facility failed to ensure the consistent services of a full time Director of Nursing during the above time periods. The NHA verified that average daily occupancy was more than 60 residents during the above time periods.
.


28 Pa. Code 211.12 (c)(e)(f)(1)Nursing services

28 Pa. Code 201.18(e)(6) Management



 Plan of Correction - To be completed: 01/18/2022

Facility cannot retroactively correct the deficiency.
Re-education provided to scheduler and back up scheduler to ensure DON is not on schedule as a nursing supervisor if she has no met a minimum of 35 hours worked as DON.
Review of the schedule will be completed daily to ensure the DON is not scheduled as the nursing supervisor.
Audit weekly schedules x4 weeks then monthly to ensure the DON is not in the nursing hours or if she is, has worked a minimum of 35 hours as the DON.
Results to QA for review and recommendations.

483.80 (h)(1)-(6) REQUIREMENT COVID-19 Testing-Residents & Staff: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.
§483.80 (h) COVID-19 Testing. The LTC facility must test residents and facility staff, including
individuals providing services under arrangement and volunteers, for COVID-19. At a minimum,
for all residents and facility staff, including individuals providing services under arrangement
and volunteers, the LTC facility must:

§483.80 (h)((1) Conduct testing based on parameters set forth by the Secretary, including but not
limited to:
(i) Testing frequency;
(ii) The identification of any individual specified in this paragraph diagnosed with
COVID-19 in the facility;
(iii) The identification of any individual specified in this paragraph with symptoms
consistent with COVID-19 or with known or suspected exposure to COVID-19;
(iv) The criteria for conducting testing of asymptomatic individuals specified in this
paragraph, such as the positivity rate of COVID-19 in a county;
(v) The response time for test results; and
(vi) Other factors specified by the Secretary that help identify and prevent the
transmission of COVID-19.

§483.80 (h)((2) Conduct testing in a manner that is consistent with current standards of practice for
conducting COVID-19 tests;

§483.80 (h)((3) For each instance of testing:
(i) Document that testing was completed and the results of each staff test; and
(ii) Document in the resident records that testing was offered, completed (as appropriate
to the resident’s testing status), and the results of each test.

§483.80 (h)((4) Upon the identification of an individual specified in this paragraph with symptoms
consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the
transmission of COVID-19.

§483.80 (h)((5) Have procedures for addressing residents and staff, including individuals providing
services under arrangement and volunteers, who refuse testing or are unable to be tested.

§483.80 (h)((6) When necessary, such as in emergencies due to testing supply shortages, contact state
and local health departments to assist in testing efforts, such as obtaining testing supplies or
processing test results.
Observations:

Based on a review of the facility's COVID-19 testing, standards established by the Centers for Medicare & Medicaid Services, and staff interview, it was determined the facility failed to timely conduct testing of two residents exhibiting signs and symptoms of COVID-19 out of 10 sampled residents. (Resident CR2 and 5)

Findings include:

According to the Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Survey & Certification Group QSO-Memo - 20-38-NH initially dated August 26, 2020 and revised September 10, 2021, residents who have signs or symptoms of COVID-19, vaccinated, or not vaccinated, must be tested immediately. While test results are pending, residents with signs or symptoms should be placed on transmission-based precautions.

A review of Resident CR2's clinical record revealed that on October 26, 2021, at 1:37 PM, the resident was noted to have malaise (a general feeling of discomfort, illness, or uneasiness), congestion, and an oxygen level of 89 percent (normal is 90 to 100) on room air.

Further review of the resident's clinical record revealed on October 26, 2021, at 2:05 PM, the resident was noted to be pale, warm to the touch, lethargic (sluggish), and congested.

A review of Resident 5's clinical record revealed on November 29, 2021, at 10:37 PM, the resident was noted to have a cough and oxygen level of 88 percent on room air.
Further review of the resident's clinical record revealed on November 30, 2021, at 12:58 PM, the resident was noted to have increased respirations and oxygen level of 86 percent of 2 liters of oxygen.

There was no documented evidence that the above residents were immediately tested for COVID-19 when the residents displayed symptoms and placed on transmission based precautions pending test results.

Interview with the Nursing Home Administrator on December 7, 2021, at approximately 2:00 PM confirmed that the residents were not tested immediately upon onset of potential symptoms of COVID-19.


28 Pa. Code: 201.14(a) Responsibility of licensee.

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

28 Pa. Code: 211.12 (c) Nursing services.



 Plan of Correction - To be completed: 01/18/2022

Facility is unable to retroactively correct the past deficiency.
Residents records reviewed for signs or symptoms of COVID 19 and testing completed as needed.
Licensed staff re-educated on monitoring of residents for symptoms of COVID 19 and completing testing as indicated.
Resident documentation will be reviewed daily for any signs or symptoms of COVID 19 and will ensure testing was completed and transmission based precautions were implemented as needed and documented as indicated.
25% of resident records will be audited for any signs or symptoms of COVID 19 to ensure testing was completed as needed.
Results to QA for review and recommendations.

§ 211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:

Based on review of facility nurse staffing data, it was determined that the facility failed to maintain a minimum of 2.7 hours of direct resident care for each resident.

Findings include:

A review of facility nurse staffing data, including deployment sheets for the weeks between November 21, 2021, through December 4, 2021, the facility's 24 hour daily nurse staffing nurse staffing was below 2.7 hrs per resident on the following day:

November 28, 2021 nursing hours of direct resident care for each resident was 2.68

An interview with the Nursing Home Administrator (NHA) confirmed the nursing hours as indicated above on December 7, 2021, at approximately 2:00 PM.



 Plan of Correction - To be completed: 01/18/2022

Nursing hours for November 28, 2021 cannot be corrected as this is a past event.
Calculation of daily PPD will be completed and reviewed daily for accuracy by scheduler and back up scheduler.
Re- education provided on calculation of PPD to scheduler and back up scheduler.
Daily PPD will be audited weekly x4, then monthly x2.
Results to QA for review and recommendations.



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