Nursing Investigation Results -

Pennsylvania Department of Health
CRANBERRY PLACE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CRANBERRY PLACE
Inspection Results For:
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CRANBERRY PLACE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on February 13, 2020, it was determined that Cranberry Place, was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

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.

§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:
Based on a review of facility policies, staff performance evaluations, and training records it was determined that the facility failed to conduct timely annual performance evaluations for five of five employees (Nursing Assistant (NA) Employees E1, E2, E3, E4, and E5) and make certain that staff received the required number of annual training hours for three of five employees (NA Employee E1, E4, and E5).

Findings include:

A review of facility "Performance Management" policy dated 12/20/19, and 1/3/2020, indicated that the policy of the facility to measure and reward employee performances. The purpose of the performance management is to provide an ongoing consistent process and tool to link job responsibilities with values, goals, and performance standards to support the vision of the facility.

During a review of facility Performnce evaluations on 2/13/2020, it was revealed that the facility failed to complete an annual performance evaluation (2019) for NA Employees E1, E2,E3, E4, and E5.

During an interview on 2/13/2020. at 3:11 p.m. the Nursing Home Administrator and Human Resources Coordinator Employee E6 confirmed that the facility had not completed annual Employee Performance Evaluations for the year 2019 for NA Employees E1,E2, E3, E4, E5.

A review of the facility training records on 2/13/19, revealed the following:
- NA Employee E1 for the training period of 3/18 through 3/19 received nine hours and 40 minutes of training which was less than the 12 hours required.
- NA Employee E4 for the training period of 9/18, through 9/19, received nine hours and 40 minutes of training which was less than the 12 hours required.
- NA Employee E5 for the training period of 9/18, through 9/19, received nine hours of training which was less than the 12 hours required.

During an interview on 2/13/2020, at 3:11 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain that NA Employees E1, E4, and E5 received 12 hours of annual training as required.

28 Pa Code 201.20(a)(c)(d) Staff development.

Plan of Correction - To be completed: 03/27/2020

UPMC recently transitioned to a continuous performance management philosophy and an update to the annual review cycle starting in January 2019.
2019 was not a typical year rather the transition year, which included a shift from an anniversary-based (rolling 12 month) annual review cycle to a common (calendar year) annual review cycle where all staff have same common time frame.
2019 performance is currently being assessed and feedback will be provided to employees by end of April 2020. Performance feedback for 4 of 5 employees will be provided, as 1 of 5 employees termed Feb 19, 2020.
Human Resources will monitor compliance with with annual performance documents.

The training year for Employees 1,2,3,4,5 have concluded. Certified Nursing Assistants will receive education from the Staff Development Coordinator or designee on the annual training requirements. Staff Development Coordinator will ensure sufficient training opportunities are available throughout the year and will include the required training topics in order for the nursing assistants to obtain their annual training requirements. The Staff development coordinator will maintain a calendar all nursing assistants training years are monitor for completion of training throughout the year. Prior to the end of the nursing assistants training year, Staff Development Coordinator will review the training hours completed and communicate with the nursing assistant to ensure the training requirements will be completed before their end of their training year. Director of Nursing will monitor Staff Development Coordinator's adherence to this plan. Staff development coordinator will report compliance with annual training education at the QAA meetings so that the committee is aware of any potential compliance issues and can recommend any further action.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:

Based on review of facility policy, observation and staff interviews it was determined that the facility failed to provide a dignified dining experience for one of three residents (Resident R8).

Review of facility policy "Meal Service in Resident Room" dated 1/3/20, indicated that staff is to assist resident with eating, encourage resident to eat independently, provide supervision, and level of assistance needed by the resident's current level of self-performance.

The Minimum Data Set (MDS - periodic assessment of care needs) dated 11/4/19, indicated that Resident R8 was admitted to the facility on 3/23/15, with current diagnoses that include depression, weakness, anxiety, seizures, respiratory difficulties, high blood pressure, falls, difficulty walking and dementia.

Review of the physician's orders for Resident R8 dated 2/20, indicated that resident is to be fed by staff.

Review of current plan of care for Resident R8 dated 2/20, revealed that staff is to allow adequate time to eat; provide cues; encouragement. Feed resident meals as ordered.

During an observation on 2/11/20, at 11:57 a.m. Resident R8 was sitting at table with food tray infront of her with other residents at the table.

During an observation on 2/11/20, at 2:17 p.m. Resident R8 was sitting at the table with same food tray in front of her, in the same location, no staff in the dining room and resident appeared to be sleeping.

During an interview on 2/11/20, at 2:27 p.m. Registared Nurse Unit Manager confirmed that Resident R8 was not provided a dignified dining experience and was left without assistance.

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

28 Pa. Code 201.29(a) Resident rights.

Plan of Correction - To be completed: 03/27/2020

The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements."
Resident8 feeds self with set-up and cueing from staff and takes a very long time to eat her meal. Unit manager provided new milk and offered new grilled cheese because of length of time resident takes to eat. Resident refused. Unit manager had been checking on resident throughout her meal. Resident 8 will be provided with assistance as ordered for meals. Residents are evaluated for any assistance needed with meals at time of admission, with any noted decline in functioning and through ST and OT assessments. All nursing and dining staff will be educated by the staff development coordinator or designee on elements of a dignified dining experience. Observations of meal time will be conducted weekly for one month by members of the nursing and dining services team to ensure residents with orders to be fed by staff are being provided with that assistance as well as a dignified dining experience. Any issues identified will be addressed. If no issues are identified after weekly observations for one month, these observations will be then be conducted twice per month for three months until substantial compliance is observed and being maintained. Results of these audits will be reported to the QAA committee for review and any further recommendations from the committee will be implemented.

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

Observations:

Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are investigated and reported to the administrator of the facility and to other officials for one of three residents. (Resident R134).

Findings include:

A review of the facility's policy "Abuse" dated 1/3/20, indicated staff will report all bruises and injuries and investigations are conducted to thoroughly determine possible causes and the administrator/designee is responsible for reporting allegations of abuse to the proper authorities.

A review of the clinical record revealed that Resident R134 was admitted to the facility on 1/24/20, with diagnoses that included, end stage kidney disease (long standing disease of the kidneys leading to failure), dialysis (process to remove impurities from the blood), and diabetes (disease where the body is unable to respond to insulin). The resident is alert and oriented and able to make needs known.

During an observation and interview on 2/10/20, at 11:30 a.m., Resident R134 stated staff was rough with me, I don't think they knew what they were doing when they put me in bed. Right upper arm noted with large bruised area and right hand swollen and bruised.

A review of a progress note dated 2/5/20, indicated Resident R134 had sustained a skin tear to the right upper extremity with a moderate amount of bleeding noted. Also noted moderate sized bruising to right forearm to hand.

A review of an incident report dated 2/6/20, indicated R134 had a skin tear to right upper arm and bruising to right hand. There was no investigation to determine the possible cause of the injury.

During an interview on 2/13/20, at 1:20 p.m. the Director of Nursing (DON) confirmed the above findings and that the facility failed to make certain that all alleged violations involving abuse, including an injury of unknown source were investigated and reported for Resident R134.

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

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

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

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

28 Pa. Code 201.20(b) Staff development.

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

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

Plan of Correction - To be completed: 03/27/2020

Upon resident reporting to surveyor that that the skin tear occurred when being positioned in bed too "roughly". Facility then initiated further investigation and reported the event per regulation and additional investigation occurred. Agency aide was provided education regarding the event. Resident R134 no longer resides in the facility.
Nursing staff will be educated by the staff development coordinator or designee on abuse and neglect and the investigation process for bruises, skin tears and other injuries or unknown origin. This training will include identifying possible abuse and neglect and the reporting process for allegations of potential abuse and neglect. All incidents will continue to be reviewed by the nursing leadership team following the event to determine if an investigation for any potential abuse or neglect has necessary and will follow the mandatory abuse reporting requirements as well as implementation of any interventions to reduce risk of further incidents from occurring. Any issues identified will be addressed.

Incidents and accidents are reviewed monthly at the QAA meetings which will include a review to determine investigations occurred when necessary and the required abuse reporting occurred. Any further follow-up requested by the QAA committee will be implemented.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on review of facility policies, observations, clinical records, and staff interviews, it was determined the facility failed to provide a safe environment for smoking, and smoking assessments and care plans failed to reflect how the facility is going to keep residents safe during smoking for two of four residents (Residents R4 and R64).

Finding include:

Review of the facility policy "Smoking" dated 1/3/20, indicated that the residents will be assessed for level of independence and safety during smoking.

Review of the facility policy "Accident and Incidents" dated 1/3/20, indicated that the facility will provide a safe environment for all residents.

During an observation on 2/12/20, at 2:30 p.m., Residents R4 and R64 were smoking in front of the facility, Resident R4 was observed lighting Resident R64's cigarette.

The Minimum Data Set (MDS - periodic assessment of care needs) dated 11/2/19, indicated that Resident R4 was admitted to the facility on 12/18/12, and has the current diagnosis that include dementia, alcohol use, liver failure, depression, diabetes and anxiety.

Review of the Smoking Evaluation for Resident R4 revealed that resident was to be supervised during smoking.

Review of the physician orders for Resident R4 dated 2/20, did not include an order for resident to smoke.

Review of the care plan for Resident R4 dated 2/20, identified resident as a smoker but does not indicate any intervention as how resident is going to remain safe during smoking.

The MDS 1/9/20, indicated that Resident R64 was admitted to the facility on 3/3/14, and has the current diagnosis that include irregular heart beat, high blood pressure, difficulty swallowing, dementia, alcohol use, difficulty walking, depression, diabetes and anxiety.

Review of the Smoking Evaluation for Resident R64 revealed that resident was to be supervised during smoking.

Review of the physician orders for Resident R64 dated 2/20, did not include an order for resident to smoke.

Review of the care plan for Resident R64 dated 2/20, identified resident as a smoker but does not indicate any intervention as how resident is going to remain safe during smoking.

During an interview on 2/13/20, at 9:07 a.m. the Director of Nursing confirmed that Residents R4 and R64 are both supervised smokers. Residents lighting each others cigarettes is not a safe environment and the smoking assessments and care plan do not reflect how the facility is going to keep residents safe during smoking.

28 Pa Code: 209.3(b)(c)(f) Smoking.

Plan of Correction - To be completed: 03/27/2020

Orders from physician to allow residents R4 and R64 to smoke will be obtained. Facility is implementing a new smoking assessment and the four residents who smoke will be re-assessed using this new assessment. Care plans for these residents will be updated to includes measures identified to keep resident safe when smoking. Smoking residents have been informed that they are not to assist each other with their smoking materials. Staff Development Coordinator will educate nursing staff on the smoking policy for the four residents that smoke as well as their responsibilities when supervising residents while smoking.
Smoking assessments will be conducted at least quarterly or with any change that could affect their ability to smoke. Director of Nursing or designee will monitor for the completion of the new smoking assessments on the residents as well as the quarterly re-assessments while the resident continues to smoke.
Compliance with the completion of quarterly smoking assessments and care plans to included measures for resident safety while smoking will be reported at the QAA meetings until substantial compliance is maintained. Any further action recommended by the QAA committee will be implemented.
Facility is a non-smoking facility with only 4 residents who have been grandfathered under the non-smoking policy. No additional new or additional residents will be permitted to smoke under the policy.

483.70(a)-(c) REQUIREMENT License/Comply w/ Fed/State/Locl Law/Prof Std:

§483.70(a) Licensure.
A facility must be licensed under applicable State and local law.

§483.70(b) Compliance with Federal, State, and Local Laws and Professional Standards.
The facility must operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility.

§483.70(c) Relationship to Other HHS Regulations.
In addition to compliance with the regulations set forth in this subpart, facilities are obliged to meet the applicable provisions of other HHS regulations, including but not limited to those pertaining to nondiscrimination on the basis of race, color, or national origin (45 CFR part 80); nondiscrimination on the basis of disability (45 CFR part 84); nondiscrimination on the basis of age (45 CFR part 91); nondiscrimination on the basis of race, color, national origin, sex, age, or disability (45 CFR part 92); protection of human subjects of research (45 CFR part 46); and fraud and abuse (42 CFR part 455) and protection of individually identifiable health information (45 CFR parts 160 and 164). Violations of such other provisions may result in a finding of non-compliance with this paragraph.

Observations:
Based on observations and interviews with staff it was determined that the facility failed to provide the State Agency with timely access to resident information, causing a delay in the survey process.

Findings include:

During an observation on 2/12/20, at 2:00 p.m. (the second day of the survey) the SA team staff were attempting to obtain documentation regarding a summary of physician orders. The SA team went into the electronic system as directed by the Director of Nursing (DON). Documentation was unable to be accessed by the SA team. The DON then attempted and was also unable to gain access using the system provided to the SA team.

During an observation on 2/13/19, at 9:00 a.m. (the third day of the survey) the SA attempted to gain access again to clinical information for summary of physician orders and did not have access.

During an interview on 2/13/19, at 2:30 p.m. the DON confirmed the facility failed to provide the State Agency with timely access to resident information causing a delay in the survey process.

28 Pa. Code:201.13(b)(e) Issuance of license.

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

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

Plan of Correction - To be completed: 03/27/2020

Administrator will provide education to the interdisciplinary team on the importance of providing information to the surveyors in a timely manner and if any difficulties arise in obtaining the information, they are to notify the administrator who will seek the appropriate support to obtain the information. Administrator will check-in with survey team frequently to ensure they are receiving the requested information timely.

483.75(g)(1)(i)-(iii)(2)(i) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role;

§483.75(g)(2) The quality assessment and assurance committee must:
(i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary.

Observations:
Based on review of facility documents and staff interview, it was determined that the facility failed to make certain that the Medical Director or other physician was in attendance at quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for one of four quarters (July through September 2019).

Findings include:

A review of the facility policy "Quality Assessment/Performance Improvement" dated 1/20/19, indicated that the facility would conduct meetings at lease quarterly, and those in attendance would include the Administrator, Director of Nursing, Physician, Pharmacy Consultant and three additional members.

A review of QAPI Committee meeting sign-in sheets for the period of July 2019, through September 2019, indicated that the Medical Director or other physician was not in attendance.

During an interview on 2/13/20, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to make certain that the Medical Director or other physician attended QAPI meetings on a quarterly basis.

28 Pa. Code Management.

Plan of Correction - To be completed: 03/27/2020

The Medical Director was in attendance at 5 monthly QAA Meeting in the past twelve months.

Administrator informed Medical Director of the need to be at the quarterly QAA meetings and will be informed of meeting dates.

The administrator will ensure that Medical Director will be in attendance at quarterly QAA meetings throughout the year.

The QAA Meeting minutes will reflect the attendance of the Medical Director on a quarterly basis.

The QAA committee will also monitor for quarterly attendance of the Medical Director.

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