Pennsylvania Department of Health
TRANSITIONAL CARE UNIT AT NAZARETH HOSPITAL, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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TRANSITIONAL CARE UNIT AT NAZARETH HOSPITAL, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey completed on March 20, 2025, it was determined that Transitional Care Unit at Nazareth Hospital 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 of Long Term Care Licensure regulations related to the health portion of the survey process.

Plan of Correction:

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

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(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on review of clinical record, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that advanced directives/code status were in place for two of 11 clinical records reviewed (Resident R110 and Resident R111).

Findings include:

Review of facility policy on Advance Directive and Healthcare Agents and Representatives revealed that under section "Purpose": The purpose of this policy is to ensure that Nazareth Hospital physicians and colleagues respect the health care decisions of its patients and comply with the requirement of Pennsylvania law governing Living Wills. Under section "Policy": Nazareth Hospital will comply with the Living Will of a patient. Under section "Admission Procedure": Upon admission to Nazareth Hospital facility, the patient shall be informed of the right to execute an Advance Health Care Directives. The patient access representative will ask the patient if the patient has executed a living will/advance health care directive and if the patient has designated someone to be the patient's health care agent. The response will be a mandatory field within the electronic medical record. (EMR). If a patient has a living will/advance health care directives, a copy will be requested and scanned directly into the EMR.

Review of Resident R110's clinical record revealed that Resident R110 was admitted to the facility on March 6, 2025.

Further review of Resident R110's clinical record revealed that there was no advance directive in place and there no code status indicated Resident R110's clinical record. Review of Resident R110's physician orders revealed no order for advance directives or code status.

Further review of Resident R110's clinical record revealed no documented evidence that advance directives was discussed with the resident.

Interview with Resident R110 conducted on March 17, 2025, at 2:52 p.m. with her sister acting as sign language interpreter revealed that she has a living will and wants one of the measures to be Do Not Resucitate.

Interview with the Social Worker Employee E3 conducted on March 17, 2025, at 3:05 p.m. revealed that she was aware of Resident R110's Advance Directives. Further Employee E3 also revealed that she was waiting for the physician to order the resident's advance directives and that only the physician can order the advance directives, and that code status will not reflect in Resident R110's clinical record until the physician orders it.

Interview with the DON (Director of Nursing) Employee E2 conducted on March 17, 2025, at 3:10 p.m. confirmed that there was no advance directive in place in Resident R110's clinical record. Further DON Employee E2 also confirmed that the physician has not ordered the advanced directive and that until the physician enters the order for Resident R110's Advance Directives, it will not be reflected in Resident R110's clinical record.

Further interview with DON Employee E2 revealed that without the advance directive or without the code status indicated in the resident's clinical record, the resident will be considered a full code.

Review of Resident R111's clinical record revealed that Resident R111 was admitted to the facility on March 8, 2025.

Review of Resident R111's physician's orders revealed that a "No CPR" (Cardiopulmonary Resuscitation) and "Do Not Intubate" was ordered on March 17,2025, nine days after Resident R111's admission to the facility.

Further review of Resident R111's clinical record revealed no documented evidence that advance directives was discussed with the resident from admission until March 17, 2025.

Interview with the DON (Director of Nursing) Employee E2 conducted on March 17, 2025, at 03:10 PM confirmed that there was no advance directive in place in Resident R111's clinical record until March 17, 2025, nine days after Resident R111 was admitted to the facility. Further DON Employee E2 also confirmed that there was no code status indicated in Resident R111's clinical record until the physician entered the order for "No CPR" (Cardiopulmonary Resuscitation) and "Do Not Intubate on March 17, 2025.

Further interview with DON Employee E2 revealed that without the advance directive or without the code status indicated in the resident's clinical record, the resident will be considered a full code.

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

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

Plan of Correction - To be completed: 05/16/2025

*All charts were immediately reviewed, and orders obtained and clarified where needed at time of survey

*Physician education is being provided to any attending physicians that admit to the TCU from Medical Director

*Education is being provided to all nurses on TCU regarding admission process which must include advanced directive or code status at time of admission from physician

*All new patient charts will be reviewed at the daily TCU AM safety huddle by DON/ Care team as part of a permanent process and all findings reported to Quality Manager/Director for physician process monitoring x 2 months and outliers to follow.

*Audits will be reviewed at the TCU Quarterly Quality Meeting

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.

Plan of Correction - To be completed: 05/16/2025

*Order was immediately clarified

- All weight orders will include timeframes and directives as to reporting loss/gain and when/who to report findings to

- All nursing staff will be educated on complete weight orders, clarifying and monitoring/reporting changes

- DON will audit weight orders for completion and review daily at the TCU AM huddle meeting

- Audis will be reviewed at the TCU QI meeting

483.25(h) REQUIREMENT Parenteral/IV Fluids:

§ 483.25(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.

Observations:

Based on observation, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to maintain a peripheral inserted central catheter (PICC) consistent with professional standards of practice for one of one resident with a PICC line. (Resident R4)

Findings include:

Review of facility policy on "Maintenance of Central Venous Catheters (CVC) revealed that under section "Purpose": intravenous therapy for the administration of blood products, fluids, and parenteral nutrition, as well as for hemodynamic monitoring is an essential part of medical practice. The following policy pertains to all central venous catheters (CVC) utilized at Trinity Health Mid-Atlantic region, including PICC. Under section "Maintenance of the Catheter Site", # C. The insertion site will be evaluated every shift for evidence of complications. Assessments include gentle palpation of the site through the intact dressing to discern tenderness and visual inspection of insertion site through the transparent dressing.

Observation conducted on March 17, 2025, at 10:35a.m. during the tour of the unit revealed that Resident R4 was in bed awake. Further an intravenoues (IV) line was observed on the inner side of Resident R4's left upper arm.

Interview with Resident R4 conducted at the time of the observation revealed that he gets antibiotics and that the nurses give him the antibiotic using the intravenous line on his left arm.

Review of Resident R4's clinical record revealed that Resident R4 was admitted to the facility on March 7, 2025.

Further review of Resident R4's clinical record revealed an order dated March 7, 2025, for Ceftriaxone (Rocephine) IV syringe 2 gm IV 400 ml/hr. every 12 hours.

Interview with DON (Director of Nursing) Employee E2 conducted on March 18, 2025, at 12:56 p.m. revealed that the facility follows the policy for central venous catheters in caring for all PICC (peripherally inserted central catheter-a thin flexible tube inserted into a vein in the upper arm and threaded into a large vein in the chest, near the heart. It is used to provide access for administering medications, fluids and nutrition.). Further DON Employee E2 also revealed that PICC lines are measured by the nurse who administers the antibiotic to ensure proper placement.

Review of Resident R4's clinical record revealed that there was no documented evidence that Resident R4's PICC line site was evaluated every shift or on a regular basis and there was no documented evidence that the PICC line length was measured at any time from Resident R7's admission on March 7, 2025, up to March 17, 2025, to ascertain proper placement of the PICC line.

Interview with DON Employee E2 confirmed that Resident R4's PICC line was not measured during his stay at the facility. Further DON Employee E2 revealed that PICC line length should be measured before administering an IV ABT (intra-venous antibiotic therapy) via PICC line.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 05/16/2025

*Immediate education with nurse caring for resident

*Education will be provided for all staff regarding policy/process review for PICC line length measurements prior to administering intra-venous therapy.

*Education will be provided regarding q-shift site assessment of PICC line site. Our EMAR guides shift assessments.

*DON to audit any residents with a PICC line to ensure length and assessment completed documentation x 2 months then random audits to occur

*Audits to be reviewed at the TCU QI meeting

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on observation, review of facility policy and procedure, it was determined that the facility failed to maintain an effective infection control program related to the hand hygiene during medication administration, and wound treatment for two of two residents observed. (Resident R61 and Resident R108)

Findings include:

Revie of facility policy on medication administration revealed that the policy did not address hand washing and other infection control subjects. Review of facility policy on "Hand Hygiene" revealed that under section "Purpose": To assure proper hand hygiene practices are utilized by employees during all activities including patient care, and to prevent transmission of infectious pathogens. Hand hygiene helps to physical remove infectious from hands. Hands can also be decontaminated using waterless alcohol hand sanitizer. Under section "Policy": It is the policy of Nazareth Hospital to decrease the risk for transmission of nosocomial pathogens that may be carried on the hands of healthcare workers. Under section "Procedure": #3 Hand hygiene will be performed at the following times and as necessary: #a. Before and after entering a patient's room #b. Before and after direct patient contact. #c. Before donning gloves. #d. After removing gloves.#g. after contact with objects (including equipment) located in a patient's environment.

Medication administration observation conducted on March 19, 2025, at 8:50 a.m. with Licensed nurse Employee E4 revealed that during medication administration for Resident R61, Employee E4 was observed wearing gloves.

Further observstion revealed that Employee E4 proceeded to administer Resident R108's oral medications with the gloves on.

Further observation revealed that Employee E4 was touching Resident R61's bed side table with the same gloves and proceeded to administer Resident R61 with an eye ointment without changing gloves.

Medication administration observation conducted on March 19, 2025, at 9:38 a.m. with licensed nurse Employee E5 revealed that during medication administration for Resident R108, Employee E5 was observed wearing gloves

Further observation revealed that Employee E5 proceeded to administer Resident R108's oral medications with the gloves on. Further, Employee E5 proceeded to apply Resident R108's Nystatin powder 100,00 units to Resident r108's groin without changing gloves.

After applying the Nystatin powder 100,00 units to Resident R108's groin, Employee E5 proceeded to pull Resident R108's pajamas up, touched the bed, adjusted the bed controls, touched the overhead table, removed resident R108's heel booties, touched the bed controls to adjust the height of the bed and to elevate the head of bed without changing gloves or washing hands.

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

Plan of Correction - To be completed: 05/16/2025

*Immediate verbal education was provided to nurse E5

*All nurses will be educated to the policy/process for Infection control/hand hygiene, including during medication administration

*DON will audit hand hygiene during medication administration 5 audits per week x 2 months then random audits to follow

*Audits will be reviewed at the TCU QI meeting

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