Nursing Investigation Results -

Pennsylvania Department of Health
PARAMOUNT NURSING AND REHABILITATION AT FAYETTEVILLE, LLC
Patient Care Inspection Results

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PARAMOUNT NURSING AND REHABILITATION AT FAYETTEVILLE, LLC
Inspection Results For:

There are  60 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.
PARAMOUNT NURSING AND REHABILITATION AT FAYETTEVILLE, LLC - 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 survey and two complaints completed on February 13, 2020, it was determined that Paramount Nursing and Rehabilitation Center at Fayetteville, LLC was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
483.60(i) Food safety requirements.
The facility must -

483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:

Based on observation and staff interviews, it was determined that the facility failed to maintain equipment used in the main facility kitchen in accordance with professional standards for food service safety for one fan used in the dish washing area.

Findings include:

Observation was made during the main facility kitchen entrance tour on February 10, 2020, at approximately 10:20 AM, with the presence of Dietary Manager (DM) 2, that revealed that at the end of the dish machine clean end return area was a large fan (in use) attached to the end wall facing the clean dishware as it exited from the dish machine. It was observed that the perimeter of the large fan was covered with a significant amount of an oily appearing dusty substance. It was also observed that there was a shelf attached to the back wall above the clean return area and that this shelf, which held a rack full of clean thermal bowls, was approximately two to three feet from the (in use) rotating fan. It was also observed that particles of the substance observed on the fan had been thrown up to the ceiling area above the clean return end of the dish machine and also across the back wall behind the dish machine for the entire length from the clean end to dirty end. DM 2 provided copy of an electronic work order which confirmed that a work order for cleaning the fan had been placed on January 30, 2020. Review of the work order form as observed on DM 2's computer (unable to print entire screen presentation) also revealed that the work order had been closed. At this time DM 2 confirmed that "closed" meant the work order had been completed.

During an interview with Nursing Home Administrator (NHA) on February 13, 2020, at 9:34 AM, the NHA revealed that the fan was cleaned on January 30, 2020, but that it was not cleaned adequately. NHA revealed that the fan needed to be removed from the wall to be cleaned properly, not just a swipe around the edge and revealed that the fan should have been cleaned properly.



28 Pa code 211.6(b)(d) - Dietary Services

































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

Interim Maintenance Director will educate Maintenance Staff on the proper way to clean the dish room fan.
The Interim Maintenance Director or designee will audit the monthly cleaning of the dish room fan is completed and cleaned properly.
The Dietary Manager or Dietitian will educate Dietary staff on the cleaning schedule for the walls in the dish room to be completed twice a week.
The Dietary Manager or Dietitian will audit the dish room cleaning schedule for completion by staff two times a week times four weeks.
Results will be reported to the Quality Assurance Quality Improvement Committee. The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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.
483.60(c) Menus and nutritional adequacy.
Menus must-

483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

483.60(c)(2) Be prepared in advance;

483.60(c)(3) Be followed;

483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

483.60(c)(5) Be updated periodically;

483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:

Based on observations, review of select facility documentation and interviews with residents and staff, it was determined that the facility failed to serve items as planned and as previously approved by a facility Registered Dietitian for the facility menu for one meal out of two meals observed in the main facility dining room and failed to provide residents' food preferences for one resident out of 36 residents reviewed (Resident 1).

Findings include:

Observation was made in the main facility dining room on February 10, 2020, at approximately 11:50 AM, that all the residents who received puree texture food items for this noon meal had received applesauce and that other diet textures of meals had received apple pie. Review of the planned menu/Diet Spreadsheet for this meal revealed that Regular, Mechanical Soft, Puree and Hi (High)Cal (calorie)/ Pro (protein) diets were to receive Creamy Swiss Chicken, Mashed Potatoes (HiCal mashed potatoes for those residents on a HiCal/Pro diet, Brussel sprouts, and Apple Pie. This menu also revealed that Puree diets would receive their apple pie as pureed. Review of dining room attendance information revealed that 11 of the residents in the dining room were to receive Puree diets and that six were to receive HiCal/Pro Puree diets. Therefore, 17 residents received applesauce instead of the pre-planned apple pie.

During an interview with Dietary Manager (DM) 2 and Registered Dietitian (RD ) 2 on February 10, 2020, at 1:53 PM, DM 2 revealed that "the menu should have been applesauce." Note: RD 2's date of hire to facility was January 20, 2020, (replaced a previous Registered Dietitian) the current menu cycle has been in use since December 2020, and menus are required to be pre-approved by a Registered Dietitian prior to implementation.

During an interview with Nursing Home Administrator (NHA) on February 13, 2020, at 12:22 PM, the NHA revealed the expectation that menus would be followed.

The facility failed to to follow the facility menu as planned.

Review of the residents' menu for the puree diet, noon meal on February 11, 2020 revealed that puree pepperoni pizza, puree green beans, and ice cream were to be served.

Observation in the assisted dining room on February 11, 2020, at approximately 11: 57 PM, revealed that Resident 1 was eating his noon meal and it was observed that there was only one food item on his plate which was Ravioli. Review of Resident 1's meal ticket revealed pre-printed food items on it: nectar ice cream, nectar thick apple juice, nectar thick water, pureed pepperoni pizza and pureed green beans. Ravioli was noted to be hand written at the bottom of the ticket.

During an interview with Resident 1 on February 11, 2020, at approximately 11:58 AM it was revealed that he does like green beans and would like to have green beans.

During an interview with Dietary Aide 1 (DA 1) on February 11, 2020, at approximately 12:00 PM it was revealed that residents are asked their meal preferences the day before. It was revealed that another staff member asked Resident 1 on February 10th for his meal preferences for February 11, 2020, and Resident 1 noted that he preferred the ravioli in place of the pizza, so ravioli was handwritten on Resident 1's meal ticket. Diet Aide 1 stated that when a resident wishes to have an alternate menu item, the staff will handwrite all the food items the resident wishes to have at that particular meal on the tray ticket. It was also revealed that the puree green beans should have been handwritten on the ticket and it wasn't, therefore Resident 1 was not served puree green beans.

During an interview with the Director of Nursing and Nursing Home Administrator on February 13, 2020, 12:20 PM it was revealed that meal preferences/selections are obtained the day prior, a dietary staff member asks residents the day prior for their menu preferences for the next day. It was also revealed that there are several vegetable selections on the always available menu and those items should be offered.

The facility failed to honor resident food preferences.


28 Pa. Code 201.18(b)(1)(3) Management


28 Pa. Code 211.6(b) Dietary services










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

The Registered Dietitian met with Resident R1 to update food preferences and ensure he was receiving his commercial supplement with lunch and dinner. R1 has had no significant weight changes and BMI is 41.1.

The Registered Dietitian will review all residents who receive Puree diets/HiCal/Pro Puree diets to see if they have suffered any weight loss. All resident significant weight losses are reviewed weekly at the Interdisciplinary Weight Committee Meeting with recommendations for interventions reviewed.


The Dietary Manager or Dietitian will provide training to Dietary staff regarding following the menu's as listed and offering alternatives if resident declines particular menu items and to offer alternatives to provide a nutritionally balanced meal. The Dietary Manager will update the menu listings with the Registered Dietitian's approval. The Dietary Manager or Dietitian will educate the Dietary staff that they need to document refusals of alternative food items and list the alternatives selected and the other items to be served to the resident.
The Dietary Manager or Dietitian will audit all puree resident's meal served to match the menu extension 2 times a week times 2 weeks and then once a week times two weeks.

The Dietary Manager or Dietitian will audit 5 residents who have made a selection on the alternative menu to ensure that the meal being served meets the nutritional daily requirements and matching the residents request two times a week times four weeks.

Results will be reported to the Quality Assurance Quality Improvement Committee. The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:

Based on observations, test tray, review of select facility documents, and resident and staff interviews, it was determined that the facility failed to provide food and beverages that are palatable, appetizing, and at a acceptable temperature for one of one meal test trays conducted.

Findings include:

During interview with Resident 52 on February 10, 2020, at 10:52 AM, resident revealed that she doesn't care for the food, is bad sometimes, it's mushed, I eat in my room (due to physical limitation) and it gets lukewarm or cold, serve a lot of things I don't care for."

During interview with Resident 4 on February 10, 2020, at 10:17 AM, resident revealed "terrible quality and how prepared, sometimes cold."

Resident Group meeting was held on February 11, 2020, at 11:00 AM. Group participants revealed regarding facility food: not the kind of food I like to eat; dinner to be served starting at 4:30 (PM) sometimes served after 5:00 (PM), sometimes after 5:30 PM. , food is cold-have to ask to get heated, food heavily seasoned with salt and pepper, too much tomato based food; potatoes not cooked, no clams in clam chowder, food is cold; frequently run out of ice cream, meat-especially pork chop is tough, pasta is doughy; fresh cantaloupe and honeydew is hard; feel abandoned in dining room-no staff.


A test tray was completed on February 12, 2020, at 12:20 PM. in the nursing unit hallway of Resident 47. It was observed that the meal cart for this hallway arrived to hallway at 12:02 PM. It was also observed that the first Nursing Aide to pass trays attended to the meal cart at 12:06 PM. It was observed that at 12:19 PM, the last meal tray was passed, Dietary Manager (DM) 2 had already been present and was available to take meal temperatures at 12:20 PM. Recorded temperatures were as follows:
oriental blend vegetables: 124.5 degrees Fahrenheit (F) appeared overcooked/texture quite mushy/ not palatable for temperature; sweet and sour chicken 127.4 degrees F/ very tender, flavor good, not palatable for temperature; rice pilaf 126.3 degrees F/ bland flavor/not palatable for temperature; egg roll 127.8 degrees F/ overcooked with dark brown very soft outside/inside vegetables mushy/no flavor/unpalatable for temperature;
cranberry juice cocktail 49.4 degrees F/ little flavor/not palatable for temperature; apple juice 46.5 degrees F; chocolate cake-no more available for test tray. It was shared with DM 2 that observation of cake in the dining room revealed that portion sizes of the chocolate cake were very inconsistent with even the "smaller" portions given appearing to be more than adequate. During an interview with DM 2 and Registered Dietitian (RD) 2 on December 12, 2020, at approximately 1:00 PM, both DM 2 and RD 2 revealed that they had not noted this. RD 2 inquired as to how to portion equally.

Review of facility Food Temperatures policy dated for 2013, revealed "Procedure:1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F" and "2. All cold food items must be maintained and served at a temperature of 41 degrees F or below."

During an interview with Nursing Home Administrator on February 13, 2020, at 12:22 PM, the NHA revealed the expectation that meal temperatures would be per guidelines and be palatable for texture.


28 Pa. Code 211.6(c) Dietary services.








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

The Dietary Manager and Registered Dietitian will speak with Resident 52 and Resident 4 regarding quality and temperature of food being served. The Dietary Manager or Dietitian will complete a weekly survey with Resident 52 and 4 ensure temperature, palpability, presentation and accuracy of meal served meets their needs.

The Dietary Manager and Dietitian will discuss the food concerns identified at the Resident Group Meeting at the monthly Food Council meeting to continue to address resident food concerns.


The Dietary Manager or Dietitian will educate Dietary staff on the use of plate warmer insert and use of plate warmer to maintain hot food items at a temperature of 135 degrees Fahrenheit or higher. The Dietary Manager or Dietitian will educate Dietary staff on the utilization of a beverage cart for milk and juices to maintain all cold food items at a temperature of 41 degrees F or below.

The Dietary Manager or Dietitian will audit 1 test tray three times a week times two weeks and then two times a week times two weeks that will be the last food tray served from a hall food cart to ensure temperature, palpability, presentation and accuracy of test tray. Results will be reported to the Quality Assurance Quality Improvement Committee.
The Dietary Manager or Dietitian will audit 1 milk and 1 juice from the drink beverage cart three times a week times two weeks and then two times a week times two weeks.
Results will be reported to the Quality Assurance Quality Improvement Committee. The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(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 clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive person-centered care plan for one of 36 residents reviewed (Resident 50).

Findings Include:

Review of Resident 50's clinical record revealed diagnoses that included Dementia with Behavioral disturbances (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) and Epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain).

Review of Resident 50's current physician orders effective on or after February 11, 2020, revealed the order "wanderguard (an active tracking application designed to prevent persons at risk from leaving a facility unless they are accompanied) to front of w/c (wheelchair) -check placement and function every shift" with a noted start date of November 11, 2019.

Review of Resident 50's current active care plan with noted Last Care Plan Review Date of January 31, 2020, failed to reveal development of a care Focus area for Elopement risk or identification of resident as being at risk of wandering risk or of using a wander guard.

During an interview with Director of Nursing (DON) on February 13, 2020. at approximately 12:00 PM, the DON confirmed that Resident 50 had a wanderguard in place. On February 13. 2020, at approximately 12:25 PM, the DON revealed that an elopement care plan had not been developed and that it should have been.


28 Pa. Code 211.11(d) Resident care plan

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




















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

Resident R 50's care plan was updated to include Elopement Risk with appropriate interventions.
Director of Nursing or designee will complete an audit of all residents with wanderguard orders to check that they have an elopement care plan.
Licensed staff will be educated by the Director of Nursing or designee on the Care Plan Policy and the need to update care plans with nursing interventions.
Care plans will be updated on an ongoing basis by the charge nurses on each shift whenever new nursing measures are implemented.
The Director of Nursing or designee will monitor 5 care plans per week times 2 weeks and then 3 care plans a week times 2 weeks to determine if nursing interventions have been updated on the care plan.
Results will be reported to the Quality Assurance Quality Improvement Committee.The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on clinical record review, as well staff and resident interview, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of twenty one residents reviewed (Residents 11 and 47).

Findings include:

Review of Resident 11's clinical record revealed diagnoses including Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) and essential hypertension (high blood pressure without a known cause).

Review of Resident 11's current physician orders dated February 11, 2020 revealed an order for "Hoyer x 2 assist" with an order date of February 4, 2020.

Review of Resident 11's current interdisciplinary care plan on February 12 revealed a care plan for Potential for falls related to: poor safety awareness with an intervention of Transfer with one assist.

Further review of Resident 11's current interdisciplinary care plan on February 12 revealed a care plan for Frequent falls with an intervention of Transfer with 2 assist.

Further review of Resident 11's current interdisciplinary care plan on February 12 revealed that there was not a care plan for use of a Hoyer lift when transferring Resident 11.

Interview with Director of Nursing on February 13, 2020 at 11:45 AM revealed that there should be a care plan including a Hoyer lift used for transferring Resident 11.

Review of Resident 47's clinical record revealed diagnoses including Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and essential hypertension (high blood pressure without a known cause).

Review of Resident 47's nursing progress notes dated January 2018 revealed that Resident 47 had cataract surgery.

Review of Resident 47's current interdisciplinary care plan on February 12 revealed a care plan for Alteration in vision, history of bilateral cataract surgery. No longer wears glasses since lens implants with cataract surgery with a date initiated of January 15, 2018.

Further review of Resident 47's current interdisciplinary care plan on February 12 revealed a care plan for Requires assist with activities of daily living with a care plan intervention of "ensure glasses are on and clean" with a date initiated of May 22, 2017

Interview with Director of Nursing on February 13, 2020 at 11:45 AM revealed that the care plan intervention of "ensure glasses are on and clean" should have been removed from Resident 47's care plan.

42 CFR 483.21(b) Comprehensive Care Plans

28 Pa. Code 211.11(d)(e) Resident care plan

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








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

Resident R 11's care plan was revised to include transfer resident with Hoyer X 2 assist. The other transfer status's in the care plan were resolved. Resident R 47's care plans was revised and care plan intervention of ensure glasses are on and clean was removed.

The Director of Nursing or designee will complete an audit of all resident care plans as related to resident transfer status to ensure Care Plans are correct with transfer status.

The Director of Nursing or designee will complete an audit of resident care plans related to glasses/vision to ensure Care Plans are accurate.

Licensed staff will be educated by the Director of Nursing or designee on the Care Plan Policy and the need to update care plans with new physician orders or change in resident transfer status and update with any new revision. Licensed staff will also be educated that resident transfer status should be located under the Falls Care Plan. Licensed staff will be educated on the process of how to care plan transfer status in Point Click Care.
Care plans will be updated on an ongoing basis by the charge nurses on each shift whenever new physician orders, nursing interventions or revisions are implemented.
The Director of Nursing or designee will monitor 5 care plans per week times 2 weeks and then 3 care plans a week times 2 weeks to determine if physician orders, nursing interventions or reveions have been updated on the resident's care plan.
Results will be reported to the Quality Assurance Quality Improvement Committee.The Quality Assurance Quality Improvement Committee will review the results of the monthly monitoring and determine if further monitoring is necessary.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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 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 483.70(e) 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 clinical record review, observation and staff interview, it was determined that the facility failed to maintain infection control practices to prevent the spread of infection for one of one (Resident 47) dressing changes observed.

Findings Include:

Review of facility policy titled, "7.1 dressing changes", with an effective date of October 1, 2018 states, "Apply clean gloves and remove the soiled dressing. Place dressing and gloves in plastic disposal bag and seal. Wash hands. Apply clean gloves. Cleanse area per physician's orders."

Review of Resident 47's clinical record revealed diagnoses including Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and essential hypertension (high blood pressure without a known cause).

Review of Resident 47's current physician orders dated February 12, 2020 revealed an order for cleanse open area right outer ankle with NSS (normal saline solution, a mixture of sodium chloride in water).

Observation of Resident 47's dressing change on February 13, 2020 at 9:36 AM revealed RN (Registered Nurse) 1 remove the dressing from Resident 47's right outer ankle, RN 1 then placed the dressing into the garbage bag, RN 1 then cleansed the wound with NSS and gauze without first washing her hands and applying new gloves.

Interview with the Director of Nursing on February 13, 2020 at 11:45 AM revealed that he would have expected RN 1 to follow facility policy and wash her hands and change her gloves after she removed the dressing, before she cleansed the wound.

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

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

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








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

The Director of Nursing observed the unstageable area to R 47's right outer ankle to ensure no infection was present on weekly wound rounds completed on 2/18/20. No signs of infection were identified.

The Director of Nursing completed wound rounds on all resident with wounds on 2/18/20 looking for any signs of infection. No signs of infection were identifed.

The Director of Nursing or designee educated RN 1 on the Dressing Change Policy to wash hands after she removed the dressing, before she cleansed the wound with NSS.

The Director of Nursing or designee will educate licensed staff on the Dressing Change, Handwashing and Infection Control Policy.

The Director of Nursing or designee will complete Dressing Change Competencies of licensed staff.

The Director of Nursing or designee will observe dressing changes 5 times a week times 2 weeks and 3 times a week for 2 weeks on varying shifts to ensure physician orders, Dressing Change policy and Infection Control hand hygiene is being followed.

Results of audit will be reviewed at the Quality Assurance Quality Improvement. The Quality Assurance Quality Improvement Committee will determine if further monitoring is needed.

211.5(d) LICENSURE Clinical records.:State only Deficiency.
(d) Records of discharged residents shall be completed within 30 days of discharge. Clinical information pertaining to a resident's stay shall be centralized in the resident's record.
Observations:


Based on record review and interview it was determined that the facility failed to provide a recapitulation of the resident's stay, with a final summary within thirty days of the discharge or death, for one of three closed resident records reviewed, Resident (82).

Findings include:

Review of the closed clinical record for Resident 82 on February 13, 2020, at 10:00 AM revealed that she was admitted to the facility on November 22, 2019, and placed on Hospice (end of life service) with a "do not resuscitate" code status. Resident 82 had diagnoses that included Atrial Fibrillation (irregular and rapid heartbeat), Heart Failure (when the heart muscle doesn't pump blood as well as it should), and Failure to Thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal).

Further review of the closed clinical record revealed that Resident 82 was pronounced deceased on November 28, 2019, at the facility. A review of the death certificate revealed the primary cause of death was Acute on Chronic Heart Failure.

A review of the discharge summary revealed that it was dated January 8, 2020, and should have been completed within thirty days of the resident's death.

During an interview with the Nursing Home Administrator (NHA) on February 13, 2020, at 1:47 PM she stated that she was not sure why it wasn't completed within 30 days and would check because there was a change in physician group on January 1, 2020. The NHA returned within 15 minutes and explained that the discharge summary was not completed timely (within thirty days of death) by the physician group that was contracted at that time and she would expect that it to be completed within thirty days.

28 Pa Code 211.5(d) Clinical Records.





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

The discharge summary for Resident 82 was completed on January 8, 2020 beyond the thirty days of the resident death. The Medical Records Clerk had flagged and reminded the physician group of completing the discharge summary by December 28, 2019. This physician provider group that was contracted at the time is no longer providing services to the facility. The new physician group started effective January 1, 2020.

The NHA will educate the Medical Records Clerk on the completion of discharge summaries within 30 days of the resident's death and to notify the NHA if discharge summaries are not found in the discharge record for the NHA to address with the physician provider group prior to the required 30 days of completion.

The NHA will educate the new physician provider group on the regulation that resident discharge summaries are to be completed no later than 30 days of the resident's death.

The Medical Records Clerk will audit discharged summaries for residents discharged in December, January and February to see if any are missing or completed beyond the required 30 days.

The Medical Records Clerk will audit all discharged residents closed charts for the next 30 days. The results of the closed chart audit will be reported to the Quality Assurance Quality Improvement Committee. The Quality Assurance Quality Improvement Committee will determine if further monitoring is needed.


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