Nursing Investigation Results -

Pennsylvania Department of Health
UNITED ZION RETIREMENT COMMUNITY
Patient Care Inspection Results

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

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
UNITED ZION RETIREMENT COMMUNITY
Inspection Results For:

There are  55 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.
UNITED ZION RETIREMENT COMMUNITY - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare and Medicaid Recertification, State Licensure and Civil Rights Compliance survey completed on January 9, 2019, it was determined that United Zion Retirement Community was not in compliance with the following requirements of 42 CFR part 483, Subpart B, Requirements for long Term Care and the 28 Pa Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to Health portion of the survey process.





 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 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.
483.35(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 employee personnel records and staff interview, it was determined that the facility failed to complete performance reviews for five of five nurse aides reviewed (Employee E7, E8, E9, E10, E11).

Findings include:

A review of facility documents, employee personnel records, revealed no documented evidence that an annual performance evaluation was completed for Employee #E7, E8, E9, E10, and E11.

An interview with the Nursing Home Administrator (NHA) on January 8, 2020, at approximately 11:15 a.m., confirmed that the annual performance evaluations for Employee #E7, E8, E9, E10, and E11 were not completed.


28 Pa Code 201.19 Personnel policies and procedures







 Plan of Correction - To be completed: 03/01/2020

1. The facility will complete performance reviews for Certified Nursing Assistants that were cited.
2. Each Certified Nursing Assistant will have an annual performance review.
3. Licensed staff will be educated on completing Certified Nursing Assistant annual performance reviews.
4. A list of current Certified Nursing Assistants that have been employed one year prior 1/9/2020 will be compiled to ensure performance reviews are completed.
5. This will be completed by 3/1/2020.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

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 a review of the facility's policies, clinical records review, staff, and resident interview, it was determined that the facility failed to thoroughly and timely investigate an injury of unknown origin for two out of 13 Residents reviewed (Resident #8, Resident #21).

Finding include:

A review of the facility nursing policy manual titled "Investigation of Injuries of Unknown Origin", undated, revealed the following: 1. All staff shall be responsible for promptly identifying and reporting all injuries to the nurse on duty. 2. Upon the receipt of the report, the nurse shall immediately evaluate the resident. 3. The bruise/skin tear will be reported through the electronic process which is automatically forwarded to the Director of Nursing (DON), if the injury cause is not immediately known, the nurse shall initiate and complete the first section of the Investigation of Unknown Origin Form. 4. The DON or designee will interview the charge nurses and assigned caregivers of the current and preceding three shifts. The interview should include observations and or resident activities that were witnessed by the staff and that may be related to the cause of injury. 5. All allegation/suspicion of abuse shall be immediately reported to the DON, Nursing Home Administrator (NHA), an abuse investigation will be initiated. 6. If further investigation revealed potential abuse/neglect, the DON will report to the NHA and all authorities as required by the Abuse Prevention policy.

Review of Resident #8's diagnosis list revealed diagnoses not limited to vascular dementia (progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), cerebral infarction (stroke), aphasia (inability to comprehend or formulate language because of damage to specific brain regions), and pseudobulbar affect ( a type of emotional disturbance characterized by uncontrollable episodes of crying and/or laughing, or other emotional displays).

A review of Resident #8's Minimum Data Set (MDS- an assessment tool used to facilitate the management of care) dated December 31, 2019, revealed that Resident #8 had a moderate cognitive impairment. Review of the same MDS revealed that Resident #8 required extensive with two-person assistance with transferring, bed mobility, toileting, and extensive with one-person assistance with personal hygiene and grooming.

Review of the facility progress note dated December 20, 2019, revealed that Resident #8 had behaviors of crying, yelling out, and abusive behaviors.

Review of the facility progress note dated December 26, 2019, at 9:23 p.m., revealed: "Purple bruise under left elbow reported by CNA (nursing assistant), after discussion another CNA reported that she had reported this bruise to the nurse on [name of the unit] last evening". A review of the same progress note revealed that the bruise was four by four centimeters.

Review of the facility documentation, incident report dated December 26, 2019, revealed that on December 26, 2019, at 7:30 p.m., CNA reported a purple bruise under the left elbow after providing care. The bruise had a measurement of four by four centimeters. The incident report further revealed that the Resident was confused.

Additional review of the facility documents, Employee E6 statement, dated December 25, 2019, revealed that while using stand aid (a mechanical lift used for transferring residents) on resident, a bruise approximately three by three on inside elbow, dark purple in color was seen, reported to [name of the nurse].

Review of the facility documentation revealed no documented evidence that Resident #8's bruise of unknown origin identified on December 25, 2019, was investigated, assessed and reported to the DON and NHA. Further review of the facility documentation revealed statements completed by the two-nursing assistant on December 26, 2019, when the bruise on Resident #8 ' s under elbow was observed again during evening care. Both statements do not have any information that can lead to the possible cause of the unknown bruise on resident #8 ' s elbow. The facility failed to provide statements from the caregivers from the preceding shifts.

An interview with the DON on January 9, 2020, at approximately 11:00 a.m., confirmed that no additional statements were completed to determine the cause of Resident #8's bruise on the elbow.

Review of Resident #21's admission MDS assessment dated June 12, 2019, revealed a BIMS (Brief Interview for Mental Status) score of 3, indicating severe cognitive impairment.

Review of Resident #21's incident note of August 18, 2019, revealed "this nurse was doing residents AM care this morning, when this nurse was washing residents lower back this nurse observed bruising to lower back and sacrum area. bruises appear purple in color. lower back bruise measures 5.9x5.3cm and sacrum area bruise measures 5.2x5cm. resident did have a fall on 8/10/19 ".

Review of facility documentation revealed that statements were obtained from the current shift and two of the three preceding shifts. Review of statement obtained from Employee E12 revealed that Employee E12 worked day shift on August 17, 2019, but did not provide direct care to the resident. Review of statement obtained from Employee E13 revealed Employee E13 worked second shift on August 17, 2019, but did not provide direct care to the resident. Review of statement obtained from Employee E14 revealed that Employee E14 worked second shift on August 17, 2019, but did not observe the resident's skin.

Intereview with the DON on January 9, 2020, at 12:27 p.m. indicated that facility procedure is to obtain statements for 24 hours preceding the identification of the injury. The DONconfirmed that statements were not obtained from all preceding three shifts and from staff who provided direct care to Resident #21.


28 Pa. Code 201.14(a) Responsibility of Licensee
Previously cited 1/31/19

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

28 Pa. Code 201.29(a)(d) Resident Rights

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code: 211.12(d)(1) Nursing service
Previously cited 1/31/19













 Plan of Correction - To be completed: 03/01/2020

1.The facility will complete thorough and timely investigations for residents with an injury of unknown origin.
a. Resident #8's statements on December 25, 2019 & Residents #21's statements on August 18, 2019 will investigated thoroughly for injury of unknown origin.
2. The Nursing staff are educated on abuse prevention and reporting at new employee orientation and annually. All departments will be re-educated abuse prevention and reporting.
3. The nursing staff will be re-educated on the facility's policy on investigation for injury of unknown origin thoroughly and timely by DON/Designee to ensure.
4. An audit of complete incident reports will be conducted weekly times three months by the DON/Designee to ensure any injury of unknown is thoroughly and timely investigated. Results of Audits will be forwarded to QAPI.
5.This will be completed by 3/1/2020.

483.20(g) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for two of 13 residents reviewed (Residents #6 and #17).

Findings include:

Review of Resident #6's significant change MDS (Minimum Data Set - periodic assessment of resident needs) dated October 22, 2019, Section N0410 - Medications Received, indicated that the resident received an anticoagulant (blood thinning medication), seven times in the past seven days. Review of the clinical record revealed that the resident did not receive an anticoagulant medication during the assessment time frame.

Interview with Employee E5, Registered Nurse Assessment Coordinator, on January 9, 2020, at 10:00 a.m. confirmed that Resident #6 did not receive an anticoagulant and the assessment did not accurately reflect the resident's status.

A review of the clinical records revealed that Resident #17 was admitted on November 6, 2019, coming from the facility's Personal Care unit.

A review of Resident #17's physician orders revealed an order on December 17, 2019, to admit the resident to Hospice care (end of life care to support resident and family).

Review of the facility documentation, Hospice logbook, revealed that Hospice had been providing services to resident #17 since November 6, 2019, and prior to that date.

An interview with the DON (Director of Nursing) on January 8, 2019, at approximately 2:30 p.m., revealed that Resident #17 had been receiving Hospice services prior to transfer to SNF (Skilled Nursing Facility). The Hospice service was continued when Resident #17 was transferred to SNF on November 6, 2019. The DON further stated that the Hospice order was missed during admission to SNF. The Hospice order was not written until December 17, 2019.

A review of Resident #17's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated November 13, 2019, under Section O- Special treatment procedure and programs revealed that Resident #17 was not on Hospice care prior and while in the facility.

An interview with licensed nurse, Employee E5 on January 9, 2020, at approximately 11:00 a.m., revealed that she/he was aware that Resident #17 was on Hospice Care. Employee #5 confirmed that Hospice care for Resident #17 was not accurately documented on Resident's MDS.


28 Pa. Code 211.5(f) Clinical records

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













 Plan of Correction - To be completed: 03/01/2020

1. The resident assessments will accurately reflect the resident status. Resident #6's assessment was modified to indicate he does not receive an anticoagulant & resident #17's assessment was modified to reflect hospice services.
2. Resident assessments for the past three months will be reviewed for accuracy and the RNAC will be re-educated on the resident assessments will accurately reflect the resident status.
3. The RNAC will review resident assessments with DON / LPNAC to ensure accuracy for one month.
4. An audit of new resident assessments will be conducted weekly times three months by the DON/designee to ensure resident assessments are accurate. Results of Audits will be forwarded to QAPI.
5.This will be completed by 3/1/2020.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 observation, clinical record review, resident and staff interview, it was determined that the facility failed to maintain an environment that was free of accident hazards for one of 13 residents reviewed (Resident #42).

Findings include:

Observations on January 6, 2020, at 5:00 p.m. revealed Resident #42 seated at a table in the dining room. A medication cup containing a white pill was observed on the tray of Resident #42's walker, which was beside the table. At approximately 5:15 p.m., Resident #42 was observed leaving the dining room with the pill still in the medication cup.

Observation on January 8, 2020, at 11:42 a.m. revealed Resident #42 seated at a table in the dining room. A medication cup containing a bottle of Systane eye drops was observed on the tray of Resident #42's walker, which was beside the table.

Interview with Resident #42 on January 8, 2020, at 11:45 a.m. revealed that the resident was having problems with her vision and the doctor had prescribed the eye drops.

Review of Resident #42's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated December 17, 2019, indicated a BIMS (Brief Interview for Mental Status) score of 13, indicating that the resident was cognitively intact. Further review of the clinical record revealed no order for the Systane eye drops. Additionally, there was no order or assessment for self-administration of medications.

Interview with the Director of Nursing (DON) on January 9, 2020, at 10:56 a.m., confirmed that there were Systane eye drops in Resident #42's room and there was no order for the eye drops. The DON also confirmed that the resident did not have an order to self-administer medications, and that the white pill in the medication cup observed on the resident's walker tray in the dining room on January 6th should not have been there, and that the pill was not able to be identified.


28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 1/31/19

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

28 Pa. Code 211.12(d)(1) Nursing Services













 Plan of Correction - To be completed: 03/01/2020

1. The facility will maintain an environment that is free of accident hazards. Resident #42 and her daughter, will be re-educated regarding orders required for prescription medication, including eye drops and her medication will be administered while licensed staff present.
2. Residents/ POA's are educated on medication administration during the admission process. An assessment is completed if a resident is interested in self-administration of medications.
3. The licensed staff will be re-educated on medication administration policy, and re-educated that residents who are not deemed capable of self-administration of medications, not be left unattended with taking medications.
4. An audit of current residents will be conducted to ensure that only residents deemed capable of self-administration of medication possess medications in their rooms.
5. This will be completed by 3/1/2020.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

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

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


Based on observation, review of medication manufacturer guidelines, and staff interview, it was determined that the facility failed to ensure that medications were properly labeled in one of two medication carts (North unit) and one medication room (Main).

Finding include:

A review of manufactures' storage guidelines for Lantus Insulin Pen (long-acting insulin) revealed that the medication may be stored at room temperature and must be discarded within 28 days after opening.

Observation of the North Hall medication cart on January 7, 2020, at approximately 9:30 a.m., in the presence of Employee E3 revealed one Lantus Insulin Pen opened and undated.

An interview with Employee E3 on January 7, 2020, at approximately 9:33 a.m., confirmed that the Lantus insulin pen should have been dated upon opening.

Observation of the Main medication room refrigerator on January 7, 2020, at approximately 9:50 a.m. in the presence of Employee E4, revealed a bottle of Florajen3 capsules (probiotics to maintain a healthy digestive tract) containing 5 capsules. The pharmacy label had been peeled off.

Interview with Employee E4 on January 7, 2020, at approximately 9:55 a.m., confirmed that the Florajen3 pharmacy label should not have been peeled off. Additionally, Employee E4 was unable to determine for whom the medication was prescribed.

Further observation of the Main medication room refrigerator on January 7, 2020, at approximately 9:50 a.m., revealed two clear small Ziploc (plastic), bags containing Acetaminophen suppositories (pain reliever and fever reducer). One Ziploc bag contained 6 Acetaminophen suppositories and one contained 10 Acetaminophen suppositories, with no pharmacy label indicating medication administration instructions. A small clear Ziploc bag containing seven Bisacodyl suppositories (stimulant laxative) with no pharmacy label indicating medication administration instructions was also observed.

Interview with Employee E4 on January 7, 2020, at approximately 9:55 a.m., confirmed that the Acetaminophen and Bisacodyl suppositories medication should have been labeled. Employee E4 was unsure to whom the medications belonged.

The above findings were discussed with the Director of Nursing on January 9, 2020, at approximately 11:00 a.m.

The facility failed to ensure that medications on the North medication cart and in the Main medication room were properly labeled.


28 Pa. Code 211.9(g)(h) Pharmacy services

28 Pa. Code 211.12(c) Nursing Services

28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited on 1/31/2019









 Plan of Correction - To be completed: 03/01/2020

1. The facility will ensure that medications are properly labeled on the North medication cart and the main medication room. The insulin pen and a bottle of Florajen3 capsules were discarded. A new insulin pen was ordered, opened, and dated. All refrigerated Ziploc bags of Acetaminophen and Bisacodyl suppositories were discarded and reordered.
2. The North medication cart and the Main medication room were audited to ensure medicine was properly labeled.
3. Licensed Nursing staff will be re-educated on proper storage and labeling of medication by ADON/Designee.
4. Audits of the medication refrigerator and medication carts will be conducted by the ADON/Designee weekly x 3 months and forwarded to the QAPI Committee.
5. This will be completed by 3/1/2020.


Back to County Map


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



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

Visit the PA Power Port