Nursing Investigation Results -

Pennsylvania Department of Health
BUCKTAIL MEDICAL CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
BUCKTAIL MEDICAL CENTER
Inspection Results For:

There are  35 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.
BUCKTAIL MEDICAL CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on May 12, 2022, it was determined that Bucktail Medical Center 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.


 Plan of Correction:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 review of select facility policy and procedures, observation, staff interview, and infection control surveillance documentation, it was determined that the facility failed to implement proper visitor and staff screening measures and infection control policy review related to COVID-19.

Findings:

Review of a facility policy entitled "COVID-19 Control Plan - Recommendations for Surveillance, Prevention, and Control," revealed the facility would implement measures to assist in minimizing the transmission and outbreaks of COVID-19, a highly contagious and potentially deadly respiratory illness. These measures would include the screening of all staff for temperature, symptoms of cough, sore throat, shortness of breath, loss of taste or smell, or contact with any known/suspected COVID-19 positive sources. The policy did not address visitors. The policy was noted as being effective March of 2020, with no evidence of any revisions or reviews since that date.

Upon entrance to the facility on May 9, 2022, at 9:00 AM, the surveyor was permitted to enter the building without having to be screened for temperature or COVID-19 symptoms as noted above. Employee 1, administrative secretary, indicated the facility was not screening staff or visitors at any entrance for temperature or signs and symptoms of COVID-19 in "some time." Employee 1 indicated the facility just tests all the staff weekly for COVID-19.

In an entrance interview with the Nursing Home Administrator and Director of Nursing on May 9, 2022, at 9:30 AM the Nursing Home Administrator indicated the COVID-19 screenings for staff and visitors entering the building were stopped due to the community positivity rate being low, they did not have any cases with residents or staff, and all staff were being tested weekly. The Director of Nursing indicated there were no COVID-19 positive cases among residents or staff in the last four weeks.

On May 9, 2022, at 1:00 PM the Director of Nursing reported there were two new COVID-19 positive staff identified that morning with testing and the facility was implementing COVID-19 screening again at all entrances.

In an interview with the Nursing Home Administrator on May 9, 2022, at 1:50 PM he indicated the COVID-19 screenings for staff and visitors were stopped on March 3, 2022.

A review of the facility's last COVID-19 positive case among residents or staff revealed Employee 2, payroll clerk, tested positive for COVID-19, on March 16, 2022. The facility could not provide evidence of COVID-19 screening for the employee prior to working in the facility that day. Employee 2 returned to work on March 23, 2022.

Review of the CMS QSO-20-39-NH revised on March 10, 2022, indicated facilities should screen all who enter for temperature and signs and symptoms of COVID-19, as a core principle of COVID-19 infection prevention.

Further review of additional facility policies and procedures for infection control related to COVID-19 including testing, exposure, quarantine, visitation, or surveillance had not been revised or reviewed within the past 12 months.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing on May 12, 2022, at 1:00 PM.

The facility failed to properly screen staff and visitors to prevent or contain COVID-19 in the facility, or review policies related to infection control of COVID-19 at least annually.

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 06/24/2022

1. Screening all staff and visitors was re-started at each facility entrance on 05/09/2022. Screening will remain in place until Centers for Disease Control (CDC) guidance changes screening guidance. Screening will be completed for everyone who enters the facility and will include:
a. Temperature
b. Fever or chills
c. Cough
d. Sore Throat
e. Shortness of Breath
f. New loss of taste or smell
g. Have you or anyone in your
household tested positive for
COVID-19 in the past 14 days or
been advised to quarantine?
h. Have you been around anyone who
is positive, who is suspected to
be positive, who has been
advised to quarantine?
i. Have you traveled to an area
with a high COVID positivity
rate in the past 30 days?
The Director of Nursing (DON)
and the Infection Preventionist
(IP) will review the screening
logs daily, or more often, if
necessary, to confirm staff and
visitors are being screened
properly. Daily COVID screening
log review has been added as a
Quality Indicator (QI) to the
facility Quality Assurance (QA)
Program. Daily reviews of the
COVID screening logs audits will
be reported each month at the
regular Quality Assurance
meetings. Daily audits will
continue until the facility has
been COVID-19 free for at least
four consecutive weeks. Audits
will then be performed weekly
and reported monthly until
compliance is achieved for three
consecutive months.

2. Immediate testing
a. All staff present in the
building were tested; no other
positives were identified.
b. All residents agreed to be
tested; no resident positives
were identified.
c. The DON and IP will develop an
employee listing for recording
the number of tests employees,
contractors, and subcontractors
are getting each week.
d. Testing levels will remain at
pandemic testing rates until the
facility has been without any
COVID-19 infections for four
consecutive weeks, at which time
testing will be determined by
the most current guidance.
Weekly COVID testing log review
has been added as a Quality
Indicator (QI) to the facility
Quality Assurance (QA) Program.
weekly reviews of the COVID
testing log audits will be
reported each month at the
regular Quality Assurance
meetings. Weekly audits will
continue until guidance from CDC
recommends that screenings are
no longer necessary.

3. Residents will be encouraged to test twice each week until there are no new positive residents or staff for four consecutive weeks.

4. The Director of Nursing will implement a staff COVID tracking worksheet and a resident COVID tracking worksheet. The director of nursing will coordinate with the IP and the medical laboratory to confirm all COVID positive residents and staff are correctly logged.
Staff and resident COVID-19 infection tracking worksheets have been added as a Quality Indicator (QI) to the facility Quality Assurance (QA) Program. COVID-19 tracking worksheets will be reviewed each month at the regular Quality Assurance meetings. Tracking worksheets will continue until guidance from CDC recommends that tracking COVID-19 infections in the facility is no longer necessary.

5. The policy "COVID-19 Control Plan - Recommendations for Surveillance, Prevention, and Control" has been reviewed and revised to include
a. Screening all people entering the facility in accordance with guidance provided in CMS QSO-20-39-NH revised March 10, 2022.
The DON and IP will bring the "COVID-19 Control Plan - Recommendations for Surveillance, Prevention, and Control" to each regular month Quality Assurance meeting for review and to ensure all new guidance is incorporated into the plan. Monthly review of the plan will continue until there has been no new guidance from the CDC for six consecutive months, at which point the plan will be reviewed at least annually.

6. The following facility policies are being reviewed and revised with information contained in 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and Control, CMS QSO-20-39-NH revised March 10, 2022, QSO 19-10 NH dated 3/11/19 and QSO 20-14 NH dated 3/13/20.
a. Pandemic/epidemic Cleaning and
decontamination after Covid-19
Exposure
b. Pandemic/epidemic Virus Testing
c. Pandemic/epidemic Masking
d. Pandemic/epidemic Resident Safety
e. Covid-19 Vaccination Employee
Tracking
f. Covid-19 Vaccination Requirement
Exemption
g. Pandemic/epidemic Visitation
Policy
h. Pandemic/epidemic Personal
Protective Equipment Use
The DON and IP will bring the
pandemic and endemic policies to
each regular month Quality
Assurance meeting for review and
to ensure all new guidance is
incorporated into the plan.
Monthly review of the policies
will continue until there has
been no new guidance from the
CDC for six consecutive months,
at which point the plan will be
reviewed at least annually.

7. Both DON and infection
preventionist will complete
Nursing Home Infection
Preventionist Course on CDC
Train.

8. DON and Infection Preventionist will nursing home specific training available on the CDC Train website along with recommended trained titled Clean Hands and Keep COVID-19 out!

9. The DON and IP will develop and implement a comprehensive COVID-19 training plan with COVID-19 specific training mandatory for all facility staff.

10. Facility will incorporate information from QSO-20-14-NH into COVID-19 policies, specifically:
a. Facility will monitor CDC
website and the PA DOH website
weekly for COVID related
information and county specific
information. County specific
information will be documented
for reference.
b. The Infection Preventionist and
Director of Nursing, each day
and more often as necessary,
will review infection prevention
tracking and trending within the
facility. Tracking and trending
will include
i. Daily temperatures on every
resident
1. Any resident with a
temperature
of 100.4 F will have a
respiratory assessment
completed which will include a
COVID-19 antigen test and a
test for Influenza A & B.
Temperature will be repeated
every shift until temperature
is resolved.
2. Respiratory assessment will be
repeated 5 days after initial
assessment.
c. The medical Director, the Public
Health Department, and the state
survey agency will be contacted
regarding any unexpected
increases in COVID-19
infections.
Daily tracking and trending has
been added as a Quality
Indicator (QI) to the facility
Quality Assurance (QA) Program.
COVID-19 tracking and trending
will be reviewed each month at
the regular Quality Assurance
meetings. Daily tracking and
trending and reporting will
continue until the facility has
been COVID-19 free for 4
consecutive weeks.

11. The IP, DON, and charge nurses will be re-educated in the proper use of Personal Protective Equipment (PPE). The IP, DON, and charge nurses will conduct rounds at least twice each shift through all departments of the facility to ensure all staff is exercising appropriate use of PPE. Observation for proper use will include:
a. Using the correct PPE
b. Properly donned PPE
c. Proper donning and doffing
procedures
When the IP, DON, and charge
nurses observe staff using PPE
incorrectly, corrective
education will be provided at
the time of the observation.
PPE monitoring has been added as
a Quality Indicator (QI) to the
facility Quality Assurance (QA)
Program. The DON, IP, and
charge nurses will audit
observations and training
provided. Results of these
audits will be reported at the
monthly QA meetings until 100%
compliance has been maintained
for two (2) consecutive months.
After compliance has been
maintained for two (2)
consecutive months, the audit
will be moved to random status
with at least two audits
completed each month for one
year.

483.25(n)(1)-(4) REQUIREMENT Bedrails: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.
483.25(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to assess for the risk of bed rail entrapment for five of five residents reviewed for accident hazards and obtain informed consent for the use of side rails for four of five residents reviewed (Residents 2, 14, 15, 10 and 25).

Findings include:

An observation of Resident 2 at 9:22 AM on May 10, 2022, revealed he was in bed with bilateral half-rails up on both sides of the bed.

Clinical record review for Resident 2 revealed a quarterly side rail assessment completed on May 9, 2022, that indicated he utilizes bilateral half-rails to assist with rolling side to side, and he utilizes the left rail to allow him to hold himself on his side after a change of position to his side.

A nursing progress note dated April 5, 2022, at 4:37 PM revealed that Resident 2 rolls side to side in bed with assistance while using bilateral half-rails.

There was no evidence in Resident 2's clinical record that indicated the facility assessed the risk of entrapment related to the use of bilateral half-rails on his bed.

An interview with the Director of Nursing on May 11, 2022, at 12:52 PM confirmed the above noted findings related to Resident 2's bilateral half-rails on his bed.

An observation of Resident 15 on May 9, 2022, at 11:38 AM revealed she was in a wheelchair in her room. Bilateral enabler bars were observed on the resident's bed. Resident 15 indicated she used them to move around in bed.

An observation of Resident 14 on May 9, 2022, at 12:05 AM revealed she was in a wheelchair beside her bed. An enabler bar was observed on the right side of the resident's bed. Resident 14 was not able to communicate what the enabler bar was used for.

There was no evidence Resident's 15's bilateral enabler bars or Resident 14's right side enabler bar was assessed for the risk of entrapment until May 11, 2022, after it was brought to the facility's attention by the surveyor in an interview with the Nursing Home Administrator and Director of Nursing on May 10, 2022, at 2:30 PM.

In an interview with the Nursing Home Administrator and Director of Nursing on May 11, 2022, at 1:45 PM, the above information regarding Resident 14 and Resident 15 was confirmed.

Clinical record review for Resident 10 revealed a current physician's order for two one-quarter rails to enable exiting and entering the bed.

Observation of Resident 10's room on May 9, 2022, at 11:29 AM and on May 10, 2022, at 11:44 AM revealed Resident 10 was in bed sleeping and there were bilateral one-half side rails up on each side of her bed. On May 11, 2022, at 11:50 AM, there were now bilateral one-quarter rails on her bed

There was no documentation available indicating that the facility assessed Resident 10 for the bilateral one-half side rails to her bed to determine if there was a need and if it was appropriate for the resident. There was no assessment regarding potential areas of entrapment for Resident 10's one-half side rails.

Clinical record review for Resident 25 revealed a current physician order for a right one-quarter rail to aid in repositioning.

Observation of Resident 25's room on May 9, 2022, at 11:23 AM revealed that there was a right one-quarter rail on her bed.

There was no documentation available indicating that the facility assessed Resident 25 for the right one-quarter side rail on her bed to determine if there was a need and if it was appropriate for the resident. There was no assessment regarding potential areas of entrapment for Resident 10's one-half side rails or an informed consent for the use of Resident 25's right one-quarter rail. There was no documentation that the facility reviewed the potential risks and benefits of the use of the right grab bar with either the resident or the resident's responsible party.

The surveyor reviewed the above information for Residents 10 and 25 during an interview with the Director of Nursing on May 11, 2022, at 12:55 PM. The Director of Nursing indicated that staff switched Resident 10's original bed with a bed with one-half side rails that was observed on May 9 and 10, 2022. She confirmed that no assessment or entrapment zone evaluation was completed on the bed with one-half side rails.

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


 Plan of Correction - To be completed: 05/20/2022

An assessment for the risk of entrapment related to the use of bilateral half-rails for resident 2 was completed on 5-9-22. An assessment for the risk of entrapment related to the use of bilateral half-rails for resident 15 was completed on May 11, 2022. An assessment for the risk of entrapment related to the use of bilateral half-rails for resident 14 was completed on May 11, 2022. An occupational therapy assessment was completed for resident 10 on 1/12/22 that determined the one quarter side rails were appropriate. An assessment for the risk of entrapment related to the use of bilateral half-rails for resident 15 was completed on 5-11-22.
An assessment for a one quarter bed rail for resident 25 was completed by occupational therapy on 2-14-22. The assessment determined that the one quarter bed rail to aid in positioning. An assessment for the risk of entrapment related to the use of bilateral half-rails for resident 10 was completed on 5/11/22. An assessment for the risk of entrapment related to the use of bilateral half-rails for resident 25 was completed on 5/11/22.
All other residents were reviewed to ensure proper assessments for use of necessary side rails and proper assessment for entrapment have been completed. All other residents had an assessment for use of siderails; 5 residents were found not to have proper assessment for entrapment. Administrator and DON completed entrapment assessments for those 5 residents.
Assessment for proper use of side rails has been added as a Quality Indicator (QI) to the facility Quality Assurance (QA) Program. The DON and her assigns will conduct audits of all bed rail assessments. Results of these audits will be reported at the monthly QA meetings until 100% compliance has been maintained for six (6) consecutive months. After compliance has been maintained for six (6) consecutive months, the audit will be moved to random status with at least two audits completed each month for one year.
Facility assessment for the risk of entrapment from bed rails and enablers has been added as a Quality Indicator (QI) to the facility Quality Assurance (QA) Program. Assessment for the risk of entrapment from bed rails and enablers will be completed on admission, with change of bed, change of mattress, change in the number or type of bed rails or enablers, and for any resident that has experienced a significant weight loss or weight gain. The DON and her assigns will conduct audits of all bed rail assessments to make sure all assessments have been completed and recommendations implemented. Results of these audits will be reported at the monthly QA meetings until 100% compliance has been maintained for six (6) consecutive months. After compliance has been maintained for six (6) consecutive months, the audit will be moved to random status with at least two audits completed each month for one year.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities: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.
483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

483.24(b)(2) Mobility-transfer and ambulation, including walking,

483.24(b)(3) Elimination-toileting,

483.24(b)(4) Dining-eating, including meals and snacks,

483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide appropriate treatment and services for a decline in activities of daily living for one of two residents reviewed (Resident 14).

Findings include:

Review of Resident 14's annual Minimum Data Set Assessment (MDS, an assessment tool selected at specific intervals to determine care needs), completed on November 5, 2021, revealed facility staff assessed the resident as requiring extensive assistance of two plus person physical assist for dressing, and physical help in part of bathing with two plus person physical assistance.

Review of Resident 14's quarterly MDS dated February 3, 2022, revealed facility staff assessed the resident as a decline in self-performance for bathing and dressing and now required total dependence of two plus person physical assistance.

There was no evidence the facility further assessed the decline in these activities of daily living for Resident 14, implemented a program to maintain the resident's ability to perform these tasks, or determined that the decline was unavoidable due to a clinical condition.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing on May 10, 2022, at 2:30 PM. In a follow up interview on May 11, 2022, at 11:05 AM, the Director of Nursing confirmed the decline in Resident 14 was not addressed.

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


 Plan of Correction - To be completed: 06/17/2022

Resident 14 was referred to physical therapy and occupational therapy for assessment of functional decline on 05/11/2022. The Physical Therapy assessment determined resident 14 would not benefit from implementation of a physical therapy program. Occupational Therapy (OT) completed an assessment for resident 14 on May 11, 2022. As a result of that assessment, OT is providing therapy services for transfers, feeding, and upper body dressing.

The Director of Nursing (DON) and the Registered Nurse Assessment Coordinator (RNAC) compared current Minimum Data Set (MDS) assessments with the previous MDS assessments for all current residents to identify any other resident with a functional decline of two or more points. No residents were identified.

Any resident experiencing a functional decline of two or more points on their MDS assessment will be referred to physical therapy, occupational therapy, speech and language pathology or other appropriate discipline for assessment and appropriate implementation of services necessary to assess and, when appropriate, implement services to address the identified decline in functional ability. Results of the assessment(s) will be clearly noted in the resident chart. Identified, recommended services will be implemented as identified through the assessments.

Referral for assessment for resident decline of two or more points on the MDS has been added as a Quality Indicator (QI) to the facility Quality Assurance (QA) Program. The DON and her assigns will conduct audits of all functional declines of more than two points from the previous MDS for all residents over the next six (6) months. Results of these audits will be reported at the monthly QA meetings until 100% compliance has been maintained for six (6) consecutive months. After compliance has been maintained for six (6) consecutive months, the audit will be moved to random status with at least two audits completed each month for one year.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observation, clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of two residents reviewed (Resident 10).

Findings include:

Review of the facility policy entitled "Medications-Small Volume Handheld Nebulizer," last reviewed without changes on July 28, 2021, revealed that after medication administration, staff is to wash the cup and mouthpiece with warm soap and water and air dry. When completely dry, store in a plastic bag .

According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag.

Clinical record review for Resident 10 revealed current physician orders for staff to administer the following:

BiPap (Bilevel Positive Airway Pressure, a type of ventilator used to treat chronic conditions that affect your breathing) setting at 20-8 with 5 liters of oxygen while sleeping every evening and night shift for hypoxemia (an abnormally low concentration of oxygen in the blood).

Pulmicort (nebulizer, a medication to open the respiratory airways) 0.5 milligram/2 milliliters, administer 2 milliliters inhaled orally in the morning related to Hypoxemia.

Observation of Resident 10 revealed that her BiPap nasal mask was unbagged on the following dates and times:

May 9, 2022, at 11:31 AM and 2:03 PM, and lying on the three-tiered stand by her bed
March 10, 2022, at 11:44 AM and looped around her wall oxygen regulator
March 11, 2022, at 11:50 AM and looped around her wall oxygen regulator

Observation of Resident 10 revealed that her nebulizer was unbagged on the following dates and times:

May 9, 2022, at 11:31 AM attached to the oxygen tubing and lying on the seat of the resident's recliner
May 9, 2022, at 2:03 PM attached to the oxygen tubing and lying on the floor to the right of the resident's recliner

The surveyor reviewed the above information for Resident 10 during an interview with the Director of Nursing and the Nursing Home Administrator on May 11, 2022, at 1:50 PM.

483.25(i) Respiratory/tracheostomy Care and Suctioning
Previously cited 5/14/21

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

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


 Plan of Correction - To be completed: 06/17/2022


All residents were reviewed for use of respiratory equipment. Three other residents were identified.

The facility policy "Medications-Small Volume Handheld Nebulizer" has been reviewed. A new policy, "Care, Cleaning, and Storage of Personal Respiratory Equipment", will be developed and implemented. The policy includes instructions for cleaning nebulizers and facial and nasal masks for C-Paps and Bi-Paps with soap and warm water, drying thoroughly, and storing each item in it's own zippered plastic bag.

The policies identifies that facility nursing staff is responsible for the proper cleaning and storage of personal respiratory equipment for all residents. The policy also outlines cleaning of tanks and tubing per manufacturers recommendations and the replacement of consumables, including masks, tubing, tanks, and filters, per manufacturers recommendations.

The DON will be responsible to conduct audits for the proper cleaning and storage of nebulizers and respiratory therapy masks. Audits will include direct observation of staff properly cleaning and storing equipment as outlined in the new "Care, Cleaning, and Storage of Personal Respiratory Equipment" policy.

Proper cleaning and storage or personal respiratory equipment has been added as a Quality Indicator (QI) to the facility Quality Assurance (QA) Program. The DON and her assigns will conduct daily audits of the proper cleaning and storage of personal respiratory equipment for all residents using personal respiratory equipment. The DON will report the results of the audits at the monthly QA meetings. Daily audits of all residents using personal respiratory equipment will continue until 100% compliance is achieved and maintained for thirty (30) consecutive days. After thirty (30) consecutive days of compliance has been maintained, audits will be completed each day for at least one resident using personal respiratory equipment. Results of these audits will be reported at the monthly QA meetings until 100% compliance has been maintained for thirty (30) consecutive days. After compliance has been maintained for thirty (30) consecutive days, at least one audit for each resident using personal respiratory equipment will be conducted weekly. After compliance has been maintained for thirty (30) consecutive days, the audit will be moved to random status with at least two audits completed each month.

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 closed clinical record review and staff interview, it was determined that the facility failed to ensure the completion of a discharge summary within 30 days of discharge for one of two discharged residents reviewed (Resident 26).

Findings include:

Closed clinical record review for Resident 26 revealed the facility admitted him on June 27, 2018. The facility discharged him on March 11, 2022.

Clinical record review revealed a nursing progress note dated March 11, 2022, at 3:15 PM that revealed Resident 26 had been placed on comfort care due to a decline. He was later found in bed unresponsive with no signs of life. He was pronounced dead at 3:15 PM.

Further clinical record review revealed that there was no discharge summary located in Resident 26's clinical record.

Interview of the Director of Nursing on May 11, 2022, at 11:59 AM confirmed the above noted findings related to Resident 26's discharge summary.

Resident 26's physician failed to complete a discharge summary within 30 days of his date of discharge.


 Plan of Correction - To be completed: 05/23/2022

Physician has completed the discharge summary for resident 26.
Residents discharged in the past twelve months were reviewed for timely discharge summaries; all discharges were properly documented.
The Director of Nursing (DON) re-educated resident 26's physician for the required discharge summary within thirty days of discharge.
Completion of discharge summaries within thirty days of discharge has been added as a Quality Indicator (QI) to the facility Quality Assurance (QA) Program. The DON and her assigns will conduct audits of all resident discharges over the next six (6) months. Results of these audits will be reported at the monthly QA meetings until 100% compliance has been maintained for six (6) consecutive months. After compliance has been maintained for six (6) consecutive months, the audit will be removed.


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