Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT TUNKHANNOCK, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT TUNKHANNOCK, THE
Inspection Results For:
There are 81 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.


GARDENS AT TUNKHANNOCK, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance Survey completed on October 4, 2019, it was determined that The Gardens at Tunkhannock 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:

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on review of clinical records, observations ans staff and resident interviews, it was determined that the facility failed to consistently provide planned care and services, consistent with professional standards of practice, to prevent pressure sore development and promote healing of pressure sores for one out of four sampled residents (Resident 91).

Findings include:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk.

ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of the clinical record revealed that Resident 91 was admitted to the facility on June 3, 2018, with diagnoses to include diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting elevated levels of sugar in the blood and urine).

A review of the resident's care plan initiated June 5, 2018, revealed that the resident was at risk for alteration in skin integrity. Interventions planned were noted as pressure reduction device to wheelchair and mattress.

A review of quarterly Minimum Data Set assessment dated September 6, 2019 (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was cognitively intact, required extensive assistance with activities of daily living, to include bed mobility, transfers, dressing, toilet use, hygiene, and bathing and was at risk for developing pressure areas.

A review of a nursing evaluation dated August 30, 2019, upon the resident's readmission to the facility after a hospitalization, revealed that the resident had a Stage I pressure area to the resident's right heel, measuring 3 cm x 3 cm, a Stage I pressure area (A reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming. The skin may be warm or cool, firm or soft) to the resident's left heel, measuring 3 cm x 3 cm, an unstageable area (is a sore whose severity cannot be determined with a visual exam. This is usually due to the exudate, or slough, covering the wound), to the resident's left toe measuring 0.3 cm x 0.2 cm and an unstageable area to the resident's left toe measuring 0.5 cm x 0.3 cm,

A review of the resident's updated care plan dated August 30, 2019, revealed that the resident was at risk for pressure ulcers, actual or at risk, due to assistance required in bed mobility, diabetes and heel wound. New interventions planned were to float the resident's heels when in bed (the resident's heels should be positioned in such a way as to remove all contact between the heel and the bed).

The resident's care plan was revised again on September 22, 2019, to include the approach of turning and repositioning the resident every hour.

A review of nursing documentation dated September 22, 2019, at 9:31 PM revealed staff discovered an unstageable left heel ulcer after noticing blood on the resident's bedsheet during care. The nurse aide reported the finding to the nurse, who cleansed the area with normal saline solution and wound cleanser; hydrogel was applied and the area was covered with clean dry dressing.

A review of a facility ulcer and pressure sore investigation dated September 22, 2019, at 9:43 PM, revealed that an unstageable pressure ulcer was discovered on left heel, measuring 2.5 cm in length x 2.0 cm in width x 0 in depth, described as black eschar (Eschar is dead tissue found in a full-thickness wound) to the center surrounded by 25 % slough (A layer dead tissue separated from surrounding living tissue, as in a wound or sore), serosanguineous (drainage pale red or pink color) drainage, thin watery, with surrounding pink tissue area.

New interventions put into place at the time of the discovery of the pressure area on September 22, 2019, were to apply heel bows (medical designed to offload pressure from the heel of a non-ambulatory individual to help prevent pressure ulcers) to bilateral feet, while in bed.

A physician order dated September 25, 2019, was noted to discontinue the bilateral heel bows. A new order was noted on that date to provide prevalon boots (boot heel protection device that completely offloads the heel to help prevent the development of heel pressure ulcers) while in bed, every shift.

According to interview with the Director of Nursing (DON) on October 3, 2019, the resident was noted to kick the heel bows off and therefore an order was obtained for prevalon boots.

There was no documented evidence in the nursing progress notes or resident's care plan regarding the resident's known behavior of kicking off the heel bows planned to promote healing and prevent worsening of the pressure sores. The facility had assessed the resident as cognitively intact, but was unable to provide documented evidence of education provided to the resident regarding the benefit of heel bows in an effort to promote compliance with their use. .

A review of a wound evaluation completed by the wound specialist dated September 30, 2019, revealed that the resident had an unstageable necrosis pressure area to the left heel measuring 3 cm by 5 cm by not measurable cm, 100 % thick adherent black necrotic tissue (eschar). Recommendations were to apply Santyl (a sterile enzyme debriding (removal of damaged tissue from a wound) ointment) once daily and dry protective dressing for 30 days, off load the wound and reposition per facility policy.

A review of a progress note dated September 25, 2019, at 5:13 PM, revealed a recommendation from therapy that the resident was a candidate for total mechanical lift due to the resident's inconsistent performance with transfers. According to interview with the DON on October 3, 2019, the resident became bed bound at that time.

A review of the facility's documentation regarding turning and repositioning the resident dated September 4, 2019, through October 3, 2019, revealed several days on which staff had documented only two occassions within a 24 hour period when the task was completed. The remaining documentation of turning and repositioning consisted solely of the times the task was completed at the beginning of each shift or indicating that the task was completed before their shift had ended.

A review of documentation of the implementation of the approach of floating heels at all times when in bed dated September 4, 2019, through October 3, 2019, revealed several days when staff documented that the approach was carried out during only two shifts of nursing duty within a 24 hour period. The remaining documentation consisted of times the task was completed at the beginning of shifts or that the task was completed before the nursing shift ended.

An observation of the resident's left heel wound on October 3, 2019 at 1:05 PM, revealed the resident lying in bed with a prevalon boot to his right foot (the foot without the pressure sore) and a heel bow and gauze at the bottom of the resident's bed, not on the resident's foot. The resident's left foot, which had the unstageable pressure area was completely exposed. There was no dressing intact and no prevalon boot in place as prescribed. The resident's bare left heel was positioned directly atop the sheet with bloody drainage approximately eight inches by 3 inches in diameter, observed on his sheet. Interview attempts at that time revealed that the resident was unable to state why his left foot was exposed, why it was not off loaded or why the protective boot was not in place. The resident was asked if the staff reposition him, elevate his feet or encourage him to reposition himself and he was unable say, but did indicate that he was in pain.

Interview with the Employee 1 (Registered Nurse), Employee 6 (Licensed Practical Nurse) and Employee 7 (Nurse Aide) on October 3, 2019, at 1:15 PM, while observing the resident's wound, revealed that none of the employees were able to explain why the resident left heel wound was exposed, lying on the sheet without a covering, a prevalon boot or elevation off the bed.

During an observation of the resident's left foot wound on October 3, 2019, at 1:15 PM, it was observed the wound covering the outer aspect of the heel, defined wound margins with slough around the outer portion of the wound and the wound was red/brown in color. The depth of the wound could not be observed, but bloody drainage was observed.

Further interview with Employee 7, whose resident caseload included Resident 91, on Ocotber 4, 2019, at 9:50 AM, regarding why the prevalon boots were not applied to both of the resident's feet, revealed that Employee 7 stated there was one one prevalon boot and one heel bow present from the previous shift. Employee 7 stated that she assumed that was what should be in place. Employee 7 acknowledged that she did not look at the resident's Kardex or care plan to confirm the proper measures that should be in place for the resident's feet/heels.

An interview with the DON on October 4, 2019 at 12:15 PM acknowledged that the facility was unable to demonstrate the consistent implementation of measures planned to prevent pressure ulcers for this resident at risk for skin breakdown. The DON also provided no explanation why the resident was not utilizing the ordered prevalon boot to his left heel or why the wound was exposed during the surveyor's observation on October 3, 2019.

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services
Previously cited 6/17/19, 2/20/19, 11/30/18

28 Pa. Code 211.5(f) Clinical records

Plan of Correction - To be completed: 11/05/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Following the Surveyors
observation, resident 91s left heel
wound was immediately treated and
both heels were offloaded with
Prevalon boots as per physician
orders.

2. Current residents with pressure
areas will be reviewed to ensure
preventatives are in place and are
being completed as per MD orders

3. Education for nursing staff will be
completed on Pressure Ulcer
Prevention as per policy

4. The DNS or designee will randomly
audit preventatives to ensure they are
in place and completed as per order,
weekly x4 then monthly x2. Audit
results will be reported and reviewed
by the QAPI Committee monthly x 3
for any further measures and to
ensure compliance

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.

Observations:

Based on resident and staff interview, review of select facility policy and minutes from Resident Council Meetings it was determined that the facility failed to demonstrate timely and adequate efforts to resolve resident grievances, which were brought forth at resident group meetings as evidenced by five of eight residents attending the group meeting (Residents 33, 50, 40, 100 and 82).

Findings include:

A review of the facility "Grievance Policy" last reviewed by the facility on May 8, 2019, revealed that the facility has a system in place to ensure residents right to prompt efforts to resolve grievances. They facility supports the resident's rights to voice any grievances without the fear of discrimination or reprisal. The reasonable timeframe the resident can expect a completed review of the grievance is within five to seven business days.

A review of the Resident Council Meeting minutes dated April 23, 2019, May 30, 2019, and June 20, 2019, revealed that during these resident group meetings residents expressed concerns that evening snacks are not always offered or provided to them on a daily basis.

During a group meeting held on October 2, 2019, at 10 AM with eight alert and oriented residents (Residents 98, 33, 67, 50, 40, 100, 57, and 82) all eight residents in attendance stated that they attend the monthly resident meetings on a regular basis. Five out of the eight residents (Residents 33, 50, 40, 100 and 82) stated that evening snacks are not consistently provided to them and the snack issue, as the residents had expressed during past monthly meetings, continues to be a problem for the residents. The residents stated that it depends on which staff members are working as to whether they receive a snack in the evening or not. Residents 33, 50, 40 and 82 all reported that they are diabetics and feel that it is important to receive a snack during the eveing hours.

During an interview with the Nursing Home Administrator on October 3, 2019, at 11:20 AM, the NHA verified that the residents had expressed concerns during past Resident Council meetings, that snacks are not consistently provided to the residents and acknowledged that the complaint has not been resolved.

28 Pa. Code 201.18 (e)(1)(4) Management
Previously cited 11/30/18

28 Pa. Code 201.29 (i)(j) Resident Rights
Previously cited 11/30/18

Plan of Correction - To be completed: 11/05/2019

Residents 82, 40, 50, 33 and 100 were interviewed. Compliance was discussed with residents cited.

Grievances derived from resident council sessions, and from residents will be recorded by the social services director/designee. Grievances will be provided to the appropriate department head director for review. NHA/designee to review grievances and follow up with resident(s).

NHA/designee will audit all grievances daily X 1 month to ensure completion and discussion with resident(s).
Grievances will be reviewed in quality assurance committee to ensure sustained compliance monthly X 2 months.

Date of Compliance: 11/5/2019

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§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.

Plan of Correction - To be completed: 11/05/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. All expired medications in Gold unit med room were immediately disposed of as per protocol. Medications in Green unit med room that were not kept at correct temperature according to manufacturer instructions were disposed of as per protocol and the malfunctioning refrigerator was replaced.

2. Med rooms on all units were checked for any similar issues, the temp log that was being done routinely on night shift was revised to be checked on all shifts.

3. Education will be completed with licensed staff on properly storing medications that require refrigeration and removing expired meds and syringes from med rooms as per protocol.

4. Random audits in med room cupboards and refrigerators will be conducted weekly x4, then monthly x2, to ensure there are no expired meds and temps are within range for medications being stored. Audit results will be reported and reviewed by the QAPI committee monthly x3 for any further measures and to ensure compliance.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

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

§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observations and staff interview, it was determined that the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment and resident care equipment in one resident room out of two residents receiving enteral tube feedings (Resident 100).

Findings include:

Observations of Resident 100 on October 2, 2019, at 10:00 AM, October 3, 2019, at 11:00 AM, and October 4, 2019, at 8:15 AM in her room, revealed that the resident's tube feeding tubing was uncapped and hanging over the enteral feeding pump. The stand and frame were soiled with dried tube feeding solution. Drippings of enteral tube feeding formula were observed on the wall next to the tube feeding pump.

Interview with Employee 1, registered nurse, on October 4, 2019, at 10:04 AM confirmed that the tube feeding pump was soiled with tube feeding solution as well as the wall.

Interview with the DON on October 4, 2019, at approximately 11:00 AM confirmed that resident care equipment and their living environment was to be maintained in a clean and sanitary manner.

28 Pa. Code 207.2(a) Administrator's Responsibility.

Plan of Correction - To be completed: 11/05/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Housekeeping was immediately made aware of resident 100s room and the dried tube feeding solution was cleaned off all items.

2. There were no other residents noted with the same issue.

3. Education for nursing and housekeeping staff will be completed on cleanliness of resident rooms that receive enteral tube feedings.

4. The NHA/designee will randomly audit resident rooms that receive enteral tube feedings to ensure cleanliness weekly x4 then monthly x2. Audit results will be reported and reviewed by the QAPI committee monthly x3 for any further measures and to ensure compliance.

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

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

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

Observations:

Based on a review of clinical records, select investigative reports and information submitted by the facility and staff interviews it was determined that the facility failed to provide necessary assistance devices as required to safely transfer one resident out 24 sampled to prevent an accident resulting in a avulsion (Resident 95).

Findings included:

A review of the clinical record revealed that Resident 95 was admitted to the facility on December 6, 2018, with diagnoses that included dementia (a decline affecting memory, normal thinking, communicating which make it difficult to perform normal activities of daily living such as dressing, eating and bathing), anxiety disorder and abnormalities of gait and mobility.

Review of a quarterly Minimum Data Set (MDS - a federally mandated assessment of a resident's abilities and care needs) assessment dated June 4, 2019, revealed that the resident required staff assistance with activities of daily living including assistance of two for transfers.

Review of the resident's care plan initiated on December 7, 2018. and revised on March 6, 2019, revealed that the resident was at risk for falls due to history of falls, disorientation and dementia. Further review of Resident 95's care plan indicated she had a deficit in physical functioning related to mobility impairment, dementia and disorientation. Planned interventions directed staff to transfer the resident with a mechanical lift (a device designed to lift patients safely) with extensive assistance of two staff.

A review of the facility's investigative report "Skin Integrity" dated July 18, 2019, revealed that the resident's right lower leg was injured during transfer. Employee 5 (nurse aide) indicated that when the resident was transferred from her wheelchair to her bed, the resident's outer right calf scraped against something resulting in an avulsion (layer of skin torn away due to trauma and/or surgery) with uncontrolled bleeding. The resident was sent to the hospital emergency room and returned to the facility later that day with new treatment orders. The resident's wheelchair and all lifts were inspected by maintenance for operation and to rule out any protruding objects with negative findings.

A nurse's note dated July 18, 2019, at 10:04 p.m., revealed that the nurse was called into the resident's room "by the (LPN) licensed practical nurse. pressure already being applied to right lower leg. large amount of blood noted. just prior to bleeding, resident was being transferred into bed."

Review of information submitted by the facility, including a Pennsylvania Department of Aging, "Act 13 Mandatory Abuse Report" (a state mandated report form for investigation of alleged abuse) dated August 6, 2019, and a Pennsylvania Bulletin PB22 (a state mandated report form for investigation of alleged abuse, neglect and misappropriation) dated August 6, 2019, revealed that Employee 5 failed to follow Resident 95's plan of care, which resulted in a serious injury to the resident. The facility substantiated neglect of Resident 95 by Employee 5. The facility noted that Resident 95 was being transferred from her wheelchair to her bed by one staff member when the staff member had to lower the resident to her bed after the resident's leg "slipped off and caught on something." The resident required a mechanical lift and an assist of two (2) staff for transfers. The PB#22 indicated that the nurse aide, Employee 5, did not follow the resident's plan of care, which instructs staff to transfer the resident with an extensive assist of two (2) staff using a mechanical lift. The facility investigation determined that the aide's actions was neglectful and was subsequently terminated.

Review of a written interview from Employee 5 dated July 19, 2019, at 10:00 p.m., revealed that the aide initially stated that Employee 8 (NA) had assisted him with the transfer while he operated the mechanical lift during the 2 PM to 10 PM shift. When Employee 5 was informed that his verbal and written statements were not corroborated with other obtained statements, he admitted that he transferred the resident by himself and without the use of a lift.

Review of a written statement by Employee 8 dated July 18, 2019, at 10:11 p.m. revealed that she was not in Resident 95's room at the time of the resident's transfer the day of the injury. The written statement indicated that Employee 5 had asked Employee 8 to "cover for him."

Interview with the Nursing Home Adminstrator on October 3, 2019, at approximately 10:24 a.m. confirmed that that Employee 5, nurse aide, failed to use the mechanical lift and the assist of two staff to safely transfer Resident 95 resulting in an accident and injury.

Refer F-607

483.25(d)(1)(2)free of Accident Hazards/Supervision/Devices
Previously cited 2/20/19, 11/30/18

28 Pa. Code 211.12 (a)(c)(d)(5) Nursing services.
Previously cited 6/17/19, 2/20/19, 11/30/18

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to follow professional standards of nursing practice in the administration of medications prescribed for one out of 24 residents sampled. (Resident 311)

Findings include:

According to the Pennsylvania Code, Title 49 Professional and Vocational Standards, Department of State, Chapter 21, State Board of Nursing 21.145. Functions of the LPN.

(a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgment based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place.

(b) The LPN adminsters medications and carries out therapeutic treatment ordered for the patient in accordance with the following:

(1) An LPN shall communicate with a licensed professional nurse and the patient ' s health care team members to seek guidance when:

(i) The patient ' s care needs exceed the licensed practical nursing scope of practice.

(ii) The patient ' s care needs surpass the LPN ' s knowledge, skill or ability.

(iii) The patient ' s condition deteriorates or there is a significant change in condition, the patient is not responding to therapy, the patient becomes unstable or the patient needs immediate assistance.

(2) An LPN shall obtain instruction and supervision if implementing new or unfamiliar nursing practices or procedures.

(3) An LPN shall follow the written, established policies and procedures of the facility.

A review of clinical record revealed that Resident 311 was admitted to the facility September 12, 2019. The resident had a physician order dated September 12, 2019, for Promethazine HCL tablet (used to treat allergy symptoms such as rash, itching, and runny nose) 12.5 mg (milligrams) three times a day for allergic rhinitis (inflammation in the nose which occurs when the immune system overreacts to allergens in the air).

Further review of the physician orders revealed that the physician discontinued the medication on September 28, 2019.

Observation of the morning medication pass on October 3, 2019, at 8:22 AM revealed Employee 2 LPN (license practical nurse) prepared Promethazine 12.5 mg tablet for administration to the resident during morning medication pass and then administered the Promethazine HCL 12.5 mg to the resident.

A review of the October 2019 MAR (medication administration record) revealed that this medication was not included on the resident's October 2019 MAR.

An interview with Employee 2 on October 3, 2019, at 9:26 AM confirmed that this nurse had administered Promethazine HCL 12.5 mg without a current physician's order for medication. and that the medication was discontinued by the physician on September 28, 2019.

Interview with the director of nursing (DON) on October 3, 2019, at approximately 9:30 AM confirmed that nursing staff failed to follow physician orders for the administration of medication.

483.25 Quality of Care F684
Previously cited 2/20/19, 6/17/19

28 Pa. Code 211.9(a)(1)(d)(e) Pharmacy Services

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 11/30/18, 2/20/19, 6/17/19

Plan of Correction - To be completed: 11/05/2019

Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Resident 311s MD/RP were made aware of the administration of a discontinued medication.

2. Recent discontinued medications were reviewed to ensure discontinued medications were removed from the med carts and/or marked on pharmacy packet accordingly.

3. Education was provided on 10/3/19 to Employee 2 on medication administration including 5 rights of medication pass. Med administration competency was performed and documented. All licensed staff will be educated on the same at the October staff in-service.

4. ADON/Designee will complete medication administration observations weekly x4, then monthly x2, to ensure discontinued medications are not still in cart and that no errors are being made. Results will be reported and reviewed by the QAPI committee monthly x3 for any further measures and to ensure compliance.

483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

Observations:

Based on review of clinical records, the facility's abuse prohibition policy and procedures, select investigative reports and staff interviews, it was revealed that the facility failed to implement established procedures for timely reporting and investigating an allegation of neglect of one resident out of 24 residents sampled (Resident 95).

Findings Include:

The facility's policy, "Abuse Prohibition and Protection" last revised by the facility May 8, 2019, revealed that each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, neglect and misappropriation of property. If an employee is involved in a suspected violation, the employee will be immediately removed from duty and the facility is required to report the allegation and submit a written report to the appropriate local and state agencies upon initiation of the investigation and/or upon completion of the investigation.

Review of the facility's investigative report "Skin Integrity" dated July 18, 2019, and information dated July 18, 2019, submitted by the facility revealed that the resident suffered an injury to her right lower leg resulting in an avulsion (an injury caused by either trauma or surgery resulting in layers of skin being torn away) when staff transferred the resident from her wheelchair to her bed. Further review of the reported information indicted that staff noticed bleeding to her leg with the injury measuring 8 centimeters x 4.5 centimeters x .4 centimeters. The resident was transferred to the hospital for evaluation.

Review of information submitted by the facility, including a Pennsylvania Department of Aging, "Act 13 Mandatory Abuse Report" (a state mandated report form for investigation of alleged abuse) dated August 6, 2019, (18 days after the injury) and a Pennsylvania Bulletin PB22 (a state mandated report form for investigation of alleged abuse, neglect and misappropriation) dated August 6, 2019, (18 days after the resident's injury) revealed that Employee 5 (NA-nurse aide) failed to follow Resident 95's plan of care, which resulted in injury to the resident.

Review of Resident 95's plan of care for her physical functioning deficit revised March 6, 2019, called for staff to transfer the resident using a sit to stand mechanical lift with the assist of two staff.

Further review of the two aforementioned reports revealed that the facility substantiated neglect of Resident 95 by Employee 5. The facility noted that Resident 95 was being transferred from her wheelchair to her bed by one staff member (Employee 5) when she suffered the injury to her leg. The resident required the use a mechanical lift with the assistance of two staff for all transfers. The PB22 indicated that the nurse aide, Employee 5, did not follow the resident's plan of care, which instructs staff to the transfer the resident with extensive assist of two (2) staff using a mechanical lift. The facility investigation determined that the aide's actions was neglectful and the aide was subsequently terminated.

Reporting requirements under Act 13 of 1997 require employees and/or administrators who have reasonable cause to suspect that a recipient (resident) is a victim of the types of abuse, including neglect (the willful deprivation by a caretaker of goods or services which are necessary to maintain physical or mental health), described in the definitions of Act 13 shall immediately make an oral report to the Area Agency on Aging (AAA). Within 48 hours of making all oral reports, the employee or adminstrator shall make a written report (using a PB22) to the AAA.

During an interview conducted on October 3, 2019, at approximately 11:55 a.m. with the Nursing Home Adminstrator (NHA), the NHA indicated that ACT 13 and PB22 reporting requirements were not initiated timely with respect to the investigation of the allegation of neglect involving Resident 95.

Refer F-689

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

28 Pa. Code 201.18(e)(1) Management.
Previously cited 11/30/18

28 Pa. Code: 201.29(j) Resident Rights.

28 Pa Code 211.2(c) Nursing services.
Previously cited 6/17/19, 2/20/19, 11/30/18

Plan of Correction - To be completed: 11/05/2019

Cannot correct deficiency as it relates to resident 95.

Events of abuse will be reported timely per Act 13 of 1997.

Abuse events will continue to be reported to the NHA as per policy. Abuse events will follow an audit checklist to ensure timely reporting.
Events of abuse will be reviewed with the Quality Assurance Committee Monthly X 12 months for compliance.

11/5/2019

483.20(g) REQUIREMENT Accuracy of Assessments:

Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to ensure that the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one of 24 sampled residents (Resident 31).

Findings include:

Observation of Resident 31 on October 1, 2019, at approximately 7:00 p.m. revealed that the resident had a right-side cochlear implant (an implantable hearing device).

Review of Resident 31's Annual MDS Assessment completed August 3, 2019, revealed that the resident did not utilize a device for hearing.

According the MDS 3.0 RAI User's Manual, if the resident did use a hearing aid (or other hearing appliance), section B0300 should be coded "yes".

Interview with Employee 3, RNAC (Registered Nurse Assessment Coordinator), on October 3, 2019, at approximately 10:00 a.m. confirmed that section B0300 should have been coded "yes" due to cochlear implant.

28 Pa. Code 211.5(g)(h) Clinical records

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 6/7/19, 2/20/19, 11/30/18

Plan of Correction - To be completed: 11/05/2019

I hereby acknowledge the CMS 2567-A, issued to GARDENS AT TUNKHANNOCK, THE for the survey ending 10/04/2019, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

MDS re-submitted with correction for resident 31.

RNACs educated on RAI manual for hearing aides and cochlear implants as they relate to definitions within the RAI and reporting on the MDS.
RNAC/designee will review MDS that contain cochlear implants to ensure it accurately reflects the status as a hearing assistance device

§ 211.9(j) LICENSURE Pharmacy services.:

(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.

Observations:

Based on a review of three closed clinical records and staff interview it was determined that the facility failed to document the quantity and disposition of medications upon discharge from the facility for one resident. (Resident 113).

Findings include:

A review of the clinical record revealed that Resident 113 expired in the facility on July 11, 2019.

Review of Resident 113's closed clinical record, conducted on October 4, 2019, revealed that there was no documented evidence available for review of the quantity and disposition of the resident's remaining medications at the time of the resident's death.

This failure to document the quantity and disposition of the resident's unused medications was confirmed in an interview with the Director of Nursing on October 4, 2019, at 1:00 p.m

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