Pennsylvania Department of Health
 GRANDVIEW NURSING AND REHABILITATION
Patient Care Inspection Results

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GRANDVIEW NURSING AND REHABILITATION
Inspection Results For:

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GRANDVIEW NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an extended abbreviated complaint survey completed on February 12, 2024, it was determined that Grandview Nursing and Rehabilitation 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:


483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):This is the most serious deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified. This deficiency was not found to be throughout this facility.
§483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.
Observations:

Based on a review of clinical records, select facility incident reports and policies, and American Heart Association guidelines and staff interviews it was determined that the facility failed to provide emergency care consistent with a resident's advanced directives for one resident (Resident CR1) out of three residents sampled. This failure placed 93 facility residents, desiring cardiopulmonary resuscitation (CPR) in the event of cardiac arrest according to their advanced directive, out of the 169 resident census in the facility, in immediate jeopardy to their health and safety with the potential for death as a result of a similar occurrence.

Findings include:

Review of the facility's policy and procedure titled "Emergency Procedure - Cardiopulmonary Resuscitation" last reviewed by the facility March 2023, revealed that if an individual (resident, visitor, staff) is found unresponsive and not breathing normally a licensed/certified staff member shall initiate CPR (Cardiopulmonary Resuscitation) unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and external defibrillation exist for that individual or there are obvious signs or irreversible death.

According to American Heart Association guidelines presumptive Signs of Death are as follows:
The patient is unresponsive;
The patient has no respirations;
The patient has no pulse;
The patient's pupils are fixed and dilated;
The patient's body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature;
The patient has generalized cyanosis (Bluish skin color due to decreased amounts of oxygen).

AHA guidelines for Conclusive (irreversible) Signs of Death are as follows:
There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin).

While these signs of irreversible death would not be expected to be seen in most practice settings, the American Heart Association also includes the following irreversible signs of death: decapitation (separation of the head from the body);
decomposition (decay or putrefaction of the body);
rigor mortis (stiffness of the limbs and body that develops 2 - 4 hours after death and may take up to 12 hours to fully develop)

A review of Resident CR1's clinical record revealed admission to the facility on February 9, 2016, with diagnoses including chronic obstructive pulmonary disease, heart failure, and diabetes.

Review of Resident CR1's clinical record revealed a physician order dated June 9, 2023, identifying that the resident was to receive CPR (emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest) in the event of cardiac arrest.

Review of the Resident CR1's vital signs record revealed that the resident's blood pressure on February 9, 2024, at 1:26 PM was 124/64 mmHg and temperature on February 9, 2024, at 3:38 PM was 97.6 degrees Fahrenheit.

A nurses note dated February 10, 2024, at 7:52 AM indicated that this nurse, Employee 4 (RN Supervisor) was called to assess Resident CR1. The RN noted "No heartbeat, no lung sounds auscultated (examine patient by listening to sounds from the heart, lungs, or other organs, typically using a stethoscope). Death pronounced at 6:28 AM, but resident appeared to have been deceased for some time (no signs or description documented). Employee 5 (CRNP) called and made aware of death at 6:33 AM. Received new order to 'Release body to mortician.' POA and emergency contact #1(name mentioned), was notified of the death at 6:37 AM."

Review of the facility incident report dated February 10, 2024, indicated that at 3:50 AM on February 10, 2024, Employee 6 (nurse aide) was in Resident CR1's room with Employee 7 (LPN working as nurse aide), had pulled the resident up in bed, changed her, and noted the resident was fine at that time.

Interview with Employee 3 (an agency LPN) on February 12, 2024, at 12:45 PM confirmed that she was the assigned nurse to Resident CR1's unit and had found the resident unresponsive on the morning of February 10, 2024. Employee 3 confirmed that she was CPR and AED certified. Employee 3 stated that "it was an overwhelming night" and she was the only LPN on the West Wing and that there were two nurse aides. Employee 3 stated there were two falls with no injuries that night, along with Resident CR1's death. Employee 3 stated that on the morning of February 10, 2024, she entered Resident CR1's room at approximately 6:20 AM to obtain a blood sugar. Employee 3 called the resident's name, and the resident did not respond. Employee 3 stated that the resident had no pulse, her hands were cold, and the resident's chest was not rising. She called a nurse aide (Employee 3 was unsure of the aide's name) into the room. Employee 3 (LPN) saw on the computer that resident desired CPR. The nurse aide went to get Employee 4 (RN Supervisor). Employee 3 (Agency LPN) stated that she did not start CPR and was waiting for Employee 4 (RN Supervisor) to get instructions. Employee 3 stated she did not know the facility policy for starting CPR, was never trained on the facility's policy, and had never been in the situation before. Employee 3 (Agency LPN) stated that Employee 4 (RN Supervisor) arrived within two minutes and checked the resident.

Interview with Employee 4 (RN Supervisor) on February 12, 2024, at 1:20 PM confirmed that she arrived in Resident CR1's room at approximately 6:28 AM on February 10, 2024. At the time she arrived in the room, Resident CR1's one eye was a quarter opened and the other eye was closed, and "blue stuff" was running out of the side of her mouth which she thought was a candy of some sort. Employee 4 stated that, using a stethoscope, she auscultated the resident's chest and found no breathing and no heartbeat, the resident's face and body were yellow and arms were very cool. Employee 4 stated that she felt the resident was "gone for a while." Employee 4 stated that she was not CPR certified and was unaware of who, on duty on that shift was CPR certified. Employee 4 stated that she then called Employee 5 (Certified Registered Nurse Practitioner) who asked Employee 4 if CPR was started and Employee 4 informed the CRNP that CPR had not been initiated.

Interview with Employee 8 (LPN) on February 12, 2024, at 2:45 PM revealed that on February 10, 2024, she arrived for work at 6:50 AM to do a double shift. Employee 8 stated that Employee 3 (LPN) told her that she "had a rough night," explaining to Employee 8 that when she \ went in to Resident CR1's room to check her blood sugar the resident was "still warm." Employee 8 (LPN) stated that she did not know why, based on what she heard from Employee 3, that CPR was not started for Resident CR1.

Interview with Employee 9 (PA-C Physician Assistant) on February 12, 2024, at 12:20 PM revealed that although she was not at the facility when the incident happened upon reviewing the incident post-occurrence, she was upset because Resident CR1 was a full code and CPR was not started when staff initially found the resident without no pulse and respirations.

The facility failed to provide cardio-pulmonary resuscitation (CPR) to a resident who had requested this emergency care and was identified as a full code status. On the morning of February 10, 2024, nursing staff found the resident unresponsive, and described the resident with no heartbeat and no lung sounds auscultated but did not initiate CPR. According to interview with the RN Supervisior, Employee 4, and documentation in the clinical record, the RN did not to perform CPR based on presumptive signs of death and not conclusive irreversible signs of death. The facility's licensed and professional nursing staff did not document specific irreversible signs of death in the resident's clinical record.

Interview with Employee 3 (Agency LPN) on February 12, 2024, at 12:45 PM who found the resident, stated that she was aware the resident had an order for CPR, but was unaware of facility procedures for initiating CPR. Employee 4 (RN Supervisor), when interviewed on February 12, 2024, at 1:20 PM was unaware of which staff member during the shift was certified to provide CPR.

These failures placed residents who desired CPR in the event of cardiac arrest in immediate jeopardy.

The facility was notified of the Immediate Jeopardy on February 12, 2024, at 2:20 PM and the IJ template provided to the facility at 2:30 PM.

An immediate plan of correction was requested and received on February 12, 2024. 2024. The plan included:

Employee 3 (Agency LPN) and Employee 4 (RN Supervisor) have been re-educated concerning the facility Emergency Procedure - Cardiopulmonary Resuscitation policy and the need to initiate CPR immediately in accordance with resident wishes.
Licensed staff education-initiated immediately concerning the Cardiopulmonary Resuscitation policy, the Obvious Clinical Signs of Irreversible Death, nursing documentation related to these signs will continue to be completed with licensed staff prior to their next shift starting on 2/12/2024 with 3 PM to 11 PM shift.
Starting with 3 PM -11 PM shift on 2/12/2024 Licensed staff education will be completed regarding the need to initiate CPR immediately in accordance with resident wishes, the location of facility crash carts and AED's (Nursing Supervisors office on East and Pavilion Nursing desk) and where staff can locate the code status for each resident [in Point Click Care(PCC) on the resident face sheet and in the orders]. Facility will designate on the deployment shift each staff member who is certified in CPR. Education will continue prior to each licensed staff member's next shift.
Residents code statuses are reflected in PCC on the resident's face sheet and in the resident's orders. Completed 2/12/2024
Director of Nursing or designee will complete an audit of EMR (electronic medical record) code status by 02/12/2024 to validate consistency of records for staff reference.
DON or designee will complete an audit of CPR certification on Licensed Facility staff 02/12/2024.

The Immediate Jeopardy was lifted on February 12, 2024, at 5:15 PM upon receipt of the facility's immediate action plan and evidence of its implementation was verified.


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

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



























 Plan of Correction - To be completed: 03/11/2024

Employees 3 and 4 have been re-educated concerning the facility Emergency Procedure – Cardiopulmonary Resuscitation policy and the need to initiate CPR immediately in accordance with resident wishes.

Licensed staff education-initiated immediately concerning the Cardiopulmonary Resuscitation policy, the Obvious Clinical Signs of Irreversible Death, nursing documentation related to these signs will continue to be completed with licensed staff prior to their next shift by the DON or designee starting on 2/12/2024 with 3-11 shift .
Starting with 3-11 shift on 2/12/2024 Licensed staff education will be completed by the DON/designee regarding the need to initiate CPR immediately in accordance with resident wishes, the location of facility crash carts and AED's and where staff can locate the code status for each resident. Facility will designate on the deployment sheet the staff member who is certified in CPR. Education will continue prior to each licensed staff member's next shift by the DON/designee.

DON or designee completed an audit of CPR certification for Licensed Facility staff on 02/12/2024.
DON or designee completed an audit of EMR code status on 02/12/2024 to validate consistency of records for staff reference. DON or designee will conduct an audit of new admissions and order changes that reflect code status during clinical morning meeting to validate consistency of records daily for four weeks and weekly for four weeks.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.
483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 resident and staff interviews and a review of clinical records and select incident reports it was determined that the facility failed to consistently implement necessary precautionary measures and adequate staff assistance to maintain resident safety during transfers resulting in a serious injuries, a fractured humerus (arm), elbow and wrist, for one resident out of four sampled (Resident B1).

Findings include:

A review of the clinical record revealed that Resident B1 was admitted to the facility on January 4, 2024, with diagnoses to include cerebral infarction (brain damage that results from a lack of blood), muscle wasting and atrophy (significant shortening of the muscle fibers and loss of overall muscle mass) and hemiplegia (one-sided paralysis) affecting the left side.

A review of an Admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 5, 2024, revealed that the resident was cognitively intact with a BIMS score of 14 (brief interview for mental status - a tool to assess cognitive function; a score of 13-15 indicates intact cognition).

A physician order, dated January 23, 2024, was noted for staff to transfer Resident B1 with the assistance of one staff and the use of a hemi-walker (one-arm walker).

During an interview with Resident B1 on February 12, 2024, at 11:09 AM the resident was observed lying in bed with a soft cast applied to her left upper extremity from above her elbow to the end of her fingertips. She stated that she fell a few weeks ago and fractured her shoulder, elbow and wrist during a transfer from the bed to the wheelchair. The resident stated that a nurse aide "was rushing" her and when she turned to get out of bed, and get into her wheelchair, the aide never locked the wheelchair brakes and the wheelchair slid out from under the resident and she fell to the floor. Resident B1 stated that she does not understand why the facility keeps saying that she tried to get out of bed by herself when the nurse aide was with her the whole time.

Review of the facility incident report dated January 26, 2024, at 4:15 PM described the incident as the "PA (Physician Assistant) observed resident lying on the floor in her room on her buttock on the right side of her bed in front of her wheelchair. The PA assessed resident while on floor and noted only complaint at that time was discomfort in her left elbow. 2 staff members able to assist resident to a standing position and transfer her to her wheelchair and out to the nursing station. Resident reported that her shoulder was hurting. RN assessed vitals. X-rays ordered for elbow and shoulder. 'On question, resident related that she wanted to get up to her wheelchair and "did not want to wait till help came."

Nursing note dated January 26, 2024, at 6:47 PM revealed that staff observed Resident B1 observed lying on the floor in her room on her buttocks on the right side of her bed in front of her wheelchair. The physician assistant assessed the resident while the resident was on the floor and noted that the resident's only complaint at the time was discomfort in her left elbow. Two staff members assisted the resident into wheelchair and resident seated at nurses station. Resident reported her shoulder was hurting. RN assessed vitals: 173/113 (blood pressure), 97.9 (temp), 120 (heart rate), 16 (respirations), 96% (oxygen level) on RA (room air). On assessment, the resident had a complaint of pain in left shoulder with movement. Physician assistant present and orders received for x-rays to left elbow and shoulder. Mobile made aware of need for studies.

According to this nursing documentation, when staff questioned the resident, she relayed that she wanted to get up into her wheelchair and "did not want to wait till help came." Nursing noted that the resident requires frequent reminders of deficits due to CVA (stroke) and need for assistance with all transfer. Resident confirmed that she was aware of same. Neuro checks within normal limits for resident.

Review of Employee 1 (nurse aide) witness statement dated January 26, 2024, indicated that at the time of the resident's fall at 4:15 PM on 1/26/24. Employee 1 reported that the nurse told her that Resident B1 needed to be changed. Employee 1 stated she changed Resident B1 and when she left her room, the resident was still in bed. Employee 1 was out of the room for 2-5 minutes when she heard a noise and went back into her room and saw her on the floor.

Review of Employee 2 (Physician Assistant) witness statement dated January 29, 2024, indicated that the date of the incident was January 26, 2024, at 4:17 PM. Employee 2 stated that she was alerted that the resident was on the floor. When she entered the room, the resident was sitting upright on the floor on right side of the bed. She had complaints of elbow pain in her left elbow but was able to straighten it and raise her arm with help from her right arm. The wheelchair was in front of her. Employee 2's statement noted that "the nurse aide had just turned around to get rid of her soiled linens and the resident attempted to self-transfer. Resident was wearing grippy socks and the wheelchair was locked when I moved it."

A nursing note dated January 26, 2024, at 10:14 PM revealed Resident B1 was sent to the emergency department (ED) around 8:00 PM.

A nursing note dated January 27, 2024, at 4:05 AM revealed Resident B1 returned from the ED at 5:00 AM with diagnosed fractures. In the emergency department, a splint was applied as well as a shoulder immobilizer. A New order to start oxycodone 5 mg every 4 hours as needed for pain. Orthopedics referral was requested.

Review of the x-ray report dated January 26, 2024, at 10:30 PM revealed the resident sustained three fractures as a result of the fall:
1.Acute, comminuted (bone broken into more than two pieces), nondisplaced (bone stays aligned in an acceptable position for healing), mildly impacted (compressed) proximal left humerus (upper arm) fracture.
2.Acute, nondisplaced, impacted radial head (left elbow) fracture.
3.Acute, nondisplaced, mildly angulated (ends of broken bone are at an angle to each other) distal radius (left wrist) fracture.

A second interview with Resident B1 on February 12, 2024, at 4:05 PM revealed that on the day of the resident's fall on January 26, 2024, "Employee 1 came in to get me out of bed in my wheelchair so I could go to the dining room for dinner. She was helping me to get into my wheelchair. I told her my left foot doesn't work too well cause I'm paralyzed. She was kind of rushing me. Then I turned around to sit and she didn't lock the wheelchair brake. She was holding onto the back of the chair but didn't lock the brakes. When I sat down, it went out from under me, and I fell down on my elbow. The pain shot up my arm. I laid on the floor for quite some time. I don't know why they keep saying I tried to get up myself, it's not true." When the surveyor asked if the facility had obtained a statement from her for her account of the incident, Resident B1 replied "oh gosh, I can't remember who they all were but a bunch of them came to ask me what happened, that's why I don't understand why they're lying about what happened." When asked if Employee 1 provided physical assistance during the resident's transfer from the bed to the chair at the time of her fall on January 26, 2024, and if the resident was using the hemi-walker, Resident B1 replied "no, she just held the chair so it wouldn't move. She didn't help me. Therapy wants me to use that walker thing, but I forgot to use it, it gets in the way."

A review of Resident B2's Admission MDS assessment dated January 22, 2024, revealed that the resident was cognitively intact with a BIMS score of 14.

Interview conducted with Resident B2, Resident B1's roommate, on February 12, 2024, at 4:20 PM revealed that Resident B2 was present in the room at the time of the fall and that she witnessed the incident. Resident B2 confirmed Employee 1 was helping Resident B1 get out of bed for dinner in the dining room. Resident B2 stated that "Employee 1 was holding the wheelchair but didn't think of putting the locks on. When \ turned to sit, she hit that floor! I felt so bad for her. Employee 1 stood there and froze. She left out of the room after the fall". When the surveyor asked if she was asked to provide a statement to the facility, Resident B2 replied "do you know how many people came to ask us questions?! Honey, I lost track of how many came in. They even woke me up at midnight to ask me questions."

Review of the facility provided nurse staffing deployment schedule for January 26, 2024, confirmed Employee 1 was assigned to Resident B1's unit during the day and time the incident occurred.

Interview with the Director of Nursing (DON) on February 12, 2024, at approximately 4:45 PM revealed that the facility was unable to provide witness statements from Resident B1 or Resident B2 even though both residents reported multiple staff members interviewed them regarding the circumstances of the fall on January 26, 2024.

The facility failed to conduct a thorough investigation into the circumstances of the fall by failing to obtain witness statements from two cognitively intact residents. The facility failed to demonstrate that staff applied preventative safety measures, locking the wheelchair brakes, to prevent a fall and failed to provide the required assistance for a transfer of a resident from the bed to the wheelchair resulting in a fractured arm, elbow and wrist.


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










 Plan of Correction - To be completed: 03/11/2024

Statement from resident B1 was obtained as part of the incident reporting/investigation process on 1/26/24, which also indicated that her wheelchair brakes were locked and the resident required one person assist with transfer.

DON or designee will audit fall events since 2/22/24 to validate thorough investigations have been completed into the circumstances of the fall.

Licensed nurses will be re-educated concerning fall event reporting and investigation expectations, and engaging direct care staff in designing/implementing fall precautions by the DON or designee. DON or designee will audit fall events and investigation materials during clinical meeting to identify components requiring completion, including validation that precautionary measures were in place. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

§483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on a review of nursing staffing, grievances filed with the facility, the facility assessment, clinical records and resident and staff interviews it was determined that the facility failed to provide sufficient nursing staff to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents including experiences described by eight residents (C1, C2, C3, A1, B1, B2, B3 and B4), grievances filed by four residents (Residents C4, C5, C6, and C7) and the delay or lack of care experienced by two residents (Resident 54 and CR1) out of 23 sampled residents.

Findings include:

Review of the facility assessment last reviewed by the facility July 2023, revealed that the facility had 172 resident beds and an average daily census was 157 to 165 residents. The general staffing plan to ensure sufficient staff to meet the needs of the residents at any given time (based on resident acuity) included 1 RN Supervisor 3:00 PM to 7:00 AM and weekend 24 hours; 1 licensed nurse to 15:20 residents on the day and evening shifts and 1 licensed nurse to 35:40 residents on the night shift; and 1 nurse aide to 8:12 residents on the day and evening shifts and 1 nurse aide to 15:20 residents on the night shift.

A review of Resident CR1's clinical record revealed admission to the facility on February 9, 2016, with diagnoses including chronic obstructive pulmonary disease, heart failure, and diabetes.

Review of Resident CR1's clinical record revealed a physician order dated June 9, 2023, identifying that the resident was to receive CPR (emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest) in the event of cardiac arrest.

A nurses note dated February 10, 2024, at 7:52 AM indicated that Employee 4 (RN Supervisor) was called to assess Resident CR1. The RN noted "No heartbeat, no lung sounds auscultated (examine patient by listening to sounds from the heart, lungs, or other organs, typically using a stethoscope). Death pronounced at 6:28 AM, but resident appeared to have been deceased for some time (no signs or description documented). Employee 5 (CRNP) called and made aware of death at 6:33 AM. Received new order to 'Release body to mortician.' POA and emergency contact #1(name mentioned), was notified of the death at 6:37 AM."

Interview with Employee 3 (an agency LPN) on February 12, 2024, at 12:45 PM confirmed that she was the assigned nurse to Resident CR1's unit and had found the resident unresponsive on the morning of February 10, 2024. Employee 3 confirmed that she was CPR and AED certified. Employee 3 stated that it was an overwhelming night and she was the only LPN on the West Wing and that there were two nurse aides.

The facility census for the 11:00 PM to 7:00 AM shift on February 9, 2024, into the morning of February 10, 2024, was 168 residents. The West Unit had a census of 52 residents. Staffing data confirmed Employee 3 (agency LPN) was the only LPN scheduled to West Unit (based on facility assessment should have 1 LPN to 35:40 residents) and only two nurse aides (employee 6 and employee 7) were scheduled to work the entire shift on the West Unit (based on the facility assessment there should be 1 nurse aide to 15:20 residents on the night shift).

During interview with Resident A1, a cognitively intact resident on February 12, 2024, at 10:40 AM, Resident A1 stated that nursing staff's response to call bells "is terrible." Resident A1 stated that she can do most things herself but worries about the residents who cannot speak for themselves. Resident A1 relayed that the facility is short on nurse staffing and most days she does not even know the name of her assigned nurse aide. She stated that call bell wait times exceed 15 minutes and can even be hours for a response from nursing staff.

A clinical record review revealed that Resident C1 revealed a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated November 7, 2023, indicating that Resident C1 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

During an interview on February 12, 2024, at 11:00 AM, Resident C1 stated that the wait time for nursing staff to respond to her call bell when she rings for assistance is dependent on nurse staffing. She explained that when staffing is good, she only waits about five minutes, but when staffing is not good, she waits up to 50 minutes for assistance.

A clinical record review revealed Resident B1 was admitted to the facility on January 4, 2024. The resident's admission MDS assessment dated January 5, 2024, revealed that Resident B1 is cognitively intact with a BIMS score of 14.

Interview with Resident B1 on February 12, 2024, at approximately 11:09 AM, revealed she has waited up to 2 hours for nursing staff to answer her call bell. The resident stated there are times when staff "will come in the room, turn off the call bell and then don't come back." She stated that she believes the facility needs more staffing because she and her roommate have to wait excessively long periods of time without receiving assistance from nursing staff.

A clinical record review revealed Resident B2 was admitted to the facility on January 17, 2024. An admission MDS Assessment dated January 22, 2024, revealed that Resident B2 is cognitively intact with a BIMS score of 14.

Interview with Resident B2 on February 12, 2024, at approximately 11:30 AM, revealed that the resident stated that the inadequate nurse staffing in the facility is a problem. She reported "Honey, we are short all the time with staff. They need more aides. We ring the bell and we have to wait. We sh*t. Some aides will say you gotta wait cause we're passing trays. We sit in our sh*t for 2 hours. They come in, ask what you need, turn off the bell, and don't come back."

A clinical record review revealed Resident B3 was admitted to the facility on September 28, 2023. A review of a quarterly MDS Assessment dated January 29, 2024, revealed that Resident B3 is cognitively intact with a BIMS score of 15.

Interview with Resident B3 on February 12, 2024, at approximately 12:00 PM, revealed that the resident stated "I've waited 1-2 hours for someone to come in and help. Ringing the bell is like talking to the wall." He continued to state "Yesterday (February 11, 2024), the whole day, I wasn't even changed." He further stated he feels that short staffing is a problem in the facility that creates these long waits for residents to receive personal assistance when requested.

A clinical record review revealed Resident B4 was admitted to the facility on June 29, 2020. A review of a quarterly MDS dated January 22, 2024, revealed that Resident B4 is cognitively intact with a BIMS score of 15.

Interview with Resident B4 on February 12, 2024, at approximately 12:10 AM, revealed that the resident stated that he waits over an hour until nursing staff answer his call bell. He stated that nursing staff will come into his room, "turn off the call bell light, but never help out." He stated that staff do not come back to provide the assistance and then he must wait all over again.

A clinical record review revealed Resident C2 was admitted to the facility on May 23, 2023. A review of a quarterly MDS assessment dated November 2, 2023 revealed that Resident C2 is cognitively intact with a BIMS score of 15.

During an interview on February 12, 2024, at 12:20 PM, Resident C2 stated that the wait times are awful for nursing staff to respond after she rings her bell for assistance. Resident C2 stated, "It is hell here." She explained that she has waited 3 hours for staff assistance after ringing her call bell, and many times she waits about an hour for nursing staff to respond. Resident C2 stated that the wait time for nursing staff assistance is especially a problem on the evening shift. She explained that the staff responses today are "just a show, because you \ are here."

A clinical record review revealed Resident C3 was admitted to the facility on April 12, 2023. An MDS assessment dated November 6, 2023, revealed that Resident C3 is cognitively intact with a BIMS score of 15.

During an interview on February 12, 2023, at 12:25 PM, Resident C3 stated that she has concerns with nursing staff response to call bell when she rings for assistance. She explained that she can't tell when she needs to use the bathroom. Resident C3 stated that she has waited 1 hour or more for staff to respond when she needed assistance using the bathroom. She explained that the wait times are the worst on the evening shift.

A review of grievances filed with the facility revealed a grievance filed by Resident C6 dated January 28, 2024, indicating that she was not changed on the dayshift or evening shift until 10:30 PM.

A grievance dated January 29, 2024, filed by Resident C4 indicated that he had a concern about a long wait time to receive ice water. Resident C4 also indicated that he waited a long time for staff assistance to be put into bed.

A grievance dated January 29, 2024, on behalf of Resident C5 indicated that he rings his call bell and can wait three hours for anyone to respond.

A grievance dated January 30, 2024, filed by Resident C7 indicated that he was not showered on January 30, 2024 as desired

A grievance dated February 7, 2024, filed by Resident C8 indicated that night shift is not getting her out of bed by 6:00 AM and she is missing breakfast in the dining room as she wishes to attend.

During an interview with Resident B1 on February 12, 2024, at 11:09 AM the resident was observed lying in bed with a soft cast applied to her left upper extremity from above her elbow to the end of her fingertips. She stated that she fell a few weeks ago and fractured her shoulder, elbow and wrist during a transfer from the bed to the wheelchair. The resident stated that a nurse aide "was rushing" her and when she turned to get out of bed, and get into her wheelchair, the aide never locked the wheelchair brakes and the wheelchair slid out from under the resident and she fell to the floor.

Nursing noted on January 7, 2024, at 8:45 PM, that staff found Resident 54 on the floor of the resident's room. The resident sustained a cross shaped cut on her right forehead. The resident reported that she hit her head on the table. The resident was sent to the hospital via ambulance at 8:40 PM, as written in the note, and returned to the facility approximately 11:54 PM on January 7, 2024, with sutures to the laceration to her forehead.

A review of the resident's January 2024 and February 2024 Treatment Administration Records (TAR) revealed a physician order dated January 9, 2024, for staff to monitor the sutures above the resident's right eye daily until sutures were discontinued, every dayshift, for signs and symptoms of infection. According to the staff initials on the TAR, nursing staff completed this task from January 9, 2024, through February 16, 2024. However, this order was not discontinued until February 20, 2024. There was no documented evidence that nursing staff continued to monitor the resident's sutures from February 16, 2024, until their eventual complete removal on February 20, 2024.

A telephone interview with the NHA on February 20, 2024, confirmed that all resident's sutures were not removed timely and nursing staff were unaware they remained in place since the resident had a scabbed area on her forehead.

There was no documented evidence that following the reported removal of six of the ten sutures on January 17, 2024, any further attempts were made to remove the last four sutures until 5 week later on February 20, 2024. There was no documented evidence that licensed and professional nursing staff were consistently monitoring the resident's forehead wound and suture site consistently until all sutures were eventually removed on February 20, 2024.

Interview with the administrator and director of nursing on February 12, 2024, at approximately 3:00 PM failed to provide documented evidence that sufficient nursing staff were being deployed in a manner to consistently provide timely quality of care and services to maintain the physical and mental well-being of the residents at the facility for all nursing shifts. The administrator and director of nursing were unable to explain why residents are reporting untimely staff responses to residents' requests for assistance, which is negatively affecting their quality of life in the facility.


Refer to F678, F684, F689

28 Pa. Code 211.12 (c)(d)(1)(2)(5) Nursing services

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
















 Plan of Correction - To be completed: 03/11/2024

The observations cannot be retroactively corrected.  

Facility residents have the potential to be affected by this practice.

Administrator or designee will educate the scheduler, nursing leadership team and RN supervisors regarding maintaining hands-on nursing staffing levels that meet resident needs in accordance with regulatory requirements and facility assessment. RN Supervisors will be re-educated to communicate unforeseen staffing challenges to the DON and NHA for further intervention. Interventions may include offering shift pick-up opportunities and advanced scheduling to staff and agency partners through a scheduling application, and redeployment of ancillary certified staff for additional support. Facility will execute a recruiting plan which involves approaches such as employee referral program, market advertising, direct mail, electronic job boards and school partnerships.

Administrator, scheduler and nursing leadership will conduct a staffing meeting daily to audit actual and projected hours and validate adequacy. Issues will be corrected upon discovery. Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

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 interviews, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment on one of the three facility nursing units (Nursing West Unit).

Findings include:

An observation on February 12, 2024, at 10:47 AM in resident room W-14 revealed yellow pieces of food debris and black-gray stains on the floor near the resident's window, two urine collection graduates on the floor in the resident's bathroom, and several brown stains on the window shades.

An observation on February 12, 2024, at 10:50 AM in resident room W-17 revealed multiple stains and discolorations on the carpet, plastic clear candy wrappers on the floor, discoloration and stains on the floor carpet, and crumbs and food debris around and under a brown wooden dresser.

An observation on February 12, 2024, at 10:53 AM revealed a black substance and discoloration on the floor between the resident rooms and in hallway between resident rooms W-17, W-18, and W-20.

An observation on February 12, 2024, at 10:55 AM outside of resident room W-20 revealed a torn gray fabric on the surface of the wall exposing a white material measuring approximately three inches by two inches.

An observation on February 12, 2024, at 10:58 AM in the West Nurse Station Resident Lounge revealed multiple dried yellow liquid floor stains, multiple pieces of food debris, a salt packet, and small pieces of paper on the floor.

Dust, dirt, and discolorations on the vent fins of the electric heater was observed.

Small tears were observed on the top of the table, along with gray scuffs, and pieces of black and tan debris.

A white liquid stain extending approximately 4 feet vertically was observed on the wall in the West Lounge.

An observation on February 12, 2024, at 11:20 AM in resident room W-1 revealed rust marks and scrapes running the length of the heating unit. The resident's bedside table was observed to have yellow and white stains on the base of the metal frame. The toilet in the resident's bathroom was observed to be continuously running. The paint, to the left of the bathroom sink was observed to be peeling, with a white mesh revealed. A buildup of dust was observed on the bathroom air vent.

An observation on February 12, 2024, at 11:30 AM outside the West Dining Hall revealed a red liquid stain on the wall.

During an interview on February 12, 2024, at approximately 2:30 PM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility is to be maintained in a clean and orderly manner.


28 Pa. Code 201.18 (e)(1)(2.1) Management







 Plan of Correction - To be completed: 03/11/2024

This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Grandview Nursing & Rehabilitation agrees with the allegations and citations listed on the statement of deficiencies.

Grandview Nursing & Rehabilitation maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Grandview Nursing & Rehabilitation's written credible allegation of compliance.

By submitting this plan of correction, Grandview Nursing & Rehabilitation does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Grandview Nursing & Rehabilitation reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.

W14 window and floor were cleaned and urine graduates were removed, W17 carpet was spot cleaned and debris removed, flooring and hallway area between rooms W-17/W-18 and W-20 was cleaned, W-20 wall fabric was covered, West lounge floor was cleaned, heater fins were cleaned, table was replaced, West lounge wall was cleaned, W-1 heater and toilet were repaired, W-1 bathroom paint was patched and heater was cleaned upon discovery.

Facility residents have the potential to be affected by this practice.

Facility staff will be re-educated concerning maintaining a safe, clean, comfortable, homelike environment by the Administrator. Additional supplies for spot cleaning have been secured and placed on each nursing unit. Facility has initiated use of the TELS system for identifying and tracking completion of environmental issues. Environmental Services Director or designee will conduct a random audit of five resident care areas weekly for three weeks and monthly for three months to validate cleanliness has been appropriately maintained. Audit results will be reported to the NHA.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(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 clinical records, select facility policy, and facility incident reports, and resident, family and staff interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse for two of the 23 residents sampled (Residents C9 and C10) and submit the results of the completed investigations to the State Survey Agency within five working days of the incident.

Findings include:

A review of facility policy titled "Abuse Prevention" dated January 27, 2024 revealed that "physical abuse- includes hitting, slapping, punching, kicking." and "verbal abuse- any use of oral, written, or gestured language that includes willfully disparaging and derogatory terms to residents or their families." The policy also indicates that "allegations of abuse or neglect which are uncovered by investigation and tracking of incident reports will be investigated further and corrective actions taken according to the facility's abuse policies and procedures."

A clinical record review revealed Resident C9 was admitted to the facility on April 23, 2021, with diagnoses to include osteomyelitis (an infection of the bones) and chronic kidney disease (gradual loss of kidney function).

A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 16, 2024 revealed that Resident C9 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

The resident's care plan, noted a behavioral management program was initiated on August 3, 2021, which indicated "tossed corner of sheet on my roommate's hand and swore at her." Planned interventions were educate the resident, as needed, on not tossing things at roommates and asking for staff assistance when having issues with roommates.

A clinical record review revealed that Resident C10 was admitted to the facility on September 12, 2023, with diagnoses to include Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination) and dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).

A significant change MDS assessment dated December 12, 2023, revealed that Resident C10 was severely cognitively impaired with a BIMS score of 03.

Resident C10's care plan also noted a behavioral management program initiated on December 20, 2023, focused on dementia with psychotic disturbance, terminal anxiety, and swearing at another resident, dated January 2, 2024. Planned interventions were to offer emotional support, active listening, validating concerns and fears through professional acceptance, understanding, empathy, reflection, and the use of silence and summarizing.

Resident C9 and Resident C10 were roommates, in room W08 since November 13, 2023.

An incident report titled "Other" dated January 2, 2024, at 14:15 revealed that Resident C9 "went to social services and stated that she was fed up with resident and hit her." The incident report indicated that Resident C9 stated, "That resident \ was yelling profanities at her, and she lifted the sheet off her lap and tossed it on roommate." The incident report indicated that no injuries were observed at the time of the incident. The incident report revealed that the facility identified a predisposing factor that Resident C9 "dislikes roommate."

A nursing behavior note dated January 3, 2024, at 1:39 PM indicates that behavior management meeting occurred today due to \ taking the corner of her sheet and tossing it on her roommate's arm and swearing at her. The resident was educated on not tossing things at other residents. Resident C9 is encouraged to ask staff for assistance when having issues with a roommate.

A nursing behavior note dated January 3, 2024, at 1:50 PM indicates that behavior management was held today due to \ swearing at her roommate, and roommate \ swore at her and tossed the corner of her sheet onto her hand.

An attempt was made to interview Resident C10 on February 12, 2024, at 11:35 AM, but the resident did not respond. Resident C10's representative was present and stated during interview that a few weeks ago she was concerned about a phone call she received from the facility. Resident C10's representative explained that she was notified that the resident's roommate was frustrated and threw an object at Resident C10. Resident C10's representative stated that Resident C10 could not describe what happened.

During an interview on February 12, 2024, at 2:15 PM, Resident C9 stated that she does not remember any incidents that she has had with roommates.

During an interview on February 12, 2024, at approximately 2:30 PM, the Director of Nursing (DON) confirmed that the facility had not submitted the results of a completed investigation into the alleged verbal abuse of Resident C10 by her roommate, as well as Resident C9's allegation of verbal abuse by Resident C10, within five working days of the incident.






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

28 Pa. Code 201.29 (b)(c) Resident rights.






 Plan of Correction - To be completed: 03/11/2024

Incident involving residents C9 and C10 was reported to the Pennsylvania DOH upon discovery.

NHA or designee will audit allegations of abuse since 2/5/24 to identify appropriate investigation and validate reporting to the appropriate agencies. Concerns will be corrected upon discovery.

DON and ADON will be re-educated concerning abuse investigation expectations. DON or designee will audit 24 hour report and events during daily clinical meeting to identify situations that may require further investigation and reporting. Events meeting reporting criteria will be reported to appropriate agencies in accordance with regulation, including submission of completed investigations within 5 working days.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and staff interviews it was determined the facility failed to provide person-centered care following a resident's injury by failing to demonstrate consistent monitoring and timely follow-up care required by one resident out of five sampled (Resident 54)

Findings include:

According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the registered nurse was to carry out nursing care actions that promote, maintain, and restore the well-being of individuals.

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care including Medication Records.
Assessments
Clinical problems
Communications with other health care professionals regarding
the patient
Communication with and education of the patient, family, and the patient's designated support person and other third parties.

According to The Pennsylvania Code, Chapter 16.91 State Board of Medicine General Provisions, Subchapter F Minimum Standards of Practice 16.95 Medical records. . (a) A physician shall maintain medical records for patients which accurately, legibly and completely reflect the evaluation and treatment of the patient. The components of the records are not required to be maintained at a single location. Entries in the medical record shall be made in a timely manner (c) Clinical information pertaining to the patient which has been accumulated by the physician, either by himself or through his agents, shall be incorporated in the patient's medical record. (d) The medical record shall also include diagnoses, the findings and results of pathologic or clinical laboratory examination, radiology examination, medical and surgical treatment and other diagnostic, corrective or therapeutic procedures.

A review of the clinical record revealed Resident was admitted to the facility on February 17, 2016, with diagnosis to include but are not limited to muscle weakness, difficulty walking and artificial knee joint.

A review of the resident's MDS assessment dated December 8, 2023, revealed that the resident was cognitively intact with a BIMS score of 14 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact)

Nursing noted on January 7, 2024, at 8:45 PM, that staff found the resident on the floor of the resident's room. The resident sustained a cross shaped cut on her right forehead. The resident reported that she hit her head on the table. The resident was sent to the hospital via ambulance at 8:40 PM, as written in the note, and returned to the facility approximately 11:54 PM on January 7, 2024, with sutures to the laceration to her forehead.

According to information from The Cleveland Clinic regarding Incision and Surgical Wound Care, sutures or staples can be removed when a wound heals or closes. The amount of time depends on the size, depth and location of the wound. It could take anywhere from three days to 14 days.

A review of the resident's January 2024 and February 2024 Treatment Administration Records (TAR) revealed a physician order dated January 9, 2024, for staff to monitor the sutures above the resident's right eye daily until sutures were discontinued, every dayshift, for signs and symptoms of infection. According to the staff initials on the TAR, staff completed this task from January 9, 2024, through February 16, 2024. However, this order was not discontinued until February 20, 2024.

A review of the resident's clinical record conducted on February 12, 2024, revealed no physician orders for suture removal from the resident's forehead wound following the resident's return to the facility on January 7, 2024.

There was no documented evidence that nursing staff continued to monitor the resident's sutures from February 16, 2024, until their eventual complete removal on February 20, 2024.

Telephone interview and email correspondence received from the facility's NHA on February 20, 2024, at 11:12 AM revealed that a physician was in the facility on January 17, 2024, and attempted to remove sutures from the resident's wound but was unable to remove all the sutures due to a large scab. According to the NHA the physician indicated she will continue to remove the sutures, as able, but did not write any orders in the clinical record.

There was no physician progress note in the resident's clinical record, for the January 17, 2024, suture removal and physician visit at the time of the survey ending February 12, 2024.

Following surveyor inquiry, a review of a medical progress note dated February 20, 2024, after the survey ending February 12, 2024, indicated that the physician provider removed the remaining 4 sutures from the resident's wound. The physician noted that there was minimal bleeding and a bandage was placed on the resident's forehead.

A telephone interview with the NHA on February 20, 2024, confirmed that the resident's remaining sutures were not removed timely and nursing staff were unaware they remained in place since the resident had a scabbed area on her forehead.

There was no documented evidence that following the reported removal of six of the ten sutures on January 17, 2024, any further attempts were made to remove the last four sutures until 5 week later on February 20, 2024. There was no documented evidence that licensed and professional nursing staff were consistently monitoring the resident's forehead wound and suture site consistently until all sutures were eventually removed on February 20, 2024.




28 Pa. Code 211.5 (f)(i)(iii)(ix) Clinical records

28 Pa. Code 211.12 (c)(d)(3)(5) Nursing Services










 Plan of Correction - To be completed: 03/11/2024

Resident 54's sutures were fully removed as indicated on 2/20/24 after the scabbed area on her head had healed.

DON or designee will audit other residents with sutures or staples to validate appropriate care, removal and documentation of such. Concerns will be corrected upon discovery.

Licensed staff will be re-educated by the DON or designee concerning documentation of care delivery and monitoring of suture or staple sites from placement until removal. RN shift supervisors will monitor order administration for suture monitoring/removal prior to end of shift to validate completion. Concerns will be corrected upon discovery. DON or designee will audit residents with sutures/staples weekly for three weeks and monthly for three months to validate physician orders for monitoring and removal. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on clinical record review and facility documentation and staff interview, it was determined that the facility failed to implement efficient pharmacy procedures for timely acquiring resident medications to ensure physician-ordered medications were readily available in a timely manner for one resident out of three sampled (Resident B1).

Finding include:

Review of Resident B1's clinical record revealed a physician order dated, January 27, 2024, for Oxycodone HCL (opioid pain medication) 5 mg one tablet by mouth every four hours for severe pain 4 to 10 for 3 days for a new diagnosis of fracture of left forearm and left shoulder.

Review of Resident B1's January 2024 Medication Administration Record revealed that on January 27, 2024, at 11:09 AM Oxycodone HCL 5 mg was administered to the resident for a complaint of left arm pain.

Review of information dated January 28, 2024, submitted by the facility revealed that on January 27, 2024, Employee 12 (LPN) took an Oxycodone IR (opioid pain medication) 5 mg from Resident CR2 PRN (as needed) narcotic card and gave it to Resident B1. Resident CR2 sustained no ill effects and showed no increased signs/symptoms of pain. The physician and responsible party of both residents were made aware.

Review of Employee Disciplinary Record for Employee 12 (LPN) revealed that if a medication is not available, the employee will notify the nursing supervisor and check back to ensure a hold or substitution order was given. If a narcotic is not available, it is expected that a substitution order is received. The employee is to call the physician and receive a verbal order.

Review of the facility Inventory Snapshot dated January 27, 2024, indicated that the minimum amount of Roxicodone [Oxycodone Hydrochloride (HCL)] 5 mg that was to be on hand in the automated dispensing system was 10 tablets. The listed amount on hand was zero.

Interview with Employee 11, an employee who did not wish to be identified, on February 12, 2024, at 12:00 PM revealed that the facility often does not have physician ordered medicine Oxycodone Hydrochloride 5 mg available in the back up automated medication dispensing system kept in the nursing supervisor's office. As a result, the procedure is for staff to contact the physician to receive an order for Percocet 5 mg/325 mg (opioid which contains both Oxycodone and Tylenol) which is available in the automated dispensing system until the Oxycodone Hydrochloride 5 mg is delivered from pharmacy.

Interview with the director of nursing (DON) on February 12, 2024, at approximately 1:30 PM failed to provide documented evidence that the automated dispensing system was maintained in a manner to ensure adequate inventory of all medications including Oxycodone HCL 5 mg for resident use when prescribed by the physician. The DON confirmed that physician ordered medications were to be promptly ordered and received from the pharmacy.



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

28 Pa Code 211.9 (a)(1)(k)(l)(1)(2) Pharmacy services.






 Plan of Correction - To be completed: 03/11/2024

Licensed nurse administering medications to Resident B1 notified the medical provider and secured orders for an alternate medication, which was subsequently administered to meet her needs.

DON or designee will audit new narcotics orders since 2/22/24 to validate narcotic medication availability. Issues will be addressed in accordance with facility policy and medical provider order.

DON or designee will re-educate licensed nurses concerning administration of new narcotics prescriptions and the protocol for the Cubex backup medication dispensing system. DON or designee will audit new narcotic order administration during the clinical morning meeting to validate medication administration compliance. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.


483.70 REQUIREMENT Administration: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.
§483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:

Based on a review of clinical records, select facility policy and reports, and employee job descriptions and staff interview it was determined the facility's administration failed to effectively use its resources to promote resident safety by failing to implement established procedures to provide cardiopulmonary resuscitation (CPR) in the event of cardiac arrest according to an resident's advanced directive for one out of three sampled residents (Resident CR1).

Findings included:

Review of the facility's policy and procedure titled "Emergency Procedure - Cardiopulmonary Resuscitation" last reviewed by the facility March 2023, revealed that if an individual (resident, visitor, staff) is found unresponsive and not breathing normally a licensed/certified staff member shall initiate CPR (Cardiopulmonary Resuscitation) unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and external defibrillation exist for that individual or there are obvious signs or irreversible death.

According to American Heart Association guidelines presumptive Signs of Death are as follows:
The patient is unresponsive;
The patient has no respirations;
The patient has no pulse;
The patient's pupils are fixed and dilated;
The patient's body temperature indicates hypothermia: skin is cold relative to the patient's baseline skin temperature;
The patient has generalized cyanosis (Bluish skin color due to decreased amounts of oxygen).

AHA guidelines for Conclusive (irreversible) Signs of Death are as follows:
There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin).

While these signs of irreversible death would not be expected to be seen in most practice settings, the American Heart Association also includes the following irreversible signs of death: decapitation (separation of the head from the body);
decomposition (decay or putrefaction of the body);
rigor mortis (stiffness of the limbs and body that develops 2 - 4 hours after death and may take up to 12 hours to fully develop)

A review of Resident CR1's clinical record revealed admission to the facility on February 9, 2016, with diagnoses including chronic obstructive pulmonary disease, heart failure, and diabetes.

Review of Resident CR1's clinical record revealed a physician order dated June 9, 2023, identifying that the resident was to receive CPR (emergency lifesaving procedure performed when the heart stops beating. Immediate CPR can double or triple chances of survival after cardiac arrest) in the event of cardiac arrest.

Review of the Resident CR1's vital signs record revealed that the resident's blood pressure on February 9, 2024, at 1:26 PM was 124/64 mmHg and temperature on February 9, 2024, at 3:38 PM was 97.6 degrees Fahrenheit.

A nurses note dated February 10, 2024, at 7:52 AM indicated that this nurse, Employee 4 (RN Supervisor) was called to assess Resident CR1. The RN noted "No heartbeat, no lung sounds auscultated (examine patient by listening to sounds from the heart, lungs, or other organs, typically using a stethoscope). Death pronounced at 6:28 AM, but resident appeared to have been deceased for some time (no signs or description documented). Employee 5 (CRNP) called and made aware of death at 6:33 AM. Received new order to 'Release body to mortician.' POA and emergency contact #1(name mentioned), was notified of the death at 6:37 AM."

Review of the facility incident report dated February 10, 2024, indicated that at 3:50 AM on February 10, 2024, Employee 6 (nurse aide) was in Resident CR1's room with Employee 7 (LPN working as nurse aide), had pulled the resident up in bed, changed her, and noted the resident was fine at that time.

Interview with Employee 3 (an agency LPN) on February 12, 2024, at 12:45 PM confirmed that she was the assigned nurse to Resident CR1's unit and had found the resident unresponsive on the morning of February 10, 2024. Employee 3 confirmed that she was CPR and AED certified. Employee 3 stated that "it was an overwhelming night" and she was the only LPN on the West Wing and that there were two nurse aides. Employee 3 stated there were two falls with no injuries that night, along with Resident CR1's death. Employee 3 stated that on the morning of February 10, 2024, she entered Resident CR1's room at approximately 6:20 AM to obtain a blood sugar. Employee 3 called the resident's name, and the resident did not respond. Employee 3 stated that the resident had no pulse, her hands were cold, and the resident's chest was not rising. She called a nurse aide (Employee 3 was unsure of the aide's name) into the room. Employee 3 (LPN) saw on the computer that resident desired CPR. The nurse aide went to get Employee 4 (RN Supervisor). Employee 3 (Agency LPN) stated that she did not start CPR and was waiting for Employee 4 (RN Supervisor) to get instructions. Employee 3 stated she did not know the facility policy for starting CPR, was never trained on the facility's policy, and had never been in the situation before. Employee 3 (Agency LPN) stated that Employee 4 (RN Supervisor) arrived within two minutes and checked the resident.

Interview with Employee 4 (RN Supervisor) on February 12, 2024, at 1:20 PM confirmed that she arrived in Resident CR1's room at approximately 6:28 AM on February 10, 2024. At the time she arrived in the room, Resident CR1's one eye was a quarter opened and the other eye was closed, and "blue stuff" was running out of the side of her mouth which she thought was a candy of some sort. Employee 4 stated that, using a stethoscope, she auscultated the resident's chest and found no breathing and no heartbeat, the resident's face and body were yellow and arms were very cool. Employee 4 stated that she felt the resident was "gone for a while." Employee 4 stated that she was not CPR certified and was unaware of who, on duty on that shift was CPR certified. Employee 4 stated that she then called Employee 5 (Certified Registered Nurse Practitioner) who asked Employee 4 if CPR was started and Employee 4 informed the CRNP that CPR had not been initiated.

Interview with Employee 8 (LPN) on February 12, 2024, at 2:45 PM revealed that on February 10, 2024, she arrived for work at 6:50 AM to do a double shift. Employee 8 stated that Employee 3 (LPN) told her that she "had a rough night," explaining to Employee 8 that when she \ went in to Resident CR1's room to check her blood sugar the resident was "still warm." Employee 8 (LPN) stated that she did not know why, based on what she heard from Employee 3, that CPR was not started for Resident CR1.

Interview with Employee 9 (PA-C Physician Assistant) on February 12, 2024, at 12:20 PM revealed that although she was not at the facility when the incident happened upon reviewing the incident post-occurrence, she was upset because Resident CR1 was a full code and CPR was not started when staff initially found the resident without no pulse and respirations.

The facility failed to provide cardio-pulmonary resuscitation (CPR) to a resident who had requested this emergency care and was identified as a full code status. On the morning of February 10, 2024, nursing staff found the resident unresponsive, and described the resident with no heartbeat and no lung sounds auscultated but did not initiate CPR. According to interview with the RN Supervisior, Employee 4, and documentation in the clinical record, the RN did not to perform CPR based on presumptive signs of death and not conclusive irreversible signs of death. The facility's licensed and professional nursing staff did not document specific irreversible signs of death in the resident's clinical record.

Interview with Employee 3 (Agency LPN) on February 12, 2024, at 12:45 PM who found the resident, stated that she was aware the resident had an order for CPR, but was unaware of facility procedures for initiating CPR. Employee 4 (RN Supervisor), when interviewed on February 12, 2024, at 1:20 PM was unaware of which staff member during the shift was certified to provide CPR.

These failures placed residents who desired CPR in the event of cardiac arrest in immediate jeopardy.

As a result of the failure of licensed staff to initiate CPR for a resident, immediate jeopardy to the health and safety and substandard quality of care was identified at the facility on February 12, 2024.

A review of the job description for the Administrator of the facility revealed that the Administrator leads and directs the overall operations of the facility in accordance with customer needs, government regulations, and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Identify and participate in the process improvement initiatives that improve the customer experience, enhance workflow, and/or improve the work environment. Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility, morale of the staff, and ensure resident needs are being addressed. Lead the facility management staff and consultants in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments.

A review of the job description for the Director of Nursing (DON) indicated that under the supervision of the administrator, and the Medical Director, the DON is to plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern the facility, to ensure that the highest degree of quality care is maintained at all times.

The DON plans, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines. Develop, maintain, and periodically update written policies, and procedures that govern the day-to-day functions of the nursing services department. Develops methods for coordination of nursing services with other resident services to ensure the continuity of the resident's total regimen of care. Develop methods for coordination of services with other resident services to ensure the continuity of the residents' total regimen of care.

The deficiency cited under the Code of Federal Regulatory Groups for Long Term Care, Quality of Life (F678) 483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives, revealed that the Administrator and DON failed to fulfill the essential job duties for ensuring the health and safety of the residents and adherence to regulatory guidelines.

Refer F678

28 Pa. Code: 201.12 (a) Responsibility of licensee

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

28 Pa. Code:211.12(c) Nursing Services



 Plan of Correction - To be completed: 03/11/2024

NHA change occurred on 2/14/24. NHA reviewed job description and expectations with DON.

Licensed staff education-initiated immediately concerning the Cardiopulmonary Resuscitation policy, the Obvious Clinical Signs of Irreversible Death, nursing documentation related to these signs will continue to be completed with licensed staff prior to their next shift by the DON or designee starting on 2/12/2024 with 3-11 shift.

Starting with 3-11 shift on 2/12/2024
Licensed staff education will be completed by the DON/designee regarding the need to initiate CPR immediately in accordance with resident wishes, the location of facility crash carts and AEDs and where staff can locate the code status for each resident. Facility will designate on the deployment sheet the staff member who is certified in CPR. Education will be provided by the DON/designee prior to each licensed staff member's next shift.

DON or designee completed an audit of CPR certification for Licensed Facility staff on 02/12/2024. DON or designee completed an audit of EMR code status on 02/12/2024 to validate consistency of records for staff reference. DON or designee will conduct an audit of new admissions and order changes that reflect code status during clinical morning meeting to validate consistency of records daily for four weeks and weekly for four weeks.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on review of nursing time schedules and the resident census and staff interviews, it was determined that the facility failed to provide a minimum one nurse aide per 12 residents during the day shift on one of seven days reviewed (February 11, 2024).

Findings include:

Review of facility census data revealed that on February 11, 2024, the resident census was 167, which required 13.92 nurse aides during the day shift. Review of the nursing time schedules revealed only 11.69 nurse aides on the day shift on February 11. 2024.

During an interview on February 12, 2024, at approximately 3:00 PM the Nursing Home Administrator confirmed that the facility failed to provide a minimum nurse aide staffing ratio on the above shift.














 Plan of Correction - To be completed: 03/11/2024

The observation cannot be retroactively corrected.  

Facility residents have the potential to be affected by this practice.

Administrator or designee will educate the scheduler, nursing leadership team and RN supervisors regarding maintaining direct nursing hours per patient day that meet state requirements, including updated tool for calculation and monitoring, which is effective 1/1/24. RN Supervisors will be re-educated to communicate unforeseen staffing challenges to the DON and NHA for further intervention.

Facility will continue to execute a labor management strategy that includes offering shift pick-up opportunities and advanced scheduling to staff and agency partners through a scheduling application, and redeployment of ancillary certified/licensed staff for additional support. Facility will execute a recruiting plan which involves approaches such as employee referral program, market advertising, direct mail, electronic job boards and school partnerships. Administrator or designee will audit daily staffing projection during staffing meeting for compliance with CNA ratios. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.

§ 211.12(i)(1) LICENSURE Nursing services.:State only Deficiency.
(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based on a review of nurse staffing and resident census and staff interview, it was determined that the facility failed to consistently provide minimum general nursing care hours to each resident daily on three of seven days reviewed.

Findings include:

A review of the facility's weekly staffing records between February 5 and February 11, 2024, revealed that on the following dates the facility failed to provide minimum nurse staffing of 2.87 hours of general nursing care to each resident:

A review of the facility's calculated total nursing care hours per resident day for February 6, 2024, was at 476.42 total hours for a maximum resident census of 166 and the facility required 470.75 total hours for a maximum resident census of 167.

Further review of PPD for February 6, 2024, revealed that the facility had 2.84 hours of direct nursing care and failed to provide the minimum of 2.87 hours of direct nursing care daily.

A review of the facility's calculated total nursing care hours per resident day for February 10, 2024, was at 444.25 total hours for a maximum resident census of 167 and the facility required 479.29 total hours for a maximum resident census of 167.

Further review of PPD for February 10, 2024, revealed that the facility had 2.66 hours of direct nursing care and failed to provide the minimum of 2.87 hours of direct nursing care daily.

A review of the facility's calculated total nursing care hours per resident day for February 11, 2024, was at 433.5 total hours for a maximum resident census of 167 and the facility required 479.29 total hours for a maximum resident census of 167.

Further review of PPD for February 11, 2024, revealed that the facility had 2.60 hours of direct nursing care and failed to provide the minimum of 2.87 hours of direct nursing care daily.

An interview with the Nursing Home Administrator (NHA) on February 12, 2024, at approximately 3:00 PM, confirmed that the facility failed to provide the minimum of 2.87 hours of direct nursing care daily for each resident on the above dates.























 Plan of Correction - To be completed: 03/11/2024

The observation cannot be retroactively corrected.  

Facility residents have the potential to be affected by this practice.

Administrator or designee will educate the scheduler, nursing leadership team and RN supervisors regarding maintaining direct nursing hours per patient day that meet state requirements, including updated tool for calculation and monitoring, which is effective 1/1/24. RN Supervisors will be re-educated to communicate unforeseen staffing challenges to the DON and NHA for further intervention.

Facility will continue to execute a labor management strategy that includes offering shift pick-up opportunities and advanced scheduling to staff and agency partners through a scheduling application, and redeployment of ancillary certified/licensed staff for additional support. Facility will execute a recruiting plan which involves approaches such as employee referral program, market advertising, direct mail, electronic job boards and school partnerships. Administrator or designee will audit daily staffing projection during staffing meeting for compliance with direct nursing hours per patient day. Concerns will be corrected upon discovery.

Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.



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