Nursing Investigation Results -

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

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Severity Designations

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GRANDVIEW NURSING AND REHABILITATION
Inspection Results For:

There are  77 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.
GRANDVIEW NURSING AND REHABILITATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance and Abbreviated Complaint Survey completed on August 30, 2019, 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:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on resident and staff interview, it was determined that the failed to meet residents' needs for assistance in a timely manner and failed to ensure fresh ice water was provided to promote each resident's quality of life in the facility including Residents 93, 151, 107, 113, 4, 60, and 365.

Findings include:

Interview with Resident 93 on August 27, 2019, at 11:30 AM revealed that the resident reported that the resident rings the call bell when toileting assistance is needed from staff Resident 93 stated the time for staff to respond often exceeds 15 minutes and can be greater than one hour. The resident stated he needs the assistance of two staff members for toileting, which increases the amount of time for staff to provide him toileting assistance.

Resident 93 also stated during interview on August 27, 2019, that staff are not passing fresh ice water to residents during each shift of nursing duty.

During interview with Resident 92 on August 28, 2019, at 10:30 AM, the resident also stated that staff are not passing fresh water to residents during each shift.

During a resident group meeting held on August 28, 2019, at 10:00 a.m., with six alert and oriented residents (Residents 151, 107, 113, 4, 60, and 365) all residents in attendance stated that during all shifts of nursing duty, the wait times for staff to respond to their requests for assistance, respond to the nurse call bell system and meet their needs is 30 minutes or longer. The residents relayed that they have raised the issue regarding extended call bell response time and significant delays to staff on each shift and during their Residents' Council Meetings, but the problem continues and has yet to be resolved by the facility. The residents also stated that the issue with call bell timeliness has not improved.

Interview with the director of nursing (DON) on August 29, 2019, at approximately 9:45 AM confirmed that staff are to respond to call bells timely and provide prompt assistance to residents, including toileting. The DON also stated that fresh ice water is to be passed on each shift and as needed to promote each resident's quality of life in the facility.

483.10 Resident rights
Previously cited: 7/13/18

28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services
Previously cited: 7/13/18, 12/15/18, 3/26/19, 6/4/19

28 Pa. Code 201.29 (j) Resident Rights
Previously cited: 7/13/18, 12/15/18, 6/4/19

28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management
Previously cited: 7/13/18, 6/4/19










































 Plan of Correction - To be completed: 10/21/2019

The residents were provide with fresh water during the survey. Unable to retroactively correct concerns with the call bells that occurred during the survey.

The facility will ensure that a sufficient number of walkie talkies and pagers are available for nursing & ancillary staff to ensure a timely response to call bells. A review of the system for providing fresh water will be reviewed to ensure compliance.

The facility will Re-educate the nursing staff that ice is to be passed every shift according to their assignment sheets on 7-3/3-11 shift and as instructed by the 11-7 LPN on night shift. The Facility will also be re-educated on the Answering Call Bell Procedure to ensure timely assistance in order to meet resident needs.

A QA designee will audit the availability of ice water each week via inspection and by resident interview. 3 audits per wing per week will be conducted times eight weeks. QA Designee will conduct 10 Call bell Satisfaction surveys weekly x 3 months to ensure appropriate response times and patient satisfaction. Results will be reviewed with the QA committee for review and recommendations. Audits will be modified as appropriate.

483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.60(f) Frequency of Meals
483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:

Based on review of select facility policy and Food Committee Meeting minutes and resident and staff interviews, it was determined that the facility failed to routinely offer evening snacks to residents included eight residents interviewed (Residents 151, 107, 113, 4, 60, 365, 141, and 89).

Findings include:

During an interview on August 27, 2019, at 10:34 AM Resident 141(cognitively intact) the resident stated that "snacks are few and far between." The resident stated they (the residents) "used to get snacks all the time" and now they "hardly get snacks."

During an interview on August 27, 2019, at 10:53 AM Resident 89 (cognitively intact) stated she does not get snacks at night, but she would like to receive snacks.

During a group meeting held on August 28, 2019, at 10:00 AM, with six alert and oriented residents, all six residents (Residents 151, 107, 113, 4, 60, and 365) in attendance stated that evening snacks are not routinely offered to them and that they would like to receive bedtime snacks. Residents 151, 107, 4, 60, and 365 stated that they have to ask for snacks. The resident stated that staff used to bring a cart around and offer them snacks, but they no longer do this. Resident 113 stated she was unaware that she could ask for snacks and has not received evening snacks as desired.

During an interview with the Nursing Home Administrator and Director of Nursing on August 29, 2019, at 1:50 p.m., these staff members were unable to verify that residents are routinely provided snacks at bedtime as preferred by each resident.



28 Pa. Code: 211.6 (b)(c) Dietary services
Previously cited 7/13/18, 6/4/19

28 Pa. Code 211.2(a) Nursing Services
Previously cited 7/13/18, 12/15/18, 6/4/19

28 Pa. Code 201.29(i) Resident rights
Previously cited 7/13/18, 12/15/18, 6/4/19








 Plan of Correction - To be completed: 10/21/2019

Snacks have always been available throughout the day at each nurses' station.

Each Nursing unit will be reviewed to make sure snacks are available.

Staff will be reeducated to offer bed time snacks to residents, via a cart, on a daily basis.

A QA designee will conduct Snack passing audits via 5 resident interviews on a weekly basis for three months. Audit findings will be shared with the QA committee for review and recommendations.


483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.25(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide services necessary to prevent complications related to the use an indwelling urinary catheter for one resident out 31 sampled (Resident 89)

Findings include:

A review of the clinical record revealed that Resident 89, was admitted to the facility on May 7, 2019, with diagnoses to include obstructive and reflux uropathy (when your urine can't flow through bladder due to some type of obstruction and instead of flowing from your kidneys to your bladder, urine flows backward, or refluxes, into your kidneys) and has an indwelling Foley catheter (A flexible plastic tube \ inserted into the bladder that remains \ there to provide continuous urinary drainage.

A review of physician orders for July 2019 revealed that the resident was to receive Foley catheter care every shift (involves cleaning the catheter, changing the drain collection bags, and washing the drainage bags; proper cleaning and care of the indwelling urinary catheter helps keep it working and lowers your risk for infection).

A review of the July 2019 TAR (treatment administration record) revealed that staff failed to provide Foley catheter care 14 times during the month of July 2019. During the day tour of nursing duty catheter care was not provided on July 1, 2, 6, 7, 13, 14, 20, 21, and 24, 2019. During the evening tour of duty catheter care was not provided on July 4, 13, 14, and 15, 2019. During the night shift catheter care was not provided on July 4, 2019

A review of nursing documentation dated July 19, 2019, at 11:30 AM indicated that the resident displayed altered mental status and a physician order was obtain a urine analysis and culture and sensitivity (UA - urinalysis is a test of your urine. A urinalysis is used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes. A urinalysis involves checking the appearance, concentration and content of urine A C&S - The urine culture is used to diagnose a urinary tract infection (UTI) and to identify the bacteria or yeast causing the infection. It may be done in conjunction with susceptibility testing to determine which antibiotics will inhibit the growth of the microbe causing the infection)

A review of the laboratory results report for the urine analysis dated July 19, 2019, revealed that the resident had cloudy urine and positive results for bacteria in her urine.

A review of nursing documentation dated July 19, 2019, at 11:22 PM indicated the physician prescribed Cipro 250 mg (milligram) for UTI (urinary tract infection).

During an interview on August 29, 2019, at approximately 1:30 PM the Director of Nursing confirmed the facility failed to follow the physician orders for cleaning the residents Foley catheter throughout the month of July 2019. The DON also confirmed that the resident was also diagnosed with and was being treated for a UTI on July 19, 2019.


28 Pa Code 211.12 (a)(c)(d)(1)(5) Nursing services
previously cited 7/13/18, 12/15/18,3/26/19, 6/4/19






 Plan of Correction - To be completed: 10/21/2019

Unable to retroactively correct the catheter care for resident 89.

Residents with catheters will be reviewed to ensure appropriate catheter care is ordered and provided.

Professional Nursing staff will be re-educated on the importance of providing catheter care as ordered to prevent UTIs.

QA Designee will conduct 10 audits weekly for three months to ensure solutions are sustained. Results will be reviewed with the QA committee for review and recommendations. Audits will be modified as appropriate.



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 81F; and

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

Based on observations and staff interview, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a clean and homelike resident environment for two of three nursing units (West and Pavilion).

Findings Include:

Observation of resident room 7 (located on the West nursing unit) on August 27, 2019, at 1:00 PM revealed a pedestal fan with a thick layer of dust on the blades of the fan.

Observation of the lounge/dining room located on the West nursing unit behind rooms 1-6 on August 27, 2019, at 10:30 a.m., revealed food debris on the floor of the room and a partially full glass of juice tipped over on the floor.

Observation of the Pavilion unit on August 27, 2019, at 11:00 a.m. revealed a coffee cup on the handrail in the main hallway to the left of the dining room. Dirt and debris were observed on floor of each hallway of the Pavilion unit.

Further observation of the Pavilion unit on August 28, 2019, at 11:00 a.m. revealed dirt and debris on the floor of the hallways of unit. Observation revealed dirt and debris on floor of resident rooms 22 and 18.


28 Pa. Code 207.2 (a) Adminstrator's responsibility
Previously cited 7/13/18








 Plan of Correction - To be completed: 10/21/2019

Areas of concerned were cleaned at time of survey. Common areas were not yet cleaned for the day and had been cleaned during the regular cleaning schedule.

The director of housekeeping and the nursing home administrator will make weekly rounds and identify areas of concern related to cleaning.

Cleaning of the personal fans has been added to the monthly maintenance checklist. Re-education of the housekeeping and maintenance staff will occur reviewing facility expectations and the requirements of the regulation.

A QA designee will conduct weekly rounds for eight weeks to ensure that solutions are sustained with results shared at the QA meetings for review and recommendations. Audit will be modified as necessary.


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, observation and staff interview, it was determined that the facility failed to follow physician orders for the administration of medications planned to manage one resident's constipation (Resident 90) and and failed to timely identify one resident's (Resident 147) change in condition out of 31 sampled.

Findings include:

A review of the clinical record revealed that Resident 90 had diagnoses that included quadriplegia (paralysis causing impaired function in the upper limbs, lower limbs, trunk and torso due to damage in that part of the spinal cord) and constipation (infrequent, irregular or difficult movement of the bowels).

The resident had current physican's orders in effect since July 1, 2019, for one Bisacodyl suppository (a laxative used to produce a bowel movement in the prevention of constipation) every night shift on even days for constipation.

Additional physician's orders in effect since July 1, 2019, called for staff to digitally stimulate (the insertion of a gloved lubricated finger into the anus using a circular motion which stimulates the lower bowel causing a bowel movement) the resident every day shift on odd days.

A review of Resident 90's medication administration record (MAR) for the months of July and August 2019 revealed that staff did not administer the Bisacodyl suppository on July 4 and 8, 2019 and on August 4, and 8, 2019. Staff did not perform the digital stimulation on July 13 and 21, 2019.

Interview with the director of nursing (DON) on August 29, 2019, at approximately 9:05 a.m. confirmed that staff failed to follow physician orders for the administration of the suppository and the digital stimulation prescribed to manage the resident's constipation.

A review of clinical record revealed Resident 141 was admitted to the facility October 21, 2011. The resident had current physician orders with a start date of January 17, 2019 for the following, Milk of Magnesia (MOM) 400 mg (milligrams) per 5ml (milliliters) give 30 ml by mouth as needed for constipation if no BM (bowel movement) after the second day, Glycerin Adult Suppository insert 1 suppository rectally as needed if no BM on the third day and no results from the MOM, and Fleets Oil Enema insert 1 application rectally as needed for constipation if no BM on the fourth day and no results from suppository.

A review of Resident 141's August bowel and bladder elimination documentation revealed the resident had a bowl movement on August 18, 2019, at 9:35 AM The resident did not have a bowel movement August 19 through August 24, 2019.

A review of August 2019 MAR (medication administration record) revealed no documentation was found that the facility followed the physician orders for administering the appropriate medication to the resident and the resident went six days with out having a bowel movement.

Interview with the director of nursing (DON) on August 29, 2019, at approximately 9:05 a.m. confirmed that staff failed to follow physician orders for the administration of medication.

Observation of Resident 147 on August 27, 2019, at approximately 11:22 a.m. revealed multiple small circular open areas, at varying stages of healing, on the resident's left and right forearms along with a dark/red substance under the fingernails on both the left and right hand.
Interview with the resident at that time regarding the injuries revealed that the resident stated that he "scratches."

A review of Resident 147's current interdisciplinary progress notes, care plan and physician orders and treatment administration record (TAR) for the months of July 2019 and August 2019 revealed no documented evidence of the identification of the resident's skin impairments, scratching or current treatment.

Interview with the Director of Nursing (DON) on August 29, 2019, at approximately 1:45 p.m. was unable to provide any explanation to staff failing to identify and provide treatment for this change in condition



28 Pa. Code 211.5 (f) Clinical records.

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services.
Previously cited 6/4/19, 3/26/19, 7/13/18








 Plan of Correction - To be completed: 10/21/2019

Unable to retroactively correct the deficiency as it relates to residents 90, 141 and 147.

Residents will be reviewed to ensure medications and treatments are administered/completed as ordered by the physician. Residents will be reviewed to ensure that they have orders for weekly skin integrity checks to ensure that changes in condition are identified and followed up on in a timely manner.

The medication administration policy will be reviewed along with the skin integrity policy and updated as necessary. Re-education will occur with professional staff to ensure the policies are being followed.
Qa Designee will conduct 10 audits of MARs and TARs weekly for three months. Results will be reviewed with the QA committee for review and recommendations. Audits will be modified as appropriate.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision: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(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

483.25(a)(1) In making appointments, and

483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.
Observations:

Based on observations and resident and staff interviews, it was determined that the facility failed to ensure that one resident was provided timely and necessary services to maintain vision abilities for one of 31 residents (Resident 4).

Findings include:

A review of Resident 4's clinical record revealed an admission date of February 28, 2019, with diagnoses to include but not limited to multiple sclerosis and depression.

During a group meeting with residents conducted on August 28, 2019, at 10:00 a.m. Resident 4 stated that she had lost her glasses upon admission on February 28, 2019. The resident further stated that the facility was aware of her missing glasses, but she still did not have glasses.

Review of Resident 4's clinical record, revealed a care plan meeting note dated May 28, 2019, indicating that the resident and her spouse reported that the resident's glasses were missing. It was noted that facility staff searched for the resident's glasses and were unable to locate them.

Further review of resident's clinical record revealed no further mention of the resident's missing glasses.

During an interview on August 28, 2019, at approximately 1:45 p.m., with Director of Social Services (employee 3) stated that she had informed the previous Nursing Home Administrator of the resident's missing glasses on June 12, 2019. However, the Director of Social Services confirmed that the facility had no evidence of further attempts to assist Resident 4 in obtaining replacement glasses.

Interview with the Nursing Home Administrator and Director of Nursing on August 29, 2019 at 9:30 a.m. verified that the facility had no evidence of assisting Resident 4 with an opportunity to see a practitioner specializing in the treatment of vision impairment or the provision of vision assistive devices.






28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
Previously cited 12/15/18, 3/26/19, 6/4/19


28 Pa. Code 211.6(a) Social Services





 Plan of Correction - To be completed: 10/21/2019

An appointment to have the eye glasses replaced has been scheduled resident 4.

A review of residents has been completed to ensure that dental, eyeglass and hearing aid concerns have been addressed.

Appropriate staff will be re-educated to the requirements for ensuring dental, eyeglasses and hearing aids are replaced timely. A log will be created for the theft/loss reports to ensure follow up has occurred.

Social service will audit the theft/loss log monthly to ensure items have been addressed. The findings of the audit will be reviewed with the QA committee for review and recommendations. Audits will be modified as necessary.


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(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 a review of clinical records and staff interview it was determined that the facility failed to consistently provide treatments and services prescribed to promote healing of pressure sores for one resident out of 31 sampled (Resident 20).

Findings included:

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 20 had diagnoses that included depression, Stage III pressure sore (right buttock - describe as full thickness skin loss involving damage or brake down of the tissue below the skin usually presenting itself as a deep crater) and dementia (symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities such as bathing, dressing, eating, etc.)

Current physican's orders in effect since July 1, 2019, called for staff to check placement of the resident's pressure sore wound dressing every shift and replace if falls off.

Additional physican's orders called for staff to apply Silvadene Cream (a medication used with other treatments to help treat wounds and infections) to the resident's right buttock every day and evening shift for pressure area, zinc oxide on top and to peri wound and border gauze.

A review of Resident 20's treatment administration record (TAR) for the months of July and August 2019 revealed that staff failed to consistently check the placement check of the right buttock dressing each shift. Further review of the TAR revealed that nursing staff failed to apply the Silvadene cream to the resident's right buttock on the following dates: July 1,2,4,6,7, 13,14 and 15, 2019

Interview with the DON on August 29, 2019, at approximately 9:05 a.m. confirmed that staff failed to follow physician orders for the application of the Silvadene and the placement check of the dressings to promote healing of the resident's pressure sores.


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

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

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






 Plan of Correction - To be completed: 10/21/2019

Unable to retroactively correct the deficiency as it relates to residents 20.

All residents with pressure ulcers will be reviewed to ensure appropriate treatments are ordered and being provided to promote healing. All residents will be reviewed to ensure they have a weekly skin integrity check ordered.

The Pressure Ulcer & Skin Care management Policy will be revised as necessary and Re-education will occur with professional staff to ensure the policy is being followed.

QA Designee will conduct 10 audits of MARs and TARs weekly for three months. Results will be reviewed with the QA committee for review and recommendations. Audits will be modified as appropriate.

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

483.45(h) Storage of Drugs and Biologicals

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

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

Based on observation and staff interview, it was determined that the facility failed to ensure adherence to pharmaceutical supplies/medication expiration/use by dates for one medication storage room of three units (East Wing).

Findings include:

An observation of the East Wing medication storage room on August 27, 2019, at 11:11 AM revealed adhesive tape remover that had expired August 2017.

An enteral feeding tube Declogger manufactured by BIONIX was opened with a white dried up substance on the bottom of the device. A date of October 17, 2018 was written on the open wrapper. The manufacturing instructions indicated the device was single use only.

A barbicide container with multiple brown particles on the bottom containing nail clippers. Two ant traps were on top of the counter.

Sani-cloth disposable bleach wipes had expired March 2019. Under sink contained a dirty water pitcher and a basin with brown film. Water stains on the back of cabinet and black substance was also noted in the cabinet.

An interview with Employee confirmed the medication room contained expired items and was presently unsanitary

During an interview with the DON (Director of Nursing) on August 28, 2019 at approximately 1:45 PM confirmed that the expired products should have been removed from the medication room and it should be kept in a sanitary manner.



28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services

28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services
Previously cited 7/13/18, 12/15/18,3/26/19, 6/4/19





 Plan of Correction - To be completed: 10/21/2019

Items of concern and biologicals with expired dates were removed promptly from East Medication rooms.

All Medication storage rooms were assessed to ensure no outdated items were noted.

Licensed Nursing Staff will be re-educated to ensure items are properly stored and adherence to pharmaceutical supplies/medication storage.

A weekly check by the Infection Control Nurse and/or QA designee will be completed weekly for two months to ensure outdated items have been removed and the area is properly cleaned. The audit findings will be shared with the QA committee for review and recommendations.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observation, review of select facility policies and clinical records and staff interviews it was determined that the facility failed to maintain infection control techniques while administering medications to three of five residents (Residents 69, 9, and 37) observed on second floor East nursing unit.

Findings included:

A review of the facility's "Medication Administration" policy, revised by the facility 2/2019, indicated that staff are to "cleanse hands before and after each administration of medication."

Observation on August 28, 2019, at approximately 9:05 a.m. revealed that Employee 1, LPN (Licensed Practical Nurse) was passing 9:00 a.m. medications to Resident 69 on the second - floor East nursing unit. Employee 1 did not sanitize or wash her hands after the administration of medication and before preparing medications for the next resident.

Observation on August 28, 2019, at approximately 9:12 a.m. revealed that Employee 1 was passing 9:00 a.m. medications to Resident 9 on the second - floor East nursing unit. Employee 1 did not sanitize or wash her hands after the administration of medication and before preparing medications for the next resident.

Observation on August 28, 2019, at approximately 9:20 a.m. revealed that Employee 1 was passing 9:00 a.m. medications to Resident 37 on the second - floor East nursing unit. Employee 1 was preparing to pour Vitamin C tablet 500 mg into the medication cup when the medication fell onto the floor. Employee 1 picked up the Vitamin C tablet with her bare hand and placed it into the garbage and proceeded to prepare additional medication for Resident 37 without sanitizing or washing her hands. Employee 1 did not sanitize or wash her hands prior to the administration of medication for Resident 37.

During an interview on August 28, 2019, at approximately 9:30 a.m., Employee 1 and Employee 2 RN (Registered Nurse) second floor East dayshift supervisor, confirmed that Employee 1 she should have sanitized or washed hands before preparing the next resident's medications.

Interview with the Director of Nursing (DON) on August 29, 2019, at approximately 1:45 p.m. confirmed that Employee 1's handling of medications was not consistent with infection control practices.

28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services.
Previously cited 12/15/18, 3/26/19, 6/4/19

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




 Plan of Correction - To be completed: 10/21/2019

Nurse was re-educated concerning proper infection control procedures during med pass.

Facility will review each nurses' station to ensure hand sanitizer is readily available for staff use during med pass.

Facility will re-educate professional nursing staff concerning proper infection control technique for medication pass.

2 Medication passes will be audited by a QA designee monthly to ensure compliance with infection control during med pass. Audit findings will be share with the Quality Assurance committee for review and recommendation.



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