Nursing Investigation Results -

Pennsylvania Department of Health
QUALITY LIFE SERVICES - WESTMONT
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
QUALITY LIFE SERVICES - WESTMONT
Inspection Results For:

There are  94 surveys for this facility. Please select a date to view the survey results.

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QUALITY LIFE SERVICES - WESTMONT - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on February 28, 2020, was determined that Quality Life Services Westmont was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of Pennsylvania's Nursing Practice Act, facility policies and clinical records, as well as observations and interviews with residents' family members and staff, it was determined that the facility failed to ensure that an assessment was completed by a professional (registered) nurse for pain and that questionable physician's orders for pain medications were clarified for one of 11 residents reviewed (Resident 5), and failed to observe a resident take medications for one of 11 residents reviewed (Resident 8).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

The facility's policy regarding pain assessment and management, dated November 12, 2019, indicated that the resident's pain would be assessed using a standard numerical scale (usually 0 to 10, with 10 being the worst pain).

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 22, 2020, revealed that the resident was cognitively impaired, had diagnoses that included a hip fracture, had occasional pain, and received pain medication "as needed." Physician's orders dated January 15, 2020, included an order for the resident to receive 650 milligrams (mg) of Tylenol every four hours as needed for pain.

An admission nursing assessment for Resident 5, dated January 15, 2020, indicated that the resident was having pain. A nursing note, dated January 16, 2020, indicated that the resident's daughter asked the nurse for a stronger pain pill for her mother. There was no documented evidence that a registered nurse assessed Resident 5 after her daughter stated that she needed something stronger for pain.

Physician's orders for Resident 5, dated January 16, 2020, included an order for the resident to receive 5/325 mg of Percocet (a narcotic pain medication) every four hours as needed for pain, and orders dated February 2, 2020, including an order for 0.5 milliliters (ml) of Morphine (a narcotic pain medication) every two hours as needed for pain. The orders did not include under what specific circumstances or pain ratings that each of the three medications ordered for pain were to be used.

Resident 5's Medication Administration Record (MAR) for February 2020 revealed that staff administered Tylenol for a pain rating of 4 on February 6 and 27, and for a pain rating of 7 on February 22; staff administered Percocet for a pain rating of 5 on February 13 and for pain rating of 8 on February 13; and staff administered Morphine for a pain rating of 5 on February 10 and 12, 2020.

Interview with the Director of Nursing on February 28, 2020, at 2:35 p.m. revealed that she expected her staff to use a pain scale for assessment of a resident's pain and to medicate the resident based on the pain scale. She indicated that she expected Morphine to be used only if hospice (end-of-life services) initiates its use, because it is ordered by the hospice physician. She also stated that she would have expected the nurses to assess Resident 5 for pain when the family stated she was having pain and to medicate accordingly.


The facility's policy regarding medication administration, dated November 11, 2019, revealed that nurses administering medications were not to leave the medication at the resident's bedside unless it is ordered that way. The nurse was to remain with the resident until the medication was taken.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated February 10, 2020, indicated that the resident was alert and oriented. Physician's orders, dated February 2, 2020, inlcuded orders for the resident to receive one packet of Metamucil Multihealth Fiber (medication used to prevent and/or treat constipation) dissolved in 8 ounces of water and given daily.

Observations during medication administration on February 27, 2020, at 7:55 a.m. revealed that Licensed Practical Nurse 1 prepared one packet of Metamucil Multihealth Fiber in a cup of 8 ounces of water and left the room before Resident 8 drank the entire cup of Metamucil.

Interview with Licensed Practical Nurse 1 on February 27, 2020, at 8:01 a.m. confirmed that she left the Metamucil with Resident 8.

Interview with the Director of Nursing on February 28, 2020, at 1:42 p.m. confirmed that staff were to observe residents taking medications and were not to leave them with the resident.

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

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



 Plan of Correction - To be completed: 04/13/2020

1. Resident R5's pain medications were clarified by the resident's physician relative to the pain scale. The Licensed Practical Nurse (LPN) that failed to observe a resident take medications was provided education that residents must be observed for the entire medication administration process to ensure consumption.
2. Residents with multiple pain medication orders were reviewed, and will be ongoing as a pharmacy alert system does not exist, to ensure that clarity relative to the pain scale was included in the orders. Rooms serviced by the LPN that failed to observe resident R8 take medications were audited to ensure there were no medications that were not taken by the residents and none were found.
3. Residents with multiple pain medication orders will have parameters for pain scale definition added to the physician order. The facility physicians will be educated that pain scale definition will need to be provided to residents with multiple pain medications. Licensed staff, including new hires and agency, will be educated on the need to observe residents taking medications to completion.
4. An audit will be conducted for the next 30 days on residents with multiple pain medication orders by the Director of Nursing or designee to ensure that the pain scale is defined. An audit will be conducted daily for 5 days and weekly for three weeks on medication pass to ensure that the LPN's were in the room for the entire pass. Results of the audits will be reviewed by the Quality Assurance Performance Improvement committee.
5. Date of Compliance: 4/13/2020

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 11 residents reviewed (Resident 5).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 22, 2020, revealed that the resident was cognitively impaired, had diagnoses that included a hip fracture and obstructive uropathy (difficulty passing urine), and had an indwelling urinary catheter (tube inserted and held in the bladder to drain urine).

A nursing note for Resident 5, dated January 5, 2020, indicated that the resident was usually incontinent of urine and that she had an indwelling urinary catheter. A nursing note, dated January 18, 2020, indicated that the resident had an indwelling catheter that was draining medium yellow urine, and a note dated January 23, 2020, indicated that the resident had an indwelling catheter.

However, nursing notes dated January 20, 21 and 23, 2020, indicated that the resident was incontinent of bladder.

Interview with the Director of Nursing on February 28, 2020, at 2:35 p.m. confirmed that staff documented inaccurately that Resident 5 was incontinent of bladder.

28 Pa. Code 211.5(f) Clinical records.

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







 Plan of Correction - To be completed: 04/13/2020

1. Education was provided to the licensed staff who documented 'incontinent" on a resident with an indwelling catheter.
2. Residents with indwelling catheters had a nursing progress note review performed for correct documentation regarding continent status.
3. The licensed staff, including new hires and agency, will be educated on the proper documentation procedures and accuracy for continence status for residents with indwelling catheters.
4. An audit of residents' charts with indwelling catheters will be performed by the Director of Nursing three times a week for four weeks to ensure accurate documentation of urinary continence status. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
483.45(e) Psychotropic Drugs.
483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) interventions were attempted prior to the administration of anti-anxiety medications for one of 11 residents reviewed (Resident 5).

Findings include:

A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 7, 2020, revealed that the resident was cognitively impaired, had diagnoses that included restlessness and agitation, and physician's orders dated May 7, 2019, included an order for the resident to receive 0.5 milligrams (mg) of lorazepam (an anti-anxiety medication) every eight hours "as needed" for restlessness and agitation. Physician's orders included an order dated February 6, 2020, for the resident to receive a combination topical gel (ABHR gel) consisting of 2 mg per 1 ml of lorazepam (anti-anxiety medication), 25 mg of Benadryl (anti-histamine medication that has a side effect of causing drowsiness), 2 mg of Haldol (anti-psychotic medication) and 10 mg of Reglan (antinausea medication) every two hours as needed for restlessness and anxiety, and order dated February 14 and 22, 2020, for the resident to receive 1 mg of lorazepam intensol (concentrated liquid) every four hours as needed for restlessness and agitation.

Resident 5's care plan, dated February 6, 2020, indicated that staff were to provide non-pharmacological interventions (such as massage, music, quiet time, reading, watching television) prior to administering anti-anxiety medication.

Resident 5's Medication Administration Records (MAR's) for February 2020 revealed that staff administered "as needed" lorazepam and "as needed" ABHR gel for restlessness or agitation on February 11 at 6:13 p.m., February 12 at 3:35 p.m., February 13 at 8:36 p.m., February 17 at 3:20 p.m. and 11:15 p.m., February 19 at 1:20 p.m. and 8:44 p.m., February 20 at 5:01 a.m., February 21 at 1:45 a.m., February 22 at 9:56 p.m., February 23 at 4:00 p.m. and 7:43 p.m., and February 25 at 6:17 a.m. Staff administered 1 mg of lorazepam intensol on February 19 at 11:37 p.m. and February 21 at 11:00 p.m.

There was no corresponding documentation in Resident 5's clinical record regarding any non-medication interventions that were attempted, in accordance with the resident's care plan, prior to the administration of lorazepam or the application of ABHR gel, and/or no documented evidence that other non-medication interventions were attempted when one intervention was ineffective.

Interview with the Director of Nursing on February 28, 2020, at 3:49 p.m. confirmed that there was no documented evidence that staff attempted one or more non-medication interventions listed in Resident 5's care plan prior to administering "as needed" lorazepam or ABHR gel on the above dates.

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

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





 Plan of Correction - To be completed: 04/13/2020

1. An audit of PRN (as needed) psychoactive medication orders was completed to determine the scope of residents with PRN psychoactive orders.
2. Residents having PRN psychoactive medications will have non-pharmacological interventions, individualized and listed in the care plan, prior to the administration of the medication.
3. Education to licensed staff, including new hires and agency, of F 0758 will also include non-pharmacological approaches.
4. An audit twice a week for 30 days will be conducted by the Director of Nursing or designee on PRN psychotropic medication orders to ensure that non-pharmacological interventions were attempted prior to the administration of the medication. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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


Based on review of facility policies, manufacturer's instructions and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment remained as free from accident hazards as possible by failing to complete an assessment after falls out of bed, to identify if the use of an air mattress created potential safety hazards or contributed to the falls for one of 11 residents reviewed (Resident 5), and by failing to ensure that an assessment was completed prior discontinuing the use of an alarm for one of 11 residents reviewed (Resident 2) who had a history of falls.

Findings include:

Undated manufacturer's instructions for Med Aire air mattresses indicated that a person should check to see if a suitable pressure is selected by sliding one hand between the air mattress and the foam base (or bed frame if there is no foam base) to feel the patient's buttock. Users should be able to feel the space in between, and the acceptable range was approximately 25 to 40 millimeters (mm) (1 inch to 1-1/2 inches).

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 22, 2020, revealed that the resident was cognitively impaired, had diagnoses that included a hip fracture, restlessness and agitation, and seizure disorder. The resident's care plan, dated January 15, 2020, indicated that she was at risk for falls and that she had an air mattress to prevent further skin breakdown.

An event report for Resident 5, dated January 30, 2020, revealed that the resident was found lying on the right side of the floor by her bed and was calling out loudly for help. Following this fall out of bed, there was no documented evidence that the use of an air mattress was assessed to determine if there were any potential safety hazards or if it could have contributed to the fall.

An event report for Resident 5, dated February 10, 2020, revealed that the resident was found lying on her side on a floor mat on the door side of the bed. Following this fall out of bed, there was no documented evidence that the use of an air mattress was assessed to determine if there were any potential safety hazards or if it could have contributed to the fall.

Observations on February 27, 2020, at 10:38 a.m. revealed that Resident 5's bed was equipped with a Med Aire air mattress.

Interview with Licensed Practical Nurse 2 on February 28, 2020, at 1:05 p.m. revealed that she believed the firmness of the mattress was determined by the resident's comfort level and that she was unaware of what the control knobs on the air mattress did. She stated that she was to check every shift to ensure the mattress was inflated.

Interview with Licensed Practical Nurse 3 on February 28, 2020, at 1:12 p.m. revealed that she believed the dial function on the air mattress was for the firmness of the mattress and that the dial was adjusted based on how the resident's wounds were doing and if they were healing or not. She stated that sometimes residents have specific orders about how firm the air mattress should be, but Resident 5 did not have specific orders. She stated there was no way of knowing if the wound nurse adjusted the firmness of the mattress or not.

Interview with the Director of Nursing on February 28, 2020, at 2:35 p.m. confirmed that the use of an air mattress was not assessed to determine if there were any potential safety hazards created for Resident 5 after she fell out of bed on January 30 and February 10, 2020.


A nursing note for Resident 2, dated February 4, 2020, at 6:15 p.m. revealed that the resident was admitted to the facility, that she was alert and oriented but forgetful, and had a history of multiple falls and a fall with hip pain. An admission comprehensive MDS assessment for Resident 2, dated February 11, 2020, revealed that the resident's cognition was intact, she required extensive assistance from staff with transfers and walking, had a history of falls, and used bed and chair alarms. The resident's care plan, dated February 4, 2020, revealed that she used electronic alarms and staff were to ensure that the devices were in place as needed. A nursing note, dated February 4, 2020, at 6:15 p.m. revealed that Resident 2 was at moderate risk for falls, and a nurse aide flow sheet, dated February 5-8, 2020, revealed that the resident had bed and chair alarms in place.

A nursing note for Resident 2, dated February 8, 2020, at 10:31 a.m. revealed that the resident's family member was very concerned that the resident did not have any chair or bed alarms in use. He stated, "She's here because she fell at home and she's gonna fall here too!" A conversation was held with the son regarding his mother's safety; however, he still wanted a chair alarm.

Resident 2's care plan revealed that the use of alarms was discontinued on February 11, 2020. However, there was no documented evidence that an assessment was completed to determine if the use of alarms was needed and beneficial for the resident's safety, and no documented evidence that the resident's responsible family member was notified prior to discontinuing the alarms. A note completed by the MDS Coordinator, dated February 17, 2020, at 6:00 p.m. revealed that Resident 2 was at moderate risk for falls.

A nursing note and facility investigation, dated February 17, 2020, at 8:42 p.m. revealed that another resident's family went to the nursing station and reported that Resident 2 was on the floor and was lying face down lying on her left side. The note indicated that the resident hit her head on the footboard of her roommate's bed and had a small amount of swelling above her right eye. A nursing note dated February 18, 2020, at 12:30 p.m. revealed that the resident was seen by Certified Registered Nurse Practitioner 4 (CRNP - a registered nurse with advanced medical training) and complained of a "really bad headache." She remembered falling and hitting her head. A nursing note, dated February 18, 2020, at 12:52 p.m. revealed that CRNP 4 evaluated the resident and noted that the resident was having right-sided facial drooping, was currently having a stroke, and was sent to the hospital. An update from the hospital At 8:09 p.m. revealed that the resident was being admitted with a traumatic brain injury.

Interview with the Director of Nursing on February 28, 2020, at 11:46 a.m. revealed that she told staff to discontinue Resident 2's alarms because she felt she was low risk for falls. She confirmed that an assessment was not completed to determine that the resident did not need alarms, and there was no documented evidence that the resident's family was notified that the alarms were discontinued.

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

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





 Plan of Correction - To be completed: 04/13/2020

1. Resident R5 was assessed for the continued use of an air mattress to ensure the air mattress does not create a potential safety hazard. R2 had been discharged from the facility.
2. Residents on air mattresses with a recent fall in the last 30 days were identified to make sure safety assessments were completed. Residents with recent orders for discontinuation of alarms within the last 30 days were reviewed to ensure alarm assessments were completed.
3. Education will be provided to the licensed staff, including new hires and agency, that assessments must be completed prior to safety alarms being discontinued and an air mattress evaluation assessment must be completed post fall if the resident utilizes an air mattress to identify any contributing factors. The air mattress evaluation and alarm assessment post discontinuation will be monitored in AM clinical.
4. Audits will be conducted for 30-days by the Director of Nursing or designee on residents who are on an air mattress with a fall and residents who are being considered for alarm discontinuation. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure proper pain management for one of 11 residents reviewed (Resident 5).

Findings include:

The facility's policy regarding pain assessment and management, dated November 12, 2019, indicated that the resident's pain would be assessed using a standard numerical scale (usually 0 to 10, with 10 being the worst pain).

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 22, 2020, revealed that the resident was cognitively impaired, had diagnoses that included a hip fracture, had occasional pain, and received pain medication "as needed." Physician's orders dated January 15, 2020, included an order for the resident to receive 650 milligrams (mg) of Tylenol every four hours as needed for pain.

An admission nursing assessment for Resident 5, dated January 15, 2020, indicated that the resident was having pain, and a nursing note dated January 16, 2020, indicated that the resident's daughter asked the nurse for a stronger pain pill for her mother. There was no documented evidence that staff administered pain medication on January 15 or January 16, 2020.

Interview with the Director of Nursing on February 28, 2020, at 2:35 p.m. revealed that Resident 5 indicated that she had pain when she was admitted to the facility and that she was medicated at the hospital prior to her leaving for the facility. However, she was not reassessed by the admitting nurse to determine if her pain had returned or if she needed medicated for pain. She confirmed that there was no documented evidence that the resident was medicated for pain after her daughter asked for something stronger for pain and she should have been medicated when she was having pain.

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

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




 Plan of Correction - To be completed: 04/13/2020

1. Resident R5 was immediately assessed for pain.
2. Residents were interviewed to see if they expressed the need for pain medications and none were found. Cognitively impaired residents were assessed for pain utilizing the FLACC (Face, Legs, Activity, Cry Consolibility) method. Appropriate orders were obtained from the residents' physicians as necessary.
3. Residents will continue to have pain assessments completed every shift. Licensed staff, including new hires and agency, will be educated on pain assessment completion per shift.
4. An audit will be completed daily for 5 days and weekly for three weeks on the per shift assessment completion. This audit will be conducted by the licensed staff and reviewed by the Director of Nursing or designee. Results of the audits will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:


Based on review of manufacturer's instructions, facility policies and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain a medication administration error rate of less than five percent.

Findings include:

Observations during medication administration on February 27, 2020, revealed that three medication administration errors were made during 27 opportunities for error, resulting in a medication administration error rate of 11.11 percent.

The manufacturer's instructions for Lamictal tablets (lamotrigine - medication used to treat seizures), dated September 2019, indicated that the tablets should be taken whole.

The manufacturer's instructions for Austedo tablets (used to control involuntary movements), dated July 2009, indicated that the tablets should be swallowed whole and should not be chewed or crushed.

The manufacturer's instructions for Keppra tablets (levetiracetam - medication used to treat seizures), dated April 2009, indicated that the tablets should be swallowed whole and should not be chewed or crushed.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated January 31, 2019, indicated that the resident was alert and oriented and had diagnoses that included seizure disorder. Physician's orders, dated August 23 and 24, 2019, included orders for the resident to receive one 150 milligram (mg) tablet of lamotrigine two times a day, one 12 mg tablet of Austedo two times a day, and two 750 mg tablets of levetiracetam two times a day.

Observations during medication administration on February 27, 2020, at 7:47 a.m. revealed that Licensed Practical Nurse 1 crushed the lamotrigine, Austedo and levetiracetam tablets and adminstered them to Resident 9. Interview with Licensed Practical Nurse 1 at that time revealed that the resident was to receive all of his medications crushed.

Interview with the Director of Nursing on February 28, 2020, at 2:36 p.m. confirmed that Resident 9's lamotrigine, Austedo, and levetiracetam should not have been crushed, and if the resident was unable to take the pills whole, the physican should have been notified.

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

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




 Plan of Correction - To be completed: 04/13/2020

1. Resident R9 was immediately assessed and experienced no adverse effects of crushing the medications. This resident's physician was notified.
2. Residents with orders for crushed medications were reviewed to ensure that there were no medications that can't be crushed.
3. A list of medications that are classified as "Do Not Crush" will be laminated and provided on every medication cart. The licensed staff, including new hires and agency, will be educated on the list of medications that are not to be crushed and that physician notification needs to be made if a resident requiring crushed medications receives an order for a medication that is on the do not crush list so the physician can make the proper recommendation.
4. An audit will be performed 5 x week for 4 weeks on residents with crushed medication requirements for new medication orders to ensure that the new order is not on the do not crush list. The results of the audit will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed, resulting in a significant medication error for one of 11 residents reviewed (Resident 5).

Findings include:

The facility's policy regarding blood sugar measurement, dated November 12, 2019 revealed that after checking a resident's blood sugar, the staff were to follow-up with insulin administration or physician notification as ordered.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated January 22, 2020, revealed that the resident was cognitively impaired and had diagnoses that included diabetes (interferes with blood sugar control). Physician's orders dated January 28, 2020, included orders for the resident to receive Novolog insulin (medication that lowers blood sugar levels) based on a sliding scale (the amount of insulin administered is determined by the resident's blood sugar result). The resident was to receive 4 units of Novolog for a blood sugar of 200-300 milligrams per deciliter (mg/dL), 8 units for a blood sugar of 301-400 mg/dL, and 12 units for a blood sugar of 401 and greater, and to call the physician.

Resident 5's Medication Administration Record for January 2020, revealed that the resident's blood sugar was 436 mg/dL on January 28, 2020. There was no documented evidence that the resident received Novolog insulin for this blood sugar, and no documented evidence that the physician was notified.

Interview with the Director of Nursing on February 28, 2020, at 3:49 p.m. confirmed that there was no documented evidence that the nurse administered 12 units of Novolog insulin to Resident 5 on January 28, 2020, and no documented evidence that the physician was notified.

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

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






 Plan of Correction - To be completed: 04/13/2020

1. Resident R5 was immediately assessed and the physician was notified of the medication error; no new orders were received.
2. Other residents on a sliding scale insulin records were reviewed to ensure the order for the sliding scale was followed as ordered.
3. Education will be provided to the licensed staff, including new hires and agency, on sliding scale insulin orders. Medication pass competencies will be completed for licensed nursing staff.
4. An audit will be performed by the Director of Nursing or designee twice a week for four weeks on sliding scale insulin administration to ensure proper administration based on physician orders. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020

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

483.45(h) Storage of Drugs and Biologicals

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

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


Based on review of facility policies and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to store medications so that only authorized persons had access.

Findings include:

The facility's policy regarding medication storage, dated November 12, 2019, indicated that no medications were to be left unattended on top of the medication cart.

Observations during medication administration on February 27, 2020, at 7:59 a.m. revealed that Licensed Practical Nurse 1 prepared medications for Resident 8 and removed a container of Clearlax (an oral laxative) from the medication cart and left the container of Clearlax unattended on top of the medication cart as she went into the resident's room to administer other medications to the resident.

Interviews with Licensed Practical Nurse 1 and the Director of Nursing on February 27, 2020, at 8:01 a.m. and February 28, 2020 at 1:42 p.m., respectively, confirmed that the Clearlax should not have been left unattended on top of the medication cart.

28 Pa. Code 211.9(a)(1) Pharmacy services.

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





 Plan of Correction - To be completed: 04/13/2020

1. The container of Clearlax was immediately stored properly in the medication cart. The LPN (Licensed Practical Nurse) was immediately educated on proper medication storage.
2. The other medication cart was checked to ensure that there were no improperly stored medications, none were found.
3. The licensed staff, including new hires and agency, will be educated on the proper storage of medications within the medication cart.
4. An audit will be performed by the Director of Nursing or designee three times a week for four weeks to ensure there are no improperly stored medications on either cart; this audit will cover both carts and three shifts. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020

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 review of manufacturer's instructions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed during medication administration and while obtaining blood sugar levels for one of 11 residents reviewed (Resident 10).

Findings include:

The manufacturer's instructions for cleaning of the Evencare Proview Glucometer (device used to test the blood sugar level in a small sample of blood) included steps to wipe the glucometer thoroughly, including the front, sides and back, and then store it.

A diagnosis record for Resident 10, dated February 26, 2020, revealed that the resident had diagnoses that included diabetes (a disease that causes problems with blood sugar control). Physician's orders, dated February 26, 2020, included an order for the resident's blood sugar level to be checked three times a day before meals.

Observations on February 27, 2020, at 8:50 a.m. revealed that Licensed Practical Nurse 5 applied gloves, obtained a sample of blood via a fingerstick from Resident 10, tested the resident's blood sample using a glucometer, and then returned to the medication cart and placed the glucometer on top of the cart. The nurse removed her gloves, cleansed her hands with gel, cleaned the glucometer, and then placed it back on the same area on the top of the medication cart. The nurse then used hand gel and placed the glucometer into the top drawer of the medication cart.

Interview with Licensed Practical Nurse 5 on February 27, 2020, at 8:55 a.m. confirmed that she should not have placed the dirty glucometer onto her medication cart and she did not realize that she cleaned it and put it on the same area on the medication cart.

Interview with the Director of Nursing on February 28, 2020, at 2:15 p.m. revealed that the facility did not have a policy for cleaning glucometers. She confirmed that Licensed Practical Nurse 5 should not have placed the dirty glucometer on the medication cart and should not have placed the cleaned glucometer back onto same spot on the medication cart.

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

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






 Plan of Correction - To be completed: 04/13/2020

1. The LPN that did not follow the manufacturer's instructions for cleaning of the Glucometer was immediately educated on the proper procedure.
2. The other medication cart's Glucometer was checked and cleaned following the manufacturer's instructions.
3. The licensed staff, including new hires and agency, will be educated on the proper procedure for Glucometer cleaning and storage. Competencies for performing accuchecks will be completed for licensed nursing staff.
4. The Director of Nursing or designee will audit blood sugar level testing three times a week for four weeks to ensure that the Glucometer is cleaned and stored properly after use. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020

211.12(f)(2) LICENSURE Nursing services.:State only Deficiency.
(2) When the facility designates an LPN as a nurse who is responsible for overseeing total nursing
activities within the facility on the night tour of duty in facilities with a census of 59 or under, a
registered nurse shall be on call and located within a 30-minute drive of the facility.
Observations:


Based on review of nursing schedules, as well as staff interviews, it was determined that the facility failed to designate a registered nurse who was located within a 30-minute drive to be on call during the night shift when the nurse responsible for overseeing nursing activities was a licensed practical nurse, and failed to ensure that the registered nurse on call was contacted to complete an assessment following falls that occurred during the night shift.

Findings include:

Nursing schedules for January 19 to 25 and February 9 to 22, 2020, revealed that there was a licensed practical nurse on duty as the charge nurse during each night shift (11:00 p.m. to 7:00 a.m.). There was no evidence that a registered (professional )nurse was on duty in the building during the night shift on these days, and no evidence that a registered nurse was assigned to be on call during the night shift on these days.

Interview with the Director of Nursing on February 28, 2020, at 4:00 p.m. revealed that she was considered the on-call registered nurse each night, but she did not reside within a 30-minute drive of the facility.

The facility's policy regarding falls, dated November 12, 2019, indicated that a registered nurse must assess a resident after a fall and that the resident should not be moved until they are assessed by a registered nurse.

A fall report for Resident 5, dated February 10, 2020, indicated that the resident fell out of bed at 1:30 a.m. and that Licensed Practical Nurse 1 and Nurse Aide 2 picked the resident up off the floor using a mechanical lift and put her back in the bed. There was no documented evidence that a registered nurse completed an assessment prior to the resident being moved.

Interview with the Director of Nursing on February 28, 2020, at 12:00 p.m. revealed that she was the on-call registered nurse during each night shift, but she was not called to assess Resident 5 following her fall out of bed on February 10, 2020.




 Plan of Correction - To be completed: 04/13/2020

1. The facility immediately developed an on-call list for RN's (Registered Nurses) that are within 30 minutes of the facility for the days when the facility designates an LPN (Licensed Practical Nurse) as a nurse who is responsible for overseeing total nursing activities.
2. The on-call list includes direction that the registered nurse on call is to be contacted to complete assessments following a fall that results in injury or change in resident status that occur during the night shift.
3. Licensed staff, including new hires and agency, will be educated on the on-call list and the need for communication to the on call nurse for assessments that need to occur following falls that result in injury or change in resident status.
4. An audit will be performed each weekday following the nights when the facility designated an LPN responsible for overseeing total nursing duties for 30 days by the Director of Nursing or designee to ensure that, if there was a fall, the RN on call was contacted to perform an assessment on the resident in question. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee.
5. Date of Compliance: 4/13/2020


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