Nursing Investigation Results -

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

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QUALITY LIFE SERVICES - WESTMONT
Inspection Results For:

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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 Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey completed on June 3, 2022, it 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:


483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that there was timely physician notification and intervention for a significant weight loss for one of 32 residents reviewed (Resident 22).

Findings include:

The facility's policy regarding weight loss, dated November 1, 2021, indicated that if a resident's weight was greater or less than five pounds from the previous weight, they would be re-weighed within the week and the physician would be notified of any weight change greater than or less than five pounds.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated May 6, 2022, indicated that the resident was cognitively impaired, was dependent on staff for daily care, and required assistance with eating. The resident's weight records revealed that she experienced a 43.2 pound weight loss in two months when her weight dropped from 168.2 pounds on October 3, 2021, to 125 pounds on December 16, 2021.

There was no documented evidence that weekly weights were obtained for Resident 22 per the facility's policy regarding significant weight loss, and there was no documented evidence that the physician was notified about the weight loss or the possibility of adding an appetite stimulant. Therefore, there was no documented evidence that any interventions were developed and implemented to prevent further unplanned weight loss for the resident.

Interview with the Director of Nursing, the Nursing Home Administrator, and the Clinical Consultant on June 3, 2022, at 3:33 p.m. confirmed that there was no documented evidence that any interventions to prevent further weight loss were implemented for Resident 22, including notifying the physician, addressing the possible need for an appetite stimulant, and obtaining weekly weights at the time the weight loss was identified in December 2021.

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

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




 Plan of Correction - To be completed: 07/30/2022

1. Resident # 22 weight was obtained. Resident # 22 should have had weekly weights with physician updates but due to recent decline per physician and POA, resident has been placed on hospice. Monthly weights will continue per policy.
2. All residents have the potential to be affected by this deficient practice of maintaining nutrition / hydration maintenance. Initial audit was conducted for all current residents with significant weight change to ensure proper interventions are in place. Weekly weight meetings will be held with the Director of Nursing, Registered Dietician and or Dietary Director to discuss at risk residents as per policy. Residents determined to be at risk for significant weight changes will be evaluated for interventions to prevent further weight changes. Physician communication will be addressed timely.
3. Documentation of significant weight change will initiate a reweight within 24 hours. Communication of significant weight change will be communicated to physician and/or Registered Dietician for appropriate interventions. Education will be provided by Director of Nursing or designee to Registered Dietician, Dietary Director, Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides, and agency staffing for policy and procedure on Weight Protocol.
4. The Director of Nursing and/or designee will complete a random audit of significant weight changes weekly x 4. Audits to be initiated on July 2022. Completed audits will be reviewed at the next Quality Assurance Performance Improvement meeting to ensure the facility staff are meeting compliance at the regulatory meeting.
5. Compliance Date is July 30, 2022

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on a review of policies and observations, as well as interviews with residents and staff, it was determined that the facility failed to serve food that was palatable and at proper temperatures.

Findings include:

The facility's policy regarding food temperatures, dated November 1, 2021, revealed that foods sent to the units for distribution were to be transported and delivered to maintain temperatures at or below 41 degrees Fahrenheit (F) for cold foods and at or above 135 degrees F for hot foods.

During an interview with a group of residents on June 1, 2022, at 14:57 p.m., the residents stated that hot foods were served cold and cold foods were served warm.

Observations on June 2, 2022, revealed that the dinner carts for A and B wings left the kitchen at 5:25 p.m. and arrived for distribution to the residents at 5:27 p.m. A test tray was prepared and placed on the B wing food cart. The last resident's tray from the B wing food cart was served at 5:41 p.m. and the test tray was tested for temperature at 5:44 p.m. The fruit cocktail was 74 degrees F, and the milk was 49 degrees F, both items were not palatable due to tasting warm.

Interview with the Dietary Manager on June 2, 2022, at 5:46 p.m. confirmed that the temperatures of the fruit cocktail and milk were too warm.

28 Pa. Code 201.18(b)(1)(2)(e) Management.

28 Pa. Code 211.6(c) Dietary services.



 Plan of Correction - To be completed: 07/30/2022

1.) To monitor food temps following annual inspection for possible time and temperature abuse. This will be reviewed through monitoring food temperature logs of cold desserts and milk, as well as through completing test trays. Additionally, the process for preparing and delivering cold items will be modified for safe temperatures upon delivery by delivering in ice prior to service.
2.) Test trays have been used to identify the potential for others to be affected and will also be used to monitor this process by Dietary Director or designee going forward.
3.) Ice bins will be used to deliver cold beverages to the unit, in addition to preparing canned fruit prior to service to allow cooling down to food safe temperatures.
4.) Once a week test trays, and daily food temperature logs of cold fruit and milk.
a. The Dietary Director or designee will complete audits through test trays, which will be conducted once a week for a month, then once monthly after
b. Cold food temperature logs will be monitored by the Dietary Director or designee daily for two weeks, then once weekly for four weeks, then once monthly to ensure the change of service remains effective.
5.) Compliance date is July 30, 2022

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' care plans were updated/revised to reflect current care needs and/or new interventions for two of 32 residents reviewed (Residents 11, 26).

Findings include:

The facility's policy regarding care plans and interdisciplinary care conferences, dated November 1, 2021, indicated that care plans are based upon all available resident-specific information, resident assessments, and physician orders. The care plan will be reviewed and updated at least quarterly, and is based on ongoing assessments and evaluation of resident needs. It may be specifically reviewed and updated when there are medications added or discontinued, when a resident returns from the hospital, or when there is a change in the resident's mood, behavior, or activities of daily living.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated April 17, 2022, revealed that the resident was readmitted from the hospital on April 11, 2022; was cognitively impaired; required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene; and had an indwelling catheter (a tube inserted into the bladder to drain urine).

A nursing note for Resident 11, dated April 12, 2022, indicated that a 16 French (the size of the tube) foley was placed during hospitalization and drained clear, yellow urine.

Observations of Resident 11 on June 1, 2022, revealed that he was sitting in his wheelchair and he had an urinary catheter.

A current bladder incontinence care plan for Resident 11, revised on May 6, 2022, had interventions to include assistance with a scheduled toileting program by offering frequent toileting, having incontinence care provided, and to place a urinal within reach.

As of June 2, 2022, there was no documented evidence that Residents 11's care plan was updated to reflect the current care needs associated with an urinary catheter.

Interviews with the Director of Nursing and the Nursing Home Administrator on June 2, 2022, at 4:32 p.m. confirmed that the care plan was not updated to reflect that Resident 11 had a urinary catheter or his current care needs.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 26, dated March 29, 2022, revealed that she was severly cognitively impaired; was totally dependent on staff for eating; required extensive assistance for bed mobility, transfers, dressing, toileting, and personal hygiene; had a feeding tube, and an active diagnosis of diabetes mellitus (a disorder which the body does not produce enough or respond normally to insulin).

A physician's order for Resident 26, dated January 19, 2022, indicated that the resident was to be provided Glucerna 1.5 strength (liquid caloric nutrition for diabetics) at a continuous rate of 50 milliters per hour every twenty- four hours through the gastrostomy tube (a tube inserted through the belly that brings nutrition directly to the stomach).

Observations of Resident 26 on June 1, 2022, at 1:13 p.m. and June 2, 2022, at 11:00 a.m. revealed that she was receiving a continous feed of Glucerna 1.5 calorie running at 50 milliters per hour.

The feeding tube care plan for Resident 26, dated September 27, 2021, indicated that she was provided a bolus feeding (a method using a syringe to deliver formula through the feeding tube at predetermined times) of Jevity 1.5 (liquid caloric nutrition) four times a day.

As of June 3, 2022, there was no documented evidence that Residents 26's care plan was updated to reflect current physician orders.

Interviews with the Assistant Director of Nursing/Registered Nurse Assessment Coordinator on June 3, 2022, at 2:32 p.m. confirmed that Resident 26's care plan was not updated or accurate for the use of a feeding tube.

28 Pa. Code 211.11(d) Resident care plans.






 Plan of Correction - To be completed: 07/30/2022

1) Care plan for R 11 was updated for a Foley catheter on June 2, 2022
Care plan for R26 was updated with her current feeding product and rate on June 3, 2022
2) The Director of Nursing and/or designee will provide education to the nurses and the Registered Nurse Assessment Coordinator on the policy for updating the care plan with changes to the resident's status.
3) In order to protect other residents with the potential to being adversely affected the Director of nursing and/or designee will review physician orders Monday through Friday for changes that need to have the care plan updated.
4) The Director of Nursing and/or designee will audit care plan updates daily x 1 week, then weekly x 4 to ensure that care plans are updated with changes from resident's orders when needed. Audits will be reviewed at the next Quality Assurance Performance Improvement meeting to determine if the audits need to continue with revision of care plans.
5) Compliance date is July 30, 2022

UPDATE: Initial audit was completed for care plans for other residents to ensure they are up to date with current orders

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 reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for one of 32 residents reviewed (Resident 8) who smoked tobacco.

Findings include:

The facility's smoking policy, dated November 1, 2021, indicated that the facility shall implement safe smoking procedures to protect the safety and health of residents who smoke as well as those residents who do not smoke.

An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated February 4, 2022, revealed that the resident was cognitively intact; required extensive assistance for bed mobility, locomotion, dressing, toileting, and personal hygiene; and had a diagnosis of stroke with impairment of the upper and lower extremity.

Physician's orders for Resident 8, dated November 1, 2018, included an order for the resident to go outside with staff to smoke. A tobacco and nicotine care plan for the resident, dated October 1, 2020, indicated that she would be free from injuries related to tobacco smoking.

Interview with Resident 8 on June 2, 2022, at 10:51 a.m. indicated that she smokes outside of the door by the therapy room at 9:00 a.m., 11:00 a.m., 4:30 p.m., and 7:30 p.m., and staff assist her outside in her wheelchair but do not stay with her while she is outside smoking.

Observations of Resident 8 on June 3, 2022, at 8:53 a.m. revealed that the resident was being pushed by a staff member out the door next to the therapy room. The staff person turned Resident 8 around so that she faced the door, then came back inside, leaving the resident outside to smoke by herself.

Observations of Resident 8 on June 3, 2022, at 9:03 a.m. revealed that she was alone outside smoking without staff present.

Interviews with the Nursing Home Administrator, on June 3, 2022, at 9:55 a.m. confirmed that the physician's order was not updated to reflected that the resident was assessed to be independent with smoking.

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



 Plan of Correction - To be completed: 07/30/2022

1) R 8's order was updated to reflect she is an independent smoker on June 3, 2022
2) The Director of Nursing and/or designee will provide education to the staff updating physician's orders on smokers when their status changes
3) In order to protect other residents who may be adversely affected who smoke the Director of Nursing and/or designee will have their orders reviewed to ensure the correct order matches the resident's assessment for smoking.
4) The Director of Nursing and/or designee will complete weekly audits for a period of 4 weeks to ensure that new admissions who smoke will have a smoking assessment and corresponding order to match if the resident is supervised or independent with smoking. Completed audits will be reviewed at the next Quality Assurance Performance Improvement meeting to determine if the audits need to continue.
5) Compliance date is July 30, 2022

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 policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that each resident received adequate assistive devices to prevent accidents, by failing to ensure that leg/foot rests were used during wheelchair transport for one of 32 residents reviewed (Resident 15).

Findings include:

The facility's policy regarding transporting residents, dated November 1, 2021, indicated that residents would be transferred safely from one area to another.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated May 2, 2022, revealed that the resident was cognitively impaired and required staff assistance for locomotion on and off the unit. The resident's care plan, dated February 24, 2022, included that the resident was to be monitored frequently for impulsivity secondary to his inability to recognize safety needs.

Observations on June 1, 2022, at 10:13 a.m. revealed that Licensed Practical Nurse 2 pushed Resident 15 around the nurse's station into and out of the dining room, and around the nurse's station again in his Broda chair (a specialized wheelchair) while his feet were dragging on the floor. The Broda chair was not equipped with leg/foot rests during this transport. The resident put his feet down on the floor multiple times and stopped the chair causing Licensed Practical Nurse 2 to have to stop abruptly and tell him to pick and keep his feet up off the floor.

Interview with Licensed Practical Nurse 2 on June 1, 2022, at 10:15 a.m. revealed that she was not aware if Resident 15 should have leg/foot rests on his chair or not. She said that she preferred to just tell him to keep his feet up even thought he could not do that.

Interview with the Nursing Home Administrator and Director of Nursing on June 1, 2022, at 1:52 p.m. confirmed that Resident 15 was not able to hold his feet up while being pushed by a staff member.

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



 Plan of Correction - To be completed: 07/30/2022

1) R 15 had her leg rests placed on the wheel chair on June 2, 2022
2) The Director of Nursing and/or designee will provide education to the staff on the policy and procedure for having leg rests on the wheel chair prior to pushing a resident.
3) In order to protect other residents with the potential for being adversely affected, the Director of Nursing and/or designee will evaluate all wheel chairs have legs rests.
4) The Director of Nursing and/or designee will complete a random audit that residents have legs rest on their wheel chair prior to a staff member pushing him/her daily x 1 week, then weekly x 4. Completed audits will be reviewed at the next Quality Assurance Performance Improvement meeting to ensure the facility staff are meeting compliance.
5) Compliance date is July 30, 2022

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(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 review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received proper care for indwelling urinary catheters for two of 32 residents reviewed (Residents 11, 23).

Findings include:

The facility's policy regarding urinary catheters (a tube inserted and held in the bladder to drain urine), dated November 1, 2021, indicated that the drainage bag would be stored above the floor, not make contact with the floor and be contained within a privacy bag.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated April 17, 2022, indicated that the resident was cognitively impaired, was dependent on staff for care, and had an indwelling urinary catheter and a history of urinary tract infections. Physician's orders, dated March 24, 2021, included an order for the resident to have an indwelling urinary catheter due urinary retention (difficulty urinating).

Observations of Resident 11 during an activity on June 1, 2022, at 10:30 a.m. revealed that he was sitting in the dining room with other residents and his urinary catheter drainage bag was exposed and the tubing was in direct contact with the floor.

Interview with Registered Nurse Supervisor 3 on June 1, 2022, at 10:31 a.m. revealed that Resident 11 pulls his urinary catheter out frequently causing the staff to have to replace it multiple times per day and that staff must have forgot to replace the cover of the catheter.

Interview with the Director of Nursing on June 1, 2022, at 1:52 p.m. confirmed that staff should have placed Resident 11's urinary catheter drainage bag in a privacy bag.

A quarterly MDS assessment for Resident 23, dated May 18, 2022, revealed that the resident was cognitively intact; was dependent on staff for transfers; required extensive assistance for bed mobility, dressing, toileting, and personal hygiene; and had an indwelling catheter.

Physician's orders for Resident 23, dated March 10, 2022, included an order for an indwelling catheter, 18 French with a 10 cc balloon to be changed for dislodgement.

Physician's orders for Resident 23, dated April 12, 2022, included and order for the supra pubic (a tube inserted to the bladder from the abdomen) insertion site should be cleaned with soap and water, patted dry, skin prep applied to peri wound, and silicone cream applied to insertion site, covered with a split dry gauze three times a day.

Nursing notes for Resident 23, dated May 30, 2022, indicated that the resident was sent to emergency department, and the urologist changed the catheter due to a foul odor related to colonized bacteria.

Observations on June 1, 2022, at 10:17 a.m. revealed that Resident 23 was in his bed, which was in the low position, and his catheter bag was lying directly on the floor. There was no privacy bag or other type of barrier between the bag and the floor. There was a gray basin next to the catheter bag

Interview with Nurse Aide 1 on June 1, 2022, at 10:19 a.m. confirmed that the catheter was on the floor and should be in the gray basin when the bed was in low position.

Interview with the Director of Nursing on June 1, 2022, at 4:07 p.m. confirmed that Residents 23's catheter bags should not be in direct contact with the floor because this puts residents at risk for infection and Resident 11's catheter bag should be stored in a privacy bag at all times.

28 Pa. Code 201.29(j) Resident rights.

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




 Plan of Correction - To be completed: 07/30/2022

1) R 11's catheter bag was changed on June 1, 2022 due to the tubing being on the floor and a cover was placed over the catheter bag to avoid exposure.
2) In order to protect other residents with the potential to be adversely affected the Director of Nursing and/or designee will evaluate all residents with catheters to ensure there is a cover over the catheter and that catheter is placed to avoid the tubing touching the floor.
3) The Director of Nursing and/or designee will provide education to the nursing staff on indwelling urinary catheter policy and procedure
4) The Director of Nursing and/or designee will compete audits daily for 1 week that the catheter is covered and the tubing is not placed so not to touch the floor, then weekly for 4 weeks. Completed audits will be reviewed at the next Quality Assurance Performance Improvement meeting to determine if audits need to continue.
5) Compliance date is July 30, 2022
UPDATE: R23's catheter bag was changed immediately and a privacy cover was placed.

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