Pennsylvania Department of Health
SARAH A. TODD MEMORIAL HOME
Patient Care Inspection Results

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SARAH A. TODD MEMORIAL HOME
Inspection Results For:

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SARAH A. TODD MEMORIAL HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights survey completed on February 1, 2024, it was determined that Misericordia Nursing & Rehabilitation 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(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of facility policy, record review, observations, and staff interviews, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of 21 residents reviewed (Resident 86).

Findings include:

Review of facility policy, titled "Procedure: Infection Control: BiPAP [bi-level positive airway pressure which is a type of ventilator used to treat sleep apnea] & CPAP [Continuous Positive Airway Pressure - a machine that uses mild air pressure to keep breathing airways open while one sleeps] Devices", dated May 14, 2013, with a last review date of January 25, 2024, revealed the following, in part: "E. The following must be done weekly: 4. Change Ziploc bag weekly that holds mask date and initial (3-11); V. SPECIAL CONSIDERATIONS: A. When the mask is not in use store in clear Ziploc bag (bags to be replaced weekly); and B. Date and initial on bag when changed."

Review of Resident 86's clinical record revealed diagnoses that included obstructive sleep apnea (intermittent airflow blockage during sleep), dementia (a chronic disorder of the mental processes caused by brain disease, and marked by memory disorders, personality changes, and impaired reasoning), and Parkinson's disease (a long term degenerative disorder of the central nervous system that mainly affects the motor system).

Review of Resident 86's physician orders revealed an order for CPAP mask-wash daily with soap and water, air dry, dated July 13, 2023.

Observations of Resident 86's room on January 29, 2024, at 10:20 AM and 12:39 PM, revealed their CPAP mask was attached to tubing, which was attached to the machine, laying directly on the nightstand and not bagged.

Observation of Resident 86's room on January 30, 2024, at 11:09 AM, revealed their CPAP mask was attached to tubing, which was attached to the machine, bagged in a black bag dated "8/[?]" The actual day date was noted be illegible as it had been written over.

During an interview with Employee 2 on January 30, 2024, at 11:28 AM, the aforementioned observation was shown. Employee 2 confirmed that the actual date was illegible on the bag in which the CPAP mask was being stored. Employee 2 further indicated that they were not sure of the policy as to when the bag should be changed, but they would look into it.

Further review of Resident 86's physician orders revealed no order for the CPAP storage bag to be changed on a weekly basis prior to January 30, 2024.

Review of Resident 86's January Medication, Treatment, and Task Administration Record Report or documentation of the CPAP storage bag being changed on a weekly basis prior to January 30, 2024.

Observation of Resident 86's room on January 30, 2024, at 11:28 AM, revealed that their CPAP mask was stored in a clear Ziploc bag dated January 30, 2024.

During an interview with the Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) on January 31, 2024, at 10:51 AM, all the aforementioned observations were shared. The ADON indicated that Resident 86 had an order for their mask to be rinsed and air dried daily. It was further discussed that the observations on January 29, 2024, revealed that their CPAP mask was still attached to the tubing and to the machine. In addition, it was again shared that the mask was laying directly on the nightstand with no barrier between the mask and the surface of the nightstand.

During a follow-up interview with the NHA and DON on January 31, 2024, at 2:25 PM, the DON confirmed that the CPAP mask should not have been laying directly on the nightstand without a barrier if it was being air dried, and that the storage bag should have been changed weekly.

28 Pa code 211.12(d)(1)(2) Nursing Services


 Plan of Correction - To be completed: 02/20/2024

Staff who take care of Resident 86's Bipap are aware of this policy and how to take care of resident's mask.


All residents' who have BIPAP/CPAP masks will have them stored per policy. They will also have a physician's order for the CPAP/BIPAP storage bag to be changed on a weekly basis. All masks will be dried using an electronic CPAP supplies drier.

Nursing staff will be educated on our CPAP/BIPAP policy/procedure.

Audits will be completed weekly on 3 residents for one quarter to ensure that the physician's orders are in place and that the ziploc bag is in intact and is being changed weekly with a legible date on the bag. After that, the audits will be completed bi-weekly on 3 residents for one month to ensure compliance. The results of these audits will be reported to the Quality Assurance and Performance Improvement Committee.

Corrective Action will be completed by 2/20/24.

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