Nursing Investigation Results -

Pennsylvania Department of Health
CORRY MANOR
Patient Care Inspection Results

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CORRY MANOR
Inspection Results For:

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CORRY MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, Civil Rights Compliance, and State Licensure Survey and an Abbreviated Complaint Survey completed on March 4, 2021, it was determined that Corry Manor was not in compliance with the 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:


483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning 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.
483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Observations:

Based on review of clinical records, facility policy, and the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (provides instructions and guidelines for completing required Minimum Data Set [MDS - federally mandated periodic assessments of a resident care needs]), and staff and resident interviews, it was determined that the facility failed to ensure that residents and/or resident representatives were afforded the opportunity to participate in an admission interdisciplinary care plan meeting for two of 25 residents reviewed. (Residents R58 and R60)

Findings include:

The RAI User's Manual dated October 2019, indicated that resident involvement in care plan meetings is imperative to address dignity and self-determination and that residents should be asked if they desire family members, significant others and/or legally authorized persons to participate. The manual further directs that if the resident is unable to understand the process, or participate, family, significant others and/or legally authorized persons should be invited to attend if possible.

The facility policy entitled "Comprehensive Care Plan," dated 11/30/2020, revealed that resident care plans would be developed within seven days following the completion of the comprehensive assessment and would be prepared by an interdisciplinary team, and to the extent practicable, the resident and the resident's family or their representative.

Resident R60's Admission MDS dated 1/11/2021, revealed an admission date of 1/04/21, with diagnoses that included surgical aftercare following surgery on the nervous system (brain surgery following a traumatic head injury), a tracheostomy (an opening made into the windpipe to aid breathing), and a gastrostomy (an opening into the stomach through the abdominal wall usually for feeding/fluid introduction). The MDS revealed that Resident R60 had severe cognitive (mental) impairment; was totally dependent on two staff to move in bed, transfer, eat, dress and use the bathroom; and that oxygen and suctioning treatments were provided during the assessment period.

During an interview on 3/04/2021, at 1:00 p.m. the facility Corporate Registered Nurse indicated that when care plan meetings are conducted an Interdisciplinary Care Plan Meeting form is completed.

Resident R60's clinical record lacked an Interdisciplinary Care Plan Meeting form, or other documentation to reflect that an interdisciplinary care plan meeting was conducted or that Resident R60 and/or his/representative were invited to participate in an interdisciplinary care plan meeting following completion of the Admission Comprehensive MDS.

During an interview on 3/04/2021, at 1:15 p.m. the Director of Nursing (DON) confirmed that Resident R60's clinical record lacked evidence that Resident R60 and/or his/her representative were invited to participate in an interdisciplinary care plan meeting or that a care plan meeting was conducted following completion of the Admission Comprehensive MDS.


Resident R58's Admission MDS dated 10/13/2020, revealed an admission date of 10/06/2020, with diagnoses that included cerebral palsy (a condition marked by impaired muscle coordination with spastic [muscle spasms] paralysis typically caused by damage to the brain before or at birth); pressure ulcers of the sacrum (tailbone area) and buttock; and a neurogenic bladder (inability to urinate from a lack of nerve stimulation to the bladder). The MDS indicated that Resident R58 was interviewable and cognitively intact.

During an interview on 3/01/20/21, at 12:55 p.m. Resident R58 indicated that he/she was admitted after developing wounds of the buttocks/sacrum, had lived with friends prior to admission and remembered participating in "maybe one" care plan meeting since admission.

Resident R58's clinical record lacked an Interdisciplinary Care Plan Meeting form, or other documentation to reflect that an interdisciplinary care plan meeting was conducted or that Resident R58 and/or his/representative were invited to participate in an interdisciplinary care plan meeting following completion of the Admission Comprehensive MDS.

During an interview on 3/04/21, at 1:55 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that Resident R58's initial care plan meeting following admission was not conducted and that care plan meetings had not been conducted as required.

28 Pa. Code 211.11(e) Resident care plan

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









 Plan of Correction - To be completed: 04/19/2021

A Care Plan meeting was unable to be completed for R60 due to the resident discharging home.
A care plan meeting was completed with R 58 and their family on 3-17-21.

An audit of the all residents admitted in the last 3 months will be completed to determine if an initial care plan meeting took place and the resident and/or resident representative has been afforded the opportunity to attend the care plan meetings per the facility policy. Care plan meetings will be completed as needed.

All residents and/or representatives will be afforded the opportunity to participate in their interdisciplinary care plan meetings. The resident and/or resident's representative will be issued a letter indicating a care plan will occur prior to the meeting date. A follow up phone call will be made to the representative prior to the meeting for confirmation. A face to face contact will be made with the resident to confirm the meeting date and time.

Interdisciplinary team will be educated by the Corporate Registered Nurse on completing care plan meetings in accordance with the Long Term Care Resident Assessment Instrument and the facility policy by March 30, 2021.

Resident Services Coordinator will audit all the new admissions' initial care conferences to ensure compliance with the facility policy 5 times a week for two weeks, weekly times 2 weeks and then monthly for 2 months. The Director of Nursing will audit the Resident Services Coordinator.

Results of the audits will be reviewed at the Quality Assurance meeting monthly as needed.

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 review of facility policies and clinical records and staff interviews, it was determined that the facility failed to comprehensively assess and monitor pressure ulcers within required timeframes for two of four residents with pressure ulcers reviewed (Residents R13 and R15).

Findings include:

Current facility policy entitled "Pressure Ulcer Policy" dated 11/30/2020, indicated that " ....the wound will be monitored at least weekly and should have documentation including: 1. Location and Staging, 2. Size (perpendicular measurements of the greatest extent of length and width of the ulceration), depth; and the presence, location and extent of any undermining or tunneling / sinus tract, 3. Drainage, the amount and characteristics, 4. Pain if present and characteristics, and 5. Wound bed and surrounding tissue."

Resident R13's clinical record revealed an admission date of 6/17/2014, with diagnoses that included diabetes, dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus), dementia, and osteoporosis (a condition in which the bones become weak and brittle)

Review of Resident R13's clinical record assessment entitled "Nursing Wound Documentation Record - V 4" revealed that measurements and assessments of Resident R13's right and left sacral ulcers were completed on 2/7/2021, and not again until 2/18/2021, a period of 11 days.

During an interview on 3/4/2021, at 1:20 p.m. the Assistant Director of Nursing (ADON) confirmed that Resident R13's pressure ulcer measurements / assessments were not completed as frequently as required from 2/07/2021, through 2/18/2021, as indicated in the "Nursing Wound Documentation Record V 4."


Resident R15's clinical record revealed an admission date of 6/9/2016, with diagnoses that included high blood pressure, diabetes, and gastro-esophageal reflux (GERD - chronic digestive disease where the liquid content of the stomach refluxes into the esophagus).

The clinical record revealed that upon readmission to the facility on 10/13/2020, Resident R15 had a Stage 4 (full thickness loss) pressure ulcer to the coccyx with tunneling that was present prior to being admitted to the hospital.

The clinical record assessment entitled "Nursing Wound Documentation Record - V 4" included measurements / assessments completed on 10/17/2020, and not again until 10/30/2020, a period of 13 days. Following the 10/30/2020, documentation of the next clinical record assessment including measurements and assessment was not completed until 11/12/2020, a period of 13 days. The clinical record assessment entitled "Nursing Wound Documentation Record - V 4" included measurements / assessments that were completed on 1/13/2021, and not again until 1/27/2021, a period of 14 days.

During an interview on 3/4/2021, at 11:59 a.m. the ADON confirmed that Resident R15's pressure ulcer measurements / assessments were not completed as frequently as required.

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

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.5(f) Clinical records










 Plan of Correction - To be completed: 04/19/2021

R13 and R15 had a comprehensive assessment of their wounds completed on 3-18-2021. R13 and R15 will have weekly documentation completed per the facility policy effective immediately.

An audit of all the residents with wounds will be completed by the Assistant Director of Nursing/designee to ensure weekly documentation has been completed. Wound assessments will be completed as needed.

All residents with wounds will have a comprehensive wound assessment completed per the facility policy.
NHA/designee will educate the ADON and the Wound Nurse on the facility policy and procedure for Nursing Wound Documentation by March 18, 2021.

The ADON will audit all the wound assessments 5 days a week for 2 weeks, weekly times two weeks and then monthly for 2 months. The Director of Nursing/designee will monitor the Assistant Director of Nursing/designee.

Results of the audits will be reviewed at the QA meeting as needed.

201.22(g) LICENSURE Prevention, control and surveillance of TB.:State only Deficiency.
(g) A written report of test results shall be maintained in the facility for each individual, irrespective of where the test is performed. Reactions shall be recorded in millimeters of induration, even those classified as negative. If no induration is found, "0 mm" is to be recorded.
Observations:


Based on review of employee personnel files and staff interview, it was determined that the facility failed to ensure that new employees that received the two-step tuberculin (TB) skin test (injection given under the skin to test for tuberculosis) had their results correctly documented for one of five new employees (Housekeeping Employee E2)

Findings include:

Housekeeping Employee E2's personnel file revealed a hire date of 12/15/2020, and had the second step of the TB test administered on 12/19/2020. There was no documented evidence regarding what the test results were recorded in millimeters.

During an interview on 3/4/2021, at 10:55 a.m. the Regional Manager confirmed that Housekeeping Employee E2's TB test results were not documented as required.



 Plan of Correction - To be completed: 04/19/2021

E2 had a new two-step TB test administered, read and the induration was documented.

All the new employees hired in the last three months will be audited to determine if their two-step TB was administered, read and induration recorded. Testing will be completed as needed.

All new employees will have a two-step PPD administered per facility policy effective immediately.

NHA/designee will educate the Human Resources Coordinator on the facility policy for the Administration of Two-Step TBs by March 18, 2021.

Human Resources Coordinator will audit all new hire TB documentation prior to start date to ensure compliance of TB testing, reading and recording 5 times a week for two weeks, weekly times 2 weeks and then monthly for 2 months. DON/designee will audit the Human Resources Coordinator

Results will be reviewed at the QA meeting as needed.



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