Nursing Investigation Results -

Pennsylvania Department of Health
KINGSTON REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

KINGSTON REHABILITATION AND NURSING CENTER
Inspection Results For:
There are 143 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


KINGSTON REHABILITATION AND NURSING CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on November 30, 2021, it was determined Kingston Rehabilitation and Nursing Center 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(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

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(b) Skin Integrity
�483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on a review of clinical records and staff interview, it was determined that the facility failed to provide care consistent with professional standards of practice to accurately assess skin breakdown and prevent pressure sores, promote healing and prevent new pressure sores from developing for one of five residents reviewed (Resident CR2).

Findings:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

Review of Resident CR2's clinical record admission on July 29, 2021, discharge on August 27, 2021 and readmission to the facility on September 24, 2021, with diagnoses to include Congestive Heart Failure, morbid obesity, and diabetes mellitus.

An Admission MDS Assessment (minimum data set - a federally mandated assessment conducted periodically to plan resident care) dated August 3, 2021, revealed that Resident CR2's cognition was intact. The resident's BIMS (brief interview for mental status, the cognitive portion of the assessment) score was 15/15. The resident required extensive assistance with activities of daily living, including bed mobility, transfers, dressing, toilet use, personal hygiene and was at risk for the development of pressure ulcers.

Review of a 5-day scheduled MDS Assessment dated October 1, 202,1 revealed that the resident had two Stage I pressure sores and was at risk for developing pressure ulcers.

A review of Resident CR2's current care plan, initially dated July 29, 2021, revealed that the resident was identified as with the potential for impairment of skin integrity. Planned interventions, prior to the development of pressure sores included the use of pressure reducing mattress, treatments as ordered, use of a draw sheet or lifting device to move resident, incontinence care, keep skin clean and dry, monitor/document location, size and treatment of skin injury. The care plan also noted that staff were to report abnormalities, failure to heal, signs and symptoms of infections, maceration etc to MD, which was initiated on July 29, 2021. A pressure reducing cushion on chair was initiated on October 8, 2021.

Review of Resident CR2's Braden Scale Assessment (a standardized, evidence -based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) dated September 28, 2021, revealed that Resident CR2 was at high risk, scoring an 11 (total score of 10-12 indicates the resident was at HIGH RISK).

Review of Resident CR2's Admission Nursing Evaluation Form dated September 28, 2021, Section 8. Skin, indicated that the resident had a Stage I pressure sore on her right buttock measuring 5.5 cm x 4.5 cm x .2 cm and a Stage I pressure injury on her left thigh measuring 7 cm x 2.5 cm x .3 cm. According to the documentation alteration location and description of a Stage I pressure sore, the skin is intact skin. However, the measurements of the resident's pressure sores noted depth, indicating an opening whereas both pressure sores had depth (right buttock .2 cm and left thigh .3 cm).

Review of Resident CR2's skin observation tool dated October 4, 2021, and locked from further documentation on October 7, 2021, indicated that the resident had skin impairments on her right outer ankle, left rear thigh and sacrum, but no measurements or descriptions were documented.

Review of Resident CR2's skin check form dated October 8, 2021 and locked on October 11, 2021, indicated that a skin check of the resident was performed and there were no new issues.

Review of Resident CR2's skin check form dated October 17, 2021, and locked October 24, 2021, indicated that a skin check was performed and new skin issues were identified. No skin issues found included an area on the resident's right buttocks measuring 5 cm x 3.5 cm identified as Moisture Associated Skin Damage (MASD- inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine/stool, perspiration), Left thigh rear 4.5 cm x 1 cm MASD, left thigh rear 1 x 0.25 MASD, and left thigh rear 3 cm x 2 cm MASD. There were no new interventions put into place upon finding the moisture associated skin damage to prevent further decline in these damaged areas of skin or if these areas of MASD had incorporated/merged with the existing pressure sores on the resident's right buttock and left thigh.

The facility failed to demonstrate timely identification of skin damage and efforts to accurately identify and address causative factors and implement applicable treatment measures inhibit further deterioration of the skin.

Review of a nurses note dated October 22, 2021, indicated that a body audit was completed on Resident CR2 which revealed an unstageable pressure ulcer to the resident's right heel measuring 2 x 1.5 x 0 cm. The area was described as necrotic, but moist and scant amount of serous drainage. The audit also noted that in addition to MASD to resident's sacrum extending into buttocks measuring 8 cm x 13 c x 0.1 cm, multiple islands of epithelialization (The process of epidermis regenerating over a partial-thickness wound surface or in scar tissue forming on a full-thickness wound is called epithelialization. The epithelium manifests as light pink with a shiny pearl appearance) with moderate amount of serous drainage were noted with surrounding skin described as moist. Additional areas of MASD were found on the resident's right posterior thigh measuring 1.5 cm x 3.5 cm x 0.1 cm and MASD to posterior left thigh measuring 1.5 cm x 10 cm x 0.1 cm with multiple islands of epithelization and serous drainage.

There was no documented evidence that the unstageable pressure sore on the resident's heel had been identified prior to finding the necrotic area during the facility house-wide body audits conducted on October 22, 2021. The resident continued to develop multiple areas of MASD without documented evidence that the facility had timely evaluated and addressed the potential contributing factors to promote healing, prevent worsening and the development of additonal areas of skin breakdown. There was no evidence that the facility had determined if staff were consistently and effectively implementing the resident's plan of care for incontinence care and keeping the resident's skin clean and dry. There was no evidence that the facility had evaluated staff's practice for bed mobility, using a draw sheet or lifting device to assure staff correctly performed these tasks in a manner to prevent shearing and friction to the resident's skin.

Interview with the Assistant Director of Nursing on November 30, 2021 at approximately 1:30 PM confirmed that there was no evidence that the resident's skin and wounds and been thoroughly consistently monitored prior to the in-house body audit sweep completed on October 22, 2021. The ADON verified that there was no documented evidence timely individualized interventions to prevent the development of further skin breakdown and worsening of existing skin impairments.

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

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

Plan of Correction - To be completed: 12/20/2021

Step 1:

Resident CR2 no longer resides at the facility

Step 2:

To identify resident with the potential to be affected the DON/designee completed body audits on current residents to identify number and types of wounds in house.

Step 3:

To prevent this from recurring the DCE/designee will provide education to the current Nursing Administration Team on the weekly documentation in the medical record. The DCE/designee will provide current licensed nursing staff and CNAs education on implementing and following the residents' plan of care for wound healing and prevention.

Step 4:

To monitor and maintain ongoing compliance the DON/designee will monitor wound documentation weekly x 4 and monthly x 2 to ensure accuracy of documentation. The DON/designee will monitor 5 residents records of residents with wound or are at high risk for skin breakdown weekly x4 then monthly x2 to ensure the resident's plan of care is followed to promote wound healing or prevent skin breakdown/ Any negative findings will be immediately corrected. The results of the audits will be brought to QAPI for review and revision as needed

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

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(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 a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to consistently and accurately monitor residents' weights and timely implement individualized measures to promote maintenance of acceptable parameters of nutritional status and management of the resident's fluid balance for one resident out of five residents reviewed (Resident CR2).

Findings include:

The facility policy "Weight Protocol" provided at the time of the survey ending November 30, 2021, indicated that it is the policy of the facility to weight each resident on admission, then weekly for four (4) weeks then monthly thereafter, unless otherwise ordered by the physician.

The policy noted any resident with weight changes of five or more pounds will be re-weighed no later than 24 hours post the original weight by the assigned CNA/designees and nurse. Additionally, interventions that are initiated in response to a weight change will be reflected in the care plan. residents with weight loss will be monitored weekly.

Review of Resident CR2's clinical record revealed admission to the facility on July 29, 2021, with diagnoses to have included unspecified systolic congestive heart failure (it is a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements), Chronic kidney disease Stage 3 unspecified (gradual loss of kidney function), and type 2 diabetes (is a condition results from insufficient production of insulin, causing high blood sugar).

A review of the resident CR2's 5- day MDS (Minimum Data Set assessment-a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated October 1, 2021, revealed that the resident was cognitively intact, weighed 349 pounds based on most recent weight in the last 30 days, and was on a therapeutic diet at the facility.

Review of CR2's clinical record revealed she was readmitted to the facility on September 24, 2021, after returning from an acute hospital stay and weighed 348.5 lbs.

A physician order dated October 27, 2021, at 6:00 AM, was noted for daily weight before breakfast. The order noted to that staff were to Notify CRNP (Certified registered Nurse Practitioner) of weight gain 2 lbs (pounds) in 24 hours or 5 lbs in 72 hours one time a daily for monitoring edema/diuretic use.

Further review of the resident's weights and vital record revealed the following:

October 18, 2021 350.2 lbs
October 22, 2021 350 lbs
October 26, 2021 343.2 pounds
October 27, 2021 263 pounds, an 80.2 lb weight loss.
October 28, 2021- 270.1 pounds
October 29, 2021- no weight recorded
October 30, 2021- 268.8 pounds
October 31, 2021- (crossed out and noted incorrect documentation by remote Registered Dietitian reviewing the resident's record offsite)
November 1, 2021- (crossed out and noted incorrect documentation by remote Registered Dietitian)
November 2, 2021- (crossed out and noted incorrect documentation by remote Registered Dietitian)
November 3, 2021, it was documented the resident weighed 314 lbs, a 45 pound weight gain in 3 days.
November 4, 2021- 301.6 pounds, a 14 pound weight loss in one day

Interview with the Assistant Director of Nursing on November 30, 2021, at approximately 1:30 PM regarding the above weight changes and cross outs by the remote Registered Dietitian, the ADON offered no comment..

Review of Resident CR2's clinical record revealed no documented evidence that the CRNP had been notified of the resident's weight gain identified on November 3, 2021, a 45 pound weight gain in 3 days, according to the physician order.

Review of Resident CR2's November 2021 Treatment Administration Record (TAR) revealed that on November 4, 2021, the resident's recorded weight listed on the November TAR was 315.8 pounds. However, Resident CR2's weights and vitals summary indicated the resident weighed 301.6 pounds on that date.

During an interview with the Nursing Home Administrator, on November 30, 2021, at approximately 2:15 PM, confirmed that the facility failed to obtain and accurately document weights as per physician order and facility policy, and failed to timely consult with the physician/physician extender regarding the resident's significant weight gain as per physician order.

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

28 Pa Code 211.6(c)(d) Dietary services

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

Plan of Correction - To be completed: 12/20/2021

Step 1:

The facility cannot retroactively correct missing weight entries in the medical record. Moving forward the facility will ensure accurate documentation in the residents' medical records.

Step 2:

To identify residents with the potential to be affected the DON/designee completed an audit of current residents to ensure accurate documentation of weight values. The facility cannot retroactively correct missing weight entries in the medical record. Moving forward the facility will ensure accurate documentation in the residents' medical records.

Step 3:

To prevent this from recurring the DCE/designee will provide education to current licensed nursing staff on obtaining and accurately documenting resident weight values.

Step 4:

To monitor and maintain ongoing compliance the DON/designee will audit 5 resident medical records weekly x 4 and monthly ensure accurate documentation of resident weight values.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

�483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at �483.70(e).

�483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

�483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

�483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on a review of information submitted by the facility, grievance reports, employee statements, clinical records and employee personnel files and staff interview, it was determined that the facility failed to assure that nursing staff possessed the necessary knowledge, competencies, and skill sets to provide care and meet a resident's individualized needs as identified in the resident's current plan of care for one resident out of five residents reviewed (Resident 3).

Findings include:

A review of Resident 3's clinical record revealed an admission date of February 26, 2021, with diagnoses including dementia (not a specific disease, dementia is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) and dysphagia (difficulty swallowing food or liquids).

A review of Resident 3's current plan of care revealed a focus of resistive/noncompliant with treatment/care dated February 26, 2021. The resident's goal was that the resident will participate with care routine/medical regimen. Intervention planned to meet this goal were to allow for flexibility in ADL routine to accommodate the resident's mood, preference and customary routine and if the resident resists care, leave (if safe to do so) and return later.

Review of an employee witness statement provided by Employee 2, Licensed Practical Nurse (Charge Nurse), in response to an allegation of resident neglect of Resident 3, revealed that Employee 1 had approached her at the nurses' station on November 17, 2021, at 10:27 PM, nearing conclusion of the 3 PM to 11 PM shift, relaying that Resident 3 refused all care throughout the shift and remained out of bed. Employee 2 noted in her statement she was not made aware of any refusals of care on the 3:00 PM- 11:00 PM shift until 10:27 PM on that date.

Employee 1's (nurse aide) witness statement indicated that Resident 3 had refused all care during the entire 3 PM to 11 PM shift on November 17, 2021. Employee 1's statement noted that she had informed two nurses and a nurse aide of Resident 3's refusals. The other nurse aide corroborated Employee 1's report.

There was no documented evidence that Employee 1 had implemented Resident 3's dementia care plan to allow for flexibility in ADL routine to accommodate the resident's mood, preference and customary routine and if the resident resists care, leave (if safe to do so) and had returned later in an attempt to promote the resident's acceptance and compliance with care. There was no evidence that Employee 1 had timely informed licensed nursing staff that the resident was refusing all care earlier during the 3 PM to 11 PM shift.

A review of Resident 3's clinical record revealed documentation that the resident had refused most nursing care on the 3:00 PM to 11:00 PM shift on November 17, 2021, for the tasks of bed mobility, dressing, personal hygiene, toilet use, bowel and bladder elimination and incontinence check and change every 2-3 hours.

A review of the employee file for Employee 1, an agency nurse aide, revealed a document dated October 9, 2021, from the staffing agency noting that Employee 1 had completed orientation through the staffing agency. However, the content of the orientation was not available nor was there demonstrated competencies detailed to ensure that the nurse aide had the required skills to carry out Resident 3's dementia-care related care plan and meet the resident's individual needs. The employee's personnel file failed to reveal evidence that Employee 1 was provided any training and orientation at the skilled nursing facility to ensure that the employee was aware and familiar with facility specific policy and possessed the specific competencies and skill sets necessary to care for residents' needs, as identified through the facility assessment, resident-specific assessments, and described in their plan of care.

Interview with the Assistant Nursing Home Administrator on November 30, 2021, indicated that the facility was unable to provide documented evidence that this agency nurse aide possessed the necessary competency and skills to render care as planned for this dementia resident and that the facility had provided the employee with the necessary training and orientation to the facility upon beginning work at the facility.

28 Pa. Code 201.20 (b)(d) Staff Development

28 Pa. Code 211.11(d) Resident care plan

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

Plan of Correction - To be completed: 12/20/2021

1.The facility cannot retroactively correct the missing evidence of Agency staff orientation including dementia training to the facility. Moving forward the facility will ensure proof of orientation including competency of dementia training of Agency staff.

2.To identify staff affected the HR director completed an audit of current Agency staff files to ensure evidence of orientation including competency for dementia training is present. The facility cannot retroactively correct the missing evidence of Agency staff orientation to the facility including competency for dementia training. Moving forward the facility will ensure proof of orientation including competency for dementia is present for Agency staff moving forward.

Step 3:
To prevent this from recurring the DCE/designee will provide education to the HR director and scheduler on ensuring proof of orientation including competency for dementia training is present for Agency staff.

Step 4:

To monitor and maintain ongoing compliance the DON/designee will audit the files of 5 agency staff members weekly x 4 then monthly x 2 to ensure proof of orientation including dementia training is present. Any negative findings will be immediately corrected. The results of the audits will be brought to QAPI for review and revision as needed.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

�483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in �483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

�483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

�483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

�483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

�483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

�483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of clinical records and select facility policy, resident and staff interview it was determined that the facility failed to provide routine and emergency drugs and biologicals for one resident out of five residents reviewed (Resident 2).

Findings include:

Review of facility policy entitled: "Pennsylvania and Delaware Narcotic Emergency Dispensing Process" revealed that the facility has a "CUBEX" in the skilled nursing facility, which is also known as an Automated Dispensing System, a locked access for narcotics requiring pharmacist authorization to remove emergency doses as this is the pharmacy supply.

Review of clinical record revealed that Resident 2, was admitted to the facility on July 18, 2021, with diagnoses to include enterocolitis (inflammation of the lining of the intestines causing severe stomach pain and diarrhea) due to clostridium difficile (bacteria).

Further review of the clinical record revealed an order dated November 26, 2021 for Percocet Tablet 10-325 milligram (Oxycodone- Acetaminophen [Tylenol]), give 1 tablet by mouth every 4 hours for pain management, to be administered at 1:00 AM, 5:00 AM, 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM

Review of progress notes in Resident 2's clinical record revealed an entry dated November 29, 2021 at 7:26 AM indicating that the Percocet Tablet 10-325 mg prescription was faxed to the physician and the Nursing supervisor was made aware.

Further review of progress notes in Resident 2's clinical record revealed an entry dated November 29, 2021 at 7:30 PM that the nurse was advised at the beginning of the shift that Resident 2 did not have any Percocet and it would be sent over from pharmacy on the evening (delivery) run. The entry noted that the nurse called the pharmacy for authorization to utilize the Automated Dispensing System (ADS) ,"CUBEX", for emergency use. The nurse advised the pharmacist that the CUBEX did not contain Percocet 10-325 mg, the dosage prescribed for Resident 2. The system contained Percocet 5-325 mg. As a result, physician notification was required to administer the dose available in the emergency supply. The Pharmacist granted authorization to obtain the medication from the CUBEX system. Resident 2 did not receive the scheduled 5:00 PM and 9 PM scheduled dose Percocet 10-325 mg

A nursing note dated November 29, 2021, at 8:55 PM indicated that the pharmacy called backed and informed the facility nursing staff that Resident 2's medications will be sent to the facility on the midnight (delivery) run. However, the pain medication did not arrive at the facility until November 30, 2021 at 10:10 AM while the surveyor was present on the nursing unit.

Interview with Resident 2 on November 30, 2021 at 10:05 AM revealed that the resident stated that she doesn't understand why her scheduled medicine is "just not available." The resident stated that she didn't receive Percocet last night or this morning.

Review of Resident 2's November 2021 Medication Administration Record revealed that the resident did not receive Percocet 10-325 mg as ordered due to unavailability on November 29, 2021, at 5 PM and 9 PM, November 30, 2021 at 1:00 AM and November 30, 2021 at 5:00 AM. The dose scheduled for November 30, 2021 at 9:00 AM. was administered later that morning, upon pharmacy delivery on November 30, 2021, at 10:10 AM.

Interview with the Nursing Home Administer on November 30, 2021 at 2:15 PM confirmed the facility failed to provide routine and emergency drugs.

28 Pa. Code 211.9 (a)(l)(d)(k) Pharmacy Services.

28 Pa. Code 211.12 (a)(c)(d)(3)(5) Nursing Services.

Plan of Correction - To be completed: 12/20/2021

Step 1:
The facility cannot retroactively correct the inability to provide resident with medication as ordered.
Moving forward the facility will ensure that residents receive medications as ordered.
Step 2:
To identify residents with the potential to be affected the DON/designee completed an audit on current
residentmedication administration times for the month of November ( Do we want to day two weeks?)
to ensure that medications were administered timely. Residents with negative findings were assessed.
Physicians/CRNPs and RPs were notified, and new orders were implemented as indicated.
Step 3:
To prevent this from recurring changes in pharmacy procedures for delivery of medications is occurring
as an outcome of a meeting held with pharmacy. The DCE/designee provided education to current
licensed nursing staff on the new process for medication delivery. The DCE/designee provided education
to current licensed nursing staff on the process of obtaining medications when unavailable on hand.
Step 4:
To monitor and maintain ongoing compliance the DON/ designee will audit 5 residents weekly x 4 and
monthly x 2 to ensure that resident meds are provided er physician order. Any negative findings will be
immediately corrected. The results of the audits will be brought to QAPI for review and revision as
needed.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:

�483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

�483.55(b) Nursing Facilities.
The facility-

�483.55(b)(1) Must provide or obtain from an outside resource, in accordance with �483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

�483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

�483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

�483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

�483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Observations:

Based on review of select facility policy, clinical records, and grievances lodged with the facility, family and staff interview it was determined that the facility failed to timely obtain dental services requested for one resident out of five residents reviewed (Resident 3).

Findings include:

Review of the current facility policy entitled: "Dental Services" indicated that dental services are available to residents, including, but not limited to examination, oral prophylaxis, and emergency dental care to relieve pain and infection. Additionally, the policy indicates the care plan is comprehensive and consistent with the resident's specific conditions, risks, needs, goals, behaviors, preferences, and current standards of practice, including measurable objectives and timetables with specific interventions/ services for the management and treatment of dental/oral symptoms, including interventions to address or resident resistance to care, if appropriate.

A review of Resident 3's clinical record revealed readmission to the facility August 24, 2020, with diagnoses including dementia (not a specific disease, dementia is a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement) and dysphagia (difficulty swallowing food or liquids).

A review of Resident 3's annual MDS Assessment dated February 2, 2021, (Minimum Data Set - a federally mandated standardized assessment completed at intervals to plan resident care) revealed, under Section L "Oral/Dental Status" that the resident had "obvious or likely cavity or broken natural teeth." The resident's cognition was severely impaired with a BIMS score of 3.

Review of the Resident 3's current plan of care failed to identify any planned interventions to address the resident's concerns with her dental status.

A review of email correspondence Resident 3's responsible party sent to the facility Nursing Home Administrator dated October 11, 2021, revealed that the Responsible Party relayed that he had been provided any information regarding dental services for his mother aside from mobile dental canceling the appointment with the facility on August 26, 2021. The resident's responsible party noted that his mother complains that her teeth are hurting, for months now.

A review of email correspondence dated October 21, 2021, between resident's Responsible Party to the NHA, revealed that the NHA advised the resident's responsible party that the mobile dental service was scheduled to be at the facility during October 2021. The resident's responsible party noted in his email that he called the facility nurse on October 21, 2021 and he was advised by a nurse that there were no notes available regarding a dental visit with Resident 3.

An electronic email transmittal dated October 28, 2021, to the Nursing Home Administrator (NHA), Resident 3's Responsible Party asks the NHA for the status of mobile dental services for his other.

Review of Resident 3's progress notes revealed an entry dated November 24, 2021, at 5:19 PM indicating that the dentist was in to see the resident, but the resident had refused. There was no further documentation regarding this dental visit.

Review of a facility grievance submitted by Resident 3's Responsible Party dated November 27, 2021, indicated that he had brought his concerns to the facility's attention regarding his mother dental health needs on multiple occassions going back to before June 2021.

Nursing progress notes dated November 29, 2021, revealed that the facility had called the emergency dental provider and dental services were arranged for Resident 3 on December 1, 2021.

Information provided by the Assistant Nursing Home Administrator (ANHA) during the survey of November 30, 2021, revealed that during August of 2021 (no day provided) mobile dental services were cancelled (did not indicate why). During September 2021 mobile dental did not come to the facility due to a COVID-19 outbreak. During October 2021 (no date provided) dental arrived at 3:30 PM and only saw "emergent" residents because they did not arrive at the facility until late afternoon as they were held up at another facility. During November 2021 ( no date provided) dental services was at the facility, but according to the facility documentation Resident 3 refused treatment.

Review of the emergency dental provided consultation report (undated), but confirmed by the ANHA during interview on December 1, 2021, was for the treatment rendered on December 1, 2021, revealed that Resident 3 had 4 lower teeth extracted and continuous dissolvable sutures placed in her mouth.

Interview with Resident 3's Responsible Party on December 2, 2021 revealed he was advised by the facility that the facility has scheduled an emergency dental appointment for his mother due to a nurse observing his mother's oral cavity and identified concerns related to her gums and teeth. Resident 3's RP indicated he had tried to coordinate dental services for his mother dating back to before June of 2021. According to the RP, he requested that he be made aware of all his mother's appointments in order to be present for familiarity for his mother and to promote her acceptance of the services. The resident's RP stated that his mother has had oral pain for months and nothing was done by the facility. He relayed that his mother had to have 4 teeth removed and sutures placed due to the severity of her dentition. The resident's RP stated that he does not understand why it took so long to obtain dental services for his mother. The RP stated that the resident received dental services only after one report from a nurse, resulting in the appointment being made. The resident's RP stated that he had been trying to obtain these services from the facility for months.

Interview with the Assistant Nursing Home Administrator on December 3, 2021, revealed that when Resident 3's responsible party sends a concern via email an in-person appointment is arranged. The ANHA stated that he was aware of Resident 3's RP's request to be present for all of Resident 3's appointments, but the ANHA stated that exact time of mobile dental arrival is not provided to the facility and it was difficult to ensure the RP is available and made aware. The Assistant Nursing Home Administer confirmed that the facility failed to timely arrange dental services for Resident 3 and coordinate the services with the resident's RP to extent possible to assure that Resident 3's dental health needs were met in a timely manner.

28 Pa. Code 201.29 (l)(2) Resident rights

28 Pa. Code 211.15 (a) Dental services

Plan of Correction - To be completed: 12/20/2021

Step 1:

Dental services were provided to Resident 3 on December 1, 2021.

Step 2:

To identify residents with the potential to be affected the DON/designee completed on audit on current residents to determine if residents are experiencing dental issues. Residents identified were provided with dental services.

Step 3:

To prevent this from recurring the DON will provide education to IDT on scheduling routine and emergent dental services.

Step 4:

To monitor and maintain ongoing compliance the DON/designee will monitor 5 resident records weekly x4 then monthly x2 to ensure that residents dentals needs are met. Any negative findings will be immediately corrected. The results of the audits will be brought to QAPI for review and revision as needed.

� 211.9(j) LICENSURE Pharmacy services.:

(j) Disposition of discontinued and unused medications and medications of discharged or deceased residents shall be handled by facility policy which shall be developed in cooperation with the consultant pharmacist. The method of disposition and quantity of the drugs shall be documented on the respective resident's chart. The disposition procedures shall be done at least quarterly under Commonwealth and Federal statutes.

Observations:

Based on review of closed clinical records and select facility policy and staff interview, it was determined that the facility failed to account for the disposition of medications upon discharge of two residents out of two closed records sampled ( Resident's CR1 and CR2)

Findings include:

A review of current facility policy entitled Disposition of Medications Upon Discharge revealed that it was facility upon discharge or leave of absence from the facility, the resident's medications are to be released with the resident or to be returned to the pharmacy based on resident's payor source.

A review of the clinical record of Resident CR1 revealed that the resident was discharged from the facility on November 8, 2021. There was no documented evidence that the facility accounted for the disposition or quantity of any remaining medications upon the resident's discharge.

A review of Resident CR2's clinical record revealed that the resident was discharged from the facility on November 9, 2021, to home. There was no documented evidence that the facility accounted for the disposition or quantity of remaining medications upon the resident's discharge.

Interview with the Assistant Nursing Home Administrator on November 30, 2021 confirmed that there was no documented evidence of the accounting and disposition or the residents' remaining medications for two closed records reviewed.

Plan of Correction - To be completed: 12/20/2021

Step 1:

The facility cannot retroactively correct medication disposition not being completed on Residents CR1 and CR2. Moving forward the facility will ensure that medication dispositions are completed on residents discharged from the facility.

Step 2:

To identify resident with the potential to be affected the DON/designee an audit was completed of all residents discharging within the last 30 days to confirm med disposition had been completed. The facility cannot retroactively correct incomplete medication dispositions on residents previously discharged. Moving forward the facility will ensure that medication dispositions are completed on residents discharged from the facility.

Step 3:

To prevent this from recurring the DCE/designee will provide education to current licensed nursing staff on completion of medication disposition for discharging residents.

Step 4:

To monitor and maintain ongoing compliance the DON/designee will audit 5 discharged resident charts weekly x 4 and monthly x 2 to ensure accurate completion of medication disposition upon discharge. Any negative findings will be immediately corrected. The results of the audits will be brought to QAPI for review and revision as needed.

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