Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-LEBANON
Patient Care Inspection Results

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MANORCARE HEALTH SERVICES-LEBANON
Inspection Results For:

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MANORCARE HEALTH SERVICES-LEBANON - 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 Civil Rights Compliance survey completed on January 9, 2019, it was determined that Manor Care Health Services-Lebanon was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment was completed to accurately reflect the resident's current status for two of 31 sampled residents. (Residents 89, 115)

Findings include:

Clinical record review revealed that Resident 89 had a diagnosis of end-stage cirrhosis. On November 22, 2019, a physician ordered for the resident to receive hospice services. Review of a nursing note dated November 21, 2019, revealed that the resident was admitted to hospice services on November 20, 2019. The significant change MDS assessment dated November 25, 2019, failed to identify that the resident was currently receiving hospice services.

Clinical record review revealed that Resident 115 had a diagnosis of chronic kidney disease and a dependence on dialysis. Review of physican's orders revealed that since August 31, 2019, the resident was on dialysis services. The annual MDS assessment dated December 9, 2019, failed to identify that the resident was currently receiving dialysis services.

In an interview on January 9, 2020, at 10:37 a.m., the Administrator stated that the aforementioned MDS assessments had not been completed accurately to reflect the residents' current status.

28 Pa. Code 211.5(f) Clinical records




 Plan of Correction - To be completed: 02/18/2020

The statements made on this plan of correction are not an admission to, and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take actions set forth in the following plan of correction. The following plan of corrections constitutes the centers allegation of compliance.

1. Minimum Data Set's for R89 and R115 have been corrected and submitted.

2.Clinical Reimbursement Specialist has conducted a review of recent Minimum Data Set assessments for current residents to determine accuracy of Minimum Data Set coding in regards to dialysis and hospice.

3.Clinical Reimbursement Specialist will review RAI Manual Chapter 3, Section O Dialysis and Hospice coding requirements with the Registered Nurse Assessment Coordinator and the Licensed Minimum Data Set Coordinator.

4. Clinical Reimbursement Specialist will review 10 random selected Minimum Data Set assessments weekly to determine accuracy of Minimum Data Set coding. Results of the audits will be reported to monthly QAPI for 3 months to determine trends or need for further audits.
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 review of facility policy, clinical record review and staff interview, it was determined that the facility failed to provide treatment and services in a timely manner for a resident with an elevated blood sugar for one of 31 sampled residents. (Resident 57)

Findings include:

Review of the facility policy entitled "Hyperglycemia:Treatment," dated January 1, 2020, revealed that when a resident experienced a hypoglycemic event (low blood sugar) the staff was to monitor the resident vital signs, included remaining with the resident, monitoring blood glucose levels every 15 minutes until stabilzed, and to update the residents family and physican of the residents condition.

Clinical record reviewed revealed that Resident 57 was admitted to the facility on May 22, 2019, with a diagnosis that included metabolic encephalopathy (a chemical imbalance in the brain caused by illness), malnutrition, diabetes and hyperglycemia (high blood sugar). The minimum Data Set assessment, dated August 21, 2019, indicated that the resident's cognition was severly impaired and required extensive staff assistance for activities of daily living. Review of the care plan revealed a problem area related to diabetes with interventions that included for staff to obtain labs and notifying the physican of the results. A progress noted dated October 29, 2019, at 8:15 a.m., revealed that Resident 57 had a blood sugar level of 556 milligrams per deciliter (mg/dl) and that the physican was notified. Documentation at 4:05 p.m., revealed the nurse practitioner was notified by staff to assess the resident. The nurse practitioner had given orders for insulin to be administered. There was no documentation in the clinical record to support that staff stayed with the resident per policy, that vitals signs were obtained, that the blood glucose levels were monitored every 15 minutes until stabilzed and that insulin was administered as ordered by the nurse practitioner.

In an interview on January 8, 2020, at 10:24 a.m., the Director of Nursing confirmed the facility policy, physician orders and care plan interventions, were not followed in response to the residents hyperglycemic episode.


28 Pa. Code 211.12(d)(1)(5) Nursing Services
Previously cited 1/14/19, 2/7/19

28 Pa. Code 211.10 (c) Resident Care Policies
Previously cited 1/4/19














 Plan of Correction - To be completed: 02/18/2020

The statements made on this plan of correction are not an admission to, and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take actions set forth in the following plan of correction. The following plan of corrections constitutes the centers allegation of compliance.

F684

1. Resident 57 has orders written by the Certified Registered Nurse Practitioner for blood sugars and is currently stable.

2. Diabetic residents getting blood glucose checks will be reviewed for a 2 week look back to ensure that the Medical Doctor/Certified Registered Nurse Practitioner were notified and resident had no ill effects. Residents identified with elevated glucose will have proper Medical Doctor/Certified Registered Nurse Practitioner notification and will be observed per policy.

3. Licensed staff will be educated on F684 and policy regarding hyperglycemia.

4. Director of Nursing/designee will audit 10 random diabetic resident's weekly who are getting blood sugar checks to validate that staff are following the hyperglycemia policy. Results of the audits will be reported to monthly QAPI for 3 months to determine trends or need for further audits.

483.30(a)(1)(2) REQUIREMENT Resident's Care Supervised by a Physician: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.
483.30 Physician Services
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

483.30(a) Physician Supervision.
The facility must ensure that-

483.30(a)(1) The medical care of each resident is supervised by a physician;

483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a physician supervised care in a timely manner of one of 31 sampled residents.

Findings include:

Clinical record review revealed that Resident 57 had diagnoses that included metabolic encephalopathy (a chemical imbalance in the brain caused by illness), malnutrition, diabetes, and hyperglycemia (high blood sugar). The Minimum Data Set assessment dated August 21, 2019, indicated the resident's cognition was severly impaired and he required extensive staff assistance for activities of daily living. Review of a progress notes dated October 29, 2019, revealed a elevated blood sugar of 556 milligrams per deciliter. At 8:15 a.m., the staff had called the resident's physcian to notified him of the residents blood sugar results. There was no documentation in the clinical record that the physcian responded.

In a interview on January 8, 2020 at 10:25 a. m., the Director of Nursing confirmed that the physican had not responded to the nurse's phone call

28 Pa. code 211.12(d)(1)(5) Nursing services.
Previously cited 1/14/19, 2/7/19

28 Pa. code 211.2(a) Physicians services.




 Plan of Correction - To be completed: 02/18/2020

The statements made on this plan of correction are not an admission to, and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take actions set forth in the following plan of correction. The following plan of corrections constitutes the centers allegation of compliance.

F710

1. Resident 57 has orders written by the Certified Registered Nurse Practitioner for blood sugars and is currently stable.

2. Diabetic residents getting blood glucose checks will be reviewed for a 2 week look back to ensure that the Medical Doctor/Certified Registered Nurse Practitioner were notified.

3. Licensed staff will be educated on F710 and Medical Doctor/Certified Registered Nurse Practitioner notification.

4. Director of Nursing/designee will audit 10 random residents for 12 weeks to validate that Medical Doctor/Certified Registered Nurse Practitioner has been notified. Results of the audits will be reported to monthly QAPI for 3 months to determine trends or need for further audits.

201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other State and local agencies responsible for the health and welfare of residents.
Observations:

Based on review of facility infection control committee documentation, policy review, and staff interview, it was determined that the facility failed to include require infection control committee members in accordance with facility policy and Act 52 Infection Control Plan (40 P.S. 1303.403).

Findings include:

Review of the facility policy entitled "Antibiotic Stewardship," dated January 1, 2020, revealed that the facility infection control committee must include medical staff and pharmacy staff.

The Act 52 Infection Control plan stipulates that a health care facility should develop and implement an internal infection control plan that should be established for improving the health and safety of residents and health care workers. The plan should include a multidisciplinary committee including a representative from each of the following, if applicable, to the specific health care facility:

(i) Medical staff that could include the chief medical officer or the nursing home medical director.
(ii)Administration representatives that could include the chief executive officer, the chief financial officer, or the nursing home administrator.
(iii) Laboratory personnel
(iv) Nursing staff that could include a director of nursing or a nursing supervisor.
(v) Pharmacy staff that could include the chief of pharmacy.
(vi) Physical plant personnel.
(vii) A patient safety officer.
(viii) members from the infection control team, which could include an epidemiologist.
(ix) The community, except that these representatives may not be an agent, employee or contractor of the health care facility.

Based on review of infection control data and meeting sign in sheets, the facility failed to ensure that a community member was part of the multidisciplinary infection control committee from October through December, 2019.

In an interview on January 9, 2020, at 10:33 a.m. the facility infection preventionist confirmed that medical or pharmacy staff were not part of the infection control committee.



 Plan of Correction - To be completed: 02/18/2020

The statements made on this plan of correction are not an admission to, and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken or will take actions set forth in the following plan of correction. The following plan of corrections constitutes the centers allegation of compliance.

400


1. No residents affected.

2. Review of last 3 months attendance records to validate required members were in attendance.

3. Educate leadership team and Interdisciplinary Care Team of required attendees for monthly meeting.

4. Audit monthly Infection Control attendance sheet for compliance times 3 months. Results of the audits will be reported to monthly QAPI for 3 months to determine trends or need for further audits.


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