Nursing Investigation Results -

Pennsylvania Department of Health
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MESSIAH LIFEWAYS AT MESSIAH VILLAGE
Inspection Results For:

There are  101 surveys for this facility. Please select a date to view the survey results.

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MESSIAH LIFEWAYS AT MESSIAH VILLAGE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights and complaint survey completed on January 9, 2020, it was determined that Messiah Lifeways at Messiah Village 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:


483.60(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 observations, meal test tray, review of select facility documents, individual resident interviews and staff interviews it was determined that the facility failed to serve food that was palatable regarding temperatures and taste for one of one test trays trialed and for two residents (Residents 113 and 153) out of 47 residents reviewed.

Findings include:

During an interview with Resident 113 on January 7, 2020, at 9:54 AM, the resident stated that the food "has gone downhill" and "the food is not always hot."

During an interview with Resident 153 on January 8, 2020, at 2:18 PM, the resident had complaints that food was cold.

Review of facility provided Nursing Care Food Committee Meeting Minutes, representing nine monthly meetings going back to March 2019, revealed concerns of foods not being served warm/hot enough for eight of the nine meeting minutes.

On January 9, 2020, a lunch meal test tray was completed of the dining service on the Donegal Nursing unit starting at 12:25 PM, following plating/service of the last resident meal, with completion of last temperature check at 12:32 PM. The test tray temperatures were taken by Assistant Dining Services Manager (ADSM) 1 using a dining services digital thermometer. Meals for residents on the Donegal unit consist of prepared bulk food items which are transported to the dining area on the unit and then placed into containers on a steam table for service, from which the desired food items are directly placed on a plate for the individual residents.

Temperature results were: one serving of Bean Soup 130 degrees Fahrenheit (F)/ taste: good/ temperature: slightly warm; one serving sliced turkey with gravy 121.8 degrees F/ taste: very good/temperature: little warmth; one serving stuffing 109 degrees F/ taste: bland/temperature: no warmth; one serving diced carrots 111 degrees F/ taste: good/temperature almost cold; one serving coffee 150 degrees F/ taste: good/temperature: very good; cranberry juice 62 degrees F/ taste: acceptable/temperature: warm; pumpkin pie 46 degrees F/ taste: sweet with little pumpkin flavor/ temperature: acceptable.

Review of provided Policy: 5.18 (SD) Food Temperatures; Section: Sanitation & Infection control; Policy: Food Temperature with noted last revised date of November 2017, revealed "A delivery standard for cold food must be served at a temperature between 33-50 F (degrees Fahrenheit) and hot food at 135 F (degrees Fahrenheit)."

During an interview with the Nursing Home Administrator (NHA) on January 9, 2020, at approximately 11:45 AM, the NHA revealed the expectation that food temperatures would be palatable to residents.

28 Pa. Code 211.6(c) Dietary services.

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















 Plan of Correction - To be completed: 02/27/2020

Plan of Correction-F0804
Immediate review of the meal service process was conducted to identify areas of improvement to maintain temperature of menu items during service.
All residents have the potential to be affected by this practice. Dining Services managers and supervisors will observe current practices in all neighborhoods to ensure that proper procedures are being followed by team members.
After reviewing the meal service process the following changes were implemented and all team members will be in-serviced on the revised process:
Temperature of the hot box used to transport the food from the kitchen to the neighborhoods to be checked each meal period to ensure food is being held at the correct temperature during transport
Hot well holding unit was inspected and temperature controls adjusted
Temperature of plate warming drawer was increased
Cold beverages and cold food (sandwiches, salads, etc.) are kept in the refrigerator and only taken out when being served immediately to the guest
Chill plate or iced pans are also used for holding cold foods during meal service
Comments from residents will be gathered during the meal service with specific questions asked regarding the guest's acceptance of the temperature and taste of the food
Audits will be conducted by Dining Services managers and supervisors daily over a four week period and then weekly over a four week period. Audits will be reviewed at the next quarterly QAPI meeting that will be held in April. Weekly audits will continue for all points of service and will be reported on at future QAPI meetings.
Completion Date: 2/27/2020

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 observations, clinical record review, and staff interviews it was determined that the facility failed to follow physician orders regarding the use of an abductor wedge for one of 47 residents reviewed (Resident 114).

Findings include:

Review of Resident 114's clinical record revealed diagnoses that included hypertension (high blood pressure), Chronic Kidney Disease (the kidneys don't filter waste and excess fluid from the blood as well as they should) and Dementia with Behavioral Disturbance (significant loss of intellectual abilities, such as memory capacity, that is severe enough to interfere with social or occupational functioning; the criteria for the diagnosis of dementia include impairment of attention, orientation, memory, judgment, language, motor and spatial skills, and function) and Abnormal Posture.

Review of Resident 114's Quarterly Minimum Data Set (MDS- tool used to assess resident's care and services needs) revealed the resident to be severely cognitively impaired with a score of 2 out of 15.

Review of Resident 114's physician orders active as of January 7, 2020, revealed an order for "Confirm Abductor wedge (small cushioned wedge placed between the legs of a person to maintain proper positioning and prevent dislocation of the hip joint) is between knees when up in w/c (wheelchair) as resident will allow every shift."

Review of Resident 114's Care Plan with noted last review date of December 10, 2019, revealed a care Focus area of "I have impaired ADL function related to impaired mobility, dementia" and revealed an associated intervention of "I utilize a Rock and Go [specialty chair designed to facilitate a rocking motion with goal to calm residents, reducing the need for protective restraints and also improves strength of leg and trunk muscles, stimulating circulation and assists with preventing sliding and pressure ulcers) to assist me with body positioning. I do not self propel. Use abductor wedge with straps between legs while in wheel chair as I will allow."

Review of Resident 114's care sheet (information sheet used by nursing aides containing individualized/personalized information specific to assigned residents for care) revealed "Abductor wedge between legs when up in rock & Go with straps as I will allow."

Observation was made of Resident 114 in his nursing unit dining room on January 6, 2020, at 12:02 PM seated in his wheel chair at a table. It was observed that he did not have the abductor wedge between his knees.

Observation was made of Resident 114 in his nursing unit dining room on January 8, 2020, at 12:15 PM seated in his wheel chair at a table. It was observed that he did not have the abductor wedge between his knees. At this time Nursing Aide (NA) 1 was approached in dining room, NA 1 confirmed that she was working with Resident 114 on this date. NA 1 was questioned regarding Resident 114's missing abductor wedge. NA 1 walked to resident, confirmed that he did not have it, and while heading to his nearby room made a comment regarding his room being cleaned earlier that day which she abruptly stopped. NA 1 then readily retrieved Resident 114's wedge from his room, walked immediately back to the resident and placed the wedge without any resistance from resident.

Request to facility management for documentation of the abductor wedge being provided for Resident 114 was provided in the form of "POC (Plan of Care) Response History." Review of Resident 114's "POC (Plan of Care) Response History" (documentation for the completion of specific care tasks for a resident) revealed two different sets of task sheets for him. Both sets related to Restorative Nursing: Splint checks/Monitoring BLE (bilateral [both sides] lower extremities. One of the sets specifically identified which area of the body was being monitored addressing location of "Splint" and also that whether for this task the Resident was Not Available, Resident Refused, or Not Applicable. Review of documentation for the dates of January 6 and 8, 2020, revealed that Resident's BLE were being monitored and revealed no documentation to indicate that the resident was not available, not applicable or refused this care. The second set of documentation addressed "Indicate the level of participation with splinting by the resident." Review of this documentation for the dates of January 6 and 8, 2020, revealed that Resident 114 participated with encouragement on January 6, 2020, as per charting at 11:51 AM, and on January 8, 2020, this was not applicable as per charting at 2:59 PM.. The second set of documentation also addressed "How did the resident tolerate ?" Review of this documentation for the dates of January 6 and 8, 2020, revealed the answer options of "Well, Poorly, Resident Not Available, Resident Refused or Not applicable. Review of the documentation for the dates of January 6 and 8, 2020, revealed that Well was checked for January 6, 2020, as per charting at 11:52 AM and Not Applicable was checked for January 8, 2020. Review of Resident 114's clinical progress notes failed to reveal any instances on January 6 and 8, 2020, of resident refusing use of the abductor wedge.

In summary, no observations, progress notes, or care documentation dated for January 6 and 8, 2020, revealed Resident 114 had refused application of the abductor wedge for lunch meal time frame.

During an interview with the Director of Nursing (DON) on January 9, 2020, at approximately 12:40 PM, the DON revealed that the Nursing Aide (NA) 2 had completed the reviewed documentation incorrectly. The DON also revealed the expectation that NA 2 should have documented that the wedge was refused or the resident should have been using the wedge. The DON did not state that NA 2 had indicated the resident had refused the wedge.


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

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

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








 Plan of Correction - To be completed: 02/27/2020

Messiah Lifeways at Messiah Village submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges are deficient under State and Federal regulations relating to long-term care. The Plan of Correction should not be construed as either a waiver of Messiah Lifeways at Messiah Village's right to appeal or an admission of past or ongoing violations of State and Federal regulatory requirements.

F 0684 483.25 Quality of Care

No resident was injured with this finding. Was immediately corrected by offering and application of the abductor wedge to the resident. Documentation was corrected in Point of Care. CNA was provided re-education and coaching/corrective action for employee file.
CNA's will review their care sheet and daily tasks in Point of Care and accurately document services provided for all assigned residents.
Re-education will be provided to CNAs regarding restorative care splinting and documentation.
Restorative Nurse will perform random audits of CNA restorative documentation for 5 residents weekly for 4 weeks, then biweekly for 1 month. The audits will observe for accuracy overall. Results of the audits will be reported to the QAPI committee.
Date of completion 2/27/20.


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on surveyor observation, manufacturer information, facility documentation, and staff interview, it was determined that the facility failed to discard expired medications for one of five medication carts observed (D hall medication cart).

Findings Include:

Observation of the D hall medication cart on January 7, 2020 at 1:10 PM revealed one Novolog insulin pen with a label indicating that the medication was opened on November 26, 2019 (42 days earlier).

Review of the manufacturer's package insert for the Novolog insulin pen indicated that once the medication is open it should be stored at room temperature and discarded after 28 days even if it still has insulin left in it.

Review of facility provided document regarding insulin storage states Novolog should be, "Refrigerate until opened, then may be stored at room temperature. Expires 28 days after first use even if some drug remains. (same for vials/cartridges/pens)"

Interview with the Director of Nursing on January 9, 2020 at 11:10 AM, revealed that she would have expected the Novolog insulin pen would have been discarded after 28 days.


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

28 Pa. Code 211.9(a)(1)(i) Pharmacy services.

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.








 Plan of Correction - To be completed: 02/27/2020

F 0761 483.45 Label/Store Drugs and Biologicals

No resident was injured with this finding. Was immediately corrected by discarding the expired insulin pen and using new insulin pen for medication administration, dated to be discarded 28 days after opening.
Medications are labeled with the proper information - Date of Open, Date of Expiration, Nurse's Initials. Expired medications will be discarded immediately and replaced.
Re-education will be provided to Licensed Staff Nurses on proper labeling of medications with expiration guidelines. Nurse's will perform daily med cart audit for expired medications on 11-7 shift. 11-7 Nurse performing daily audit will sign that med cart audit was completed for their shift. Expired medications will be discarded immediately and replaced.
Clinical Managers will perform random audits on their assigned neighborhood of med cart to ensure all expired meds were identified and discarded during 11-7 audit. Audit schedule will be completed weekly for 4 weeks, then biweekly for 1 month. The audits will observe for accuracy overall. Results of the audits will be reported to the QAPI committee.
Date of completion 2/27/20.


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