Nursing Investigation Results -

Pennsylvania Department of Health
 TWIN LAKES REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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TWIN LAKES REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:
There are  149 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.
TWIN LAKES REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on February 12, 2020, it was determined that Twin Lakes Rehabilitation and Healthcare 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 more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 clinical record reviews, observations and staff interviews, it was determined that the facility failed to prevent new pressure ulcers for a resident who entered the facility without a pressure ulcer, resulting in the development of multiple avoidable pressure ulcers for one of 47 residents reviewed (Resident 59), and failed to ensure that appropriate treatment and services were provided to promote healing of pressure ulcers for two of 47 residents reviewed (Residents 17, 40), resulting in the deterioration of a pressure ulcer for Resident 17.

Findings include:

The facility's policy regarding skin checks, dated December 31, 2019, revealed that if a resident had a score of 18 or lower on the Braden scale (a standardized form for predicting pressure ulcer risk) then the nurse aide would complete a daily skin inspection form and it would be noted on the daily assignment sheet. Any abnormal findings were to be reported to the licensed nurse assigned to the resident or the charge nurse.

Admission information for Resident 59 revealed that the resident was admitted to the facility on October 11, 2019, with diagnoses that included insulin dependent diabetes (interferes with blood sugar control), respiratory failure with tracheostomy (a surgical hole in the neck for mechanical ventilation), aspiration pneumonia (inhalation of a foreign substance into the lungs which has caused an infection), and a percutaneous endoscopic gastrostomy (PEG) tube (a tube surgically inserted through the abdomen and into the stomach to provide liquid nutrition). A nursing note, dated October 11, 2019, revealed that the resident arrived to the facility on that date and that his skin was intact, clean and dry. An admission nursing assessment for Resident 59, dated October 12, 2019, revealed that the resident had impaired tactile sensation (loss of feeling), was totally dependent on staff for bed mobility, was always incontinent of bowel, his Braden scale was 7 (very high risk for skin breakdown), and he had no skin alterations (no skin breakdown).

Resident 59's care plan, dated October 12, 2019, revealed that he was at risk for skin breakdown and that staff were to turn and reposition him.

Nurse aide documentation for October 2019, revealed that on October 16, 2019, Resident 59 had a red foot/heel. There was no documented evidence that the nurse aide informed the licensed nurse about the red foot/heel on that date.

A nursing note for Resident 59, dated October 17, 2019, revealed that the nurse aide requested that the resident be assessed for discoloration of the left heel, the resident had a deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue) that measured 3.0 x 3.0 x less than 0.1 (depth) centimeters (cm), and the staff were to off-load the heels (remove pressure from the heels by elevating them off surfaces).

However, there was no documented evidence that Resident 59's heels were off-loaded.

A certified registered nurse practioner's note (CRNP - a nurse with advanced training who can practice independently), dated October 28, 2019, revealed that Resident 59 had a Stage 3 pressure ulcer (full-thickness skin loss potentially extending into the subcutaneous tissue layer) of the left heel and that he required debridement for healing (surgical removal of dead tissue). The CRNP recommended to float the resident's heels while in bed, off-load the wound, and reposition per the facility's protocol.

However, there was no documented evidence that Resident 59 was repositioned per the facility's protocol or that staff were floating the resident's heels and off-loading the wound on the left heel.

A nursing note for Resident 59, dated October 24, 2019, revealed that the resident had a new pressure ulcer on his right heel that measured 2.0 x 2.0 cm with eschar (dead tissue) noted.

A nursing note for Resident 59, dated November 18, 2019, revealed that the resident had two small Stage 2 pressure ulcers (open, superficial wound) on his tailbone. A CRNP note, dated November 25, 2019, revealed that the resident had one Stage 2 on the coccyx (sacrum) that measured 1.0 x 0.5 x 0.1 cm and she recommended to off-load the wound and reposition the resident per facility protocol.

There was no documented evidence that the wound was off-loaded or that Resident 59 was repositioned in accordance with the facility's protocol.

A CRNP note, dated February 10, 2020, revealed that Resident 59's coccyx wound was now unstageable due to necrosis (dead tissue) and measured 6.5 x 2.5 x 1.5 cm with undermining of 3.6 cm at 10 o'clock (the wound continued under the skin). The CRNP debrided (removed dead tissue with a scalpel) the wound on that date.

Observations of Resident 59 on February 11, 2020, at 9:02 a.m. revealed that he was lying in bed with the head of the bed slightly elevated, and his feet were at the bottom of the bed against the foot board.

Interview with Licensed Practical Nurse 12 on February 11, 2020, at 9:02 a.m. revealed that Resident 59's heels/feet should not have been touching the footboard. She stated that the resident frequently slides down in the bed and he needed repositioned.

Interview with the Director of Nursing on February 12, 2020, at 12:00 p.m. confirmed that there was no documented evidence that Resident 59 was turned and repositioned, that his heels were floated, or that the left heel wound was off-loaded per the recommendations of the CRNP, and the resident then developed pressure ulcers on his heels and sacrum after admission to the facility.

A comprehensive annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated September 11, 2019, revealed that the resident was comatose, dependent on staff for daily care tasks, including bed mobility, and had a Stage 4 pressure ulcer (a deep wound caused by prolonged, unrelieved pressure where bone, tendon and/or muscle is exposed). The assessment indicated that the resident was not receiving a turning and repositioning program.

Resident 17's care plan, dated September 19, 2019, included that she was to be turned and repositioned "frequently" as tolerated. However, there was no documented evidence that Resident 17 was turned and repositioned "frequently" in accordance with her care plan.

A diagnosis record for Resident 17, updated January 9, 2020, revealed that the resident had medical diagnoses that included a Stage 4 pressure ulcer of the sacral region (base of the spine). Wound documentation for Resident 17, dated January 27, 2020, revealed that the Stage 4 pressure ulcer measured 1.5 x 0.8 x 0.2 (depth) centimeters (cm) and the area around the wound was red/blanchable (when you apply and release pressure, the normal skin color returns) and that the healing status was stable.

There was still no documented evidence that Resident 17 was turned and repositioned "frequently" in accordance with her care plan.

Wound documentation dated February 3, 2020, revealed that Resident 17's sacral wound measured 5.8 x 4.5 x 0.3 cm with undermining of 2.0 cm, granulation tissue (new, vascular tissue) of 40 percent, slough (dead tissue that is white or yellow) of 40 percent, and 20 percent of the wound was thick necrotic tissue (dead tissue that is black/brown) with surrounding deep tissue injury (a pressure-related injury to tissues under the skin) with maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) to the periwound (the skin surrounding the wound). The wound was debrided (removal of unhealthy tissue from a wound) by the wound physician.

Interview with the Director of Nursing on February 12, 2020, at 10:45 a.m. confirmed that the facility had no documented evidence that the staff were turning and repositioning residents.

The facility's policy regarding dressing changes, dated December 31, 2019, indicated that during a dressing change, staff were to cleanse the wound of drainage, debris, or dressing/filler residue.

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 40, dated December 17, 2019, indicated that the resident had severe cognitive impairment; required extensive assistance from staff for daily care tasks, including bed mobility and transfers; and had a pressure ulcer (skin breakdown caused by prolonged, unrelieved pressure). Physician's orders, dated February 4, 2020, included an order for a wound on the resident's coccyx (tailbone) to be cleansed with normal saline (sterile salt and water solution), patted dry, for calcium alginate silver - cut to fit (wound dressing sponge) to be applied, and to cover with a foam dressing.

Observations on February 9, 2020, at 10:14 a.m. revealed that Licensed Practical Nurse 18 and Registered Nurse 10 positioned Resident 40 on her left side (facing the window) and unfastened her brief. Registered Nurse 10 opened the brief and exposed the coccyx and buttocks. Once the brief was removed, a dark brown, liquid substance could be seen between the resident's legs, near her buttocks and vaginal area. Registered Nurse 10 continued with wound care by cleaning the coccyx wound with normal saline, then patting it dry. She then applied the calcium alginate and a sponge dressing over top of the wound, pulled the brief back up over the resident's coccyx wound, and then the two staff rolled her onto her back and pulled her up in the bed to reposition her. The two nurses then covered the resident with sheets. Registered Nurse 10 then stated that she would have the nurse aides come to the room and clean the bowel movement off the resident.

Interview with Registered Nurse 10 on February 9, 2020, at 10:24 a.m. revealed that she should have cleaned the bowel movement from Resident 40 before completing the wound care, but she did not think she saw it until she was done.

Interview with the Director of Nursing on February 9, 2020, at 9:09 a.m. confirmed that Registered Nurse 10 should have completed incontinent care for Resident 40 prior to completing wound care, and should not have covered her up and repositioned her with bowel movement in her brief.

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

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





 Plan of Correction - To be completed: 03/18/2020

1. Resident 59 and 17 each had an individualized turning and positioning program developed. Each is routinely seen by the facility's wound care physician for any needed changes in the treatment plan. Resident 40 was cleaned, and a new dressing was applied. No ill effects occurred.
2. Braden Risk Assessments will be reviewed for residents to ensure accuracy. Updates will be made to the plan of care based upon this review.
3. Directed Inservice training will be completed on March 10, 2020 by an approved Department of Health vendor for directed inservicing. Inservice will be for all levels of nursing staff and agency nursing staff to receive training regarding their roles related to the monitoring of skin integrity and the prevention, identification and reporting of skin integrity issues, including pressure ulcers. The training will include information about the documenting care planned interventions and/or physician ordered care and treatments. Training for licensed nurses and agency licensed nurses will include their roles in supervision of the care and services provided to residents who require interventions for pressure ulcer prevention and/or healing including facility's policy and procedure to ensure care plan interventions for pressure ulcer prevention and care are implemented.
4. Director of Nursing or designee will audit 5 residents identified as 'at risk' for skin breakdown or with skin breakdown and corresponding documentation weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:


Based on resident and staff interviews, as well as observations and review of Resident Council meeting minutes, it was determined that the facility failed to maintain a comfortable and homelike environment by failing to ensure that there was hot water on one of three nursing units (Palmer).

Findings include:

Interview with Resident 25 on February 8, 2020, at 10:16 a.m. revealed that the resident expressed concerns about not having hot water for several weeks. Observations in the resident's bathroom at that time revealed that the hot water remained cold to the touch after running it for approximately five minutes.

Interview with Employee 15 on February 8, 2020, at 11:01 a.m. revealed that the hot water has been a problem on the Palmer unit for a long time now, and that on some days it was hot, but most days it was freezing cold.

Interview with Nurse Aide 16 on February 8, 2020, at 11:07 a.m. revealed that the hot water on the Palmer unit has not worked properly since September (2019) and the staff have to take residents to another unit to give them showers.

Review of Resident Council meeting minutes (with permission from the Resident Council President) on February 8, 2020, at 2:35 p.m. revealed that on December 24, 2019, the Resident Council complained about not having hot water to wash with. The maintenance department ordered parts and reported that the hot water was working on December 31, 2019. However, Resident Council meeting minutes from January 28, 2020, revealed that concerns about not having hot water to wash with continued to be expressed.

Observations on February 9, 2020, at 9:22 a.m. revealed that while accompanied by a nurse aide, a resident ambulated from her room on the Palmer unit to the Rodgers unit for a shower.

Interview with the Maintenance Director on February 11, 2020, at 2:36 p.m. confirmed that a lack of hot water on the Palmer unit has been a problem for a while. He indicated that a plumber was at the facility again yesterday and replaced two more boxes on the boiler, so as of a few hours ago it was working. He also stated that everything except the "brain" of the boiler has been replaced and he went ahead and ordered that too.

28 Pa. Code 207.2(a) Administrator's responsibility.





 Plan of Correction - To be completed: 03/18/2020

1. NHA spoke with Resident 25 regarding the hot water repairs and accommodations for his bathing needs
2. Residents on effected unit were educated on the repairs and the accommodations made for their bathing needs
3. The boiler has been repaired and is functional, maintaining required temperature. Consultant Engineering is available should an additional need arise. Maintenance department personnel complete take water temperatures on a daily basis.
Residents have been notified and asked to let us know if they are not satisfied with the hot water.
4. Maintenance Director or designee will audit 6 additional rooms on the effected unit weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.70(e) and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:


Based on review of a list of nurse aides provided by the facility, and the nurse aide's education records, as well as staff interviews, it was determined that the facility failed to enure that nurse aides received 12 hours of annual in-service training based on their dates of hire for five of seven nurse aides reviewed (Nurse Aides 2, 3, 4, 5, 6).

Findings include:

A list of nurse aides provided by the facility and the nurse aides' education records revealed that based on their months and days of hire, Nurse Aides 2 through 6 did not receive at least 12 hours on inservice training as follows:

Nurse Aide 2 received 9.25 hours of inservice training between October 19, 2018, and October 19, 2019.
Nurse Aide 3 received 8.75 hours of inservice training between September 13, 2018, and September 13, 2019.
Nurse Aide 4 received 7.75 hours of inservice training between October 10, 2018, and October 10, 2019.
Nurse Aide 5 received 6.0 hours of inservice training between September 7, 2018, and September 7, 2019.
Nurse Aide 6 received 5.75 hours of inservice training between February 9, 2019, and February 9, 2020.

Interview with the Registered Nurse Clinical Educator on February 12, 2020, at 1:40 p.m. confirmed that there was no documented evidence that Nurse Aides 2 through 6 received the required 12 hours of annual in-service training.

28 Pa. Code 201.20(a) Staff development.





 Plan of Correction - To be completed: 03/18/2020

1. Nurse aide required training is being completed.
2. Nursing Assistants will be tracked based on hire date for completion of required training. Any missed required trainings will be completed.
3. Administrator will educate the Director of Education that the required inservicing of nursing assistants is tracked and monitored according to the nursing assistant hire date. System Change is the implementation of a tracking system of nursing assistant anniversary dates for performance reviews.
4. Human Resource Director or designee will audit inservice training hours monthly x 3 months for completion of required 12 hours within anniversary year. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending August 8, October 18 and December 3, 2019, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 12, 2020, identified repeated deficiencies related to failures to promptly notify the resident's physician about changes in condition, to complete accurate Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), to develop individualized care plans, to ensure that a professional (registered) nurse performed an assessment when required, to ensure that questionable/incomplete physician's orders were clarified with the physician, to ensure that residents were free from significant medication errors, to ensure that psychotropic medications were not used unnecessarily, and to label medications with the date they were opened.

The facility's plan of correction for a deficiency regarding a failure to notify the resident's physician in a timely manner, cited during the survey ending August 8, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F580, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding notifying the resident's physician in a timely manner.

The facility's plan of correction for a deficiency regarding a failure to complete accurate MDS assessments, cited during the survey ending October 18, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F641, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding completing accurate MDS assessments.

The facility's plan of correction for a deficiency regarding a failure to develop individualized care plans to address residents' care needs, cited during the surveys ending August 8 and October 18, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F656, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding developing individualized care plans.

The facility's plan of correction for a deficiency regarding a failure to ensure that a professional (registered) nurse performed an assessment when required and for failing to clarify physician's orders when needed, cited during the survey ending August 8, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F658, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding maintaining acceptable standards of quality.

The facility's plan of correction for a deficiency regarding a failure to ensure that psychotropic medications were not used unnecessarily, cited during the surveys ending August 8 and October 18, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F758, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that psychotropic medications were not used unnecessarily.

The facility's plan of correction for a deficiency regarding a failure to ensure that residents were free from significant medication errors, cited during the survey ending October 18, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F760, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that residents were free from significant medication errors.

The facility's plan of correction for a deficiency regarding a failure to label medications with the date they were opened, cited during the surveys ending August 8 and December 3, 2019, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F761, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding labeling medications.

Refer to F580, F641, F656, F658, F758, F760, F761.

28 Pa. Code 201.14(a) Responsibility of licensee.

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




 Plan of Correction - To be completed: 03/18/2020

1. Quality Assurance Performance Improvement committee is meeting weekly to review status of the plan of correction
2. Vice President of Clinical Operations will provide training to the Quality Assurance Performance Improvement committee on committee functions to include root cause analysis
3. Audits are being completed on each cited deficiency with compliance percentage calculation being completed
4. Audit findings are presented at the monthly Quality Assurance Performance Improvement committee meeting for review and recommendation.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(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 review of policies and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure proper medication labeling on two of three nursing units (Mellon, Palmer).

Findings include:

The facility's policy regarding medication storage, dated December 31, 2019, indicated that once opened, certain medications, such as multi-dose vials, required an expiration date that was shorter than the manufacturer's expiration date, to ensure medication purity and potency.

Undated manufacturer's instructions for Aplisol (a solution injected under to skin to test for tuberculosis - a bacterial infection that affects the lungs) indicated that vials in use more than 30 days should be discarded due to possible oxidation and degradation which could affect potency.

Observations in the medication refrigerator on the Mellon unit on February 12, 2020, at 8:18 a.m. revealed that there was one multidose vial of Aplisol that was opened and not labeled with the date it was opened.

Observations in the medication refrigerator on the Palmer unit on February 12, 2020, at 9:41 a.m. revealed that there were two multidose vials of Aplisol that were opened and not labeled with the date(s) they were opened.

Interviews with Licensed Practical Nurses 12 and 13 and with the Director of Nursing on February 12, 2020, at 8:18 a.m., 9:41 a.m. and 9:44 a.m., respectively, confirmed that the vials of Aplisol should have been dated when they were opened.





 Plan of Correction - To be completed: 03/18/2020

1. The 3 open, undated multidose vials of Aplisol were thrown out.
2. Other open multidose vials were checked to ensure that they were dated. If any were found undated, they were discarded.
3. Director of Education or Designee will educate licensed nursing personnel that when opening a multi-dose medication, it must be dated. System Change includes 11 – 7 Registered Nurse Supervisor checking all open medications to ensure each is dated.
4. Director of Nursing or designee will audit open meds for dates weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for three of 47 residents reviewed (Residents 40, 65, 78).

Findings include:

Physician's orders for Resident 40, dated January 6, 2020, included an order for the resident to receive Novolog Flexpen (a type of insulin used to lower blood sugar levels) every four hours according to a sliding scale (the amount of insulin is based on the result of a fingerstick blood sugar test). The sliding scale included giving various amounts of Novolog for blood sugar levels between 151-400 mg/dL, and 20 units for a blood sugar that was greater than 400 mg/dL, and to also notify the physician and defer to the "greater than 400 mg/dL sliding scale."

Physician's orders for Resident 40, dated January 6, 2020, included an order for the resident to receive Humalog insulin (fast-acting insulin used to lower blood sugar levels) as needed according to a sliding scale for a blood sugar that was greater than 400 mg/dL. For a blood sugar level greater than 400 mg/dL, staff were check the blood sugar level every two hours until it was less than/equal to 250 mg/dL. For blood sugar levels greater than 250 mg/dL, medium dose sliding scale Humalog was to be given, which included giving 8 units for a blood sugar level of 251-300 mg/dL, 10 units for levels of 301-350 mg/dL, and 12 units for levels of 351-400 mg/dL.

Resident 40's Medication Administration Records (MAR's) for February 2020 revealed that on February 3, 2020, at 4:00 a.m. the resident's blood sugar level was 455 mg/dL and staff administered 20 units of Novolog Flexpen. However, there was no documented evidence that the resident's physician was notified about the elevated blood sugar level or that staff followed "greater than 400 mg/dL Humalog sliding scale and instructions, as ordered by the the physician for a blood sugar level that was greater than 400 mg/dL.

Interview with the Director of Nursing on February 12, 2020, at 2:55 p.m. confirmed that Resident 40's physician's orders for the "greater than 400 mg/dL sliding scale" and instructions were not followed on February 3, 2020.


Physician's orders for Resident 65, dated October 10, December 21 and December 27, 2019, included an order for the resident to receive Novolog insulin before meals and at bedtime according to a sliding scale. The sliding scale included giving various amounts of Novolog for blood sugar levels between 151-400 mg/dL, 8 units for a blood sugar that was greater than 400 mg/dL, and to also notify the physician and defer to the "greater than 400 mg/dL sliding scale." For a blood sugar level greater than 400 mg/dL, staff were check the blood sugar level every two hours until it was less than/equal to 250 mg/dL. For blood sugar levels greater than 250 mg/dL, low dose sliding scale Novolog was to be given, which included giving 4 units for a blood sugar level of 251-300 mg/dL, 6 units for levels of 301-350 mg/dL, and 8 units for levels of 351-400 mg/dL or greater.

Resident 65's Medication Administration Records (MAR's) for October 2019 revealed that on October 18 at 5:00 p.m. the resident's blood sugar level was 512 mg/dL, on October 19 at 6:00 a.m. the resident's blood sugar level was 460 mg/dL, on October 26 at 9:00 p.m. the resident's blood sugar level was 529 mg/dL, and on October 31 at 9:00 p.m. the resident's blood sugar level was 441 mg/dL. Staff administered 8 units of Novolog Flexpen on each of these dates and times; however, there was no documented evidence that the resident's physician was notified about the elevated blood sugar levels or that staff followed "greater than 400 mg/dL Novolog sliding scale and instructions, as ordered by the the physician for a blood sugar level that was greater than 400 mg/dL.

Resident 65's MAR's for November 2019 revealed that on November 3 at 11:00 a.m. the resident's blood sugar level was 590 mg/dL, on November 4 at 5:00 p.m. it was 532 mg/dL, on November 11 at 5:00 p.m. the resident's blood sugar level was "Hi," on November 14 at 5:00 p.m. it was 483 mg/dL, on November 18 at 7:00 a.m. the resident's blood sugar level was 562 mg/dL, and at 9:00 p.m. the resident's blood sugar was "Hi." Staff administered 8 units of Novolog Flexpen; however, there was no documented evidence that the resident's physician was notified about the elevated blood sugar levels or that staff followed "greater than 400 mg/dL Novolog sliding scale and instructions, as ordered by the physician for a blood sugar level that was greater than 400 mg/dL.

Resident 65's MAR's for December 2019 and January 2020 revealed that on December 3 at 7:00 a.m. the resident's blood sugar level was 519 mg/dL and at 5:00 p.m. it was 593 mg/dL, on December 5 at 7:00 a.m. the resident's blood sugar level was 512 mg/dL, on January 4 at 4:00 p.m. it was 499 mg/dL, on January 10 at 4:00 p.m. it was 552 mg/dL, on January 20 at 4:00 p.m. the resident's blood sugar level was 404 mg/dL, and on January 26 at 12:00 p.m. the resident's blood sugar level was 522 mg/dL. Staff administered 8 units of Novolog Flexpen; however, there was no documented evidence that the resident's physician was notified about the elevated blood sugar levels or that staff followed "greater than 400 mg/dL Novolog sliding scale and instructions, as ordered by the the physician for a blood sugar level that was greater than 400 mg/dL.

Interview with the Director of Nursing on February 10, 2020, at 4:14 p.m. confirmed that Resident 65's physician's orders for the "greater than 400 mg/dL sliding scale" and instructions were not followed on the above dates and times.


A nursing note for Resident 78, dated January 18, 2020, at 5:00 p.m. revealed that the resident was admitted to the facility and had a surgical site on the right knee. A comprehensive admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 78, dated January 25, 2020, revealed that the resident was cognitively intact and had a wound infection.

Physician's orders for Resident 78, dated January 19, 2020, included an order for the resident to receive one 250 milligram (mg) capsule of Vancomycin (an antibiotic) every six hours for 42 doses. However, the resident's MAR for January 2020 revealed that staff administered only 39 doses of Vancomycin to the resident instead of 42 doses as ordered by the physician.

Interview with the Director of Nursing on February 12, 2020, at 1:35 p.m. confirmed that Resident 78's physician ordered 42 doses of Vancomycin and the resident received only 39 doses.

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





 Plan of Correction - To be completed: 03/18/2020

1. Medication Error Reports were completed on Resident 40, 65, and 78.
2. Diabetic residents with sliding scale insulin orders will be reviewed. Residents with antibiotic orders will be reviewed for administration as ordered.
3. Director of Education or Designee will educate licensed nurses on the following all steps of a physician's order, including notification of physician as outlined in an order and the necessary documentation to support the physician notification. Director of Education or Designee will educate staff on the procedure for ensuring that medications are received timely and the procedure to follow in the event they are not. System Change includes that pharmacy will arrange for the local back up pharmacy to supply an ordered med if it cannot be delivered timely. Consultant pharmacist will be requested to review diabetics with sliding scale insulin orders and antibiotics for proper administration.
4. Director of Nursing or designee will audit 5 residents' medication administration records for residents with a medication change and will audit diabetic residents with sliding scale insulin orders for physician documentation as needed weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:


Based on review of a list of nurse aides provided by the facility and the nurse aides' personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on dates of hire for five of five nurse aides reviewed (Nurse Aides 1, 2, 3, 4, 5).

Findings include:

A list of nurse aides provided by the facility revealed that based on their months and days of hire, annual performance evaluations were due for Nurse Aides 1 through 5 between September 7 and November 12, 2019. However, documentation of annual performance evaluations revealed that the evaluations were not completed timely as follows:

Nurse Aide 1's annual performance evaluation was due to be completed in November 2019, but was not completed until January 28, 2020.

Nurse Aide 2's annual performance evaluation was due to be completed in October 2019, but was not completed until January 27, 2020.

Nurse Aide 3's annual performance evaluation was due to be completed in September 2019, but was not completed until January 28, 2020.

Nurse Aide 4's annual performance evaluation was due to be completed in October 2019, but was not completed until December 17, 2019.

Nurse Aide 5's annual performance evaluation was due to be completed in September 2019, but was not completed until January 16, 2020.

Interview with the Director of Nursing on February 12, 2020, at 2:27 p.m. confirmed that she could provide no evidence that annual performance evaluations were completed timely for Nurse Aides 1 through 5.

28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.

28 Pa. Code 201.20(a)(c) Staff development.






 Plan of Correction - To be completed: 03/18/2020

1. Nurse aide performance evaluations were completed by recently hired director of nursing or designee once identified as not having been completed.
2. Nursing Assistants will be tracked based on hire date for completion of performance evaluation. Any performance evaluations that were due will be completed.
3. Vice President of Human Resources educated the director of nursing and administrator that performance evaluations of nursing assistants must be completed annually in accordance with their anniversary date. System Change is the implementation of a tracking system of nursing assistant anniversary dates for performance reviews.
4. Human Resource Director or designee will audit performance evaluation tracking file monthly x 3 months for timely completion of nurse assistant reviews. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to monitor fluid intake as ordered by the physician for one of 47 residents reviewed (Resident 3) who received dialysis services.

Findings include:

The facility's policy regarding fluid restrictions, dated December 31, 2019, indicated that when there was a fluid restriction, fluid input/intake was to be monitored, and the care team was to periodically assess the resident's fluid intake.

A diagnosis record for Resident 3, dated August 22, 2019, revealed that the resident had medical diagnoses that included chronic kidney disease, Stage 4 (severe loss of kidney function). Physician's orders, dated December 31, 2019, included an order for the resident to be transported to the dialysis center on Tuesdays, Thursdays and Saturdays for dialysis treatments (mechanical method of removing waste products and excess water from the blood when the kidneys are not functioning properly).

A nutrition note for Resident 3, dated January 22, 2019, indicated that the dialysis center's registered dietician inquired about the decrease in the resident's albumin (protein in the blood) from last month. It was noted that the resident had a large fluid gain on January 13, 2020, and it was suspected that the lab (blood test result) was altered related to increased fluid. The registered dietician recommended that the resident have a 1400 milliliter (ml) fluid restriction (in 24 hours) due to the weight gains noted between the dialysis treatments.

Physician's orders for Resident 3, dated January 22, 2020, and February 1, 2020, included an order for the resident to be on a fluid restriction of 1400 ml daily, with 960 ml provided by dietary, and 440 ml by nursing - broken down into shifts as 200 ml during the day shift (7:00 a.m. to 3:00 p.m.), 200 ml during the evening shift (3:00 p.m. to 11:00 p.m.) and 40 ml during the night shift (11:00 p.m. to 7:00 a.m.).

Documentation of Resident 3's fluid intake for January 22 to 27, 2020, revealed that fluid intake during two meals was recorded on January 25, 2020; however, there was no other documentation regarding the resident's fluid intake or monitoring of her fluid intake during this time period.

Interview with the Director of Nursing on February 10, 2020, at 10:03 a.m. revealed that the fluid restriction order for Resident 3 was entered incorrectly; therefore, the resident's fluid intake was not being monitored as ordered by the physician, since the time of the order on January 22, 2020.

Interview with Dietician 9 on February 10, 2020, at 11:26 a.m. revealed that Resident 3 had a 9.9 pound weight gain from January 9 to 14, 2020; therefore, the fluid restriction was ordered.

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




 Plan of Correction - To be completed: 03/18/2020

1. Resident 3 no longer resides in the nursing facility.
2. Other residents with a fluid restriction are now being documented by nursing.
3. Director of Education or designee will educate license nurses and agency licensed nurses on how to input the order into the electronic medical record system and have it flow to the medication administration record in order to be documented. System change includes review in morning clinical meeting to validate that orders are added correctly to allow for documentation. Fluid restrictions are reviewed following the Minimum Data Set schedule and if a need arises.
4. Director of Nursing or designee will audit 5 residents with fluid restrictions for proper documentation weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed for one of 47 residents reviewed (Resident 65).

Findings include:

The facility's policy regarding venous catheters (a thin tube placed in a vein that can be used for an extended period of time to deliver fluids and/or medications), dated December 31, 2019, did not include procedures regarding how and when to flush the catheter when it was not in use.

A nursing note for Resident 65, dated January 5, 2020, at 3:20 p.m. revealed that the resident had a midline (venous) catheter inserted. Physician's orders, dated January 4 and 5, 2020, included orders for the resident to receive 2 grams of ceftriaxone (an antibiotic) intravenously (administered directly into a vein) once a day for pneumonia and to have the midline catheter site dressing changed every week.

Resident 65's Medication Administration Records (MAR's) for January and February 2020 revealed that staff administered ceftriaxone daily through the midline catheter on January 4 through 7, 2020, and the midline catheter site dressing was changed on January 11, 18 and 25, and February 1, 2020. The MAR for February 8, 2020, indicated that the midline catheter was discontinued.

There was no documented evidence that Resident 65's midline catheter was flushed during the period of time from January 8 through February 7, 2020, when the resident was not receiving medication via the catheter.

An interview with the Director of Nursing on February 11, 2020, at 10:26 a.m. confirmed that the facility did not have a policy for flushing midline catheters when they were not in use, and there was no documented evidence that Resident 65's midline catheter was flushed from January 8 through February 7, 2020.

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

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

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





 Plan of Correction - To be completed: 03/18/2020

1. Resident 65 intravenous line was removed.
2. All intravenous lines will be reviewed for correct orders. Any intravenous lines not in use will be discussed with physician and removed or maintained per physician order.
3. Director of Education or designee will educate licensed nurses on proper care of intravenous lines and dressing applications. System change includes residents with intravenous lines having their orders reviewed in clinical meeting. If intravenous line is no longer in use, discussion will occur with physician regarding removal. If not removed, intravenous line will be maintained.
4. Director of Nursing or designee will audit 5 residents with intravenous sites not in use for maintenance orders weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on review of clinical records and facility investigation reports, as well as observations and staff interviews, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards, by failing to ensure that air mattresses were assessed for potential safety hazards following falls from bed for one of 47 residents reviewed (Resident 52).

Findings include:

An admission comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated January 6, 2020, and the resident's care plan dated January 16, 2020, revealed that the resident was understood and could understand, required extensive assistance with bed mobility, had a pressure ulcer, and had a right above-the-knee amputation. Physician's orders, dated December 30, 2019, included an order for an air mattress with bolsters to be on the resident's bed.

Fall investigation documents, dated January 2, 2020, at 5:37 a.m. revealed that Resident 52 was in bed and rolled out of bed when trying to clean himself up. Investigation documents dated January 3, 2020, at 1:57 a.m. revealed that the resident was in bed and slid out of bed when trying to use his urinal. Investigation documents dated January 7, 2020, at 5:30 a.m. revealed that the resident was found on the floor next to his bed. Investigation documents dated January 9, 2020, at 5:00 a.m. revealed that the resident was found on the floor next to his bed and did not know what happened.

There was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to the air mattress being placed on Resident 52's bed and following the falls from bed on January 2, 3, 7 and 9, 2020.

Observations of Resident 52 on February 10, 2020, at 11:54 a.m. revealed that he was lying in his bed, which was equipped with an air mattress.

Interview with the Director of Nursing on February 12, 2020, at 2:53 p.m. confirmed that there were no assessments completed for any potential safety hazards associated with the use of an air mattress for Resident 52, either prior to the air mattress being placed on the resident's bed on December 30, 2019, or following the falls from bed on January 2, 3, 7 and 9, 2020.

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





 Plan of Correction - To be completed: 03/18/2020

1. Resident 52 suffered no ill effects from the falls and discharged home on 2/27/2020.
2. Residents using air mattresses will have their air mattress assessment reviewed for accuracy. If needed, assessment will be updated.
3. Director of Education or Designee will educate licensed nurses and agency licensed nurses on the system change that includes any resident utilizing an air mattress that falls from bed will have a new air mattress assessment completed to ensure appropriate utilization of the air mattress and bolsters ensuring it did not contribute to a fall. Air mattress assessments are completed prior to initiating use, quarterly, annually and with change in condition.
4. Director of Nursing or designee will audit air mattress assessment completion for 5 residents using an air mattress who fall from bed from weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp: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)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.
Observations:


Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that prior to permitting residents to self-administer medication, the facility failed to ensure that the interdisciplinary team determined that self-administration of medications was clinically appropriate for one of 47 residents reviewed (Resident 28).

Findings include:

The facility's policy regarding medication administration, dated December 31, 2019, indicated that the licensed nurse was to remain with the resident until he/she swallowed the medication(s) being administered.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 28, dated December 3, 2019, revealed that the resident was cognitively intact. A diagnosis record dated February 13, 2019, revealed that the resident had diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that makes it difficult to breathe), diabetes (disease that interferes with blood sugar control), high blood pressure and heart failure.

Observations on February 8, 2020, at 10:40 a.m. revealed that Resident 28 was in bed sleeping and his overbed table was next to the bed. There was a cup of water and two medicine cups, one with liquid and the other with nine pills, on the overbed table, and there were no staff in the room at that time.

Resident 28's Medication Administration Record (MAR) for February 8, 2020, at 8:00 a.m. indicated that Licensed Practical Nurse 14 documented that she administered 5 milliliters of guaiasorb DM cough syrup, and at 9:00 a.m. the nurse documented that she administered one 0.1 milligram (mg) tablet of clonidine (treats high blood pressure), one 10 mg tablet of amlodipine (treats high blood pressure), one 50 mg tablet of hydralazine (treats high blood pressure), two 200 mg tablets of labetalol (treats high blood pressure), one 40 mg tablet of Lasix (treats heart failure by reducing extra fluid in the body), one 650 mg tablet of sodium bicarbonate (treats heartburn), and two 1,000 unit tablets of vitamin D3 (vitamin supplement).

Inteview with Licensed Practical Nurse 14 on February 8, 2020, at 10:44 a.m. revealed that Resident 28 started to take his medications at 9:00 a.m. so she left the room. She was not certain if the resident finished taking the medications.

Resident 28's clinical record contained no documented evidence that the interdisciplinary team determined that it was clinically appropriate for the resident to self-administer medication.

Interview with the Director of Nursing on February 8, 2020, at 12:30 p.m. confirmed that Resident 28's medications should not have been left on his overbed table.

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





 Plan of Correction - To be completed: 03/18/2020

1. Resident 28 was assessed for self-administration and was determined to not be appropriate for self-administration of medications
2. No other residents were identified as being able to self-administer medications per the requirements of policy
3. Director of Education or Designee will educate licensed nurses and agency licensed nurses on the self-administration of medications policy. Licensed nurses will also be educated that they are not permitted to leave medications at bedside for residents to take unwitnessed. If a resident desires to self-administer medications, the self-administration assessment will be completed. Per the results, determination of ability will be made. Care plan will be updated to reflect self-administration if appropriate.
4. Director of Nursing or designee will audit 5 residents for 4 weeks for 1 month, every 2 weeks x 1 month and monthly x 1 month for medications at bedside left unattended weekly. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:


Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 47 residents reviewed (Resident 83).

Findings include:

The facility's policy regarding call bells, dated December 31, 2019, indicated that when leaving a resident's room, staff were to be sure that the call light was placed within the resident's reach.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 83, dated January 21, 2020, indicated that the resident was understood and could understand, and she required the extensive assistance of two staff for bed mobility and transfers. The resident's care plan, dated January 21, 2020, included that staff were to keep her call bell close and answer it promptly.

Observations of Resident 83 on February 9, 2020, at 8:16 a.m. and 9:00 a.m. revealed that the resident was in bed and her call bell was draped over her bedside stand, which was not within her reach.

Interview with Registered Nurse 10 on February 9, 2020, at 9:00 a.m. revealed that Resident 83 was capable of using her call bell and it should have been placed within her reach.

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





 Plan of Correction - To be completed: 03/18/2020

1. Resident 83's call cord had a clip added to it and it was clipped to the sheet within her reach
2. Resident call bells were audited to ensure all cords have clips on them and are the appropriate length that will allow securing of the cord near to the resident.
3. Staff, including agency personnel, will be educated by the director of Education or designee to note location of the call bell in relation to the proximity of the resident and to be sure it is within their reach. Staff also educated that during their normal trips in and out of resident room to ensure call bell is accessible. System change will include call cord clips being added to each call cord in order to secure 2 the bedding or clothing.
4. Central supply coordinator or designee will audit call bell location of 10 residents who are in their rooms weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's attending physician was notified timely about a change in condition for two of 47 residents reviewed (Residents 57, 83).

Findings include:

The facility's policy regarding changes in condition, dated December 31, 2019, indicated that the physician should be notified with changes in the resident's medical condition.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 57, dated January 2, 2020, revealed that the resident was understood and could understand, required extensive assistance from staff for daily care tasks, and had medical diagnoses that included diabetes (disease that interferes with blood sugar control). Physician's orders, dated September 25, 2019, included an order for the resident to receive Novolog flexpen (a type of insulin used to lower blood sugar levels) before meals and at bed time according to a sliding scale (the amount of insulin administered is based on the result of a fingerstick blood sugar test). The sliding scale included that for a blood sugar level that was greater than 340 milligrams per deciliter (mg/dL), the resident was to receive 18 units of Novolog, and the physician was to be called.

Resident 57's Medication Administration Record (MAR) for February 2020 revealed that the resident's blood sugar level on February 5, 2020, at 5:00 p.m. was 391 mg/dL. However, there was no documented evidence that the resident's physician was notified regarding the resident's elevated blood sugar level.

Interview with the Director of Nursing on February 12, 2020, at 11:05 a.m. confirmed that there was no documented evidence that Resident 57's physician was notified regarding his blood sugar level being greater that 340 mg/dL at 5:00 p.m. on February 5, 2020.


A quarterly MDS assessment for Resident 83, dated November 20, 2019, revealed that the resident was cognitively impaired and required supervision for eating. A diagnosis record for Resident 83, dated December 27, 2019, revealed that the resident had diagnoses that included age-related cognitive (mental) decline, dysphagia (difficulty swallowing) and gastroesophageal reflux (GERD - acid reflux).

A nursing note for Resident 83, dated December 4, 2019, at 6:34 p.m. revealed that a nurse aide brought the resident from the dining room during the evening meal with an apparent episode of choking, and she had wheezing and was coughing.

There was no documented evidence that the physician was notified about Resident 83's episode of choking.

Interview with the Director of Nursing on February 10, 2020, at 10:07 a.m. revealed that the physician should be notified with any choking episodes and the notification should be documented on the clinical record.

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

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




 Plan of Correction - To be completed: 03/18/2020

1. Resident 57's physician was notified of the elevated blood sugar level on February 5, 2020 and was documented as such. Resident 57 had no ill effects from the elevated blood sugar. Resident 83's physician was notified of the episode of coughing. Rehab will screen resident 83 for any interventions deemed necessary.
2. 24-hour report will be reviewed in clinical meeting to ensure changes in condition of residents had the appropriate physician and family notification completed. If a notification was not completed, it will be done.
3. Director of Education or designee will educate licensed nurses and agency licensed nurses on changes in condition and need to notify physician and family. System change includes the implementation of a 24-hour nursing report and review of the report in the morning clinical meeting.
4. Director of Nursing or designee will audit documentation of 10 residents for physician notification weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 47 residents reviewed (Residents 40, 56).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, revealed that Section N0410A (Medications Received) was to be coded with the number of days the resident received an antipsychotic medication (medications used to treat psychiatric disorders) during the seven-day assessment period, and Section N0450A (Antipsychotic Medications) was to be coded zero (0) if the resident did not receive an antipsychotic medication during the assessment period, one (1) if the resident received an antipsychotic medication on a routine basis only, two (2) if antipsychotic medication was received on an "as needed" basis only, and three (3) if antipsychotic medication was received on a routine and "as needed" basis.

Physician's orders for Resident 40, dated December 10, 2019, and discontinued on January 6, 2020, included an order for the resident to receive 25 milligrams (mg) of quetiapine (an antipsychotic medication) daily at bed time. The resident's Medication Administration Record (MAR) for December 2019 revealed that the resident received 25 mg of quetiapine daily from December 10 through 31, 2019.

Section N0401A of an admission MDS assessment for Resident 40, dated December 17, 2019, revealed that the resident received antipsychotic medications on seven days during the review period. However, Section N0450A was coded with zero (0), indicating that the resident did not receive antipsychotic medication during the assessment period.

Interview with Registered Nurse Assessment Coordinator 7 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on February 12, 2020, at 11:45 a.m. confirmed that Section N0450A of Resident 40's MDS assessment dated December 17, 2019, should have been coded with a one (1) to indicate that the resident received antipsychotic medication on a routine basis during the assessment period.


The RAI User's Manual, dated October 2019, revealed that Section P0200F was to capture the use of "other" alarms (includes devices such as alarms on the resident's bathroom and/or bedroom door, toilet seat alarms, or seatbelt alarms), and the section was to be coded zero (0) if such an alarm was not used during the seven-day assessment period, one (1) if the alarm was used less than daily, or two (2) if the alarm was used daily.

Initial physician's orders for Resident 56, dated June 8, 2018, and current physician's orders, dated January 16, 2020, revealed that the resident attempts to self-transfer, had a history of multiple falls, and was to use an alarming self-releasing seat belt when out of bed in a wheelchair, in order to cue the resident to ask for assistance with transfers, as well as to alarm staff and reduce the risk of falls if the resident was attempting to self-transfer.

Resident 56's care plan, dated June 13, 2019, included that the resident was to use an alarming self-releasing seat belt when out of bed in a wheelchair, in order to cue the resident to ask for assistance with transfers.

A quarterly MDS assessment for Resident 56, dated January 2, 2020, revealed that Section P0200F was coded with a zero (0), indicating that the resident did not use any "other" alarms.

Observations on February 8, 2020, at 1:03 p.m. and 2:17 p.m., and February 10, 2020, at 9:17 a.m., 10:16 a.m., and 12:45 p.m. revealed that Resident 56 was sitting in her wheelchair and had an alarming self-releasing seatbelt in use.

Interview with RNAC 7 on February 10, 2020, at 10:45 a.m. confirmed that Resident 56 used an alarming self-releasing seatbelt daily during the MDS review period, and Section P0200F of the MDS assessment dated January 2, 2020, should have been coded with a two (2) for daily use of an "other" alarm.

28 Pa. Code 211.5(f) Clinical records.




 Plan of Correction - To be completed: 03/18/2020

1. The Minimum Data System assessments for Resident 40 and 56 were modified.
2. Minimum Data System completed over 14 days were reviewed for accuracy in coding of anti-psychotics and alarms. Modifications were made as needed to the Minimum Data System assessments.
3. Vice President of Clinical Reimbursement will educate Nurse Assessment Coordinators on the use of the Resident Assessment Instrument manual and need for accuracy of coding. System change is that Minimum Data System assessments are run through the data analytics system to alert nurse assessment coordinators on inconsistencies in the coding. Inconsistencies will be reviewed during the clinical meeting.
4. Vice President of Clinical Reimbursement or designee will audit 5 completed Minimum Data System assessments for accuracy of anti-psychotics and alarms weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that resident-centered care plans were developed to meet each resident's care needs for two of 47 residents reviewed (Residents 65, 96).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated January 10, 2020, revealed that the resident had moderate cognitive impairment, required extensive assistance from two staff with daily care tasks, and had a tracheostomy (a surgical hole in the neck used to help with breathing). A Certified Registered Nurse Practitioner's note for Resident 65, dated January 29, 2020, at 2:08 p.m. revealed that the resident had dark, increased sputum (thick mucous) with a foul odor and a sputum culture (test used to identify an infection) was ordered. A laboratory report, dated February 2, 2020, revealed that the resident had a respiratory infection.

Physician's orders for Resident 65, dated February 2, 2020, included orders for the resident to receive one 500 milligram (mg) tablet of Cipro (an antibiotic) twice a day for ten days, and one 250 mg capsule of Vancomycin (an antibiotic) four times a day for ten days.

There was no documented evidence that a care plan was developed to address Resident 65's care needs related to having a respiratory infection that required treatment with antibiotics.

Interview with the Director of Nursing on February 10, 2020, at 7:25 p.m. confirmed that a care plan to address Resident 65's respiratory infection and antibiotics use was not developed and should have been.


An admission comprehensive MDS assessment for Resident 96, dated October 25, 2019, revealed that the resident was cognitively impaired, required extensive assistance from two staff with daily care tasks, had an indwelling urinary catheter (tube held in the bladder to drain urine), and had a history of a urinary tract infection. A nursing note, dated January 6, 2020, at 9:46 p.m. revealed that a urinalysis and culture and sensitivty (tests used to identify a urinary tract infection) were obtained, and a laboratory report, dated January 9, 2020, revealed that the resident had a urinary tract infection.

Physician's orders for Resident 96, dated January 10, 2020, included an order for the resident to receive one 500 mg tablet of Cipro twice a day for ten days.

There was no documented evidence that a care plan was developed to address Resident 96's care needs related to having a urinary tract infection and using an antibiotic.

Interview with the Director of Nursing on February 12, 2020, at 2:53 p.m. confirmed that a care plan to address Resident 96's care needs related to having a urinary tract infection and using an antibiotic was not developed and should have been.

28 Pa. Code 211.11(d) Resident care plan.

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






 Plan of Correction - To be completed: 03/18/2020

1. Resident 66 and 96 have had their care plans updated to reflect the antibiotic therapy.
2. Physician orders over last 14 days will be reviewed and care plans checked to ensure they reflect orders as needed.
3. Director of Education or designee will educate Nurse Assessment Coordinators, licensed nurses, and agency licensed nurses to update the resident care plans to reflect the physician order changes. System change will be that Nurse Assessment Coordinators will review physician orders and update care plans as needed during the morning clinical meeting.
4. Director of Nursing or designee will audit 5 residents' care plans for individualized needs weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that care plans were reviewed and revised to meet residents' individualized care needs for two of 47 residents reviewed (Residents 17, 59).

Findings include:

A diagnosis record for Resident 17, dated January 9, 2020, revealed that the resident had diagnoses that included vegetative state, abnormal posture and Stage 4 pressure ulcer of the sacral region (skin breakdown caused by pressure with exposed bone, tendon or muscle). Physician's orders, dated August 1, 2019, included orders for the resident to receive nothing by mouth and to receive Jevity 1.5 (a nutritional formula) via a feeding tube (tube inserted through the abdomen and into the stomach) at 85 cubic centimeters (cc) per hour for 12 hours a day (1020 cc's total volume per day).

Resident 17's care plan, dated September 19, 2019, included that she was to be turned and repositioned frequently as tolerated and to encourage 75-100 percent of her diet as ordered.

There was no documented evidence that Resident 17's care plan was revised to include individualized interventions regarding how often she required turning and repositioning to prevent skin breakdown/further skin breakdown, and that she was not to receive any nutrition by mouth and her nutrition was received via a feeding tube.

Interview with the Director of Nursing on February 12, 2020, at 1:30 p.m. confirmed that residents' care plans should be individualized to meet their needs.


A diagnosis record for Resident 59, updated January 1, 2020, revealed that the resident had medical diagnoses that included a Stage 3 pressure ulcers (skin injury that may expose underlying fat, but not bone, tendon or muscle) of the right and left buttocks and left heel, a Stage 2 pressure ulcer (open, superficial skin injury) of the sacrum (base of the spine), and an unstageable pressure ulcer (cannot be staged because the wound bed is not visible) of the right heel. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated January 8, 2020, revealed that the resident was cognitively impaired and dependent on two staff for daily care tasks.

Physician's orders for Resident 59, dated January 1, 2020, included an order for the resident to have limited sitting up to 60 minutes at a time, then break. A Certified Registered Nurse Practioner's (CRNP - a nurse with additional education that can practice independently) note, dated October 28, 2019, included recommendations for the resident's heels to be floated while in bed (not in contact with the mattress), to off-load wounds (no pressure on the wound), and to reposition him per the facility's protocol.

Resident 59's care plan, dated October 12, 2019, included that he was to be turned and repositioned frequently as tolerated.

There was no documented evidence that Resident 59's care plan was revised to include individualized interventions regarding how often he required turning and repositioning to prevent skin breakdown/further skin breakdown.

Interview with the Director of Nursing on February 11, 2020, at 12:00 p.m. revealed that Resident 59's care plan was not revised to be specific regarding preventing further skin breakdown and it should have been.

28 Pa. Code 211.10(d) Resident care plan.





 Plan of Correction - To be completed: 03/18/2020

1. Resident 17 and 59 have had their care plans updated.
2. Completed Minimum Data Sets and Physician orders for past 14 days will be reviewed, and care plans checked to ensure they reflect needed information.
3. Director of Education or designee will educate Nurse Assessment Coordinators and licensed nurses and agency licensed nurses to update the resident care plans to reflect resident related and physician order changes. System change included the implementation of morning clinical meeting that would include resident changes as well as physician orders and update of care plans as needed during the morning clinical meeting.
4. Director of Nursing or designee will audit 5 residents' care plans for revisions and individualized needs weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on review of the Pennsylvania Nursing Practice Act and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse completed an assessment of a resident following a change in condition for two of 47 residents reviewed (Residents 17, 59), and failed to ensure that physician's orders were clarified when needed for one of 47 residents reviewed (Resident 32).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

A diagnosis record for Resident 17, updated January 9, 2020, revealed that the resident had medical diagnoses that included persistent vegetative state, contracture (shortening of muscles, tendons and ligaments) of multiple sites, muscle wasting and atrophy (loss of muscle mass) and reduced mobility. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated January 29, 2020, revealed that the resident was totally dependent on two staff for bed mobility and transfers, and she had impaired range of motion (joint movement) of the upper and lower extremities on both sides.

Skin observation documentation completed by a licensed practical nurse, dated February 4, 2020, revealed that Resident 17's left shin was discolored.

Observations on February 9, 2020, at 9:16 a.m. revealed that Resident 17 had a bruise on her left medial shin and a contracture of her right lower extremity.

There was no documented evidence that a registered nurse assessed Resident 17's left shin area until February 11, 2020, when a nursing note indicated that the resident had an ecchymotic area (bruise) to her left medial shin that measured 12.5 x 8.0 centimeters (cm), and that she had contractures of the right lower extremity and her right foot turned inward, causing it to rest upon the left shin. Physician's orders, dated February 11, 2020, included an order for staff to place a pillow between the right contracted foot and the left shin area every shift.

Interview with the Director of Nursing on February 11, 2020, at 11:37 a.m. confirmed that there was no documented evidence of a registered nurse assessment of Resident 17's bruise between when it was first noted on February 4, 2020, and February 11, 2020, when the nursing note was written by a registered nurse.


A diagnosis record for Resident 59, updated January 1, 2020, revealed that the resident had medical diagnoses that included vomiting, dehydration, aspiration pneumonia (foreign substance enters the lungs), tracheostomy (a surgical hole in the throat for mechanical ventilation) and percutaneous endoscopic gastrostomy tube (a tube surgically inserted through the abdomen into the stomach to receive liquid nutrition). A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated January 8, 2020, revealed that the resident was cognitively impaired and totally dependent on two staff for daily care tasks.

A nursing note, authored by a licensed practical nurse for Resident 59, dated November 12, 2019, at 6:05 a.m. revealed that the resident had a large emesis (he vomited) that was brown in color and appeared like his tube feeding formula, and a note on November 12, 2019, at 6:17 a.m. revealed that the resident was medicated to prevent further vomiting. A respiratory therapy note on November 12, 2019, at 8:39 a.m. revealed that the resident was continuing to vomit and that the registered nurse was made aware by the respiratory therapist. A respiratory therapy note, dated November 12, 2019, at 2:40 p.m. revealed that the resident was having large amounts of drainage from his tracheostomy site, she believed the resident may have aspirated on his tube feeding, and she turned his tube feeding off at that time.

There was no documented evidence that a registered nurse assessed Resident 59 after he continued to vomit on November 12, 2019.

Interview with the Director of Nursing on February 11, 2020, at 10:30 a.m. confirmed that a registered nurse should have assessed Resident 59 after he continued to vomit and the respiratory therapist suspected that he had aspirated and notified the registered nurse.


A quarterly MDS assessment for Resident 32, dated January 29, 2019, revealed that the resident was understood and could understand, required extensive assistance from staff for daily care tasks, was totally dependent on staff for transfers and locomotion on and off the unit, and had medical diagnoses that included coronary artery disease (CAD damage or disease of the major blood vessels that supply the heart). Physician's orders, dated May 21, 2019, included an order for the resident to receive 40 milligrams (mg) of Lasix (used to treat fluid retention) every 12 hours as needed for increased edema (swelling caused by excess fluid trapped in the body's tissues).

There was no documented evidence that Resident 32's physician was contacted to clarify the parameters and/or the signs/symptoms that were to be present when "as needed" Lasix for increased edema was to be given.

Interview with the Director of Nursing on February 12, 2020, at 11:05 a.m. confirmed that there was no documented evidence that Resident 32's physician was contacted to clarify the parameters and/or the signs/symptoms for the use of "as needed" Lasix for increased edema.

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

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




 Plan of Correction - To be completed: 03/18/2020

1. The Registered Nurse assessed Resident 17's left shin and notified physician of the prior bruised area. Registered Nurse notified Resident 59's physician regarding the prior vomiting episode. Resident 32's physician discontinued the "as needed" Lasix.
2. The facility will perform a 14 day look back of 24-hour report and new physician orders for opportunities of physician order clarification or additional assessment needed.
3. Director of Education or designee will educate registered nurses and agency registered nurses that with any change in condition, they are responsible to assess, document findings and notify physician. System Change will include review of the 24-hour report and new physician orders for needed clarifications and/or additional assessment at morning clinical meeting.
4. Director of Nursing or designee will audit 24-hour report and new physician orders. The facility will audit 5 residents' weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month to ensure that physician orders are clarified, and Registered Nurse assessments are completed. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide appropriate equipment to maintain or improve mobility, in accordance with physician's orders for one of 47 residents reviewed (Resident 72).

Findings include:

The facility's policy regarding splinting, dated December 31, 2019, indicated that once a resident adjusted to the use of a new splint, and a splinting schedule was established, an order would be obtained from the physician for the splint's use.

A diagnosis record for Resident 72, dated March 22, 2019, revealed that the resident had diagnoses that included hemiplegia and hemiparesis (weakness of one entire side of the body) affecting the right (dominant) side following a stroke. An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs), dated January 8, 2020, indicated that the resident was cognitively impaired, required extensive assistance from two staff for bed mobility, was non-ambulatory (did not walk), and had impaired range of motion (joint mobility) of the upper and lower extremities on one side of his body.

An occupational therapy discharge summary for Resident 72, dated December 2, 2019, recommended that the resident continued wearing a right resting hand splint, on at bedtime and off with a.m. care, in order to manage his muscle tone. Physician's orders, dated December 5, 2019, included an order for the resident to wear a right resting hand splint to be put on at bedtime and taken off with a.m. care as tolerated.

There was no documented evidence that the splint was applied as ordered by the physician, or why it was not applied at bedtime daily.

Interview with the Director of Nursing on February 10, 2020, at 5:44 p.m. confirmed that there was no documented evidence that Resident 72's hand splint was applied as ordered by the physician. Interview with Licensed Practical Nurse 8 on February 10, 2020, at 5:54 p.m. revealed that staff were to document splint application or any refusals by residents to wear splints.

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





 Plan of Correction - To be completed: 03/18/2020

1. Rehab director spoke with resident 72 regarding the need to wear his splint and the risks and benefit of its use. Occupational Therapy Evaluation completed on 2/28/2020. Resident 72's splint is at bedside for application when he is agreeable.
2. Rehab reviewed other residents with splints and insured that their application was entered into Point Of Care system for appropriate documentation.
3. Director of Education or designee will educate nursing staff on splint usage including the risks and benefits, application of splints, and documentation. System change was the addition of documenting application of the splint in the Point Of Care system.
4. Director of Rehabilitation or designee will audit the documentation 5 residents with splints weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to ensure that residents who were fed via gastrostomy tubes received appropriate treatment and services to prevent complications, by failing to follow physician's orders for gastrostomy tube care and by failing to address weight changes in a timely manner for one of 47 residents reviewed (Resident 17).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated November 28, 2019, revealed that the resident was in a persistent vegetative state, was dependent on staff for all daily care needs, had a gastrostomy tube (a tube placed surgically through the abdomen into the stomach), received 51 percent or more of her nutrition and fluids via the tube, and had a recent significant, unplanned weight loss.

Physician's orders for Resident 17, dated April 10, 2019, included orders to clean the gastrostomy tube site with saline (sterile salt and water solution), pat it dry, then apply a drain sponge (a dry dressing) daily and as needed for soilage or dislodgement.

Observations of Resident 17 while in bed on February 9, 2020, at 9:16 a.m. and February 10, 2020, at 6:46 p.m. revealed that she did not have a dressing on her gastrostomy tube site as ordered by the physician.

Interview with Licensed Practical Nurse 11 on February 10, 2020, at 6:48 p.m. confirmed that Resident 17 did not have a drain sponge under her feeding tube and she was not aware that one was to be used after cleaning the site. However, after checking the physician's orders, she confirmed that a dressing was to be under the tube at all times.

The facility's policy regarding resident weights, dated December 31, 2019, indicated that if the month-to-month weight showed more than a 5 percent gain or loss, the resident was to be reweighed within 24 hours.

Physician's orders for Resident 17, dated August 1, 2019, included an order for the resident to receive Jevity 1.5 (a tube feeding formula) at 85 cubic centimeters per hour (cc/hour) for 12 hours a day (1020 cc's total volume per day).

A dietary note for Resident 17, dated November 20, 2019, indicated that a possible discrepancy was noted with the resident's weights and that a reweigh was requested on November 15, 18 and 19, 2019, which was not obtained until November 20, 2019. The resident's weight was 155 pounds on November 20, 2019, which was a loss of 8.08 percent. The note indicated that a gradual weight loss was desirable for obesity; however, it was recommended that the resident's tube feeding be increased for a more "gradual loss." Physician's orders for Resident 17, dated November 20, 2019, indicated that her tube feeding rate was increased to 90 cc/hr (total volume of 1080 cc's per day and 1620 calories per day).

Interview with the Director of Nursing on February 11, 2020, at 1:31 p.m. confirmed that nursing staff should have obtained a reweigh for Resident 17 within 24 hours when there was a significant weight change noted.

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





 Plan of Correction - To be completed: 03/18/2020

1. Dressing is being applied to gastrostomy site as ordered for resident 17. Resident 17's weights are being obtained and tube feeding adjustments are being made as needed based on weight changes.
2. Dietitian will review the physician orders for residents that are enterally fed. Director of Nursing or designee will review enteral fed residents for dressing orders.
3. Director of Education or designee will educate licensed nurses and agency licensed nurses regarding the need to follow physician orders for enteral fed residents and their responsibility to ensure that reweighs are communicated and completed. Registered Dietitian reviews residents receiving tube feedings to ensure nutritional needs are met.
4. Registered Dietitian or Designee will audit weights of 5 residents weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Director of Nursing or designee will monitor 5 enteral fed residents for proper application of ordered dressings weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

§483.45(d)(1) In excessive dose (including duplicate drug therapy); or

§483.45(d)(2) For excessive duration; or

§483.45(d)(3) Without adequate monitoring; or

§483.45(d)(4) Without adequate indications for its use; or

§483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

§483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:



Based on review of clinical records, records from the facility's emergency medication dispensing unit, and pharmacy packing slips, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary drugs that were used for a longer duration than what was ordered by the physician for two of 47 residents reviewed (Residents 72, 90).

Findings include:

A diagnosis record for Resident 72, dated March 2, 2019, revealed that the resident had diagnoses that included diabetes (interferes with blood sugar control and increases the risk of damage to the feet). A certified registered nurse practitioner's (registered nurse with specialized training) note, dated January 3, 2020, indicated that the resident had left great toe trauma with cellulitis (a bacterial infection of the inner layers of the skin) and that he was to be started on a 10-day course of Keflex (an antibiotic).

A laboratory report for Resident 72, dated January 9, 2020, indicated that a wound culture of the left great toe showed Methicillin-resistant staphylococcus aureus (MRSA - bacteria with antibiotic resistance). Physician's orders dated January 9, 2020, included that the resident was to receive Bactrim DS (an antibiotic) 800-260 mg every 12 hours for ten days.

Records from the facility's medication dispensing unit, dated January 9, 2020, revealed that one dose of Bactirm DS was removed for administration to the resident that day, and a pharmacy packing slip dated January 9, 2020, revealed that the pharmacy delivered 20 doses of Bactrim DS for the resident.

Resident 72's Medication Administration Record (MAR) for January 2020 revealed that staff administered Bactrim DS to the resident one time on January 9, and then two times a day from January 10 through 19, for a total of 21 doses, instead of 20 doses as ordered by the physician.

Interview with the Director of Nursing on February 10, 2020, at 4:57 p.m. confirmed that staff administered 21 doses of Bactrim DS to Resident 72, instead of 20 doses as ordered by the physician.


A diagnosis record for Resident 90, dated November 20, 2019, revealed that the resident had diagnoses that included Methicillin-resistant staphylococcus aureus (MRSA - bacteria that is resistant to some commonly used antibiotics) infection. A nursing note, dated January 13, 2020, indicated that the resident had an ingrown toenail of the left great toe and that he was to be started on a 10-day course of Cipro (an antibiotic), and a physician's order was given on January 13, 2020, for the resident to receive 500 milligrams (mg) of Cipro twice a day for 10 days (total of 20 doses).

Resident 90's MAR for January 2020 revealed that staff administered Cipro to the resident one time on January 13, and then two times a day from January 14 through 23, for a total of 21 doses, instead of 20 doses as ordered by the physician.

Interview with the Director of Nursing on February 11, 2020, at 10:30 a.m. confirmed that staff administered 21 doses of Cipro to Resident 90, instead of 20 doses as ordered by the physician.

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




 Plan of Correction - To be completed: 03/18/2020

1. Resident 72 and 90 experienced no ill effect from the additional dose of antibiotic and the physician was notified.
2. Residents will be reviewed for additional antibiotic dosages. Physician will be notified if any one identified.
3. Director of Education or designee will educate license nurses and agency licensed nurses on how to refer to physician's order for appropriate dosing. System change includes review in morning clinical meeting to validate that orders are added correctly to allow for documentation.
4. Director of Nursing or designee will audit 5 residents receiving antibiotics to validate number of doses administer matches the physician's order weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:


Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that non-pharmacological (non-medication) behavioral interventions were attempted prior to the administration of anti-anxiety medications for one of 47 residents reviewed (Resident 65).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated January 10, 2020, indicated that the resident had moderate cognitive impairment and exhibited no behavior symptoms during the assessment period. Physician's orders, dated January 3, 2020, included an order for the resident to receive 0.5 milligrams (mg) of Xanax (an anti-anxiety medication) twice a day "as needed" for anxiety (excessive and persistent worry and fear about everyday situations). The resident's care plan, dated March 18, 2019, indicated that the resident had anxiety and staff were to attempt non-medication interventions and document the non-medication interventions that were attempted on the behavior tracking sheets, which included activity programs (pets, bingo, crafts, cards, news, sports, movies), and quiet time/rest.

Resident 65's Medication Administration Records (MAR's) for January and February 2020 revealed that staff administered 0.5 mg of "as needed" Xanax for anxiety on January 15 at 8:15 p.m., January 16 at 8:17 p.m., January 18 at 8:30 p.m., January 30 at 9:38 p.m., January 31 at 10:34 p.m., February 3 at 8:25 p.m. and February 7 at 1:25 a.m. and 6:54 p.m.

There was no corresponding documentation in Resident 65's clinical record regarding any non-medication interventions that were attempted in accordance with the resident's care plan prior to the administration of Xanax on the above days.

Interview with the Director of Nursing on February 11, 2020, at 10:26 a.m. confirmed that there was no documented evidence that staff attempted one or more non-medication interventions listed in Resident 65's care plan prior to administering "as needed" Xanax on the above dates.

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

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





 Plan of Correction - To be completed: 03/18/2020

1. Resident 65 suffered no ill effects from medication administration without prior non-pharmacological interventions.
2. Residents receiving prn (as needed) psychotropic medications will be reviewed for appropriate non-pharmacological interventions.
3. Director of Education or designee will re-educate licensed nurses and agency licensed nurses on the electronic documentation system for documenting the non-pharmacological interventions attempted prior to the administration of psychotropic meds. Non-pharmacological interventions need to include one or more prior to medications. System Change will include the use of the electronic documentation system to track non-pharmacological interventions prior to administration of medications and consultant pharmacist review.
4. Director of Nursing or designee will audit 5 residents receiving psychotropic meds to validate the use of non-pharmacological interventions prior to medication administration for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.70(o)(1)-(4) REQUIREMENT Hospice Services: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.
§483.70(o) Hospice services.
§483.70(o)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(o)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(o)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(o)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.
Observations:


Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of 47 residents reviewed (Resident 9).

Findings include:

An agreement between the facility and a hospice provider (provider of end-of-life services), dated February 25, 2019, indicated that the facility would designate an area in each resident's chart where all hospice administrative documentation would be maintained, including the hospice referral sheet, hospice election statement (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness), hospice consent form, hospice physician's plan of treatment, the hospice plan of care, hospice emergency plan, and advance directive information.

Physician's orders for Resident 9, dated February 25, 2019, revealed that the resident was admitted to the facility's contracted hospice provider. However, as of October 2019, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the physician's recertification of terminal illness (a form signed by the resident's hospice physician and specific to each patient).

Interview with the Director of Nursing on February 12, 2020, at 11:30 a.m. confirmed that there was no documented evidence that Resident 9's clinical record and/or the hospice clinical record contained the physician's recertification of terminal illness.

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




 Plan of Correction - To be completed: 03/18/2020

1. The physician's recertification of terminal illness was obtained for resident 9.
2. Residents currently receiving hospice services have the physician's recertification of terminal illness in their medical record.
3. Director of Education or designee will provide education to the social service staff that the recertification of terminal illness form is a required part of the medical record. System change will be that the Director of Social Services coordinates with the hospice provider the timely receipt of the recertification of terminal illness documentation.
4. Director of Nursing or designee will audit 5 residents on hospice to validate receipt of the hospice documentation weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month. Findings of the audit will be presented to the Quality Assurance Performance Improvement committee for review and recommendation.

483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ: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.
§483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:


Based on review of safety information, as well as observations and staff interviews, it was determined that the facility failed to ensure that the environment was maintained in a safe manner for residents in one of three shower rooms (Palmer).

Findings include:

A Material Safety Data Sheet (MSDS - document that lists information related to occupational safety and health for various substances and products) for PDI wipes (disinfectant wipes that are used on hard, non-porous surfaces and equipment) revealed a label warning with a hazard statement that the product "causes eye irritation." If the product was in the eyes, they were to be rinsed cautiously with water for several minutes, and if the eye irritation persisted, to get medical attention.

Observations in the shower room on the Palmer unit on February 8, 2020, at 10:04 a.m. revealed that there was an open container of PDI wipes that was unsecured and accessible to residents.

Interview with Registered Nurse 17 on February 8, 2020, at 10:12 a.m. confirmed that the PDI wipes should not have been left out in the open and accessible to residents.

28 Pa. Code 207.2(a) Administrator's responsibility.





 Plan of Correction - To be completed: 03/18/2020

1. The Germicidal Disposable (PDI) wipes were secured in a locking cabinet in the shower room. No residents were injured by the deficient practice.
2. Locking cabinets are now in shower rooms for securing of Germicidal Disposable (PDI) wipes.
3. Director of Education or designee will educate staff that hazardous items including Germicidal Disposable (PDI) wipes are to be secured in the locked cabinet when not in use. System change included addition of functional locks on cabinets in the resident shower rooms.
Director of Housekeeping or designee will audit 3 shower rooms to ensure that any hazardous items are secured weekly for 4 weeks, every 2 weeks x 1 month and monthly x 1 month.


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