Pennsylvania Department of Health
 ACCELERATE SKILLED NURSING AND REHABILITATION EXTON
Patient Care Inspection Results

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ACCELERATE SKILLED NURSING AND REHABILITATION EXTON
Inspection Results For:

There are  42 surveys for this facility. Please select a date to view the survey results.

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ACCELERATE SKILLED NURSING AND REHABILITATION EXTON - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey and two complaint investigations completed on March 15, 2024 , it was determined that Accelerate Skilled Nursing and Rehabilitation was not in compliance with the following requirements of 42 CFR 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as it relates to the Health portion of the survey process.




 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on review of facility policy, clinical record, and facility documentation, it was determined that the facility failed to timely assess, monitor, and treat for suspected laundry detergent poisoning of Resident 222, resulting in actual harm of vomiting and diarrhea with a subsequent hospitalization to the Intensive Care Unit (ICU) for one of 22 residents reviewed.

Findings include:

Review of facility policy, "Poisoning," effective December 1, 2006, revealed: "Upon discovery of suspected poisoning, call for help and instruct staff to call 911."

Review of Resident 222's clinical record revealed a diagnosis of Dementia (loss of cognitive functioning that interferes with daily life and activities) with behavioral disturbances.

Review of Resident 222's July 2023 Admission MDS (Minimum Data Set - periodic assessment of resident care needs) revealed a BIMS (Brief Interview of Mental Status) was unable to be completed due to the resident's cognitive impairment.

Review of Resident 222's nursing progress notes revealed a nursing note from Licensed Nurse Employee 12 dated November 17, 2023, at 1:44 a.m., indicating: "Previous nurse [(Licensed Nurse Employee 11)] reported that resident was found with laundry pods around 1530 [(3:30 p.m.)] opened in his room. Nurse reported he seemed fine. About 2030 [(8:30 p.m.)] an aide needed assistance with incontinent care for resident. When I entered the room, resident was sitting on [the bed] with vomit and feces noted around him. Resident was alert. Resident was given a shower assessed and vitals were taken. Resident was able to follow commands during assessment. On call was contacted and spoke with [provider] who gave order to send resident out. Contacted [hospital] who reported patient is currently admitted to ICU with vomiting from ingesting toxic chemical (Gain laundry pods). Daughter was contacted and notified."

Review of facility documentation revealed a witness statement from nurse aide Employee 13 dated November 17, 2023, indicating: "I was rounding went into [Resident 222's] room at 1530 found [laundry detergent] pods on bedside cabinet ripped open. I suspected that the patient ripped the bag open. I found 1-2 open on the floor. [Licensed Nurse Employee 11] brought [Resident 222] out to nurses station. He seemed ok. Around dinner time he started having loose stools. I went to get towels to clean it up. [Licensed Nurse Employee 11] was at nurses station. She kept sitting there even though she knew [Resident 222] was having loose stools. I had to get [another nurse aide] to help me. We cleaned him up and put him in bed. At 7:30 he sat up - he had vomited. I got [Licensed Nurse Employee 12] & I showered him again. I asked [Licensed Nurse Employee 12] if we need to call poison control. She said she was calling [provider.] [Emergency Medical Services] arrived about 9pm." Further review of nurse aide Employee 13's witness statement revealed: "I reported the findings of the ripped open bag of pods to nurse @1550. I reported the diarrhea at dinner time."

Further review of facility documentation revealed a witness statement from Licensed Nurse Employee 11, undated, which revealed: "Nurse made aware by [nurse aide] at 6pm that patient had an opened bag of laundry pads [pods] in his room. Patient was found sitting in the chair in his room. [Vital signs stable.] No signs of distress or pain noted. Visualized [his] mouth and mucous membranes pink and moist. No abnormal smell noted. No residue around mouth or on his hands was noted. Inspected room, no signs that pods was used or tampered with. Patient brung out to the nurses station. Patient sat and flipped through a book. Snack was given. Consumed 100%. Report given to oncoming nurse."

Review of Resident 222's clinical record failed to reveal documented evidence that the resident was assessed or vital signs were obtained following Nurse Aide Employee 13's witnessed account from 3:30 p.m. on November 16, 2023.

Review of Resident 222's clinical record failed to reveal documented evidence the physician was notified at the time Resident 222's was found with an open laundry detergent pod.

Review of Resident 222's clinical record and facility documentation revealed resident was unable to articulate if he/she ingested the contents of the laundry detergent pod due to impaired cognition and poor safety awareness.

Review of Resident 222's clinical record and facility documentation failed to reveal evidence of staff contacting Poison Control or researching signs/symptoms of laundry detergent poisoning at the time Resident 222 was observed with open laundry deteregent pod and possible ingestion of the contents.

Review of Resident 222's Emergency Room notes revealed: "Reported to be found by staff at 1500 today with an open bag of laundry detergent pods next to him [Patient] reported to be vomiting and having diarrhea-unknown time of onset EMS dispatched at 2113 for a poisoning- arrived at 2123 to find [patient] 78% on Room air [(normal is 95-100%] , sitting up in a recliner slumped over. [Patient] arrives on nebulizer, slumped forward, emesis [(vomit)] bag with bright orange emesis with odor of detergent."

Review of Resident 222's discharge summary from the hospital on November 29, 2023, revealed the resident was admitted to the ICU on high flow nasal cannula oxygen, placed on IV fluids and IV antibiotics, had a chest x-ray that showed aspiration (when fluids or stomach contents are breathed into the lungs), placed on bronchodilators (medications that relax the muscles around your airways and help clear mucus from your lungs) every 4 hours, and required frequent suctioning.

Interview with the Interim Nursing Home Administrator and Corporate Nurse on March 15, 2024, at 9:35 a.m. confirmed the (nursing agency) staff failed to timely assess, monitor, and treat Resident 222 for suspected laundry detergent poisoning.

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

28 Pa Code 211.5(f) Clinical Records

28 PA Code 211.10(a) Resident care policies




 Plan of Correction - To be completed: 04/16/2024

1. CORRECTIVE ACTION FOR AREAS AFFECTED:
Patient R222 was discharged from the facility on 11/16/2023.
Employee E11 is no longer employed at the center.

2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Nursing Home Administrator/Designee on current patients rooms to validate that no laundry pods/ laundry detergents or any other potential poisonous substances are in any patient room.


3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Licensed nursing staff will be re-educated by the Director Of Nursing/Designee on timely assessments for any patient who has a suspect poisoning from laundry detergent or any other substance, location of MSDS binders, calling poison control, physician and 911 if appropriate.

All staff will be re-educated that if a potential poisonous substance is noticed in a patient room to remove the item and secure the item for the patient until the family is able to pick it up and remove it from the facility.


4. MONITORING OF CORRECTIVE ACTION:
The Licensed Nursing Home Administrator/designee will conduct weekly random audits for the next 90 days of 5 patient rooms with cognitive impairments on each unit to validate that no laundry pods or other laundry detergents are in any resident room. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(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 facility policy, clinical record, and facility documentation, it was determined that the facility failed to ensure a cognitively impaired resident's (Resident 222) environment was free from known environmental hazards including laundry detergent pods resulting in actual harm of suspected poisoning and subsequent hospitalization to the Intensive Care Unit (ICU) for one of 22 residents reviewed.

Findings include:

Review of facility policy, "Poisoning," effective December 1, 2006, revealed: "Upon discovery of suspected poisoning, call for help and instruct staff to call 911."

Review of Resident 222's clinical record revealed a diagnosis of Dementia (loss of cognitive functioning that interferes with daily life and activities) with behavioral disturbances.

Review of Resident 222's July 2023 Admission MDS (Minimum Data Set - periodic assessment of resident care needs) revealed a BIMS (Brief Interview of Mental Status) was unable to be completed due to the resident's cognitive impairment.

Review of Resident 222's clinical record revealed a nursing progress note dated November 13, 2023 (15:49 aka 3:49 p.m) indicating "pt [patient] AAOx1 [Awake/Alert/Oriented x1] w/ hx [with history] of adv [advanced] dementia. steady gait, able to ambulate independently. impulsive, often wanders and tries to enter other patients' rooms. no s/s [signs/symptoms] of respiratory distress or sob [shortness of breath]. no c/o [complaints of] pain or discomfort. [resident] accepted [his/her] medications crushed with applesauce this morning. pt often refuses care. pt is grossly incontinent and often refuses incontinence care. becomes combative and agitated w/ at times. [Resident] is unable to make [resident] needs known. needs anticipated. call bell within reach."

Review of Resident 222's nursing progress notes revealed a nursing note from Licensed Nurse Employee E12 dated November 17, 2023, at 1:44 a.m., indicating: "Previous nurse [(Licensed Nurse Employee 11)] reported that resident was found with laundry pods around 1530 [(3:30 p.m.)] opened in his room. Nurse reported he seemed fine. About 2030 [(8:30 p.m.)] an aide needed assistance with incontinent care for resident. When I entered the room, resident was sitting on [the bed] with vomit and feces noted around him. Resident was alert. Resident was given a shower assessed and vitals were taken. Resident was able to follow commands during assessment. On call was contacted and spoke with [provider] who gave order to send resident out. Contacted [hospital] who reported patient is currently admitted to ICU with vomiting from ingesting toxic chemical (Gain laundry pods). Daughter was contacted and notified."

Review of facility documentation revealed a witness statement from nurse aide Employee 13 dated November 17, 2023, indicating: "I was rounding went into [Resident 222's] room at 1530 found [laundry detergent] pods on bedside cabinet ripped open. I suspected that the patient ripped the bag open. I found 1-2 open on the floor. [Licensed Nurse Employee 11] brought [Resident 222] out to nurses station. He seemed ok. Around dinner time he started having loose stools. I went to get towels to clean it up. [Licensed Nurse Employee 11] was at nurses station. She kept sitting there even though she knew [Resident 222] was having loose stools. I had to get [another nurse aide] to help me. We cleaned him up and put him in bed. At 7:30 he sat up - he had vomited. I got [Licensed Nurse Employee 12] & I showered him again. I asked [Licensed Nurse Employee 12] if we need to call poison control. She said she was calling [provider.] [Emergency Medical Services] arrived about 9pm." Further review of nurse aide Employee 13's witness statement revealed: "I reported the findings of the ripped open bag of pods to nurse @1550. I reported the diarrhea at dinner time."

Further review of facility documentation revealed a witness statement from Licensed Nurse Employee 11, undated, which revealed: "Nurse made aware by [nurse aide] at 6pm that patient had an opened bag of laundry pads [pods] in his room. Patient was found sitting in the chair in his room. [Vital signs stable.] No signs of distress or pain noted. Visualized [his] mouth and mucous membranes pink and moist. No abnormal smell noted. No residue around mouth or on his hands was noted. Inspected room, no signs that pods was used or tampered with. Patient brung out to the nurses station. Patient sat and flipped through a book. Snack was given. Consumed 100%. Report given to oncoming nurse."

Review of Resident 222's clinical record failed to reveal documented evidence that the resident was assessed or vital signs were obtained following Nurse Aide Employee 13's witnessed account from 3:30 p.m. on November 16, 2023.

Review of Resident 222's clinical record failed to reveal documented evidence the physician was notified at the time Resident 222 was found with an open laundry detergent pod.

Review of Resident 222's clinical record and facility documentation failed to reveal evidence of staff contacting Poison Control or researching signs/symptoms of laundry detergent poisoning at the time of Resident 222's suspected ingestion of the laundry detergent pod contents.

Review of Resident 222's Emergency Room notes revealed: "Reported to be found by staff at 1500 today with an open bag of laundry detergent pods next to him [Patient] reported to be vomiting and having diarrhea-unknown time of onset EMS dispatched at 2113 for a poisoning- arrived at 2123 to find [patient] 78% on Room air [(normal is 95-100%] , sitting up in a recliner slumped over. [Patient] arrives on nebulizer, slumped forward, emesis [(vomit)] bag with bright orange emesis with odor of detergent."

Review of Resident 222's discharge summary from the hospital on November 29, 2023, revealed the resident was admitted to the ICU on high flow nasal cannula oxygen, placed on IV fluids and IV antibiotics, had a chest x-ray that showed aspiration (when fluids or stomach contents are breathed into the lungs), placed on bronchodilators (medications that relax the muscles around your airways and help clear mucus from your lungs) every 4 hours, and required frequent suctioning.

Interview with the Interim Nursing Home Administrator and Corporate Nurse on March 15, 2024, at 9:35 a.m. when the above information was presented for staff failed to ensure a safe environment for cognitively impaired Resident 222 from ingesting laundry pod contents and timely assess, monitor, and treat suspected poisoning.

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

28 Pa Code 211.5(f) Clinical Records

28 PA Code 211.10(a) Resident care policies


 Plan of Correction - To be completed: 04/16/2024


1. CORRECTIVE ACTION FOR AREAS AFFECTED:
Patient R222 was discharged from the facility on 11/16/2023.

2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee on current patients rooms to validate that no laundry pods/ laundry detergents or any other potential poisonous substances are in any patient room.


3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Licensed nursing staff will be re-educated by the Director Of Nursing/Designee on timely assessments for any patient who has a suspect poisoning from laundry detergent or any other substance, location of MSDS binders, calling poison control, physician and 911 if appropriate.

All staff will be re-educated that if a potential poisonous substance is noticed in a patient room to remove the item and secure the item for the patient until the family is able to pick it up and remove it from the facility.


4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/designee will conduct weekly random audits for the next 90 days of 5 patient rooms with cognitive impairments on each unit to validate that no laundry pods or other laundry detergents are in any resident room. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.


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 upon review of staffing records and performance reviews it was determined the facility failed to ensure performance reviews were completed for five of five staffing records reviewed, (E6, E7, E8, E9, E10).

Findings include:

Review of staffing records and performance reviews revealed five staff members, E6, E7, E8, E9 and E10, did not have annual performance reviews performed within the appropriate timeframe.

Interview with the Corporate Nurse on March 15, 2024, at 2:27 p.m. confirmed staff performance reviews were not completed timely.

Further interview with Corporate Nurse a performance plan has been made to catch up on past due staff performance reviews.

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


 Plan of Correction - To be completed: 04/16/2024

1. CORRECTIVE ACTION FOR AREAS AFFECTED:
E6, E7, E8, E9 and E10 performance reviews have been completed.


2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee to identify Cna requiring performance reviews, reviews will be completed and areas of training identified upon completion of review with CNA.


3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Director Of Nursing and Administrator will be re-educated by HR lead/Designee on Cna annual performance review and education with review of Policy HR217 Nurse Aide Training and Certification


4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/designee will conduct monthly random audits for the next 90 days to identify and CNA requiring an annual performance review and areas of training. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.



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 staffing records and interviews with staff, it was determined the facility failed to perform the minimal 12 hours of annual training for five of five staffing records reviewed, (Employees E6, E7, E8, E9 and Employee E10).

Findings include:

Review of staffing records failed to reveal the minimal 12 hours of annual training for five staff members reviewed, Employees E6, E7, E8, E9 and Employee E10.

Interview with the Corporate Nurse (E3) on March 15, 2024, at 2:27 p.m. confirmed staff did not receive the minimal 12 hours of annual training.

Further interview with Corporate Nurse E3 confirmed a performance plan has been made to catch up on past due staff training.

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



 Plan of Correction - To be completed: 04/16/2024

CORRECTIVE ACTION FOR AREAS AFFECTED:
Employee E6, E7, E8, E9, E10 will be scheduled to complete mandatory training hours.


2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee on all current CNA to verify the amount of training hours completed to date.

3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Nurse Practice educator will be re-educated by the Director Of Nursing/Designee on Policy HR217 Nurse Aide Training and Certification to emphasize in-service education for nurse aides will include:Continuing competence for no less than 12 hours per year; Dementia management and patient abuse prevention; Nurse aides serving individuals with cognitive impairments also must have training in care of such individuals; and Required state specific training.


4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/designee will conduct weekly audits for the next 90 days on all current CNA to verify the amount of training hours completed to date until all CNA's have met the minimum 12 hours of training.Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

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 and pharmacy record reviews, and staff interview, it was determined that the facility failed to ensure residents were free from significant medication error for three of the 22 residents reviewed (Residents 3, 67, and 81).

Findings include:

Review of Resident 3's clinical record revealed a diagnosis of seizure disorder (a sudden, uncontrolled burst of electrical activity in the brain that can affect behavior, movements, feelings and consciousness.)

Review of Resident 3's physician orders from admission revealed an order for Phenytoin (medication used to control and prevent seizures) 100 milligrams (mg) once daily in the morning and 200 mg at bedtime.

Review of Resident 3's March 2024 Medication Administration Record (MAR) and progress notes revealed the resident missed Phenytoin doses due to awaiting pharmacy delivery on the following dates:

March 10, 2024, 100 mg in the morning
March 11, 2024, 100 mg in the morning and 200mg at bedtime
March 13, 2024, 100 mg in the morning
March 14, 2024, 100 mg in the morning
March 15, 2024, 100 mg in the morning

Review of the pharmacy documentation revealed Phenytoin was available on the facility's automated dispensing machine (Omnicell).

Interview with the Director of Nursing on March 15, 2024, at 2:30 p.m. confirmed Resident 3 should have received the abovementioned doses of Phenytoin.

Review of Resident 67's clinical record revealed Resident 67 was re-admitted on January 26, 2024, with Osteomyelitis (Infection to the bone) on the sacrum (tailbone).

Review of Resident 67's physician's order sheet (POS) dated January 26, 2024, at 7:38 p.m., revealed an order for Piperacillin Sod-Tazobactam (Antibiotic) Intravenous Solution 3.375 gm intravenously every six hours for wound infection. The medication administration was scheduled every 6:00 a.m., 12 noon, 6:00 p.m., and 12:00 a.m.

Review of Resident 67's January 2024 Medication Administration Record (MAR) revealed Resident 67 was not administered the ordered medication until January 28, 2024, at 6:00 p.m. The MAR revealed Resident 67 missed seven doses of the ordered Piperacillin (January 27, 2024, at 12:00 a.m., 6:00 a.m., 12 noon, 6:00 p.m., January 28, 2024, at 12:00 a.m., 6:00 a.m., and 12 noon).

Review of Resident 67's pharmacy documentation revealed medication Piperacillin was available on the facility's automated dispensing machine (Omnicell).

Review of Resident 67's clinical record failed to reveal the reason why medication was not administered.

Interview with Employee E3 was conducted on March 15, 2023, at 1:00 p.m. Employee E3 was not able to provide a reason as to why medication Piperacillin was missed seven times.

The facility failed to ensure Resident 67's medication to treat wound infection was administered as ordered.

Review of Resident 81's clinical record revealed Resident 81 was admitted to the facility on February 1, 2024, with an infected surgical wound to the mid-upper back. The resident had an order for Intravenous (Medication administered into a vein) Vancomycin (antibiotic) and Vancomycin trough (a Vancomycin check at least eight hours after the last dose).

Review of Resident 81's physician order revealed an order for Vancomycin HCL intravenously two times a day, scheduled at 9:00 a.m., and 9:00 p.m.

Review of Resident 81's laboratory results dated February 29, 2024, reported at 8:24 p.m., revealed a critical Vancomycin trough result of 27.7 (normal range 10-20).

Review of Resident 81's nursing progress notes dated March 1, 2024, at 3:22 a.m., revealed on call NP (nurse practitioner) was notified of the critical Vancomycin trough result and ordered to hold the IV Vancomycin, recheck Vancomycin level in the morning before next administration and have the in-house physician/NP see the resident and review blood work in the morning.

Review of Resident 81's NP's telehealth notes dated March 1, 2024, at 6:07 a.m., revealed laboratory result was reviewed, the Vancomycin trough was 27.7, recommended holding Vancomycin, repeating the Vancomycin trough, and checking the result before the next dose.

Review of Resident 81's physician order dated March 1, 2024, at 3:48 a.m., revealed an order for Vancomycin through, check result before IV administration.

Review of Residente 81's March 2024, Medication Administration Record (MAR) revealed Resident 81's IV Vancomycin was not administered on March 1, 2024, at 9:00 a.m., but was administered on March 1, 2024, at 9:00 p.m.

Review of Resident 81's clinical record failed to reveal a Vancomycin trough level was done/checked before administering the IV Vancomycin on March 1, 2024, at 9:00 p.m.

Review of the NP's progress notes dated March 2, 2024, at 4:29 p.m., revealed a "Medication Error", The resident's Vancomycin trough was 27.7 on February 29, 2024, the note stated to hold Vancomycin and ordered Vancomycin trough. Per the nurse, it was not held, Vancomycin was given, and laboratory was not done.

Interview with Employee E3 on March 15, 2024, at 1:00 p.m., confirmed that Vancomycin was administered as documented in MAR. There was no incident report/statements completed for the medication error incident, the nurse involved no longer works in the facility.

The facility failed to ensure Resident 81's Vancomycin medication was administered as ordered.

28 Pa. Code 211.5(f) Clinical Records

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


 Plan of Correction - To be completed: 04/16/2024

1. CORRECTIVE ACTION FOR AREAS AFFECTED:
Patient R3 was discharged from the facility on 3/19/2024.
Patient R67 Piperacillian order will be reviewed by physician and stop date adjusted if indicated by physician.
Patient R81 was discharged from the facility on 3/19/2024.


2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee on current patients to ensure no medications were missed within the last 3 days, if any missed doses identified, the pharmacy and physician will be notified.

An initial audit will be completed by the Director of Nursing/Designee on current patients over the last 7 days with IV vancomycin orders to ensure vancomycin was not administered prior to reviewing that the vancomycin trough level was within normal limits.


3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Licensed nursing staff will be re-educated by the Director of Nursing or designee on Pharmacy services procedure 5.1- Delivery and Receipt of Routine Deliveries with emphasis on If any item ordered by the facility is not received in the delivery, facility staff should check for a pharmacy communication slip and contact Pharmacy for an explanation for the missing items or medications and notify doctor of any missed doses of medications. Licensed nursing staff will be re-educated on omnicell location, access and contents.

Licensed nursing staff will be re-educated by the Director of Nursing or designee on reviewing Vancomycin trough level prior to administration of IV Vancomycin.


4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/designee will conduct weekly random audits for the next 90 days to ensure no medications were missed, if any missed doses are identified, the pharmacy and physician will be notified.

The Director of Nursing/designee will conduct weekly random audits for the next 90 days patients with IV vancomycin orders to ensure vancomycin was not administered prior to reviewing that the vancomycin trough level was within normal limits.

Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.


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 clinical records review and staff interview, it was determined that the facility failed to notify the physician of a significant weight change for one of the 22 residents reviewed (Resident 39).

Findings include:

Review of Resident 39's clinical records revealed resident was admitted to the facility on February 16, 2024, after brain surgery for a tumor resection. Further review of Resident 39's clinical record revealed additional diagnoses of Diabetes (group of metabolic disorders characterized by a high blood sugar level over a prolonged period), and Chronic Kidney Disease (CKD).

Review of Resident 39's weights and vitals revealed an admission weight of 297. 1 pound on February 16, 2024. The resident was again weighed on February 17, 2024, with the result of 296.9 lbs.

Review of Resident 39's weights and vitals dated February 21, 2024, revealed a weight of 353.2 lbs. A re-weight conducted on February 22, 2024, revealed a weight of 362 lbs., a 65.1-pound (17.98%) weight gain in five days.

Review of dietitian's progress notes dated February 22, 2024, revealed that the significant weight change was identified and is likely related to scale variance. The note revealed that the admission weight was taken from the hospital record and no new interventions were warranted at this time.

Review of Resident 39's clinical record failed to reveal the physician was notified of Resident 39's significant weight gain identified on February 22, 2024.

Review of the physician's progress notes dated March 5, 2024, revealed Resident 39 reported a concern about his/her weight change/discrepancy.

Interview with the Dietitian, Employee E5, was conducted on March 16, 2024, at 11:00 a.m. Employee E5 confirmed that Resident 39's baseline weight was from the hospital record. Employee E5 confirmed that the physician was not notified of the significant weight change until mentioned by the resident as documented on March 5, 2024.

Interview with Employee E3 conducted on March 16, 2024, at 1:00 p.m., confirmed Resident 39's significant weight change was not reported timely to the physician.

The facility failed to ensure physician was notified of the significant weight change of Resident 39.

28 Pa. Code 211.5(f) Clinical Records

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


 Plan of Correction - To be completed: 04/16/2024
1. CORRECTIVE ACTION FOR AREAS AFFECTED:
Patient R39 was discharged from the facility on 3/13/2024.

2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee on current patients to identify any patient with a significant weight change and verify that the doctor has been notified of weight change.

3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Licensed nursing will be re-educated by the Director of Nursing/Designee on the Weight and Height procedure with emphasis on notifying the physician/APP and Dietitian of significant weight changes; a Significant weight change defined as: 5% in one month and 10% in six months.

4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/designee will conduct random weekly audits for the next 90 days on patients to identify any patient with a significant weight change and verify that the doctor has been notified of weight change. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.


483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on review of the facility's policy, clinical records, and staff interview, it was determined that the facility failed to ensure a baseline care plan was developed for one of the 22 residents reviewed (Resident 67).

Findings include:

Review of the facility's policy titled "Person-Centered Care Plan," dated October 24, 2022, revealed the facility must develop and implement a baseline person-centered care plan within 48 hours of admission, readmission for each resident that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Review of Resident 67' clinical record revealed Resident 67 was readmitted to the facility on January 26, 2024, with a diagnosis of Osteomyelitis (bone infection) to the sacrum (tail bone).

Review of Resident 67's physician's order sheet dated January 26, 2024, revealed an order for Piperacillin Sod-Tazobactam (Antibiotic) Intravenous Solution 3.375 gm intravenously every six hours for wound infection.

Review of Resident 67 ' s care plan failed to reveal that a baseline care plan was developed for residents receiving IV (intravenous - medication administered in the vein) antibiotics for wound infection.

Interview with Employee E3 conducted on March 15, 2024, at 1:00 p.m. confirmed Resident 67's care plan for IV antibiotics for wound infection was not developed.

The facility failed to ensure Resident 67's baseline care plan for IV antibiotics was developed.

28 Pa. Code 211.5(f) Clinical Records

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

28 Pa Code: 211.10(c) Resident care policies



 Plan of Correction - To be completed: 04/16/2024

1. CORRECTIVE ACTION FOR AREAS AFFECTED:
Patient R67 care plan was reviewed and updated.

2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee on all current patients to ensure baseline care plans were developed.

3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Interdisciplinary Team will be re-educated by the Director Of Nursing/Designee on OPS416 Person centered care plan with review of baseline care plans must be developed within 48 hours of admission, readmission and include the minimum healthcare information necessary to properly care for a patient including, but not limited to Initial goals based on admission orders; Physician orders; Dietary orders; Therapy services; Social services; and PASRR recommendation, if applicable


4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/designee will conduct weekly random audits for the next 90 days on 8 admission/readmissions to ensure baseline care plans were developed within 48 hours.
Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:


Based on review of the facility's policy, clinical records, and staff interview, it was determined that the facility failed to ensure the resident's weights were appropriately monitored and significant weight loss was timely addressed for two of 22 residents reviewed (Resident 3 and 67).

Findings include:

Review of the facility's policy titled "Weights and Heights", dated June 15, 2022, revealed "patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Hospital weights will not serve as admission or re-admission weight."

Review of Resident 3's clinical record revealed the resident was admitted to the facility on February 23, 2024.

Further review of Resident 3's clinical record failed to reveal any weights obtained from the time of admission through the duration of the survey (March 15, 2024.)

Review of Resident 3's progress notes revealed a nutrition note dated February 26, 2024, which stated: "admission weight pending, Most recent hospital weigh of 156 [pounds.]"

Interview with Dietitian, Employee 5 on March 15, 2024, at 11:20 a.m. confirmed the facility should have obtained an admission weight, then weekly weights on Resident 3, and using the hospital weight was not acceptable.

Review of Resident 67's clinical record revealed Resident 67 was admitted to the facility on November 21, 2023, with a diagnosis of Sepsis (Infection in the blood).

Review of the weights and vitals revealed an initial weight of 225 pounds taken on November 21, 2023. The resident weight taken on November 22, 2024, revealed a weight of 225 pounds. On November 30, 2023, the resident's weight was 184.7 pounds, a 40.4 pounds (17.91%) significant weight loss in eight days.

Review of Resident 67's clinical record failed to reveal that Resident 67's weight was re-checked after a significant change was identified on November 30, 2023. The records also failed to reveal that the physician was notified of the significant weight loss.

Review of Resident 67's clinical record revealed Resident 67's significant weight loss identified on November 30, 2023, was not addressed by the dietitian until December 13, 2023. A dietary note dated December 13, 2023, revealed resident intake was documented at 100% but the patient stated that he only eats about 50%. Ensure Supplement three times daily was recommended.

Interview conducted with Employee E3 on March 15, 2024, at 1:00 p.m., confirmed Resident 67's significant weight change identified on November 30, 2023, was not addressed until 13 days after.

28 Pa. Code 211.5(f) Clinical Records

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

28 Pa Code: 211.10(c) Resident care policies


 Plan of Correction - To be completed: 04/16/2024

 CORRECTIVE ACTION FOR AREAS AFFECTED:
Patient R3 was discharged from the facility on 3/19/2024.
Patient R67 weights will be reviewed by physical and dietician and interventions added as appropriate.

2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee on current patients to validate weights were completed on admission/re-admission than weekly for four weeks and monthly thereafter.
An initial audit will be completed by the Director of Nursing/Designee on current patients to identify any patient with a significant weight change and verify that the doctor has been notified of weight change.


3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Licensed nursing will be re-educated by the Director of Nursing/Designee on the Weight and Height policy NSG244 -Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Weight and Height procedure, reviewing notifying the physician/APP and Dietitian of significant weight changes; a Significant weight change defined as: 5% in one month and 10% in six months.4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/designee will conduct random weekly audits for the next 90 days on 10 patients to identify weights were completed upon admission/readmission and weekly times four then monthly, identify any patient with a significant weight change and verify that the doctor has been notified of weight change. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.




483.50(a)(1)(i) REQUIREMENT Laboratory 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.
§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.
Observations:


Based on clinical record and laboratory documentation reviews, and staff interview, it was determined that the facility failed to ensure blood work ordered by the physician was completed for one of the 22 residents reviewed (Resident 257).

Findings include:

Review of Resident 257's clinical record revealed Resident 257's diagnosis list including Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), Parkinson's Disease (disorder of the central nervous system that affects movement, often include tremors), and weakness.

Review of Resident 257's physician's notes dated February 7, 2024, revealed the resident was seen due to the wife's concern about the resident's increased lethargy and inability to participate in therapy. The resident was evaluated, and would momentarily respond to verbal stimuli then fall back to sleep. An order to decrease the psychotropic medication was ordered, a Neurology consult and to do blood work on February 8, 2024

Review of Resident 257's physician order sheet (POS) dated February 7, 2024, at 12:16 p.m., revealed an order for CBC (Complete Blood Count), and BMP (Basic Metabolic Panel) on February 8, 2024, for altered mental status.

Review of Resident 257's laboratory documentation revealed the facility placed the request to the laboratory for the blood work to be completed on February 8, 2024.

Review of Resident 257's clinical record failed to reveal the blood work ordered by the physician was completed on February 8, 2024. Further review of the clinical record also failed to reveal the physician was notified of the missed blood work.

Interview with the Corporate Nurse, Employee E3 conducted on March 15, 2024, at 10:00 a.m., confirmed the laboratory did not come to the facility to take the resident's blood and therefore blood work order was not completed.

The facility failed to ensure Resident 257 had physician ordered ordered laboratory blood work completed.

28 Pa. Code 211.5(f) Clinical Records

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


 Plan of Correction - To be completed: 04/16/2024

CORRECTIVE ACTION FOR AREAS AFFECTED:
Patient R257 was discharged from the facility on 2/19/2024.

2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee on current patients over the last 7 days to ensure all laboratory blood work has been completed.


3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Licensed nursing staff will be re-educated by the Director Of Nursing/Designee to review Lab Log daily to ensure that the laboratory company has come to the facility and no laboratory blood work has been missed.

4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/designee will conduct weekly random audits for the next 90 days on patients to ensure all laboratory blood work has been completed. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.

§ 211.12(f.1)(2) LICENSURE Nursing services. :State only Deficiency.
(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:
Based on review of certified nursing aide time schedules and staff interviews, it was determined that the facility administrative staff failed to provide a minimum of one certified nurse aide per 12 residents during the evening shifts, and one certified nurse aide per 12 residents during the day shift on 2 of 21 days (3/11/24, 3/14/24).

Findings include:

Review of facility census data indicated that on 3/11/24, the facility census was 103, which required 8.58 certified nurse aides during the evening shift.

Review of the nursing time schedules revealed 7.71 certified nurse aides provided care on the day shift on 3/11/24. No additional excess higher-level staff were available to compensate this deficiency.

Review of facility census data indicated that on 3/14/24, the facility census was 115, which required 9.58 certified nurse aides during the evening shift.

Review of the nursing time schedules revealed 8.04 certified nurse aides worked on the evening shift on 3/14/24. No additional excess higher-level staff were available to compensate this deficiency.



 Plan of Correction - To be completed: 04/16/2024

1,2) Nurse aide staffing ratios will be reviewed for the last 7 days to evaluate if nurse aide ratios is met.
3) Nursing admin and scheduler will be re-educated on new July 1 nurse staffing and PPD requirements.
4) Weekly audit of nurse aid ratios will be conducted for 60 days by NHA/designee to ensure nurse aid ratios are met. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.


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