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

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KINZUA HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  49 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.
KINZUA HEALTHCARE AND REHABILITATION CENTER - 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 completed on January 26, 2024, it was determined that Kinzua Healthcare and Rehabilitation 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:


483.10(f)(1)-(3)(8) REQUIREMENT Self-Determination: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(f) Self-determination.
The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.

§483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.

§483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.

§483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.

§483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.
Observations:

Based on review of facility policy, clinical records, observations, and resident and staff interviews it was determined that the facility failed to promote self-determination through the support of resident choices about aspects of their lives that were identified as important for five of 24 residents reviewed (Residents R14, R37, R40, R82, and R186).

Findings include:

A facility policy entitled, "Dining and Food Preferences" dated 1/16/24, indicated the following:

- licensed nurse will notify the dining services department of food allergies upon admission and prior to any meals served.
- Dining Services Director or designee will interview the resident/representative to complete a Food Preference Interview within 48 hours (two days) of admission.
- Food Preference Interview will be entered into the medical record.
-Food allergies, food intolerances, food dislikes, and food and fluid preferences will be entered into the resident profile menu management software system.
- individual tray assembly ticket will identify allergies, food and beverage preferences, and special requests.

Resident R14's clinical record revealed an admission date of 11/19/23, with diagnoses including broken left thigh, difficulty swallowing, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), heart failure, Type 2 Diabetes (condition that affects how the body uses glucose [sugar]), and high cholesterol.

Observation on 1/24/24, at 12:10 p.m. revealed Resident R14's individual tray assembly ticket lacked identification of food/beverage likes and dislikes, and special requests.

During an interview at that time Resident R14 confirmed that he/she has told staff of his/her dislike of eggs and continues to receive them almost every day.

Resident R37's clinical record revealed an admission date of 11/09/23, with diagnoses including broken right thigh, pelvis, and lower back, high cholesterol, kidney disease, heart failure, and gastro-esophageal reflux disease (GERD- occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus).

Observation on 1/24/24, at 12:13 p.m. revealed Resident R37's meal tray contained beets, and the individual tray assembly ticket lacked identification of food/beverage likes and dislikes, and special requests.

During an interview at that time Resident R37 confirmed that he/she does not like beets.

Resident R40's clinical record revealed an admission date of 1/08/24, with diagnoses including Type 2 Diabetes, high cholesterol, GERD, kidney disease, and anemia.

Observation on 1/24/24, at 12:16 p.m. revealed Resident R40's meal tray contained beets and an opened four-ounce carton of milk, and the individual tray assembly ticket indicated coffee, milk, and no fish.

During an interview at that time Resident R40 confirmed that he/she does not like beets and does not drink milk due to it not "agreeing" with him/her.

Resident R82's clinical record revealed an admission date of 1/04/24, with diagnoses including bone infection of the lower back, obesity, anemia, and high blood pressure.

Observation on 1/24/24, at 12:20 p.m. Resident R82's meal tray contained beets, and the individual tray assembly ticket lacked identification of food/beverage likes and dislikes, and special requests.

During an interview at that time Resident R82 confirmed that he/she does not like beets.

During an interview on 1/24/23, at 12:30 p.m. Nurse Aide (NA) Employee E1 confirmed the following:

-Resident R14 does not like eggs and receives them for breakfast, and the individual assembly meal ticket lacked food/beverage likes and dislikes, and special requests.
-Resident R37's meal tray contained beets, and the individual assembly meal ticket lacked food/beverage likes and dislikes, and special requests.
-Resident R40's meal tray contained beets, and an opened four-ounce carton of milk, and the individual assembly meal ticket lacked food/beverage likes and dislikes, and special requests.
-Resident R82's meal tray contained beets, and the individual assembly meal ticket lacked food/beverage likes and dislikes, and special requests.

Resident R186's clinical record revealed an admission date of 1/13/24, with diagnoses including bone infection of the foot, Type 2 Diabetes, high cholesterol, high blood pressure, and GERD.

During an interview on 1/23/24, at 3:10 p.m. Resident R186 confirmed that noone has met with him/her for his/her food likes and dislikes.

Observation on 1/24/24, at 12:40 p.m. Resident R186's meal tray contained beets and one coffee, and the individual tray assembly ticket lacked identification of food/beverage likes and dislikes, and special requests.

During an interview at that time Resident R186 confirmed that he/she wants two coffees with each meal and does not like beets.

During an interview on 1/24/24, at 12:50 p.m. NA Employee E2 confirmed that Resident R186's meal tray contained beets and one coffee, and the individual assembly meal ticket food/beverage likes and dislikes, and special requests.

During an interview on 1/26/24, at 9:30 a.m. the Dietary Manager confirmed there was no evidence the Food Preference Interview was completed within 48 hours of admission, and no documentation of resident likes, dislikes, allergies, and special requests/choices for the above identified residents.

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

28 Pa. Code 201.24.(e)(4) Admission Policy

28 Pa. Code 201.29(a) Resident rights







 Plan of Correction - To be completed: 03/06/2024

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Residents 14, 37, 40, 82, & 186 were interviewed and completed food preferences. Residents likes/dislikes, allergies, and special requirements/choices were updated for those residents and meals tickets were updated to match.
2. How the facility will act to protect residents in similar situations.
Audit completed for current residents to validate that food/preference interviews had been completed.
3. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Administrator or designee will educate the Dietary Manager on completing the Resident Preference interview within 48hrs of admission per facility policy. Ed. signed
4. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Audit of 5 residents will be completed to ensure that residents have a food/preference interview completed within 48hrs of admissions. Audit will be completed wkly x 3wks then monthly until compliance is met. Audits will be reviewed at QAPI meeting monthly. Audits will be completed by the DON or designee.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Observations:


Based on review of a facility policy, observations, and staff interview, it was determined that the facility failed to ensure that food was stored in accordance with standards for food safety in one of three stand up refrigerators and one of one dry storage areas reviewed in the kitchen.

Findings include:

Review of facility policy entitled "Food Receiving and Storage" dated 1/16/24, indicated "Dry foods that are stored ... labeled and dated use by date. Such foods are rotated using a first in first out system" and "Refrigerated foods are labeled dated and monitored so they are used by their use by date, frozen or discarded."

Observation during kitchen tour on 1/23/24, at 11:35 a.m. revealed an open half used container of parsley flakes with an open date of 11/9/21, a use by date of 11/9/23, and a manufacturer best by date of 9/19/22. Further observations revealed three unshelled hardboiled eggs in the refrigerator with a use by date of 1/22/23, and ten cans of tomato soup with a manufacturer's expiration date of 1/17/24.

During an interview with the Dietary Manager on 1/23/24, at 11:43 a.m. he/she confirmed that items should be used before their expiration date and/or best buy date. He/she also confirmed that items should be discarded per the manufacturer's expiration date and/or discarded by the use by date.


28 Pa. Code 201.14(a) Responsibility of licensee

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






 Plan of Correction - To be completed: 03/06/2024

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Parsley, hard boiled eggs, and tomato soup were thrown away when identified as being expired/reaching expiration.
2. How the facility will act to protect residents in similar situations.
Audit completed of Dry storage as well as kitchen refrigerators to ensure that any open items had an open date on them and that they were not expired.
3. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Administrator or designee will educate Dietary manager and dietary staff to ensure that items are being used within their dates and that they are putting an open date on items when opened.
4. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Audit of Dry storage foods and kitchen Refrigerators will be completed by the Administrator or a designee weekly x 3wks then monthly until compliance is met. Audits will be reviewed at QAPI meeting monthly.

483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.
Observations:

Based on review of facility policy and clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that the resident was offered the opportunity to participate in the development, review, and/or revision of their person-centered care plan for two of 24 residents reviewed (Residents R29 and R73).

Findings include:

Review of facility policy dated 1/16/24, entitled, "Resident Participation - Assessment/Care Plan" indicated:
- the resident and his or her representative have the right to participate in the development and implementation of his or her care plan.
- the resident and his/her legal representative are encouraged to attend and participate in development of the resident's person-centered care plan.
- the care planning process will facilitate the inclusion of the resident and/or representative.
- a seven (7) day advance notice of the care planning conference is provided to the resident and/or representative
- the Social Services Director or designee is responsible for notifying the resident and/or representative and for maintaining records of such notices (date, time, and location of conference; name of person contacted and date of contact; method of contact; input from resident/representative if not able to attend; refusal of participation; and date and signature of individual making contact).

Resident R29's clinical record revealed an admission date of 6/10/15, with diagnoses that included diabetes (a condition where the body produces insufficient amounts of insulin, causing high blood sugar), atrial fibrillation (an abnormal, rapid heartbeat that is present all the time, causing shortness of breath, heart palpitations, and weakness and can lead to development of blood clots), and abnormalities of gait and mobility (difficulty walking).

Review of Resident R29's Significant Change Minimum Data Set (MDS- a federally mandated standardized assessment conducted at specific intervals to plan resident care needs), with an Assessment Reference Date (ARD-a look back period of time for the MDS assessment) of 1/9/24, revealed that Resident R29 has mild cognitive impairment.

During an interview with Resident R29 on 1/24/24, at approximately 2:20 p.m. resident reported that he/she has not been invited to attend a care plan meeting nor had he/she attended one in many months.

Resident R29's clinical record lacked any evidence that Resident R29 was invited to or ever attended a care plan meeting.

During an interview on 1/25/24, at 11:31 a.m. the Social Worker confirmed that there was no evidence of Resident R29 being invited to or attending a Care Plan Meeting.

Resident R73's clinical record revealed an admission date of 10/24/23, with diagnoses including dementia, cognitive communication deficit, difficulty talking and swallowing, Type 2 Diabetes, and high blood pressure.

Resident R73's most recent Quarterly MDS with an ARD date 12/22/23, revealed that Section C0500 indicated severe cognitive function, and the clinical record lacked evidence that the resident and/or representative had been invited to or participated in a care plan conference.

During an interview on 1/24/24, at 1:10 p.m. Resident R73's legal representative confirmed that his/her resident was admitted in October, and they have not been invited to a care plan meeting, and that they were told the delay was due to COVID and then people were off.

During an interview on 1/25/24, at 10:20 a.m. Social Services Director confirmed there was no evidence that a family care plan meeting has been held since Resident R73's admission on 10/24/23, is not on the January schedule, and should have had care plan meetings.

During an interview on 1/25/24, at 11:54 a.m. the Nursing Home Administrator confirmed that if the Social Services Director is not available, the Registered Nurse Assessment Coordinator is responsible for scheduling the care plan meetings.

28 Pa. Code 201.29 (a) Resident rights



 Plan of Correction - To be completed: 03/06/2024

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Residents and responsible parties for the affected residents were contacted before the conclusion of survey and appointments for the care plan sessions were made.
2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A quarterly care plan schedule has been developed. An invitation will be delivered to the resident and their responsible party. The interdisciplinary team will be provided with the schedule for their attendance, as well.
3. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Administrator or assign will review the upcoming schedule on a monthly basis, confirming that it includes new admissions. Notification of approaching meetings will be reviewed during the morning interdisciplinary team meetings.
4. How the facility plans to monitor its performance to make sure that solutions are permanent, i.e., what quality assurance programs will be established?
Audit of 5 residents will be completed by the Administrator or designee to ensure that resident have a CP meeting schedule and notification had been given. Audit will be completed weekly x 3wks then monthly until compliance is met. Audits will be reviewed at QAPI meeting monthly.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:


Based on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon transfer for two of 24 residents reviewed (Residents R8 and R19).

Findings include:

Review of facility policy entitled "Bed holds and Returns" dated 1/16/24, indicated that "All residents/representatives are provided written information regarding the facility and state bed-hold policies ... regardless of payor source... at the time of transfer ..."

Review of Resident R8's clinical record revealed an initial admission date of 9/8/23, with diagnoses that included osteomyelitis (an infection in the bone), diabetes (a disease that cause high blood sugars due to the body not releasing enough insulin), and hypertension (high blood pressure).

Review of Resident R8's clinical record revealed progress notes dated 9/26/23, at 6:05 p.m. and 12/1/23, at 3:16 p.m. indicating transfers to the hospital. The clinical record lacked documentation indicating that Resident R8 and/or their representative was provided with a copy of the facility bed-hold policy upon transfers.


Review of Resident R19's clinical record revealed an initial admission date of 11/21/23, with diagnoses that included dementia (a disease that affects short term memory and the ability to think logically), hypokalemia (low potassium level), and anemia (a disorder when blood cells cannot carry enough oxygen to the body tissues).

Review of Resident R19's clinical record revealed progress notes dated 1/5/24, at 6:33 a.m. and 1/15/24, at 9:07 p.m. indicating transfers to the hospital. The clinical record lacked documentation indicating that Resident R19 and/or their representative was provided with a copy of the facility bed-hold policy upon transfers.

During an interview on 1/25/24, at 12:00 p.m. the Director of Nursing, confirmed that there was no evidence that Resident R8 or R19 and/or his/her representative was provided with a copy of the facility bed-hold policy that included the cost per day. He/she also confirmed that the Registered Nurse working when the transfers occurred should have provided the resident and/or his/her representative with bed hold policy then documented in the resident clinical record.

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

28 Pa. Code 201.29(c.3) (2) Resident rights






 Plan of Correction - To be completed: 03/06/2024

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
RN Supervisors have been educated concerning a checklist addressing transfers from the facility, and the necessity to include the bed hold policy with all transfers from the facility and to document same in the Resident progress notes.
2. How the facility will act to protect residents in similar situations.
All transfers from the facility will be reviewed in the morning Interdisciplinary Team meeting to insure that a) the bed hold notice has been sent with all transfers from the facility, and b) the appropriate progress note has been entered in the Resident chart.
3. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All transfers will be reviewed in the morning Interdisciplinary Team meeting to insure that a) the bed hold notice has been sent with all transfers, and b) the appropriate progress note has been entered in the Resident chart.
4. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Audit of weekly discharges will be completed by the DON or designee to ensure that the Bed Hold Notice had been provided to outgoing Residents, and that a progress note addressing the same has been entered. Audit will be completed weekly x 3wks then monthly until compliance is met. Audits will be reviewed at QAPI meeting monthly.

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 review of facility policy and clinical records, and staff interview, it was determined that the facility failed to review and revise comprehensive care plans timely and to reflect the current necessary care and services for one of 24 residents reviewed (Resident R66).

Findings include:

Review of facility policy entitled "Care Plans,Comprehensive Person-Centered " dated 1/16/24, indicated that the care plan is reviewed and updated with clinical changes.

Review of Resident R66's clinical record revealed an admission date of 11/2/21, with diagnoses that included dementia (brain disorder that slowly destroys memory, thinking skills, and, over time the ability to carry out the simplest tasks), dysphagia (difficulty swallowing), pain and weakness.

Review of Resident R66's nutrional care plan revealed that the diet was a regular diet/ mechanical soft texture with a revision date of 11/20/23. The care plan also identified that the last review or revision date was 1/24/24.

Review of Resident R66's physcian's orders dated 11/17/23, revealed an order for a regular diet mechanical soft, ground texture.

During an interview on 1/25/24, at 12:08 p.m. the Director of Nursing confirmed that Resident R66's care plan should have been updated with the resident's additional current diet order of ground texture.

28 Pa. Code 211.5(f)(vii) Medical records

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

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









 Plan of Correction - To be completed: 03/06/2024

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Before the end of the survey, the facility audited every residents' dietary order and care plan to insure that they were in consonance and accurate.
2. How the facility will act to protect residents in similar situations.
A review of dietary orders and their care plan will be conducted by the Registered Nurse Assessment Coordinator (RNAC) and the DON upon admission and with each new dietary order change. This will be monitored in the daily review of the Order Listing Report.
3. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A review of dietary orders and their care plan will be conducted by the Registered Nurse Assessment Coordinator (RNAC) and the DON upon admission and with each new dietary order change. This will be monitored in the daily review of the Order Listing Report.
4. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Audit of Dietary orders will be completed by the DON or designee on a weekly basis to ensure that the Dietary orders have been reconciled with the care plan. Audit will be completed weekly x 3wks then monthly until compliance is met. Audits will be reviewed at QAPI meeting monthly.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on review of facility policy and clinical records, observation, and resident and staff interview, it was determined that the facility failed to obtain a physician's order for the provision of oxygen therapy for one of one residents reviewed for respiratory services (Resident R286).

Findings include:

Review of a facility policy dated 1/16/24, entitled, "Oxygen Administration" indicated to verify that there is a physician's order for procedure.

Resident R286's clinical record revealed an admission date of 1/15/24, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), fractured hip, and hypertension (high blood pressure).

Observations on 1/23/24, at 2:10 p.m. and on 1/26/24 at 8:38 a.m. revealed Resident R286 wearing an oxygen nasal canula (a thin tube with two prongs that fits into the resident's nostrils to deliver oxygen) connected to an oxygen concentrator delivering 3 liters per minute (lpm - a unit of oxygen flow rater that is delivered to the resident). Upon interview with Resident R286, about their oxygen usage, he/she indicated that it is used all day, every day, he/she stated that they use it all the time.

Resident R286's clinical record lacked evidence of a physician's order for oxygen therapy.

During an interview on 1/26/24, at 8:40 a.m. Licensed Practical Nurse (LPN) Employee E6 confirmed that Resident R286 was being administered oxygen therapy and their clinical record lacked a physician's order for oxygen therapy.

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



 Plan of Correction - To be completed: 03/06/2024

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
1/26/24 – An Order for Oxygen at 2LPM via nasal canula was obtained for resident 286.
2. How the facility will act to protect residents in similar situations.
Completed an audit of current residents using oxygen and verified that resident have orders for Oxygen.
3. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Director of Nursing or Designee will educate license staff to ensure that any resident using oxygen or needing oxygen will need a physician order. Order will be put in PCC.
4. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Audit of 5 residents will be completed by the DON or designee to ensure that residents have an order for oxygen if they are using oxygen. Audit will be completed weekly x 3wks then monthly until compliance is met. Audits will be reviewed at QAPI meeting monthly.

§ 201.22(b) LICENSURE Prevention, control and surveillance of tuber:State only Deficiency.
(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:

Based on review of facility policy and personnel files, and staff interview, it was determined that the facility failed to ensure a baseline tuberculosis (TB) status to rule out active TB (a contagious infection caused by bacteria that mainly affects the lungs but can also affect any other organ) was obtained on new employees in the facility for three of five personnel files reviewed (Activities Assistant Employee E3 and Licensed Practical Nurse (LPN) Employees E4 and E5) and that the facility failed to follow CDC (Centers for Disease Control) guidelines for administration and reading of a tuberculin skin test for one of five personnel files reviewed (LPN Employee E4).

Findings Include:

Review of facility policy dated 1/16/23, entitled "Tuberculosis, Employee Screening for" indicated "Each newly hired employee is screened for LTBI (latent tuberculosis infection - a person is infected with TB, but does not actively have the disease) and active TB disease after an employment offer has been made but prior to the employee's duty assignment."

According to the most recent CDC guidelines - Testing for TB infection (last updated 7/11/2023) for TB skin testing, the TB test was to be read within 48 to 72 hours after the administration of the TST (Tuberculin Skin Test) injection in order to determine latent or active TB.

Review of Activities Assistant Employee E3's personnel file revealed he/she was hired and started employment on 11/3/23, and had his/her first TST administered on 11/13/23, ten days after starting employment at the facility.

Review of LPN Employee E5's personnel file revealed he/she was hired on 11/30/23, started employment on 12/1/23, and had his/her first TST administered on 12/5/23, four days after starting employment at the facility.

Review of LPN Employee E4's personnel file revealed he/she was hired and started employment on 10/31/23. LPN Employee E4's file also revealed he/she received his/her first TST on 10/31/23, and had it read on 10/31/23.

Interview on 1/25/24, at 2:45 p.m. with Human Resources confirmed that the facility failed to determine the baseline TB status for Activities Assistant Employee E3 and LPN Employees E4 and E5 prior to the start of the duty assignments and that the facility failed to follow CDC guidelines in reading a TST 48 - 72 hours after administration for LPN Employee E4.





 Plan of Correction - To be completed: 03/06/2024

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
We audited every employee file to insure compliance with TB testing. This was completed by January 31, 2024.
2. How the facility will act to protect residents in similar situations.
During the hiring process and prior to start date, the TB tests will be completed.
3. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Administrator or designee will audit new hire records to insure adherence.
4. Measures the facility will take or systems it will alter to ensure that the problem does not recur.
Administrator or designee will audit the new hire records weekly x 3wks then monthly until compliance is met. Audits will be reviewed at QAPI meeting monthly.

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