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

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LOGAN SQUARE REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

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LOGAN SQUARE 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 an abbreviated survey with six complaints completed January 24, 2024, it was determined that Logan Square Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
§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 documentation, review of policy and procedures, review of clinical records, review of hospital records, observation and interviews with staff, it was determined that the facility failed to provide adequate supervision to a resident with a history of over-the-counter medication usage. The facility failed to conduct a thorough assessment of the resident's environment to ensure that the resident was not in possession of over-the-counter medication for one of seven residents reviewed (Resident R31), which resulted in an Immediate Jeopardy situation.

Findings include:

Review of facility policy, Visitation, revised September 2022, revealed, "Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of others in the facility. 1. Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security, and or rights of the facility's residents. Restriction of Individual Visitors 6. If it is determined that an illegal substance (s) has been brought into the facility by a visitor, it is immediately reported to the charge nurse or supervisor. The supervisor and the Director of Nursing Services determine whether the situation warrants a referral of law enforcement. b. If items or illegal substances are in plain view, and these pose a risk to the residents' health and safety, the items may be confiscated by facility staff. The circumstances, description of the item(s), and rationale for confiscating are documented in the resident's record. c. Facility staff does not conduct searches of a resident or their personal belongings, unless the resident or representative agrees to the search and understands the reason for the search."

Review of facility policy, Administering Medication, revised April 2019, revealed, "Medications are administered in a safe and timely manner, and as prescribed. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely."

Review of facility policy, Personal Property, revised August 2022, revealed, "Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of other residents. 8. If items or illegal substances that belong to the resident are in plain view, and these pose a risk to the residents' health and safety, the items may be confiscated by facility staff. The circumstances, description of the itemand the rationale for confiscating are documented in the resident's record. 9. Facility does not conduct searches of a resident or their personal belongings, unless the resident or representative agrees to the search and understands the reason for the search."


Review of clinical record for Resident R31 revealed that the resident was admitted to the facility on August 29, 2022, with the diagnoses of metabolic encephalopathy (altered mental status); hepatic encephalopathy (a loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage); chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform); protein calorie malnutrition; cognitive communication deficit; muscle weakness; major depressive disorder (major loss in interest in pleasurable activites); alcohol dependence; unspecified dementia; history of falling; shortness of breath; insomnia; anxiety disorder, hypertension (high blood pressure) and atrial fibrillation (irregular and rapid heart beat).

Review of a Nurse Practitioner note dated June 25, 2023, at 1:06 p.m. revealed "seen today for an acute visit requested by nursing for increased anxiety, screaming out, and fixating on Tylenol dosage. Per nursing, behavior started a few days ago. Patient asks for Tylenol every two hours. Nursing educated patient on Tylenol regimen and daily limit of 3 mg ( milligrams). Patient then begins with agitation, anxiety and yelling out not controlled with redirection. Of note, patient's family member bring her OTC (over the counter) Tylenol found by nursing and removed from room multiple times. Nursing supervisor previously educated family member about policy and protocol of patient self medicating. Patient Currently on Klonopin BID (twice a day) for hx (history of) anxiety. On assessment, patient reports wanting Tylenol or chronic pains. Agreeable to Q6H (every 6 hours) regimen."

Review of nurse practitioner note for Resident R31 on September 7, 2023 at 12:39 p.m. revealed, "Eighty-one year old long term care female seen today for an acute visit requested by nursing for altered mental status described as increased lethargy, weakness and garbled speech. On assessment, patient lying in bed, easy to arouse, uncomprehendable speech (not baseline), generalized weakness throughout. Pupils 4mm brisk b/l. Facial features symmetrical. BP (blood pressure)180/70; heart rate 110; temperature 96.0 rectal. Of note, nursing reports new Tylenol bottle found in patient's room. 125 tablets missing, unclear when she obtained bottle and how much was taken. Patient has history of this occurrence with Tylenol overdosing. Rapid Covid-19 is negative. Resident was transported to hospital 911 with altered mental status, hypothermia (a condition of having a lower body temperature than normal body temperature) and possible Tylenol overdose. All emergency contacts called with no replies, unable to leave a voicemail, resident is responsible party."

Review of hospital toxicology revealed, "Acetaminophen level is 173.3. Acetaminophen level elevated. Will start NAC " (N-Acetyl Cysteine which comes from the amino-acid L-cysteine. Amino acids are building blocks of protein). "Spoke with Poison Control Center. Initiate NAC). Will admit.

Further review of Resident R31's clinical record revealed Resident R31 was discharged from the hospital and readmitted to the facility on September 12, 2023.

Review of Resident R31's updated care plan revealed that I am at risk for medication overdose related to history of overdose of Tylenol. The goal was " I will be free of overdose related to Tylenol Medication." The interventions listed included "Assess resident's pain level; Psych consult; Staff to observe environment for safety concern." Continued review included: Physician's order update: "Monitor resident's room for medication not prescribed."

Further review of Resident R31's clinical record of December 4, 2023, revealed, "During AM care, Resident R31 was found with a bag of pills, marked Tylenol ER (about 45 pills in total). Resident would not give explanation about why she has the pills or who gave them to her. The resident stated, 'I did not take any tonight.' Assessed the resident and resident is AAO X 3 (alert to person, time and place), able to make own needs per baseline vital signs. Message left for MD (physician) and house supervisor was made aware. Attempted to educate resident on harmful amount of Tylenol, and self administration without MD and staff aware, and resident did not verbalize understanding and may need further teaching and reinforcement. Nursing will continue to monitor."

Review of Nurse Practitioner's note of December 4, 2023 revealed, "seen today for an acute visit requested by nursing after a bag of OTC Tylenol found in patient's room. This is a reoccurring issue with this patient, in which visitors bring patient large amounts of Tylenol and patient self-administers over the recommended amount (3G daily). This is evidenced by previous hospitalization for AMS 2/2 to Tylenol overdose. At that time, patient found with large quantity of Tylenol in her room. Unclear how many Tylenol she ingested, but Tylenol level at hospital was 173.3, poison control involved at that time and NAC (N-acetylcysteine) given. Today, patient observed lying in bed, alert and conversing STAT (immediate) Tylenol level ordered. Collection Date: December 4, 2023 11:00 Reported Date: 12/07/2023 15:07: 121 ug/ml Ref. Range 10-30" There is no follow up note to review.

Review of Nurse Progress note of December 20, 2023, revealed, "Resident was found with a large bag of pills in her bed, approximately 50 white oblong pills that appear to be Tylenol ES. Resident refuses to report where the pills came from or how many if any were taken. Resident appears stable at baseline. House Supervisor made aware and Nurse Practitioner. NP (Nurse Practitioner) ordered a stat Tylenol level. Resident ordered to be seen by Psych. (Tylenol stat level revealed: none detected)

Review of care plan Follow-up Action: "I am at risk for medication overdose related to history of overdose of Tylenol. Goal: I will be free of overdose related to Tylenol medication. Interventions: Assess resident's pain level; Grandson educated on the importance of supplying resident with Tylenol without facility/doctor's approval. Grandson educated on risk of resident taking additional medications; Psych consult; Staff to observe environment for safety concerns; stat Acetaminophen level ordered."

Review of Psych note of December 20, 2023, revealed, "There is concern that somebody brought her Tylenol She continuously complains of pain and that she needs Tylenol. Does not remember when she last received and insists 'I did not have it' when asked about her pain she is very non-specific. She becomes more irritated with continuous questions. Relates she is depressed and wants to go to the 'other place'.
Medication change was made. (Ariprizole 2-3 mg may help better treat the anxiety in collaboration with duloxetine)."

An interview on January 23, 2024, at 1:00 p.m. with Employee E17, Regional Vice President, revealed, "We were unable to find the supplier. Staff reports that this resident does not have visitors. We were unable to reach any of the emergency contacts. Resident is her own responsible party. Finally, on December 20, 2023, the Unit Manager saw the resident's grandson visiting. The nurse spoke with grandson to see if he knew how resident was receiving outside Tylenol. Grandson stated that he had been bringing them in because resident calls him and says that she needs them due to her being in pain. Grandson educated on resident receiving prescribed Tylenol and that she has a scheduled time that she receives them. Grandson reported that she tells him that she does not receive Tylenol at all and that Tylenol is the only thing that helps with her pain. Grandson educated on Tylenol toxicity affects on the body, including lethargy, nausea and vomiting as well as abdominal pain. Grandson voiced understanding and apologized. He stated that no matter how much she calls and begs, he will not bring her anymore Tylenol."

An Immediate Jeopardy situation was identified to the Nursing Home Administrator on January 23, 2024, at 3:29 p.m. for the facilities failure to provide adequate supervision to a resident with a history of over the counter medication usage. The facility failed to conduct a thorough assessment of the resident's environment to ensure that the resident was not in possession of over the counter medication. An IJ template was provided to the facility

The facility submitted a written plan of action on January 23, 2024, at 8:18 p.m. and implemented the the plan of action which included:

1. Resident has been assessed by the physician for pain management and psychosocial support. No changes were made to the pain medication regimen and the Geripsychologist was contacted for a follow up bedside visit. The diagnosis of PTSD (Post Traumatic Stress Disorder) was added with interventions for psychosocial support. Additionally, interventions were added for evaluation, management and compliance with pain medication regimen. All care plans have been updated. Completed 1/21/2024.
2. Licensed Nursing Home Administrator completed a visual audit of all resident rooms for both nonprescription and prescription medications. Any variances were reported to the physician for clarification and orders for self-medication, if appropriate. Completed 1/19/2024.
3. Immediate Actions/Education
-Nursing Administration completed an audit of all residents to ensure anyone identified with similar concerns was assessed and provided immediate treatment and care planning. Any identified variances were immediately referred for physician evaluation. Completed 1/21/2024.
-Nursing Administration completed a 7 day look back in EHR(Electronic Health Record) to identify any omission of documentation or any medication administered outside of parameter/indication for usage. Any variances were reported to the physician for follow up. Completed 1/21/2024.
-LNHA, DON and ADON were educated on ERS (Electronic Reporting System) and requirements for reporting. Completed 1/21/2024.
-Staff have been educated in visually inspecting rooms during care and in room visits for the presence of prescription and non-prescription medications at the bedside, in room searches as resident allows, greeting all visitors and monitoring for items brought in and the reporting requirements. Completed 90% by 1/21/2024. The remainder will be completed by 1/24/2024.
-Resident has an updated pain assessment and care plan mapping the pathway for pain control including PRN medications with specific indications for usage. Completed 1/20/2024.
-A mattress audit has been completed to ensure all are in good shape and maintaining pressure reduction. This audit was completed in an attempt to eliminate all causes of discomfort/pain. Any variances were reported to Plant Operations for installation of new mattress. Completed 1/21/2024.
-Resident has an updated trauma informed care evaluation and care plan mapping the pathway for individualized psychosocial care. Completed 1/20/24.
-Social Service designee will review all diagnoses and behavioral indicators to ensure anyone identified with similar concerns was assessed and provided immediate treatment and care planning. Completed 1/20/2024.
4. Ongoing Compliance will be monitored by:
-Visual audit of all resident rooms for both non-prescription and prescription medications every shift for three days, then daily for three days, the three times per week for two weeks, weekly for two weeks then monthly for two months. Any variance will be reported to the RN Supervisor on duty for immediate follow-up.
-Review of PCC dashboard on all PRN usage for any patterns/trends every shift for three days, then daily for three days, then three times a week for two weeks, weekly for two weeks then monthly for two months. Any variance will be reported to the RN Supervisor on duty for immediate follow-up.

On January 24, 2024, the Action Plan was reviewed and interviews were conducted with nursing staff to confirm the in-service education was completed. Following the verification of the immediate action plan, the Nursing Home Administrator was notified that the Immediate Jeopardy was lifted on January 24, 2024 at 3:50 p.m.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

28 Pa. Code 201.10(d) Resident care policies

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























 Plan of Correction - To be completed: 02/27/2024

1. Resident 31 has been assessed by the physician for pain management and psychosocial support. No changes were made to the pain medication regimen. The Geri-psychologist consult was completed addition interventions were added to resident 31's care plan.

2. The Licensed Nursing Home Administrator completed an audit of all resident rooms for both nonprescription and prescription medications. Variances were addressed and recorded on the facility audit tool.

3. The Director of Nursing and Designee re-educated all staff on the process for visually inspecting rooms during care and in room visits for the presence of prescription and non-prescription medications at the bedside, as well as in room searches as resident allows, greeting all visitors and monitoring for items brought in and the reporting requirements.

4. The Director of Nursing / Designee will complete visual audits of all resident rooms for both non-prescription and prescription medications every shift for three days, then daily for three days, then three times per week for two weeks, then weekly for two weeks then monthly for two months. Variances will be reported to the RN Supervisor on
duty for immediate follow-up. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:


Based on review of facility policy, review of clinical record, and interviews with staff and residents, it was determined that the facility failed to ensure that one of 34 residents received showers. (Resident R6).

Findings Include:

Review of undated facility policy "Resident Rights" revealed federal and state laws guarantee certain basic rights to all residents of the facility. These rights include the residents right to self-determination.

Review of Resident R6's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 5, 2024, revealed the resident was admitted to the facility on December 29, 2023, and was cognitively intact. Further review of the MDS revealed the resident was dependent on staff for shower/bathing.

Interview with Resident R6 on January 18, 2024, revealed the resident had only received a bed bath since admission but would prefer to take a shower.

Review of Resident R6's nursing Kardex (electronic documentation system that enables nurses and nurse aides to write, organize, and easily reference key patient information that shapes their nursing care) revealed the resident was scheduled for showers on Thursday's during the 7:00 a.m. to 3:00 p.m. shift and on Sundays during the 3:00 p.m. to 11:00 p.m. shift. Further review of the nursing Kardex revealed staff documented "not applicable" for Resident R6's showers.

Interview on January 23, 2024, at 2:06 p.m. with nurse aide, Employee E14, confirmed the aide provided bed baths for Resident R6 and was unable to explain why the resident was not being provided with showers.

Interview on January 24, 2024, at 1:49 p.m. with the Director of Nursing, Employee E2, revealed a shower schedule is developed for every resident on admission which would provide each resident the opportunity to receive a shower.

Further interview with the Director of Nursing, Employee E2, confirmed that Resident R6 had no limitations regarding the ability to receive a shower and that Resident R6 expressed a preference in wanting a shower via the shower chair and was "looking forward to it".

28 Pa. Code 211.10 (c) Resident care policies

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





 Plan of Correction - To be completed: 02/27/2024

- Resident 6 was interviewed for their shower preference. The residents care plan was updated to reflect this preference. Resident 6 received their shower based on this preference.
- The facility completed and audit of current residents and their bathing preference. Resident care plans were updated and staff were re-educated. Variances were outlined on the facility audit tool.
- The Director of Nursing re-educated all nursing staff on the bathing policy with a focus on resident preferences.
- The Director of Nursing / Designee will complete 10 random audits weekly of resident bathing preferences 3 times per week x 4 weeks then monthly x 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.

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 review of facility policy, review of clinical record, observations, and interviews with staff and residents, it was determined that the facility failed to administer a resident's tube feeding per the physician orders for one of one resident with tube feeding reviewed (Resident R6).

Findings Include:

Review of undated facility policy "Enteral Nutrition" revealed adequate nutritional support through enteral nutrition is provided to residents as ordered. The nurse confirms that orders for enteral nutrition are complete and include volume and rate of administration.

Review of Resident R6's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated January 5, 2024, revealed the resident was admitted to the facility on December 29, 2023, and received nutrition via tube feeding (also known as enteral nutrition - nutrition is delivered using a flexible tube inserted through the nose, or directly into the stomach or small intestine). Further review of the MDS revealed Resident R6 was cognitively intact.

Review of Resident R6's care plan dated January 2, 2024, revealed the resident had a nutritional problem related to NPO (nothing by mouth) and nutritional needs being met via enteral nutrition. Interventions dated January 2, 2024, revealed to provide tube feeding and water flushes as ordered.

Review of Resident R6's physician orders dated January 2, 2024, revealed an order to provide water flushes of 200 milliliters (ml) every 6 hours (total 800 ml) (additional water provided to help meet a residents daily fluid needs).

Further review of Resident R6's physician orders revealed an enteral feed order dated January 19, 2024, to provide "Nutren 1.5 liquid (calorically dense tube-feeding formula) via feeding tube every shift, feeding pump set at 70ml per hour for 20 hours or until total volume 1440 ml infused. Feeding tube up at 6:00 p.m. and down at 2:00 p.m. the next day"

Observations on January 23, 2024, at 1:07 p.m. revealed Resident R6 was not hooked up to the tube feeding equipment and the tube feeding formula or additional water was not infusing per physician orders. Resident R6 indicated the tube-feeding was stopped either last night or earlier in the morning.

Further observations on January 23, 2024, at 1:14 p.m. with Licensed Nurse, Employee E13, confirmed Resident R6 was not hooked up to the tube feeding pump for formula and water administration. Observations of the history on the tube-feeding pump with Licensed Nurse, Employee E13, indicated Resident R6 had only received 1036 ml of tube feeding formula and 600 ml of additional water.

Interview on January 23, 2024, at 1:16 p.m. with Resident R6's licensed nurse, Employee E15, revealed the nurse was unaware the resident's tube feeding was not infusing. Licensed Nurse, Employee E13, suggested that therapy may have stopped the tube-feeding prior to services provided in the morning.

Interview on January 23, 2024, at 1:55 p.m. with physical therapist, Employee E11, revealed Resident R6 was not hooked up to the tube-feeding when the employee came to get the resident for physical therapy. Physical therapist, Employee E11, reported that it is not within their scope of practice to manipulate the tube-feeding.

Interview on January 23, 2024, at 2:06 p.m. with nurse aide, Employee E14, revealed the aide provided morning care before the resident went for therapy and Resident R6's tube feeding was not hooked up at that time.

Follow-up interview on January 23, 2024, at 2:11 p.m. with licensed nurse, Employee E15, revealed it was undetermined when the tube-feeding was stopped for Resident R6.


28 Pa. Code 211.10 (a) Resident care policies

28 Pa. Code 211.12 (c) Nursing Services





 Plan of Correction - To be completed: 02/27/2024

- Resident R6 tube feeding was reviewed and administered in accordance with physician orders.
- The facility completed an audit of all residents with tube feeding orders. No further variances were identified.
- The Dietitian reviewed all current resident tube feeding orders for adjustment in administration times. Recommendations were submitted to the resident's physician. The Director of Nursing re-educated all licensed nursing staff and therapy staff on the policy related to tube feeding administration.
- The Director of Nursing / Designee will complete weekly audits for resident tube feeding administration 3 times per week x 4 weeks then monthly x 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.

483.70 REQUIREMENT Administration: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 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:

Based on review of clinical records, facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility to ensure that residents were free from accidents related to self administration of medication. This failure placed Resident R31 at high risk for injury and was identified as an Immediate Jeopardy.

Findings include:

Review of the job description for the Nursing Home Administrator (NHA) revealed: "The primary purpose of your position it is to direct the day to day functions of the Center in accordance with current federal, state and local standards, guidelines and regulations that govern nursing Centers to assure that the highest degree of quality care can be provided to our residents at all times. As Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties."

Review of job description for the Director of Nursing (DON) revealed: the primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state and local standards, guidelines and regulations that govern our Center, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. As Director of Nursing Services, you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties. In the absence of the Medical Director, you are charged with carrying out the resident care policies established by this Center."

Review of clinical record for Resident R31 revealed that the resident was admitted to the facility on August 29, 2022, with the diagnoses of metabolic encephalopathy (altered mental status); hepatic encephalopathy (a loss of brain function as a result of failure in the removal of toxins from the blood due to liver damage); chronic obstructive pulmonary disease (disease process that causes decreased ability of the lungs to perform); protein calorie malnutrition; cognitive communication deficit; muscle weakness; major depressive disorder (major loss in interest in pleasurable activites); alcohol dependence; unspecified dementia; history of falling; shortness of breath; insomnia; anxiety disorder, hypertension (high blood pressure) and atrial fibrillation (irregular and rapid heart beat).

Review of a Nurse Practitioner note dated June 25, 2023, at 1:06 p.m. revealed "seen today for an acute visit requested by nursing for increased anxiety, screaming out, and fixating on Tylenol dosage. Per nursing, behavior started a few days ago. Patient asks for Tylenol every two hours. Nursing educated patient on Tylenol regimen and daily limit of 3 mg ( milligrams). Patient then begins with agitation, anxiety and yelling out not controlled with redirection. Of note, patient's family member bring her OTC (over the counter) Tylenol found by nursing and removed from room multiple times. Nursing supervisor previously educated family member about policy and protocol of patient self medicating. Patient Currently on Klonopin BID (twice a day) for hx (history of) anxiety. On assessment, patient reports wanting Tylenol or chronic pains. Agreeable to Q6H (every 6 hours) regimen."

Review of nurse practitioner note for Resident R31 on September 7, 2023 at 12:39 p.m. revealed, "Eighty-one year old long term care female seen today for an acute visit requested by nursing for altered mental status described as increased lethargy, weakness and garbled speech. On assessment, patient lying in bed, easy to arouse, uncomprehendable speech (not baseline), generalized weakness throughout. Pupils 4mm brisk b/l. Facial features symmetrical. BP (blood pressure)180/70; heart rate 110; temperature 96.0 rectal. Of note, nursing reports new Tylenol bottle found in patient's room. 125 tablets missing, unclear when she obtained bottle and how much was taken. Patient has history of this occurrence with Tylenol overdosing. Rapid Covid-19 is negative. Resident was transported to hospital 911 with altered mental status, hypothermia (a condition of having a lower body temperature than normal body temperature) and possible Tylenol overdose. All emergency contacts called with no replies, unable to leave a voicemail, resident is responsible party."

Review of hospital toxicology revealed, "Acetaminophen level is 173.3. Acetaminophen level elevated. Will start NAC " (N-Acetyl Cysteine which comes from the amino-acid L-cysteine. Amino acids are building blocks of protein). "Spoke with Poison Control Center. Initiate NAC). Will admit.

Further review of Resident R31's clinical record revealed Resident R31 was discharged from the hospital and readmitted to the facility on September 12, 2023.

Review of Resident R31's clinical record of December 4, 2023, revealed, "During AM care, Resident R31 was found with a bag of pills, marked Tylenol ER (about 45 pills in total). Resident would not give explanation about why she has the pills or who gave them to her. The resident stated, 'I did not take any tonight.' Assessed the resident and resident is AAO X 3 (alert to person, time and place), able to make own needs per baseline vital signs. Message left for MD (physician) and house supervisor was made aware. Attempted to educate resident on harmful amount of Tylenol, and self administration without MD and staff aware, and resident did not verbalize understanding and may need further teaching and reinforcement. Nursing will continue to monitor."

Review of Nurse Practitioner's note of December 4, 2023 revealed, "seen today for an acute visit requested by nursing after a bag of OTC Tylenol found in patient's room. This is a reoccurring issue with this patient, in which visitors bring patient large amounts of Tylenol and patient self-administers over the recommended amount (3G daily). This is evidenced by previous hospitalization for AMS 2/2 to Tylenol overdose. At that time, patient found with large quantity of Tylenol in her room. Unclear how many Tylenol she ingested, but Tylenol level at hospital was 173.3, poison control involved at that time and NAC (N-acetylcysteine) given. Today, patient observed lying in bed, alert and conversing STAT (immediate) Tylenol level ordered. Collection Date: December 4, 2023 11:00 Reported Date: 12/07/2023 15:07: 121 ug/ml Ref. Range 10-30" There is no follow up note to review.

Review of Nurse Progress note of December 20, 2023, revealed, "Resident was found with a large bag of pills in her bed, approximately 50 white oblong pills that appear to be Tylenol ES. Resident refuses to report where the pills came from or how many if any were taken. Resident appears stable at baseline. House Supervisor made aware and Nurse Practitioner. NP (Nurse Practitioner) ordered a stat Tylenol level. Resident ordered to be seen by Psych. (Tylenol stat level revealed: none detected)

This failure placed Resident R31 at risk for serious injury after intoxification with an over the counter medication and resulted in an Immediate Jeopardy situation.

Based on the deficiencies identified in this report the Nursing Home Administrator and Director of Nursing failed to fulfill essential duties and responsibilities of the position, contributing to the Immediate Jeopardy situations.

Refer F689

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

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

28 Pa. Code 201.18(d) Management

28 Pa. Code 211.12(c) Nursing services





 Plan of Correction - To be completed: 02/27/2024

1. Resident 31 has been assessed by the physician for pain management and psychosocial support. No changes were made to the pain medication regimen. The Geri-psychologist consult was completed addition interventions were added to resident 31's care plan.

2. A visual audit of all current resident rooms was completed for both nonprescription and prescription medications. Variances were addressed and recorded on the facility audit tool.

3. The Regional Director of Operations re-educated the Administrator and Director of Nursing on their respective job description.

4. The Administrator / Designee will complete visual audits of all resident rooms for both non-prescription and prescription medications every shift for three days, then daily for three days, then three times per week for two weeks, then weekly for two weeks then monthly for two months. Variances will be reported to the RN Supervisor on duty for immediate follow-up. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.

483.70(n)(2)(i)(ii)(3)-(5) REQUIREMENT Entering into Binding Arbitration Agreements: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(n) Binding Arbitration Agreements
If a facility chooses to ask a resident or his or her representative to enter into an agreement for binding arbitration, the facility must comply with all of the requirements in this section.

§483.70(n)(1) The facility must not require any resident or his or her representative to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility and must explicitly inform the resident or his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n)(2) The facility must ensure that:
(i) The agreement is explained to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands;
(ii) The resident or his or her representative acknowledges that he or she understands the agreement;

§483.70(n)(3) The agreement must explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

§483.70(n) (4) The agreement must explicitly state that neither the resident nor his or her representative is required to sign an agreement for binding arbitration as a condition of admission to, or as a requirement to continue to receive care at, the facility.

§483.70(n) (5) The agreement may not contain any language that prohibits or discourages the resident or anyone else from communicating with federal, state, or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees, and representative of the Office of the State Long-Term Care Ombudsman, in accordance with §483.10(k).
Observations:

Based on review of facility policy, review of facility documents and resident clinical record and staff and resident interviews, it was determined that the facility failed to ensure a resident had the capacity to understand the terms of a binding arbitration agreement for one of one residents reviewed (Resident R49).

Findings Include:

Review of facility policy "Binding Arbitration Agreements" dated October 2022, revealed binding arbitration agreements are explained to the resident or their representative in a language form, and manner that they can understand.

Review of Resident R49's admission Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated August 19, 2023, revealed the resident was admitted to the facility on August 9, 2023, and had a diagnosis of senile degeneration of brain (loss of intellectual ability).

Further review of the MDS, Section C - Cognitive Patterns (items in this section are intended to determine the resident's attention, orientation, and ability to register and recall new information - these items are crucial factors in many care-planning decisions), indicated that Resident R49 scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severe cognitive impairment.

Review of Resident R49's care plan dated August 10, 2023, revealed the resident had impaired cognitive function and/or impaired thought processes related to senile degeneration of the brain.

Review of Resident R49's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated the resident signed the document on August 15, 2023. Further review of the Binding Arbitration Agreement revealed it was also signed by facility employee, Concierge, Employee 16.

Interview on January 24, 2024, at 11:30 a.m. with Social Services, Employee E19, confirmed Resident R49 had cognitive impairments.

Interview on January 24, 2024, at 12:04 p.m. with Concierge, Employee E16, revealed when the employee asks a resident to sign the arbitration agreement, the employee will speak with nursing or makes a personal judgement/perception, if social services assessment is not available, on whether the resident can fully understand or not when signing the arbitration agreement.

Interview on January 24, 2024, at 2:15 p.m. with Resident R49 revealed the resident was unable to explain the binding arbitration agreement that was signed.

28 Pa. Code 211.10 (d) Resident care policies




 Plan of Correction - To be completed: 02/27/2024

- Resident R49 Binding arbitration agreement was discontinued due to resident competence at time of signing.
- All Current Resident Agreements were reviewed for signature outlined in the policy and procedure. Variances were addressed and outlined on the facility audit tool.
- The Administrator re-educated the Admissions Director and Concierge on the policy and procedure for signing arbitration agreements.
- The Administrator / Designee will complete weekly audits of signed arbitration agreements 3 times per week x 4 weeks then monthly x 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on observation, interviews with staff and review of facility policies and procedures, it was determined that the facility did not ensure an effective infection control program was maintained related to hand hygiene during wound care for one of one resident observed with wounds. (Resident R96)

Findings include:

Review of facility policy, Handwashing/Hand Hygiene, revised August 2019, revealed: "This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol based hand rub containing at least 62% alcohol; or, alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: m. After removing gloves;
Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene.

Observation on January 23, 2024, at 10:30 a.m. with Employee E5, licensed nurse, of wound treatment for Resident R96 revealed: Employee E5 washed her hands anf gathered supplies for wound treatment. Employee E5 wiped overbed table and placed supplies on the bedside table. Employee E5 again washed her hands and donned new gloves. Employee E5 removed Resident R96's heel protector boot.. There was no dressing present on the heel wound. Employee E5 cleased the wound and patted it dry. Employee E5 then removed gloves and donned a clean pair of gloves without hand sanitizing. Employee E5 then applied the clean dressing.

Review of Glucometer Policy (Manufacturers Policy) revealed: The EVENCARE G3 Meter should be cleaned and disinfected between each patient The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years.
Bloodborne Pathogen Contact times by Wipe Product Disinfectant Name---Contact Time
Medline Micro-Kill Bleach Germicidal Bleach Wipes--- 30 secnds
Dispatch@Hosp Cleaner Disinfectant Towels with Bleach---1minute
Medline Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol---2 minutes
Chlorox Healthcare Bleach Germicidal and Disinfectant Wipes---1 minute

Observation on January 22, 2024 at 12:15 p.m. with Employee E18, licensed nurse, revealed Employee E18 monitoring blood glucose for Resident RX and returning to medication cart and cleaning the glucometer with an alcohol swab. Employee E18 then checked the blood glucose of Resident RX and returned to the medication cart and cleansed the glucometer with an alcohol swab.


28 Pa. Code 211.12(d) Nursing services





















 Plan of Correction - To be completed: 02/27/2024

- No residents experienced any negative effects due to the occurrence.
- The facility completed and audit of all medication carts for disinfecting products. Variances were addressed at the time of the audit and outlined on the facility audit tool. The facility completed competency evaluations on all licensed nurses for Hand hygiene during wound care.
- The Director of Nursing re-educated all licensed nurses on the policy and procedure for handwashing during wound care and disinfecting glucometers.
- The Director of Nursing / Designee will complete weekly audits of glucometer disinfecting and hand hygiene during wound care 3 times per week x 4 weeks then monthly x 2 months. Audit findings will be submitted to the Quality Assurance Performance Improvement Committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on the outcome of the previously completed audit findings.


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