Pennsylvania Department of Health
LECOM AT PRESQUE ISLE, INC.
Patient Care Inspection Results

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LECOM AT PRESQUE ISLE, INC.
Inspection Results For:

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LECOM AT PRESQUE ISLE, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance Survey completed on February 16, 2024, it was determined that LECOM at Presque Isle, Inc., 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:


483.60(f)(1)-(3) REQUIREMENT Frequency of Meals/Snacks at Bedtime: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(f) Frequency of Meals
§483.60(f)(1) Each resident must receive and the facility must provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care.

§483.60(f)(2)There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span.

§483.60(f)(3) Suitable, nourishing alternative meals and snacks must be provided to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with the resident plan of care.
Observations:


Based on review of facility policy and facility documents, and staff and resident interviews, it was determined that the facility failed to ensure that the residents were offered snacks at bedtime daily for four of four nursing units.

Findings include:

Review of facility policy entitled "Resident Nourishments," with a policy review date of 10/30/2023, revealed "Nourishments will be provided in addition to regular meals in order to promote high levels of nutritional intake. These items are located in the pantries. At any time, residents can request food from the kitchen or direct care staff. When kitchen staff are not available, the direct care staff can access food if it is not in the pantry."

Review of meal times revealed that breakfast is delivered to the first hallway at 7:35 a.m. and dinner delivered to the first hallway at 4:35 p.m., which is fifteen hours between meals. The facility must provide meals within 14 hours unless a nourishing snack is served.

During a resident council meeting held on 2/14/2024, at 1:00 p.m. there were seven cognitively intact residents that regularly attend resident council meetings. The residents were asked if the facility offers them snacks in the evening. The residents responded that the kitchen area is stocked with snacks after dinner, you have to get what you want right away or else they are out of snacks. If you try to request a snack, staff are either too busy or you have to wait long periods of time to get what you want. Sometimes they forget and you don't get anything. Residents who can't request a snack do not get one.

Observation of the snack cabinets on 2/15/24, at 9:30 a.m. in the dining area revealed snacks were available for resident consumption. It was observed that the pantry doors were unlocked, and snacks were available for residents to take when they wanted.

During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA), on 2/15/2024, at 8:45 a.m. they confirmed that the facility does supply and stock snacks to residents in the kitchen area. Residents have to obtain them themselves if they are able to go to the kitchen area, or wait for staff assistance to request a snack from staff members. It was confirmed that snacks are not offered or delivered to all residents by staff members routinely. Residents unable to request or obtain a snack themselves do not get snacks.

28 Pa. Code 201.14(a) Responsibility of licensee







 Plan of Correction - To be completed: 03/17/2024

The resident mealtimes will change so there is fourteen (14) hours between the evening meal and breakfast meal.

The facility will continue to provide nourishing snacks between meals. The snacks will be available in the pantries at all times. Snacks will be both refrigerated and unrefrigerated. A nourishing snack cart will be utilized by the nursing staff in the evenings, to offer each resident a snack. The Certified Nursing Assistant assigned to the unit will be responsible to offer the residents a nourishing snack. The nurse on the unit will monitor to ensure the cart is utilized.

The Activity Director will add offering of nourishing snacks to her agenda at all Resident Council meetings to determine if the residents are satified. Corrections will occur as needed.

All nursing and kitchen staff will be educated by the Director of Nursing/designee on utilizing the snack cart in the evenings to ensure all residents are offered a nourishing snack. The Nursing Home Administrator will monitor to ensure completion.

The Director of Nursing Designee will audit the staff to ensure the snack cart is utilized in the evening 5 times a week times two weeks, weekly times two weeks and then monthly times two months.

Results of the audits will be reviewed at the Quality Assurance Meeting

Breakfast 7:00am
Lunch 12:00pm
Dinner 5:00pm
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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


Based on observation, review of drug manufacturer instructions, and staff interviews, it was determined that the facility failed to appropriately date and store medications on one of two nursing units (North medication room) and one of five medication carts (South medication cart).

Findings include:

Observation on 2/14/2024, at 9:45 a.m. in the North medication room, revealed an opened vial of Tubersol Purified Protein Derivative (PPD-a skin testing agent for tuberculosis) without an open date marked on the vial.

A review of the drug manufacturer leaflet indicated a vial of Tubersol which has been entered and in use for 30 days should be discarded.

At the time of the observation, the Registered Nurse Supervisor Employee E1 confirmed the PPD vial was opened, undated and not dated to indicate when the medication should be discarded. The Director of Nursing (DON) confirmed on 2/15/2024, at 9:45 a.m. the PPD vial should have been identified with an open date to indicate after 30 days of use, the vial would be discarded.

Observation on 2/14/2024, at 3:10 p.m. of the South medication cart, revealed an opened Humalog insulin pen without an open date marked on the pen.

A review of the drug manufacturer leaflet indicated a Humalog insulin pen which has been entered and in use for 28 days should be discarded.

At the time of the observation, the Licensed Practical Nurse Employee E2 confirmed the insulin pen was opened, undated and not dated to indicate when the medication should be discarded. The DON confirmed on 2/15/2024, at 9:45 a.m. the insulin pen should have been identified with an open date to indicate after 28 days of use, the insulin pen would be discarded.

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

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










 Plan of Correction - To be completed: 03/17/2024

The open vial of Tubersol Purified Protein Derivative that was opened and not dated was immediately discarded. The Humalog insulin pen that was not dated when opened was discarded. All multidose vials and insulin pens will be dated when they are opened.

All medication carts and medication rooms will be audited to ensure all open multidose vials and insulin pens are dated. Open multidose vials and insulin pens that are not dated will be discarded.

All nurses will be trained by the Director of Nursing/designee on dating multidose vials and insulin pens when they are opened. The Nursing Home Administrator/designee will monitor to ensure training is completed.

The Director of Nursing/designee will audit medication rooms and medication carts Five (5) times a week times two (2) weeks, weekly times two (2) weeks and then monthly times two (2) months.

Director of Nursing has developed and implemented a Medication Room and Medication Cart Audit to ckeck for expired medications, opened multidose vials for date opened and insulin pens for date opened. Audit and checklist is completed nightly. Medications are discarded and reordered as needed.

Results of the audits will be discussed at the Quality Assurance Process Improvement.

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