Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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ROSE CITY NURSING AND REHAB AT LANCASTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated revisit survey completed on July 2, 2019, it was determined that Rose City Nursing and Rehab at Lancaster failed to follow their plan of correction dated April 16, 2019 and continued to be in non-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 for the Health portion of the survey.

 Plan of Correction:

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.

Based on review of facility policy and procedure, observation, and clinical record review, it was determined that facility failed to ensure that infection prevention and control was maintained during tracheostomy care on one of four residents reviewed (Resident R1)

Findings include:

Review of facility's policy and procedure titled "Tracheostomy Care", revised on August 2013, under procedure guidelines revealed, "remove old dressing; pull the soiled glove over dressing; discard into the appropriate receptacle; wash hands".
Further review of facility's "Tracheostomy Care" policy, revealed, "secure the outer neck plate with a non-dominate gloved hand; unlock the inner cannula with gloved dominate hand; remove and discard gloves into the appropriate receptacle; wash hands and put on fresh gloves; replace the cannula carefully and lock in place".
Further review of this policy and procedure under "Site and Stoma Care" revealed, "apply clean gloves; clean the stoma with two peroxide-soaked pads (using single sweep for each side); rinse the stoma with saline-soaked gauze pads (using a single sweep for each side); wipe with dry gauze (using a single sweep for each side)".
Review of Resident #R1's diagnoses list revealed that the resident's diagnoses included but were not limited to, acute respiratory failure, quadriplegia (paralysis of all four limbs), cerebrovascular disease (stroke), and tracheostomy status (an incision in the neck that opens the airway and aids in breathing).
An observation of tracheostomy care on July 2, 2019, at approximately 11:35 a.m., revealed, licensed nurse, Employee E3 completed hand washing prior to tracheostomy care. Employee E3 put on a pair of sterile gloves, lifted the supplemental oxygen mask from resident's tracheostomy; removed disposable inner cannula using both hands then discarded it in the plastic bag receptacle placed in resident's bed. Employee E3 removed his/her gloves and put on a new pair of sterile gloves; opened the tracheostomy care kit. Employee E3 removed his/her gloves and put on another sterile pair of gloves that was taken from the tracheostomy care kit; placed a drape in resident's chest using both hands; opened the sterile water, poured it into the sterile basin; wiped the tracheostomy tube neck plate with a gauze, wet with sterile water; cleaned the surrounding stoma with a sterile swab. The entire procedure was executed using both hands, occasionally touching resident's neck, and tracheostomy tube strap. Employee E3 opened a package of a disposable inner cannula, picked up the sterile inner cannula wearing the same gloves used in cleaning the neck plate of the tracheostomy tube then proceeded to insert the inner cannula to Resident R1's tracheostomy tube. Employee E3 changed his/her gloves three times during the entire procedure but failed to perform handwashing or hand hygiene after changing gloves.
Further observation revealed Resident R1's tracheostomy oxygen mask had yellow secretions. Employee E3 used the towel that was on resident's chest to clean the yellow secretions in the mask then proceeded to place the tracheostomy mask back on Resident R1's neck. Employee E3 removed the soiled towel, discarded used tracheostomy care supplies then performed handwashing.
Observation of Medication Pass Administration on the fourth floor nursing unit on July 2, 2019 at approximately 10:10 a.m. revealed Licensed Employee E3 removed two capsules from the medication cup without using gloves and place the capsules on the top of the medication cart. Licensed Employee E3 crushed the remaining pills and placed them in a medication cup. Licensed Employee E3 then picked up the two capsules from the top of the medication cart, opened them and poured the contents into the medication cup containing the crushed pills. No gloves were used during the above procedure.
Further observation of the Medication Pass Administration revealed Licensed Employee E3 administer the above medication to a resident, return to the medication cart and prepared medication for administration to another resident without washing hands.
The above information was conveyed to the nursing home administrator (NHA) and director of nursing (DON) on June 2, 2019, at approximately 2:30 p.m.

28 Pa. Code 211.10(d) Resident care policies
Previously cited 4/16/19, 5/14/18,

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 4/16/19, 2/28/19, 9/20/18, 5/14/18

 Plan of Correction - To be completed: 07/11/2019

1. Resident #1 is receiving tracheostomy care with proper infection control procedures including hand washing. Nursing staff are using proper infection control during med passes.
2. Review of current residents was completed and there are no other residents with tracheostomy. Observations of tracheostomy care and medication passes were completed and no additional nurses identified.
3. Education will be provided to Licensed nursing staff on proper infection control procedures including hand washing for tracheostomy care and med pass. Education to Employee #3 was completed and she was able to demonstrate proper infection control process including hand washing.
4. DON/Designee will observe tracheostomy care and medication passes daily for 3 weeks and then weekly for 3 weeks to ensure that proper infection control procedure including hand washing is being followed. Trends will be reported to the QAPI Committee for further planning and determination for the continuation of the assignment.

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