Nursing Investigation Results -

Pennsylvania Department of Health
LANCASHIRE HALL
Patient Care Inspection Results

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LANCASHIRE HALL
Inspection Results For:

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LANCASHIRE HALL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an abbreviated survey completed on July 9, 2019, in response to two complaints at Lancashire Hall, it was determined that Lancashire Hall 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 for the health portion of the survey process.






 Plan of Correction:


483.90(i) REQUIREMENT Safe/Functional/Sanitary/Comfortable Environ: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.
483.90(i) Other Environmental Conditions
The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
Observations:


Based on observation and interview, it was determined that the facility failed to ensure a safe odor free environment on one of 12 halls. (300 hallway)

Findings include:

Observations conducted on June 17, 2019, at 12:51 PM in the 300 hallway, accompanied by the Nursing Home Administrator, revealed a strong chemical smell coming from an unoccupied room. The smell was pervasive in the hall, as the door to the room was open and two fans were placed in the room. The smaller fan was blowing from the interior wall across the floor to another fan placed in the window on the exterior wall of the room. However; the fan in the window was in the window backwards and instead of blowing the fumes out the window was blowing them back into the open door way and into the hall. The Nursing Home Administrator (NHA), admitted at the time of observation the "fumes are really strong." The NHA and the surveyor entered the room and turned the fan in the window around it then was drawing the air in the room outside instead of blowing fumes into the hallway.

The NHA stopped Maintenance Employee (ME) 1 and questioned him about the smell. ME 1 revealed he had used floor stripper in the room approximately an hour ago and had set the fans up to dry the floor and didn't think about where the fumes were going.

An immediate interview with the NHA, June 17, 2019, at 12:51 PM revealed the hallways should not have excessive fumes from chemicals in them.

28 Pa Code 201.18(3) Management

28 Pa Code 207.2(a) Administrator's responsibility




 Plan of Correction - To be completed: 07/22/2019

Preparation and submission of this Plan of Correction is required by state and federal law & #8239. This POC does not constitute and admission for purposes of general liability, professional & #8239; malpractice, or & #8239 any other court proceeding.
1. The direction of the fan was corrected by the surveyor himself at the time of survey.
2. All housekeeping staff and the Environmental Services Director were re-educated on the proper direction of the fan for use in controlling odors.
3. The Environmental Services Supervisor will announce at morning meeting any rooms being stripped on that day. All QAPI members will randomly check for the use of a fan in the designated room. The Environmental Supervisor will be informed if any corrections had to be made when a fan is identified for odor control and was corrected. The Environmental Supervisor will monitor.
4. A monthly audit will be completed by the Environmental Services supervisor and reviewed at the monthly QAPI meeting for two months to ensure 100% compliance. The NHA to monitor.
483.10(e)(2) REQUIREMENT Respect, Dignity/Right to have Prsnl Property: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents.
Observations:


Based on facility observation and staff interviews, it was determined that the facility failed to provide dignity for two of five residents observed. (Residents 3, and 4).

Findings include:

Review of Resident 3's clinical record revealed he was admitted to the facility on January 8, 2014, with diagnoses that included, neuromuscular dysfunction of bladder (a dysfunction of the urinary bladder due to disease of the central nervous system or peripheral nerves involved in the control of urination), and urinary tract infections.

An observation on the initial tour on June 17, 2019, at approximately 12:14 PM revealed Resident 3 propelling himself in the main hallway of the facility near the main dining room. Resident 3 was noted to have a catheter collection bag attached to his wheelchair. The catheter collection bag was not covered and observable to anyone in the common area of the facility. An Immediate interview with Resident 3 revealed "they used to cover it, but they haven't in a while." Resident 3 also stated when asked, "well, yes, I would prefer it was covered."

Review of Resident 4's clinical record revealed he was admitted to the facility on April 19, 2007, with diagnoses that included, intellectual disabilities, and legal blindness.

Further observations on June 17, 2019, at 12:38 PM. revealed Resident 4 was observed from the hallway in his room with no clothing on. Resident 4 was in his wheelchair with only an incontinence brief on. Resident 4's room door was open and exposed to anyone in the hallway. At the time of observation two staff members were in the same hallway serving lunch trays and nothing was done to enhance the dignity of the resident until told to do so by the Nursing Home Administrator.

During an immediate interview with the Nursing Home Administrator, June 17, 2019, at 12:38 PM revealed the resident should not be exposed to the hallway without clothes on.

An interview on June 17, 2019, at 6:40 PM with the Director of Nursing, revealed, catheter collection bags should be covered.

28 Pa. Code: 201.18(b)(2) Management.

28 Pa. Code: 201.29(j) Resident's rights.

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

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





 Plan of Correction - To be completed: 07/26/2019

#0557
Preparation and submission of this Plan of Correction is required by state and federal law & #8239. This POC does not constitute and admission for purposes of general liability, professional & #8239, malpractice or & #8239 and any other court proceeding.
1. Resident # 3 was given blue bag to cover the urinary drainage bag immediately. During the survey, the SS Director entered Resident #4 room to assist in dressing and to close the door. The Unit Managers for both units were re-educated immediately as it relates to drainage coverage bags and privacy.
2. A 100% audit of all residents with catheters were audited to ensure the drainage bags were covered. The staff on the unit for Resident #4 were re-educated immediately to provide privacy for this resident. Any deficient practice identified was corrected immediately.
3. Staff education and a post-test were completed for all full and part-time direct care staff by the Staff Development Director on catheter drainage bad covers and resident privacy/dignity. The Central Supply clerk was educated to visually inspect daily x one week that residents with catheters have drainage bag covers covers. The results of those audits were reviewed to identify any further remedial education as required. The Central Supply clerk will randomly audit every two weeks for six weeks thereafter to determine if 100% compliance has been achieved. All Department Directors will complete random audits to identify and privacy/dignity issues for immediate correction. All observable incidents will be communicated via a grievance form to the DON/NHA immediately. Correction and/or education will be completed immediately. All privacy/dignity issues will be logged for review and analysis each month x two months by the DON/NHA. The DON/NHA/ designee will monitor.
4. The results of the random catheter bag cover audits will be reviewed by the Administrator with nursing administration at the monthly QAPI meeting to determine 100% compliance or if the audits need to continue based on the QAPI committee recommendations. The monthly grievance log for privacy/dignity grievances will be analyzed monthly x two months for compliance and trends and presented at the monthly QAPI meeting for additional comments and or recommendations if not at 100% compliance. The NHA/DON/designee will monitor for compliance.
483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on a review of clinical records, observation, resident and staff interview it was determined that the facility failed to implement care plan interventions for one of five residents reviewed, (Resident 5).

Findings include:

Review of a facility policy titled, "Assistance with Meals," last reviewed November 2018, revealed a section for "Residents Requiring Full Assistance". Review of this section revealed "Nursing staff/ Feeding Assistants will remove meals from the from the food cart and deliver to each resident's room. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: Not standing over residents while assisting them with meals; keeping interactions with other staff to a minimum while assisting, residents with meals".

A review of the clinical record revealed that Resident 5 was admitted to the facility on May 23, 2013. Current diagnoses include adult failure to thrive (weight loss of more than 5%, decreased appetite, poor nutrition, and physical inactivity) and encounter for palliative care (specialized medical and nursing care for people with life-limiting illnesses, focusing on providing relief from the symptoms, pain, physical stress, and mental stress associated with end of life).

Observation on June 17, 2019, at 12:42 PM revealed Resident 5 in bed in her room with the overbed table in position in front of her, with an uncovered meal sitting on it. There was no staff in the room at the time of observation. When asked why she wasn't eating Resident 5 replied, "waiting for someone to help me eat."

A review of Resident 5's current plan of care revealed a focus care area, "resident has potential nutritional problem related to elevated BMI (Body Mass Index), therapeutic diet, Edentulous (not having own teeth), not wearing dentures; depleted protein stores". Interventions included in this focus group included, "Resident requires assistance at meals", which was initiated on April 29, 2019 and still active at the time of observation. An additional intervention of, "Resident to be fed by staff", also initiated on April 29, 2019, was active at the time of observation.

At the observation of Resident 5 in her room alone, without assistance to eat, the Nursing Home Administrator, who was accompanying this surveyor, went to the nurse's station to obtain assistance for this resident. After 8 minutes of waiting, without staff coming to assist, the Director of Nursing entered the room and started assisting the resident to eat.

Interview with the Nursing Home Administrator on June 17, 2019, at approximately 5:40 PM revealed her expectation that the plan of care should be followed.

28 Pa Code 211.11(d) Resident care plan.

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





 Plan of Correction - To be completed: 07/28/2019

#0656
Development and/or execution of this plan of correction does not constitute and admission or agreement by this provider of the truth in this statement of deficiency. This poc is prepared and or executed by provision of State and or Federal law.
1. Resident #5 was reassessed by the Speech Therapist to determine assistance needed for meals. The care plan was updated with any new findings.
2. A 100% audit was completed on all residents for level of assistance required for meals. All meal tickets, care plans and Kardex's were updated to reflect any changes.
3. All Unit Managers were re-educated on their role during meal service by the NHA to ensure residents requiring feeding assistance have it. Random audits have been completed weekly x four weeks to determine compliance with feeding assistance as identified through the most current audit. All unit staff have received a post-test to ensure staff are aware of what assistance each resident needs during meal service. Department Directors will randomly audit weekly x four weeks to ensure compliance. The Unit Managers/Nursing Administration to monitor.
4. Feeding assistance audits will be completed every 90 days or sooner as indicated by a decline and/or improvement for each resident by therapy and a direct care representative. Meal tickets will be updated and staff notified of any changes made before the audit schedule. The NHA/DON/designee will monitor for compliance and update monthly as needed at the QAPI meeting.

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 record review and interviews it was determined that the facility failed to revise the individualized plan of care for one of five residents reviewed (Resident 2).

Findings include:

Review of resident 2's clinical record revealed the resident was admitted to the facility on May 28, 2015. Current diagnoses include, Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability)., and diabetes mellitus (DM- failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment).

Review of Resident 2's Significant Change Minimum Data Set (MDS- periodic assessment of resident care and service needs) dated May 30, 2019, revealed in Section G: Functional Status a subsection G0110 Activities of Daily Living (ADL) Assistance. A sub subsection of Functional Status G0110 E locomotion on the unit (how a resident moves between location in his/her room and adjacent corridor on same floor. If in wheelchair, self-sufficiency once in chair) was coded as a three (3) for self-performance. The key located in this section of the MDS revealed a three as "Extensive Assistance-resident involved in activity, staff provide weight bearing support". Sub subsection G0110E further evaluated the support provided to the resident for locomotion on the unit, this was coded as a two (2). The key noted above revealed a "2" to be "one-person physical assist."

Review of the current plan of care for Resident 2 revealed a focus care area described as "Self-care deficit due to decline in functional mobility, decline in personal care awareness related to dementia/arthritis, pain both knees. 01/22/19 Readmitted with diagnosis of closed displaced fractur (spelling in the document) of right femoral neck." An intervention under this focus area was " Independent in ambulation on the nursing unit without assistive device." This intervention was initiated on June 5, 2015, and on the current plan of care provided by the facility.

Further review of Resident 2's, May 30, 2019, MDS revealed also under Section G, a subsection G0600-Mobility Devices, which was coded as using a wheelchair (manual or electric) as a mobility device.

Further review of Resident 2's MDS revealed section H- Bladder and Bowel. Section H subsection H0200 Urinary toileting Program had two sections section A) Has a trial toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in the facility. This question was marked as a zero (0). Zero is noted to be " No- Skip to H300, Urinary Continence".

Section H0500 Bowel Toileting Program- "Is a toileting program currently being used to manage the resident's bowel continence?" This question was marked as a zero (0). Zero is noted to be "No".

Review of the current plan of care for Resident 2 revealed a focus care area described as "Self-care deficit due to decline in functional mobility, decline in personal care awareness related to dementia/arthritis, pain both knees. 01/22/19, Readmitted with diagnosis of closed displaced fractur (spelling in the document) of right femoral neck." An intervention under this focus area was "Habit/Scheduled voiding program." This intervention was initiated on July 12, 2015, and on the current plan of care provided by the facility.

Interview with the Director of Nursing on June 17, 2019, at approximately 5:40 PM revealed that the care plan should have been updated

28 Pa Code; 211.10(c) Resident care policies

28 Pa Code 211.11(b) Resident care plan





 Plan of Correction - To be completed: 07/28/2019

#0657
The plan of correction is prepared and/or executed by provision of Federal and State law. Development and/or execution of this POC does not constitute and admission or agreement of this provider of the truth in the statement of the deficiency.
1. Resident #2 care plan was reviewed and updated to reflect this residents" current functional status.
2. A 100% audit of care plans completed since June 1, 2019 have been reviewed and updated to reflect current individualized functional status. Any areas identified as not being relevant to the current level of care provided were updated to be reflective of that resident.
3. The Care Plan Coordinator ( Director of MDS) and care plan team were re-educated by the appropriate Regional Consultant. Any care plan completed June 1 forward have been reviewed by the Consultant to ensure that the care plan is accurate and reflective for those residents. All care plans completed moving forward will be reviewed by the NHA and Director of Nurses/designee to ensure the accuracy of that care plan before it is locked. The care plan team will not convene unless the identified members are present: a nurse, an aide, dietary, therapeutic recreation and social services to ensure that all care plans are reflective of the current status of that resident.
4. The regional consultant will randomly review 2 care plans weekly for four weeks to ensure that the care plans are relevant and accurate for each resident reviewed. The findings will be submitted by the consultant to the NHA via an audit tool for analysis to be presented at the monthly QAPI meeting. Less then 100% compliance will result in audits being extended by the regional consultant for four more weeks until 100% compliance is achieved. The NHA will monitor for compliance.
35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.


Observations:


Based on observation and staff interview it was determined that the facility failed to ensure personnel providing direct care to residents wore facility issued identification tags on two of 12 Hallways observed.

Findings Include:

Review of facility employee handbook revealed a section titled, "Dress Code/Personal Appearance". This section revealed, "Company's name badges must be worn while on duty."

Observation on June 17, 2019, at 12:20 PM revealed Nursing Assistant (NA) 1 coming out of a resident room with no facility issued identification badge. An immediate interview with NA 1 revealed " I forgot it."

Observation on June 17, 2019, at 12:48 PM revealed Housekeeper/Laundry (HK) 1 walking in the 300 hallway with no facility issued identification badge. An immediate interview with HK 1 revealed, no response when asked about the badge.

An interview on June 17, 2019, at 6:40 PM with the Director of Nursing, revealed, name badges should be worn by the staff while working.





 Plan of Correction - To be completed: 07/22/2019

#0010
Preparation and submission of this Plan of Correction is required by state and federal law & #8239. This POC does not constitute an admission for purposes of general liability, professional $ #8239; malpractice, or & #8239, any other court proceeding.
1.Nursing Assistant #1 and HSP #1 were immediately directed to obtain a temporary name badge during the survey.
2. A 100% audit was completed on all three shifts to ensure that all staff had photo identification badges. Any deficient practice identified was corrected immediately.
3. All department directors were re-educated to the requirement of identification badges when in the building by the NHA. In turn, all department Directors re-educated their staff to this requirement. Daily audits for name badges occurred daily times one week. Staff Development also completed re-education of staff and this requirement with a post-test. Random audits for the presence of name badges have been completed weekly since the complaint survey. The NHA will monitor for compliance.
4. Random name badge audits will be completed by the HR department and/or department directors monthly x 2 months for 100% compliance. The audits will be analyzed and presented at the monthly QAPI meeting for any further recommendations if the audits do not demonstrate 100% compliance for each of the months. The NHA will monitor for compliance.

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