Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-LANCASTER
Patient Care Inspection Results

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MANORCARE HEALTH SERVICES-LANCASTER
Inspection Results For:

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MANORCARE HEALTH SERVICES-LANCASTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey and state monitoring survey completed on November 26, 2019 in response to two complaints at Manor Care Health Services at Lancaster, it was determined that Manor Care Health Services at Lancaster 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:


483.24 REQUIREMENT Quality of Life: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 Quality of life
Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the
necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.
Observations:

Based upon observation, it was determined that the facility failed to answer call bells in a timely manner on one of four units observed (Roosevelt Nursing Unit).

Findings include:

Observation of the Roosevelt Unit on November 26, 2019 at approximately 2:00 p.m. revealed call bells ringing in Rooms 163 and Rooms 169.

Further observation of the Roosevelt Unit failed to reveal any staff members in the hall or on the unit.

Observation of the Roosevelt Unit nurses' station on November 26, 2019 at approximately 2:19 p.m. revealed two nurses at the nurses' station desk.

Further observation revealed one nurse enter the clean linen room on November 26, 2019 at approximately 2:21 p.m. After entering the clean linen room, three nursing assistants exited the clean linen room and answered the call bells in Room 163 and Room 169.

Observation on November 26, 2019 revealed call bells ringing from approximately 2:00 p.m. until 2:21 p.m. with no staff members present on the unit and two nurses at the nurses' station desk.

Interview with the Director of Nursing and Nursing Home Administrator on November 26, 2019 at approximately 2:45 p.m. confirmed that the call bells should have been answered in a timely manner.




 Plan of Correction - To be completed: 01/15/2020

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

Residents identified in the complaint survey did not experience negative outcomes as result of the alleged deficient practice.

2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

New admissions and current residents who require their call bells to be answered have the potential to be affected by the deficient practice.

3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

Nursing Staff will be educated, by the DON or designee before the date of compliance, on Focus on F Tag 675 Quality of Life and the Nursing Procedure: Call Light.

4. How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?

Facility Staff will conduct Call Light audits 5 per week for 5 weeks. These audits will be reviewed at QAPI to determine the need for further audits.

5. Dates of when the corrective action will be completed.

January 15, 2020

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based upon clinical record review and review of documentation provided to the State Agency by the facility, it was determined that the facility failed to ensure interventions were in place for the prevention of pressure ulcers and failed to timely identify a pressure ulcer for one of four residents reviewed (Resident R4).

Findings include:

Review of Resident R4's diagnosis list revealed diagnoses including muscle weakness, hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD - disease process that causes decreased ability of the lungs to perform), atrial fibrillation (irregular and rapid heart beat) and major depressive disorder (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine).

Review of Resident R4's Minimum Data Set (MDS - periodic assessment of resident needs) dated September 16, 2019 revealed Resident R4 required extensive assistance of two staff members for turning and repositioning in bed.

Review of Resident R4's physician orders dated September 17, 2019 revealed "skin prep to heels bid [two times per day] every day and evening shift for to prevent skin breakdown."

Review of Resident R4's progress notes dated October 11, 2019 revealed "body audit every day shift every Friday for skin observation no skin issue noted."

Review of documentation provided by the facility to the State Agency dated October 14, 2019 revealed "resident noted to have pressure ulcer on b/l [bilateral] heel."

Further review of documentation provided by the facility to the State Agency dated October 15, 2019 revealed "I gave pt a shower on Friday 10/11/19, pt c/o [complained of] discomfort on heels, I looked at them there no open areas upon my checking."

Further review of documentation provided by the facility to the State Agency dated October 14, 2019 revealed "I was putting [resident] to bed, and when I took slippers off, blood started pouring down from [resident's] feet."

Review of Pressure Ulcer Skin Assessment dated October 14, 2019 revealed Resident R4's "right heel had an open blister measuring 5 centimeters (cm) x 4 cm, pale pink, surrounding skin reddened, moderate amount of bloody drainage noted. For MDS purpose area appears to be Stage II pressure ulcer."

Further review of the Pressure Ulcer Skin Assessment dated October 14, 2019 revealed Resident R4's left heel "3 cm x 3 cm open blister, pale pink tissue, scant amount of bloody drainage. Surrounding skin is reddened. For MDS purpose area on left heel appears to be Stage II pressure ulcer."

Review of Resident R4's active plan of care revealed Resident R4 was at risk for alteration in skin integrity with interventions including observe skin condition with ADL care daily, report abnormalities; skin prep to heels for prevention and elevate heels as able.

Review of Resident R4's October 2019 Treatment Administration Record (TAR) revealed that Resident R4 was receiving skin prep to bilateral heels two times per day. Further review of Resident R4's clinical record failed to reveal evidence of any abnormalities in Resident R4's heels until October 14, 2019 when open blisters were discovered.

Interview with the Director of Nursing on November 26, 2019 at approximately 2:45 p.m. confirmed that other interventions should have been put into place prior to the development of Resident R4's bilateral heel ulcers. This interview further confirmed that Resident R4's bilateral pressure ulcers should have been identified prior to becoming open blisters.






 Plan of Correction - To be completed: 01/15/2020

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

Resident R4's plan of care, medication orders and clinical record correctly demonstrate the current condition of the residents pressure ulcers on bi-lateral heels. The resident is being carefully monitored and treated for pressure ulcers.

2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

New admissions and current residents who require assistance with pressure ulcers have the potential to be affected by the deficient practice. A comprehensive review of current patients with pressure ulcers using the skin QAPI tool will be completed by the DON/Designee to validate and identify pressure ulcer care and treatments are appropriate for prevention/healing of pressure ulcers as ordered by physician.

3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

Licensed Nursing staff will be in-serviced on focus on the F Tag 686 and Skin Practice Guide by the DON/Designee.

4. How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?

The Director of Nursing/Designee will complete weekly audits x 5 of residents with pressure ulcers using the Skin QAPI tool. Audit results will be reported to the QAPI committee monthly and the QAPI committee will determine the need for further audits.

5. Dates of when the corrective action will be completed.

January 15, 2020

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:
Based upon clinical record review and review of documentation provided to the State Agency by the facility, it was determined that the facility failed to ensure residents were free from medication errors for one of four residents reviewed (Resident R1).

Findings include:

Review of Resident R1's diagnosis list revealed diagnoses including diabetes mellitus (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), hypertension (high blood pressure), chronic kidney disease (progressive loss of kidney function), and coronary artery disease (CAD - narrowing of the blood vessels which supply the heart with blood and oxygen).

Review of Resident R1's progress notes dated November 19, 2019 revealed "Resident was given wrong med at 0530 [5:30 a.m.], RP [responsible person] and MD [medical doctor] aware, VS 129/64, 74, 95%, 97.9, 18, no pain or discomfort, no SOB, no chest pain, no H/A [headache] or dizziness, resident was given Gabapentin 600 mg [milligrams] [nerve pain medication and anti-convulsant medication] and Lisinopril-Hydrochlorothiazide [high blood pressure medicine and diuretic combination] 10 mg - 12.5 mg, neuro checks WNL [within normal limits], will continue to monitor."

Review of employee statement dated November 19, 2019 revealed "I gave resident the wrong medication. I gave [resident] Gabapentin 600 mg and Lisinopril-Hydrochlorothiazide tab. I had [resident's] med to give to [resident's] roommate and he noticed it was not his and I noticed that I gave [resident] the wrong med. VS [vital signs] were obtained 129/64, 74, 95% on oxygen, 97.9, 18, neuro checks WNL, no pain or discomfort, no dizziness, H/A or chest pain. MD called, RP called, will continue to monitor."

Interview with the Nursing Home Administrator and Director of Nursing on November 26, 2019 at approximately 2:45 p.m. confirmed that a medication error occurred with Resident R1.






 Plan of Correction - To be completed: 01/15/2020

1. What corrective action will be accomplished for those residents found to have been affected by the deficient practice?

Resident R1 experienced no ill effects from the medication error.

2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

New admissions and current residents who receive medication have the potential to be affected by the deficient practice. A comprehensive review of the last 30 days of incident reports using the medication error QAPI tool will be completed to ensure no other patients have been affected.

3. What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

Licensed Nursing Staff will be educated on the facility procedure, Medication Administration: Oral.

4. How the corrective action will be monitored to ensure that the deficient practice will not recur i.e. what quality assurance programs will be established?

The Director of Nursing/Designee will audit medication passes for 5 weeks (minimum of 3 per week). The results of the audits will be reviewed in QAPI to determine the need for continued audits.

5. Dates of when the corrective action will be completed.

January 15, 2020


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