12/17/2015 F 0000 F 0314 F 0314 SS=G PRINTED: 9/12/2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES HEALTH CARE FINANCING ADMINISTRATION SQC111

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1 1.00 DEPARTMENT O HEALTH AND HUMAN SERVICES (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH 0000 INITIAL COMMENT Based on an abbreviated revisit survey and state monitor survey and complaint investigation completed on December 17, 2015, it was determined that Susquehanna Valley Nursing and Rehabilitation Center corrected all the deficiencies cited during the complaint survey of October 22, 2015 and the complaint survey of November 6, 2015, but continues to be in non compliance with the following requirements of 42 CR Part 483, Subpart B Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE: (X6) : Any deficiency statement ending with an asterisk (*) denotes a deficiency which may be excused from correction providing it is determined that other safeguards provide sufficient protection to the patients. The findings stated above are disclosable whether or not a plan of correction is provided. The findings are disclosable within 14 days after such information is made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. This form is a printed electronic version of the CMS 2567L. It contains all the information found on the standard document in much the same form. This electronic form once printed and signed by the facility administrator and appropriately posted will satisfy the CMS requirement to post survey information found on the CMS 2567L. I CONTINUATION SHEET Page 1 of 9

2 (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH Continued from page (c) TREATMENT/SVCS TO PREVENT/HEAL PRESSURE SORES Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. This REQUIREMENT is not met as evidenced by: The Susquehanna Valley Nursing and Rehabilitation Center submits this plan of correction under procedures established by the Department of Health in order to comply with the Departments directive to change conditions which the Department alleges are deficient under State and ederal regulations relating to long-term care. This plan of correction should not be construed as either a waiver of the facility's right to appeal and to challenge the accuracy of the alleged deficiencies or an admission of past or ongoing violations of State and ederal regulatory requirements. Completion Date: 01/08/2016 Status: APPROVED Date: 12/29/ Resident C16 areas on left fourth toe, left posterior foot and right posterior foot are being treated and followed by wound consultant. 2. A facility wide audit of all residents' skin will be completed by DON and/or designee to ensure that all pressure sores are identified and proper treatment is in place. I CONTINUATION SHEET Page 2 of 9

3 (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH Continued from page 2 3. DON and/or designee will in-service all nursing staff on performing daily skin checks with routine daily dressing, AM-PM care. DON and/or designee will develop a skin management program and will in-service all licensed staff on skin management program. DON and/or designee will educate licensed staff on proper identification and treatment of pressure sores, including RN education on proper staging of wounds. 4. DON and/or designee will audit daily skin sheets for 2 weeks by assessing random residents. DON and/or designee will audit skin sheets weekly for 4 weeks by assessing random residents. DON and/or designee will audit skin sheets monthly for 3 months by assessing random residents. All results will be presented to monthly QA for review and evaluation. 5. January 8, 2016 I CONTINUATION SHEET Page 3 of 9

4 (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH Continued from page 3 Based on review of clinical records and interviews with residents and facility staff, it was determined that the facility failed to identify, assess, provide treatment and implement preventative measures for new pressure ulcers, resulting in actual harm to one of three residents reviewed. (Resident C16) indings include: Review of Resident C16 ' s clinical record revealed that the resident had the following (but not limited to) diagnosis: Multiple Sclerosis (MS) (a slow progressive disease of the central nervous system), diabetes mellitus type 2 (failure of the body to produce insulin to enable sugar to pass from the blood stream to cells for nourishment), and paraplegia (paralysis of the lower half of the body). Review of the Resident C16 ' s Activity of Daily Living (ADL) sheets dated December 1, 2015 to December 8, 2015 revealed that the resident was total dependence or extensive assist with dressing I CONTINUATION SHEET Page 4 of 9

5 (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH Continued from page 4 (meaning a staff member was needed to get the resident dressed/undressed due to his physical condition). Review of the Resident C16 ' s Skin Assessment completed on December 1 and December 4, 2015 there were no skin issues identified. A nursing note dated December 8, 2015 stated the following DTI (deep tissue injury) noted on left forth toe 1.2 cm (centimeter) x 1.5 cm area. Light tan in center and dark brown around outer aspect. The left posterior foot (back of foot on the inside) 3.1 cm x 2.4 cm, black in color; Right posterior foot (back of foot on the inside) 6.0 cm x 6.5 cm, black in color. Interview with Resident C16 on December 17, 2015 at approximately 11:00 a.m. revealed that the resident was fitted for new shoes, through the therapy department, and the consultant ordered him a size 9 ½ shoe. The resident states that he wore a 10 ½ shoe size and the shoes were too tight when they arrived. urther investigation revealed that the resident voiced that the shoes were too small but the I CONTINUATION SHEET Page 5 of 9

6 (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH Continued from page 5 staff continued to place them on his feet. An interview was conducted with the Director of Nursing on December 17, 2015 at approximately 1:30 p.m. that revealed that the nurse believed that the new areas identified were caused by the new shoes not fitting properly. An additional interview was conducted with Employee E4 which revealed that due the Resident C16 being diabetic a consultant, that specialized in foot ware for diabetics, measured the residents foot but could not verify if the resident was asked his shoe size. There was no documented evidence stating that the nursing assistants notified nursing licensed staff of any redness or discoloration while performing ADL ' s before December 8, urther review of the clinical record revealed the resident was seen on December 14, 2015 by the wound specialist and stated a Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure wound of the left, distal plantar I CONTINUATION SHEET Page 6 of 9

7 (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH Continued from page 6 (back of foot on the inside) measuring 2.3 cm x 2.5 cm x not measurable centimeters, 50% thick adherent (sticking to) black necrotic (death of) tissue (eschar) and 50% thick adherent devitalized (no strength) necrotic tissue. Stage II (partial thickness skin loss involving the outer layers of the skin) pressure wound of the left, fifth toe measuring.8 cm x.3 cm x not measurable cm. Unstageable [due to necrosis (dead tissue)] of the right, plantar foot measuring 4.5 cm x 6 cm x not measurable cm with thick adherent black necrotic tissue (eschar) 100%. Arterial wound result (from an inadequate blood supply) of the left, posterior (back) ankle measuring 2.4 cm x 1.8 cm x not measurable cm. with thick adherent devitalized necrotic tissue 100%. An interview was conducted with the Nursing Home Administrator and Director of Nursing on December 17, 2015 at approximately 2:30 p.m. revealed that due to the extensive dressing need of the resident it would be expected that the nursing assistants would report redness or any suspicious discoloration of the residents ' feet. It was revealed that these pressure I CONTINUATION SHEET Page 7 of 9

8 (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH Continued from page 7 ulcers could have been detected earlier by monitoring the proper shoe fitting and sizing and staff reporting them immediately to the nursing supervisor. The facility failed to accurately assess and monitor the resident ' s skin to prevent pressure ulcer, and/or timely identify development of a pressure ulcer for Resident C16 who was at risk for skin breakdown which resulted in an actual harm to the resident. 28 Pa. Code: (b)(1)(e)(1) Management. Previously cited 11/06/ Pa. Code: (f) Clinical records. Previously cited 3/18/15, 6/1/15, 10/22/ PA Code: (d) Resident care policies Previously cited 1/23/14, 04/25/ Pa. Code: (c) and (d)(1)(5) Nursing services. Previously cited 3/18/2015, 6/01/15, 10/22/2015, I CONTINUATION SHEET Page 8 of 9

9 (XI) PROVER/SUPPLIER/CLIA ENTIICATION NUMBER: (X3) SURVEY D: NAME O PROVER OR SUPPLIER: (X4) PROVER'S PLAN O CORRECTION (EACH Continued from page 8 11/06/2015, 11/24/2015 I CONTINUATION SHEET Page 9 of 9

1.00 Certified End Page SURVEY EXIT : I Certify This Document to be a True and Correct Statement of Deficiencies and Approved acility Plan of Correction for the Above-Identified acility Survey

10 1.00 Certified End Page SURVEY EXIT : I Certify This Document to be a True and Correct Statement of Deficiencies and Approved acility Plan of Correction for the Above-Identified acility Survey Christine C. ilipovich, MSN, RN Deputy Secretary or Quality Assurance Karen M. Murphy, PhD, RN Secretary of Health THIS IS A CERTIICATION PAGE PLEASE DO NOT DETACH THIS PAGE IS NOW PART O THIS SURVEY

PRINTED: 01/25/2008 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L (X2) MULTIPLE CONSTRUCTION STREET ADDRESS, CITY, STATE, ZIP CODE

PRINTED: 01/25/2008 FORM APPROVED CENTERS FOR MEDICARE & MEDICAID SERVICES 2567-L (X2) MULTIPLE CONSTRUCTION STREET ADDRESS, CITY, STATE, ZIP CODE S FOR MEDICARE & MEDICA SERVICES 2567-L NAME OF PROVER OR SUPPLIER (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D (X4) PROVER'S PLAN OF CORRECTION F 000 INITIAL COMMENTS F 000 No Plan of