Transitional Care Unit At Nazareth Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical record, review of facility policy and interviews with staff, it was determined that the facility failed to ensure that advanced directives/code status were in place for two of 11 clinical records reviewed (Resident R110 and Resident R111). Findings include: Review of facility policy on Advance Directive and Healthcare Agents and Representatives revealed that under section Purpose: The purpose of this policy is to ensure that [NAME] Hospital physicians and colleagues respect the health care decisions of its patients and comply with the requirement of Pennsylvania law governing Living Wills. Under section Policy: [NAME] Hospital will comply with the Living Will of a patient. Under section admission Procedure: Upon admission to [NAME] Hospital facility, the patient shall be informed of the right to execute an Advance Health Care Directives. The patient access representative will ask the patient if the patient has executed a living will/advance health care directive and if the patient has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and the review of clinical records, it was determined that the facility failed to clarify a physician's order related to daily weights for one out of 11 residents reviewed (Resident R61). Findings include: Review of the facility policy, Weights, with a review date of August 2019 indicted that the purpose of the policy is to monitor weight gain or loss. The policy also indicated that nursing will notify the physician or any weight gain of 2 or more pounds in one day, and the dietician of any weight loss. Review of the guidelines that the facility follows for the managemement of heart failure, 22 AHA/ACC/HFSA Guideline for the Management of Heart Failure indicated that the facility's disease management programs may compromise education, self-management, medication optimization, device management, weight monitoring, exercise and dietary advices . Review of Resident R61's nursing note dated March 13, 2025 at 11:54 a.m. indicated that the resident was admitted in to the facility with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews with resident and staff, review of clinical records and facility policy, it was determined that the facility failed to maintain a peripheral inserted central catheter (PICC) consistent with professional standards of practice for one of one resident with a PICC line. (Resident R4) Findings include: Review of facility policy on Maintenance of Central Venous Catheters (CVC) revealed that under section Purpose: intravenous therapy for the administration of blood products, fluids, and parenteral nutrition, as well as for hemodynamic monitoring is an essential part of medical practice. The following policy pertains to all central venous catheters (CVC) utilized at [NAME] Health Mid-Atlantic region, including PICC. Under section Maintenance of the Catheter Site, # C. The insertion site will be evaluated every shift for evidence of complications. Assessments include gentle palpation of the site through the intact dressing to discern tenderness and visual inspection of insertion site…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of facility policy and procedure, it was determined that the facility failed to maintain an effective infection control program related to the hand hygiene during medication administration, and wound treatment for two of two residents observed. (Resident R61 and Resident R108) Findings include: Revie of facility policy on medication administration revealed that the policy did not address hand washing and other infection control subjects. Review of facility policy on Hand Hygiene revealed that under section Purpose: To assure proper hand hygiene practices are utilized by employees during all activities including patient care, and to prevent transmission of infectious pathogens. Hand hygiene helps to physical remove infectious from hands. Hands can also be decontaminated using waterless alcohol hand sanitizer. Under section Policy: It is the policy of [NAME] Hospital to decrease the risk for transmission of nosocomial pathogens that may be carried on the hands of healthcare workers.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical records review, it was determined the facility did not develop a person centered baseline care plan for two of five resident clinical records reviewed. (Residents R3 and R116) Findings include: Review of facility policy titled Care Plan Policy last revised August 2012 revealed The transitional care unit at [NAME] Hospital will develop a comprehensive care plan for each resident that includes measurable objectives a timetables, to meet a residents medical, nursing and mental , and psychosocial needs that are identified in the comprehensive assessment. Review of Resident R3's clinical record revealed the resident was admitted to the facility on [DATE], to receive rehabilitation services for ambulatory disfunction (a condition that make it difficult to walk). Continued review of the clinical record revealed that Resident R3 had the diagnoses of urinary tract infection, ambulatory disfunction (a condition that makes it difficult to walk), shortness of breath, kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, interviews with staff and policy and procedure review, it was determined for one of two closed resident records, the facility failed to ensure a comprehensive, orderly, systematic and coordinated discharge to the community. (Resident R9) Findings include: Review of Resident R9's closed clinical record revealed that the resident was admitted to the facility on [DATE] for rehabilitation. On May 8, 2023 the physician's progress note indicated that the resident was requesting to be discharge. On May 9, 2023 the nursing staff documented in the clinical record that Resident R9 left the facility at 8:05 p.m., with a family member to return home. The resident was documented as advised to continue Nexium 40 milligrams (mg) twice daily to treat acid reflux, Ibuprofen 800 mg three times a day and as needed for pain, Carisoprodol 350 mg daily as needed for muscle spasm, Calcitrol 25 mg daily (a vitamin supplement) and Lisinopril 20 mg daily to treat high blood pressure. The physician…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, and staff interview, it was determined that the facility failed to ensure that physician orders were follow related to medications for diabetes mellitus and hypotension for two of six residents reviewed. (Residents R61 and R70) Findings include: Clinical record review revealed that Resident R70 was admitted to the facility on [DATE]. The physician's assessment dated [DATE] indicated that the resident had a diagnosis of diabetes mellitus (a metabolic disorder in which the body has high blood glucose levels for prolonged periods of time, that was caused by an inadequate production of insulin). Clinical record review revealed that Resident R70 had physician' orders for insulin (Lispro Humalog); which was a fast acting insulin used to control high blood glucose. The physician directed the nursing staff to monitor Resident R70's blood glucose three times daily with meals. The physician orders also included directions for the nursing staff to treat hypoglycemia (low blood glucose).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review and interviews with staff, it was determined that the facility did not maintain respiratory equipment according to professional standards of practice for two of two residents reviewed in oxygen therapy (Resident R3 and Resident R112). Findings include: Observations conducted on July 25, 2023, at 10:56 a.m. revealed that Resident R3 was receiving supplemental oxygen via nasal cannula and the tubing was undated. Observations conducted on July 25, 2023, at 11:15 a.m. revealed that Resident R112 was receiving supplemental oxygen via nasal cannula and the tubing was undated. Interview with Licensed nurse, Employee E11 on July 26, 2023 at 2:05 p.m. confirmed that the tubing has not been dated. Interview with Director of nursing on July 27, 2023 at 2:40 p.m. revealed that the tubing is changed every Sunday and should be dated. 28 Pa. Code 211.12(c) Nursing services 29 Pa. Code 211.12(d)(1) Nursing services

Based on observation, facility policy review, and interview with staff, it was determined that the facility failed to ensure the security of a medication cart for one of one cart observed. Findings include: Review of facility policy titled Administering Medications, dated February 15, 2023 revealed never leave poured or prepared medications unsupervised. Observations conducted on July 24, 2023 at 9:00 a.m. revealed that a medication cart stationed on the second floor was unlocked and unattended for a period of 7 minutes not in view of licensed nurse, Employee E24. At 9:08 a.m., Licensed nurse, Employee E24, approached the cart. When the surveyor asked why the cart was unlocked, Employee E24 stated, she was tending to a resident on isolation and could not bring the cart in the room. Interview with the Nursing Home Administrator, and the Director of Nursing, Employee E2 on July 25, 2023, at 12:30 p.m. confirmed that medication cart should be locked at all times when unattended. 29 Pa. Code 211.12(c) Nursing services 29 Pa. Code 211.12(d)(1) Nursing services

Based on a review of facility documents and interviews with staff, it was determined that the facility failed to provide completed documentation and information as required within the appropriate time frames. Findings include: An entrance conference was held on July 24, 2023, at 9:15 a.m. the entrance conference worksheet was provided to the Director of Nursing informing the facility of needed documents and their expected time frames for delivery. The list of documents included but was not limited to, the wifi access and patient records access, to be delivered immediately. On July 24, 2023, at 12:10 p.m. another request was made for patient record access. Interview with Director of Nursing at the time stated that the requests for access was made but has been denied. Director of Nursing was waiting for IT (information technology) to respond to the requests. On July 25, 2023, at 9:00 a.m., surveyors were given computers to be able to access they system but still surveyors were unable to gain access to the facility program. At 10:33 a.m., surveyors were given access and assisted into…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.