Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that a call bell was accessible for one of 19 sampled residents. (Resident 8)
Findings include:
Clinical record review revealed that Resident 8 had diagnoses that included cirrhosis of the liver (scarring of the liver), chronic viral hepatitis (inflammation of the liver lasting more than six months), and encephalopathy (change in brain function due to injury or disease). According to the Minimum Data Set assessment dated December 5, 2023, the resident was able to communicate needs to staff and required assistance for mobility and activities of daily living, including toileting, grooming, and hygiene. Observations on February 28, 2024, at 10:30 a.m., and 12:30 p.m., revealed the resident was in bed and the call bell was wrapped under the wheel of the bed, out of reach. Observations on February 29, 2024, at 9:40 a.m., 11:30 a.m., and 1:00 p.m., revealed Resident 8 was in bed and the call bell was wrapped under the wheel of the bed, out of reach.
In an interview on March 1, 2024, at 9:24 a.m., the Administrator confirmed the resident's call bell was wrapped under the wheel of the bed and should have been within reach.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 03/27/2024
1. Call bell was untangled from the wheel and placed correctly for Resident #8 2. To identify others with the potential to be affected, Audit completed for other residents, No resident affected by deficient practice 3. To prevent this from reoccurring, NHA/Designee completed in-service to IDT on Calls bells, concierge rounds, and thorough inspection of calls bells in resident rooms. Ongoing monitoring for compliance, Audit will be completed by maintenance daily and submitted weekly to NHA for 4 weeks, then completed monthly for 2 months 4. Results will be submitted for review during monthly quality assurance performance improvement program
* Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
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