Pennsylvania Department of Health
KINZUA HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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KINZUA HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Complaint Survey completed on March 6, 2024, it was determined that Kinzua Healthcare and Rehabilitation Center 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:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on review of facility policy and clinical record, and staff interview, it was determined that the facility failed to notify the resident's responsible party of a change in condition for one of five residents reviewed (Resident R1).

Findings include:

A facility policy entitled "Change in Resident's Condition or Status" last reviewed 1/16/24, indicated that the facility must inform the resident's representative, or family member when there is a "Significant Change" an example of which was the development of Stage 2 (partial-thickness skin loss) skin breakdown.

Resident R1's clinical record revealed an admission date of 5/06/2018, with diagnoses that included Dementia, Type II Diabetes (condition of improper blood sugar control), Heart Failure and Pain.

Review of an Admission / Re-Admission Evaluation form dated 1/03/24, documented that Resident R1 had newly developed a Stage 2 open area around the coccyx area. There was no further documentation to indicate that Resident R1's responsible party was notified of these areas of skin breakdown.

During an interview on 3/06/24, at approximately 12:20 p.m. the Director of Nursing confirmed that Resident R1's responsible party was not notified of the area of skin breakdown as required.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 03/26/2024

Resident R1 was discharged from the facility on 2/2/24. Unable to provide notification of the change in skin integrity to family/responsible party.

Audits will be done from 3/1/2024 forward to verify significant changes have proper notification.

Director of Nursing or Designee will provide education to licensed staff to follow the facility policy "Change in a Resident's Condition or Status" for proper notification. Family/responsible party will be updated of the changes and it will be documented in the clinical record. Careplan will also be updated.

Audits will be completed to ensure that family/responsible party notification of significant changes were completed and documented in the clinical record. Audits will take place for 5 residents 5x weekly x 2 weeks; then 5 residents weekly x 2 weeks; then 10 residents monthly until compliance is met. Audits will be reviewed at QAPI meeting monthly.

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