Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  149 surveys for this facility. Please select a date to view the survey results.

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MOUNTAIN CITY NURSING & REHAB CTR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on April 3, 2019, it was determined that Mountain City Nursing & Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Based on observation, a review of clinical records and facility investigation and staff interview, it was determined that the facility failed to ensure that two residents, were free from physical abuse and failed to timely and consistently implement measures to protect these residents from abusive behavior resulting in minor physical injury to two (Resident 46 and 103) out of two sampled residents.

Findings include:

A review of Resident 46 clinical record's revealed admission to the facility on May 28, 2015, and diagnoses that included dementia with behavioral disturbances. A review of the resident's most recent quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated March 24, 2019, indicated that the resident was severely cognitively impaired with a BIMS score of 0 (brief interview for mental status - a tool to assess the residents' attention, orientation and ability to register and recall new information, a score of 0-7 indicates severe cognitive impairment).

A review of Resident 103's clinical record revealed that the resident was admitted to the facility on October 9, 2016, and had diagnoses, which included dementia with behavioral disturbances. A review of the resident's most recent annual MDS Assessment, dated February 01, 2019, indicated that the resident was cognitively impaired with a BIMS score of 6.

A review of a facility investigative report dated July 5, 2018, revealed that on June 29, 2018, Resident 46 and Resident 103 were observed in a physical altercation. A statement by a nurse aide, indicated that she heard "scuffing" upon entering the room of Resident 46. She observed Resident 46 and Resident 103 in a physical altercation. Following this incident, the facility indicated that both residents were placed on increased supervision (observation) and the residents were moved to separate wings of the nursing unit.

However, there was no evidence at the time of the survey ending April 3, 2019, that Resident 46 and Resident 103 were moved to separate wings of the unit as indicated on the above investigative report.

A facility investigation dated December 8, 2018, indicated that Resident 46 approached nurse's station and was observed with ecchymosis to the nose and scratches to the resident's neck and face. Resident 103 was observed in hallway with blood on his shirt and a swollen upper lip, scratches to arm, chest, and back. Resident 103 verbalized that Resident 46 was combative towards him.

Further review of the facility documentation and investigative reports revealed that the residents remained in rooms located only one room apart from each other. The facility failed to implement effective interventions to prevent this second physical altercation between these two residents.

Interview with DON on April 3rd, 2019, at 1:30 p.m. confirmed that Residents 46 and 103 had not been relocated to separate wings of unit as indicated in the facility's abuse investigation (PB-22) dated dated July 5, 2018, and that subsequently, these two residents were involved in another episode of physical abuse on December 8, 2018.

28 Pa. Code 201.18(e)(1) Management
previously cited 6/22/2018

28 Pa. Code 201.29 (a)(c) Resident rights
previously cited 7/26/2018

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services
previously cited 6/22/2018, 11/17/2018

 Plan of Correction - To be completed: 04/12/2019

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both Federal and State laws.

1. Supportive visits from Social Services were made in December 2018 after resident to resident altercation and no further resident to resident incident between residents. When resident (46) returns to facility from current hospital stay he will be moved to a separate wing of blue 3 than resident (103) as discussed by the interdisciplinary team and approved by resident's responsible party.
2. Facility reviewed investigative reports (PB22s) involving resident to resident altercations from June 2018 until present to ensure that effective interventions were implemented as reported to Department of Health. Any corrections were documented and updated as necessary.
3. Reportable events with investigative reports will be reviewed weekly in Resident Review Meeting by Interdisciplinary Team. Interventions will be discussed for implementation and effectiveness. If there is need for change to interventions the interdisciplinary team will write note explaining reasons for new interventions.
4. Director of Nursing/Designee will audit 3 reportable events with investigative reports weekly x4 then twice monthly x 2 to ensure all interventions are documented, appropriate and in place. The QAPI Committee will review these audits one time per month and provide further guidance as needed. The QAPI committee will review monthly until a period of substantial compliance has been achieved and maintained for a period of three months.

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