Nursing Investigation Results -

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

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JEFFERSON HILLS HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are  109 surveys for this facility. Please select a date to view the survey results.

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JEFFERSON HILLS HEALTHCARE AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey and Civil Rights Compliance survey, completed on March 15, 2019, it was determined that Jefferson Hills Healthcare and 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:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:


Based on review of facility policy, observation, and resident and staff interviews, it was determined that the facility failed to provide a comfortable water temperature for showering for six of 12 residents (Resident R301, R302, R303, R306, R307 and R309), comfortable noise levels for eight of 12 residents (Resident R301, R303, R304, R305, R306, R307, R309 and R310) and safe environment for laundry chute in one of one bathrooms (A Wing).


Findings include:

A review of the facility policy "Shower/Tub Bath" indicated that the bath area should be a comfortable temperature for the resident. The policy indicated that a tub should be filled with water that is 105

During a group interview on 3/13/19, at 1:00 pm, six of 12 residents (Resident R301, R302,R303, R306, R307, R309) indicated that the water temperature for showering is too cold and is uncomfortable.

During an observation in the B Wing shower room on 3/12/19, at 1:57 p.m. the water temperature in the front shower was measured at 50 (degrees Fahrenheit) and the back shower water temperature was measured at 96

During an observation on 3/12/19, at 2:06 p.m. the first floor shower water temperature was measured at 97.7

A review of resident council meeting minutes indicated that residents had complained of cold water temperature on January 29, 2019, and again on March 7, 2019.

A review of maintenance weekly water temperatures documentation indicated that the water temperature fluctuated between 98 and 104

During an interview on 3/12/19, at 2:15 pm the Nursing Home Administrator was informed that the facility failed to make certain that water temperatures and sound levels were comfortable for residents.

During a group interview on 3/13/19, at 1:00 p.m., eight of 12 residents (Resident R301, R303, R304, R305, R306, R307, R309 and R310) indicated that the noise level at the facility is too loud and that staff members yell down the hallway to each other on a regular basis.

During an observation on 3/14/19, at 2:55 p.m. staff person was observed yelling down the hallway to other staff member, saying "are these anyone's keys" very loudly.

During an interview on 3/14/19, at 2:58 p.m. Licensed Practical Nurse Employee E4 confirmed that staff was yelling down the hall which created a noisey environment.

During an observation on 3/12/19, at 2:10 p.m. of the A Wing resident bathroom, an approximately 12" x 18" laundry chute was unlocked and accessible to residents.

During an interview on 3/12/19, at 2:15 p.m. Certified Nurse Aide Employee E5 confirmed that the laundry chute was unlocked and could create an unsafe environment for residents.


28 Pa Code: 201.14(a) Responsibility of licensee.
Previously cited 3/30/18, 2/9/17 and 8/30/16.




 Plan of Correction - To be completed: 05/02/2019

1. The mixing valve on the hot water tank servicing the B and C wing shower room was changed by maintenance. A lock was immediately placed on the laundry chute. The staff member identified was educated on using a loud tone when speaking.
2. Resident council held 3/25/2019. No further concerns regarding water temperature of showers. No concerns regarding staff speaking in loud tones. No residents affected by unlocked laundry chute.
3. Education will be provided to nursing staff by DON/designee to check water temperature prior to showers and to communicate with resident regarding comfort level of water temperature. Education to be provided to staff by DON/designee regarding lock placed on laundry chute. Education to be provided to staff by DON/designee regarding appropriate noise levels when speaking amongst one another.
4. Audits of water temperatures to be completed 5 times a week for 2 weeks, then 3 times a week for 2 weeks, then weekly at random times for 2 weeks. Audit of lock in place on laundry chute will occur 3 times a week for 4 weeks, then at weekly at random times for 2 weeks. Audit of noise levels in facility will occur 3 times a week for 4 weeks, then weekly at random times for 2 weeks. Findings will be summarized and reported to the Quality Assurance Performance Improvement Meeting. Quality Assurance Performance Committee will determine the need for further audits and/or recommendation

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
483.60(d) Food and drink
Each resident receives and the facility provides-

483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.
Observations:


Based on review of facility policy, observation, and resident and staff interviews, it was determined that the facility failed to maintain palatable food temperatures for six of 12 residents (Resident R303, R304, R305, R306, R307, and R308) and two of three nursing units (A Wing nursing unit and C Wing nursing unit).


Findings include:

Review of facility policy "Monitoring Trayline/Meal Service Temperatures" dated 1/7/19, indicated that resident food should be served at 135 for hot foods and under 41 for cold foods.

During a group interview on 3/13/19, at 1:00 p.m. six of 12 residents (Resident R303, R304, R305, R306, R307, and R308) indicated that food was frequently served colder than they would like.

During an observation on the C Wing nursing unit on 3/14/19, at 11:46 p.m. food temperatures for the lunch meal were recorded as follows:

Chicken parmesan- 120 (degrees Fahrenheit)
Noodles- 112 an interview on 3/14/19, at 11:55 p.m. the dietary manager Employee E2 confirmed the above food temperatures.

During an observation on the A Wing nursing unit on 3/14/19, at 12:26 p.m. food temperatures for the lunch meal were recorded as follows:
Chicken parmesan- 125 (degrees Fahrenheit)
Noodles- 120

During an interview on 3/14/19, at 12:26 p.m. the dietary manager Employee E2 confirmed the above food temperatures.


28 Pa Code: 211.6(c)









 Plan of Correction - To be completed: 05/02/2019

1. No residents adversely affected by food temperatures.
2. Root cause noted to be current plate warmer not working to capacity, facility ordered new equipment.
3. Education to be provided to dietary staff by dietary manager on use of new equipment upon arrival.
4. Audit to be completed by dietary manager/designee of food temperatures. Audit will occur 5 times a week for 2 weeks, then 3 times a week for 2 weeks, then at random meals weekly for 2 weeks. Findings will be summarized and reported to the Quality Assurance Performance Improvement Meeting. Quality Assurance Performance Committee will determine the need for further audits and/or recommendation

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
483.24(c) Activities.
483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:



Based on review of facility policy and activity documentation, observation and resident and staff interviews, it was determined that the facility failed to meet the activity needs for 16 of 19 residents (Resident R3, R7, R18, R50, R300, R301, R302, R303, R304, R305, R306, R307, R308, R309, R310 and R311).

Findings include:

A review of the "Activity Evaluation" policy dated 1/7/19, indicated that each resident would have an activity evaluation which would be used to create an individual care plan for the resident to participate in activities that would meet his or her needs.

During a group interview on 3/13/19, at 1:00 p.m. 12 of 12 residents Residents R300, R301, R302, R303, R304, R305, R306, R307, R308, R309, R310 and R311) indicated there were no staff directed activities on the weekends or evenings, and that they would like more weekend activities.

A review of the facility activity calendars from September 2018, through March 2019, indicated that there were no staff directed activities on the weekends or after 2:00 p.m. on weekdays.

A review of the activity staffing documentation indicated that there were no activity staff scheduled for 20 of 26 weekend days.

A review of the clinical record indicated that Resident R3 was admitted on 4/18/18, with diagnoses that included Parkinson's disease (a reduction in a chemical, causing symptoms such as slowness in movement and muscle stiffness), diabetes (a metabolic disorder that leads to an increase in blood glucose levels), and depression.

A review of Resident R3's Annual Minimum Data Set (MDS- periodic review of care needs) dated 4/25/18, MDS Section F, Question 0500 indicated that it is very important to Resident R3 to listen to music, be around animals, keep up with the news, do things with groups of people, to favorite activities and to participate in religious services.

During an interview on 3/12/19, at 10:43 a.m. Resident R3 stated that she is not aware of what activities are available and is unable to read the Activities calendar due to macular degeneration (a vision impairment resulting from deterioration of the central part of retina).

During multiple observations throughout the survey, Resident R3 was seated in her wheelchair, facing into her room with no music playing and no television on. Resident R3 was not observed in any group activities and was not observed to have been engaged in any one-to-one activities.

Review of Resident R3's care plan indicated a goal of engaging in one-to-one activities such as watching television, doing arts and crafts with others, and conversing with others.

Review of Resident R3's Activity Participation Log for March 2019 indicated that Resident R3 solely engages in independent activity.

A review of the clinical record indicated that Resident R7 was admitted on 3/14/17, with diagnoses that included anoxic brain injury (an injury that occurs to brain tissue due to oxygen deprivation), presences of a tracheostomy (an opening in the neck in order to place a tube into a person's windpipe), and presence of a gastrostomy (an artificial external opening into the stomach for nutritional support or gastric decompression). The current clinical record indicates that Resident R7 is in a semi-comatose state.

During an interview on 3/14/19, at 10:05 a.m. Resident R7's mother stated that Resident R7 has times when she in completely unaware of her surroundings, and times when she is more aware and smiles and laughs. Resident R7 ' s mother stated that her daughter is not engaged in activities during the times she is able to enjoy them.

Review of Resident R7's care plan indicated a goal of participating in independent activities, and that she enjoys listening to music and being read to.

Review of Resident R7's Activity Participation Log for March 2019 indicated that Resident R7 solely engages in family visits and independent activity.

A review of the clinical record indicated that Resident R18 was admitted on 9/7/18, with diagnoses that included sequelae of cerebral infarction (physical and mental consequences of a stroke), high blood pressure, and muscle weakness.

A review of Resident R18's annual Minimum Data Set (MDS- periodic review of care needs) dated 9/14/18, MDS Section F, Question 0500 indicated that it is very important to Resident R18 to listen to music, keep up with the news, do things with groups of people, to favorite activities and to participate in religious services.

During multiple observations throughout the survey, Resident R18 was laying in her bed, facing into her room with no music playing and no television on. Resident R18 was not observed in any group activities and was not observed to have been engaged in any one-to-one activities.

Review of Resident R18's care plan indicated a goal of engaging in one-to-one activities such as watching television and conversing with others.

Review of Resident R18's Activity Participation Log for March 2019, indicated that Resident R18 solely engages in independent activity.

A review of the clinical record indicated that Resident R50 was admitted to the facility on 2/7/19, with diagnoses that included abnormal gait and mobility, muscle weakness and a cognitive communication deficit.

During an observation on 3/12/19, at 9:40 a.m. and again at 11:45 a.m. Resident R50 was observed in the resident lounge by herself and not engaged in any activities.

During an observation on 3/15/19, at 10:15 a.m. Resident 50 was observed in her room sitting in her wheelchair not engaged in any activity.

During a review of the clinical record, the care plan for Resident R50 did not include any activities goals or interventions.

During an interview on 3/15/19 at 12:00 p.m. the Activities Director confirmed that the facility failed to meet residents needs for activities on weekends and evenings and for residents who were unable to do independent activities.


28 Pa Code: 211.10(d) Resident care policies.



 Plan of Correction - To be completed: 05/02/2019

1. Interviews conducted with resident council participants identified regarding what activities they prefer on weekends and evenings.
2. Residents with BIMS 12-15 will be interviewed to validate the appropriateness of weekend/evening activities. House audit to be completed on residents who are unable to do independent activities for care plan in place, including goals and interventions.
3. Education to be provided to activity director by NHA/designee regarding meeting residents needs for activities on weekends and evenings; meeting residents needs for activities related to residents who are unable to do independent activities.
4. Audit activity schedule weekly for 4 weeks. Random resident interviews to be completed regarding appropriateness of weekend/evening activities offered. Random audits of activity participation logs in relation to residents who are unable to do independent activities to ensure resident needs are being met. Audits will take place 3 times a week for 4 weeks. Findings will be summarized and reported to the Quality Assurance Performance Improvement Meeting. Quality Assurance Performance Committee will determine the need for further audits and/or recommendation

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with 483.12(a)(2).

483.12
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)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:


Based on review of facility policy, observation and staff and resident interview, it was determined that the facility failed to make certain that a resident was free from restraints for one of two residents (Resident R56).

Findings include:

A review of the facility policy "Use of Restraints" dated 1/7/19, defined a physical restraint as any method, device or equipment that was attached to or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom or movement or restricts normal access to one's body.

A review of the Admission Record indicated that Resident R56 was admitted to the facility on 12/4/18, with diagnoses that included seizures, osteoporosis, and abnormalities of gait and mobility.

During an observation on 3/12/19 at 2:20 p.m. Resident R56 was seated in a wheelchair with a seatbelt on. When asked if she was able to removed the seatbelt, the resident did not respond.

During a review of the clinical record on 03/15/19 at 10:15 a.m. documentation did not include a physician order, a care plan, or any assessment conducted by the facility to determine if the seatbelt was necessary for Resident R56.

During an interview on 3/15/19, at 12:16 p.m. the Director of Nursing (DON) confirmed that the facility had failed to assess Resident R56 for safe use of a seatbelt and to determine if the seatbelt was being used as a restraint.


28 Pa Code: 211.8 (c)(d)(e) Use of Restraints.










 Plan of Correction - To be completed: 05/02/2019

1. Resident R56 was utilizing her personal wheelchair with seatbelt. Therapy evaluated R56 for continued use of seatbelt and deemed appropriate for restraint reduction. Seatbelt removed 3/15/2019.
2. House audit completed of resident wheelchairs for seatbelt placement with no evaluation, no concerns found.
3. Education to nursing staff by DON/designee regarding proper evaluation for seatbelt placement prior to use.
4. Audit of residents wheelchairs for seatbelt placement. These audits will occur 3 times a week for 4 weeks, then weekly at random times for 2 weeks. Findings will be summarized and reported to the Quality Assurance Performance Improvement Meeting. Quality Assurance Performance Committee will determine the need for further audits and/or recommendation

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Findings include:

A review of the facility "Showers/Tub Bath" policy dated 1/7/19, indicated that staff are to stay with the resident during a shower or bath.

A review of Resident R52's clinical record indicated the resident was admitted to the facility on 9/30/18, with diagnoses that included heart failure, muscle weakness and spinal stenosis (a condition where spinal column narrows and compresses the spinal cord, causing numbness, tingling, and weakness).

A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/13/19, Section G Functional Status, Question G0120 indicated that Resident R52 requires physical help in part of bathing activity and requires a support of one person. Question G0600 indicated that Resident R52 uses a walker and a wheelchair.

A review of the plan of care for Resident R52 indicated that he had an ADL self-care deficit related to physical limitations, and would receive assistance with hygiene needs.

During an interview on 3/14/19, at 11:27 a.m. Resident R52 stated that the previous evening the nursing aide provided towels and told him to shower by himself. Resident R52 stated he was only able to wash to his knees and was scared of falling.

During an interview on 3/15/19, at 2:00 p.m. Director of Nursing DON confirmed that Resident R52 required staff assistance to shower.

A review of the clinical record indicated that Resident R50 was admitted to the facility on 2/7/19, with diagnoses that included abnormal gait and mobility, muscle weakness and a cognitive communication deficit.

A review of the care plan indicated that Resident R50 had physical and cognitive limitations and would require assistance with self care.

During an observation on 3/15/19, at 10:15 a.m. Resident R50 was noted to have long jagged unkempt fingernails. When looking at the fingernails, Resident R50 said, "I don't like those."

During an interview on 3/15/19, at 10:15 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that Resident R50 was in need of nail care.


28 Pa. Code 211.11(d)(e) Resident care plan.

28 Pa. Code 211.12(3)(5) Nursing services.


 Plan of Correction - To be completed: 05/02/2019

1. Nursing aide was educated on providing appropriate assistance per the R52 plan of care. Staff member trimmed and filed R50 fingernails.
2. Fingernail audit completed, nails trimmed and filed as warranted. House audit to be completed of resident kardex to ensure assistance level for bathing is available for staff.
3. Education to be provided by DON/designee regarding providing nail care on shower days and as needed. Education to be provided by DON/designee regarding referring to the resident kardex to ascertain assistance level needed for bathing.
4. Audit of resident fingernails will be completed 3 times a week for 4 weeks, then weekly at random times for 2 weeks. Audit of staff assistance provided during bathing will be completed 3 times a week for 4 weeks, then weekly at random times for 2 weeks. Findings will be summarized and reported to the Quality Assurance Performance Improvement Meeting. Quality Assurance Performance Committee will determine the need for further audits and/or recommendation

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on facility policy, clinical record review, observation and staff interview it was determined that the facility failed to make certain that medication was labeled correctly for one of three residents (Resident R5).


Findings include:

The facility "Medication Administration" policy dated 1/7/19, indicated that the facility was not to accept medications from Pharmacy that were labeled incorrectly.

Review of the clinical record indicated that Resident R5 was admitted to the facility on 9/26/17, with diagnoses that included heart disease, hypokalemia (low potassium blood levels) and muscle weakness.

During an observation of a medication pass for Resident R5 on 9:05 a.m. Licensed Practical Nurse (LPN) Employee E4 was observed administering 40 mg of potassium chloride (medication used for low potassium blood levels). The medication was stored in a bubble pack, each pill contained 20 mg extended release tablet of the medication. The package documentation indicated that Resident R5 was to take 60 mg of Potassium Chloride each day.

Review of the original physician orders dated 7/2/18, revealed that Resident R5 was to be given 40 mg of Potassium Chloride in the morning, and 20 mg of Potassium Chloride in the afternoon.

During an interview on 3/13/19, at 9:30 a. m. LPN Employee E4 confirmed that the medication packaging did not include the correct instructions for dosage.

During an interview with the Director of Nursing on 3/13/19, at 10:50 a.m. confirmed that the facility failed to make certain that medications obtained from the pharmacy were labeled with correct dosage.

Pa. Code: 211.9(a)(1) Pharmacy services.






 Plan of Correction - To be completed: 05/02/2019

1. Pharmacy notified and sent medication with appropriate dosage/administration of potassium chloride on the label per the electronic medical record for resident R5.
2. House audit completed of residents receiving potassium chloride to as well as all medication labels to confirm appropriate dosage on the label.
3. Education provided to licensed staff by DON/designee regarding pharmacy notification of labels containing incorrect dosage information.
4. Audit of residents receiving potassium chloride for the correct dosage/administration on the label will occur 3 times a week for 4 weeks, then weekly for 2 weeks. Findings will be summarized and reported to the Quality Assurance Performance Improvement Meeting. Quality Assurance Performance Committee will determine the need for further audits and/or recommendation

483.90(g)(2) REQUIREMENT Resident Call System: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.
483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area.

483.90(g)(2) Toilet and bathing facilities.
Observations:
Based on observation and staff interview, it was determined that the facility failed to maintain an effective call system for two of three shower room bathrooms (2A Wing and 2B Wing shower room bathrooms) and one of one visitor/staff bathroom (First floor lobby).

Findings include:

During an observation on 3/12/19, at 2:10 p.m. of the 2A Wing shower room bathroom revealed the call light for the toilet was mounted on the same wall and the pull cord for the toilet did not have a pull cord attached for use.

During an observation on 3/12/19, at 2:20 p.m. of the 2B Wing shower room bathroom revealed the call light for the first shower stall was mounted in the shower and did not have a pull cord attached for use.

During interview on 3/12/19, at 2:20 p.m. Certified Nurse Aide Employee E5 confirmed that the facility failed to make certain that the call light system in the 2A and 2B shower room bathroom was accessible for use.

During an observation on 3/14/19, at 11:00 a.m. of the first floor visitor/staff bathroom that is unlocked and accessible to residents, revealed there was no call system available.

During interview on 3/14/19, at 11:05 a.m. Nursing Home Administrator confirmed that the facility failed to make certain an effective call system was available for use.



28 Pa Code 201.14 (a) Responsibility of licensee.

28 Pa Code 201.18 (b) (1) Management.






 Plan of Correction - To be completed: 05/02/2019

1. Maintenance replaced the call cords for the call light system on 2A wing shower room bathroom, 2B shower room (1st shower room). The first floor bathroom will be locked from the outside and accessible with a code for visitors/staff.
2. House audit completed to ensure call cords are in good repair for the call light system. No concerns noted. No residents affected by first floor visitor/staff bathroom.
3. Education to be provided to staff by DON/designee regarding reporting call cords in need of repair to maintenance. Education to be provided to department heads by NHA/designee regarding assigned rounds and reporting call cords in need of repair to maintenance. Signage will be placed at visitors/staff bathroom on obtaining the code to gain entrance.
4. Audits of call bell cords will be completed 5 times a week for 2 weeks, then 3 times a week for 2 weeks, then weekly at random times for 2 weeks. Findings will be summarized and reported to the Quality Assurance Performance Improvement Meeting. Quality Assurance Performance Committee will determine the need for further audits and/or recommendation


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