Nursing Investigation Results -

Pennsylvania Department of Health
WESTMORELAND MANOR
Patient Care Inspection Results

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

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WESTMORELAND MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on May 16, 2019, it was determined that Westmoreland Manor 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 observations and staff interviews, it was determined that the facility failed to ensure that the resident environment was maintained in a homelike manner in the hallways on the C2 and C3 nursing units.

Findings include:

Observations of hallways on the C3 nursing unit on May 16, 2019, at 9:45 a.m. revealed that there was a build-up of a removable, black substance on the floors at the baseboard and part way up the base board, and also at the base of doorframes into residents' rooms and the activity/dining room.

Observations of hallways on the C2 nursing unit on May 16, 2019, at 3:15 p.m. revealed that there was a build-up of a removable black substance on the floors at the baseboard, and part way up the base board, and also at the base of doorframes into residents' rooms and the activity/dining room.

Interview with the Director of Housekeeping on May 16, 2019, at 2:35 p.m. confirmed that the above areas on the C2 and C3 nursing units could be cleaned. He indicated that they were cleaned on August 14, 2018, and then the facility started installing new windows, and then when winter came the priority was to keep the floors cleaned from the salt, and then they were waiting to do the floors because they were painting the hallways.

42 CFR 483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment.
Previously cited 9/20/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 9/20/18.

28 Pa. Code 207.2(a) Administrator's responsibility.






 Plan of Correction - To be completed: 06/06/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
The C-3 unit corridors had preventative floor maintenance completed on 5/26/19. C-2 corridor preventative floor maintenance has been scheduled and will be completed by 6/5/19. Both units, have been placed on a preventative floor maintenance schedule on an annual basis and as needed via a monthly preventative audit. Housekeeping has been re-educated on mopping procedures to include edges, corners and baseboards. During the mopping process housekeepers will be educated to also visualize daily signs of build up and report to Director of Housekeeping.
Housekeeping staff educated regarding the need to ensure cleaning includes baseboards and doorways, when needed by housekeeping director/designee
Floor maintenance staff educated regarding the new process for preventative floor maintenance by housekeeping director/designee
The director or Housekeeping or designee will complete random audits on 3 floors per week for 2 weeks and then randomly to ensure floors remain maintained in a homelike manner.
The results of these audits will be reported to Quality Assurance Performance Improvement Committee for review and recommendation. Any corrective action will be implemented to achieve and maintain compliance with the intent of preventing any re-occurrence.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on clinical record reviews, observations and staff interviews, it was determined that the facility failed to assess the safety of transporting residents in shower chairs for one of seven residents reviewed (Resident 6).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated March 11, 2019, indicated that the resident was understood, could understand, and required extensive assistance from staff for transfers and locomotion on the unit. A diagnosis list, dated August 6, 2016, revealed that the resident had medical diagnoses that included cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture) and right and left foot drop (a general term that describes a difficulty in lifting the front part of the foot). Physician's orders for Resident 6, dated November 22, 2017, included an order for the resident to use bilateral leg rests when he was out of bed in his wheelchair for transport.

Observations of Resident 6 on May 16, 2019, at 10:00 a.m. revealed that Nurse Aide 1 pushed the resident down the hallway from the resident's room to the shower chair. During the transport, the resident's right and left toes were sliding on the floor. At 10:24 a.m., Nurse Aide 1 pushed the resident down the hallway from the shower room to his room, and during the transport, the resident's right and left toes were sliding on the floor.

There was no documented evidence that the safety of transporting Resident 6 in a shower chair that was not equipped with leg rests was assessed.

Upon interview with Nurse Aide 1 on May 16, 2019, at 10:54 p.m. he indicated that he believed it was okay to transport Resident 6 in the shower chair, and leg rests were optional when transporting the resident on the nursing unit, but were to be used when transporting the resident off the unit. The nurse aide stated that when the resident was out of bed in his wheelchair, he liked to have the leg rests in place.

Interview with the Director of Nursing on May 16, 2019, at 4:31 p.m. revealed that the facility did not have a specific policy regarding transporting residents in a shower chair. She indicated that if a resident can self-propel, then leg rests were not needed; however, if staff were transporting a resident, then leg rests should be in place.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 9/20/18.

28 Pa. Code 211.10(a) Resident care policies.
Previously cited 9/20/18.

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

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 1/8/19, 9/20/18.



 Plan of Correction - To be completed: 06/06/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
R6 was assessed following shower transport for open areas or trauma to feet and toes. None present. R6 will be taken to the shower room and transferred directly into the shower chair at the time of the shower to ensure safety.
Policy/procedure for the use of a shower chair updated to include the new process that residents who are to use a shower chair for showers will be transferred into the shower chair in the bathing room if the chair they are to use for showering does not have leg rests. Those residents who utilize a shower chair for bathing that does have leg rests will be transferred into the chair in their room or in the shower room and will transported with their feet on the foot rests. Residents who utilize a mechanical lift for transfers will utilize a shower cart for showering.
Nurse Aide 1 was educated regarding the importance of providing safe transports for Residents to and from the bathing area, including transferring in the bathroom when legs rests are not available on the shower chair. Staff responsible for showering residents will be educated on the new policy and procedure.
The Director of Nursing and/or designee will complete random audits on all units of 10 showers given in the facility weekly x 2 weeks then randomly to ensure the safety in transporting residents in shower chairs.
The results of these audits will be reported to Quality Assurance Performance Improvement Committee for review and recommendation. Any corrective action will be implemented to achieve and maintain compliance with the intent of preventing any re-occurrence.



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