Nursing Investigation Results -

Pennsylvania Department of Health
PLEASANT RIDGE MANOR- WEST
Patient Care Inspection Results

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PLEASANT RIDGE MANOR- WEST
Inspection Results For:

There are  78 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
PLEASANT RIDGE MANOR- WEST - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey and a complaint investigation survey completed on February 28, 2019, it was determined that Pleasant Ridge Manor West 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:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to implement infection control measures for one of 35 residents (Resident R102).

Findings include:

The "Treatments, Licensed Staff" policy, dated 1/16/19, stated to wash hands or sanitize when gloves are changed. The "Hand washing Guidelines" Policy, dated 1/16/19, revealed that a faucet should be shut off with a clean paper towel.

During observation of Resident R102's dressing change on 2/29/19 at 8:40 a.m. Licensed Practical Nurse (LPN) Employee E1 washed his/her hands and turned the faucet off with his/her forearm. In addition, LPN Employee E1 did not wash or sanitize his/her hands after cleaning the wound and before putting on new gloves. LPN Employee E1 confirmed the above information at 8:50 a.m.

During interview on 2/29/19, at 10:15 a.m. the Director of Nursing confirmed that the faucet should have been turned off with a clean paper towel and hands should have been washed or sanitized.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 2/10/17, 3/30/18, 9/14/18










 Plan of Correction - To be completed: 04/15/2019

Licensed Practical Nurse employee E1 was counseled regarding inappropriate technique during Resident Treatment and Handwashing Policy.

Completed: 02/28/19

All Licensed Staff members will be observed and tested for competency regarding completing resident dressing changes/treatments as well as handwashing techniques.

Completion Date: 04/15/19

An In-Service will be provided by the Nurse Educator and/or designee to all Nursing Staff regarding Handwashing.

Completion Date: 04/15/19

A monthly Quality Assurance Monitor will be completed by the Nursing Supervisors and Infection Preventionist to assure that Resident Treatments are completed per policy and that Handwashing guidelines are being followed as per policy. The monitor will be completed weekly on all three (3) shifts. A minimum of seven (7) observations per week, per shift for four (4) weeks, then the monitor will be completed monthly observing seven (7) occasions of handwashing during treatments per shift.

If the monitor reflects 100% compliance for three (3) consecutive months the some monitor will be completed on a quarterly basis. The results of the monthly monitor will be reported at the monthly Quality Assurance meeting.

Completion Date: 04/15/19



483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:


Based on clinical record review and staff interviews it was determined that the facility failed to send copies of notice for emergency transfers to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for six of 39 residents reviewed (Residents R54, R88, R246, R150, R16, and R100)

Findings include:

Resident R54's clinical record revealed an admission date of 7/7/16, with diagnoses including but not limited to acute osteomyelitis (infection of bones) to left tibia and fibula (bones in legs), skin graft (transplanting skin from one area to another), bone graft (replacing missing bone) infection, and cutaneous (relating to the skin) abscess (tender mass filled with pus due to infection). Departmental notes indicated that Resident R54 was transferred to the hospital on 10/30/18, for surgical removal of the infected bone and returned to the facility on 11/5/18. Resident R54 was again transferred to the hospital on 1/4/19, for surgical procedure involving skin graft and returned to the facility on 1/7/19. The facility failed to provide documentation that they notified the Office of the State LTC Ombudsman.

Resident R88's clinical record revealed an admission date of 7/23/15, with diagnoses including but not limited to sepsis (infection in blood stream), atrial fibrillation (irregular heartbeat), diabetes, and chronic kidney disease. Departmental notes indicated that Resident R88 was transferred to the hospital on 11/29/18, for acute kidney injury, urinary tract infection, and pneumonia and returned to the facility on 12/5/18. The facility failed to provide documentation that they notified the Office of the State LTC Ombudsman.

Resident R246's clinical record revealed an admission date of 6/16/17, with diagnoses including but not limited to atrial fibrillation, high blood pressure, osteoarthritis (inflammation of the joint), and thrombocytopenia (low platelets). Departmental notes indicated that Resident R246 was transferred to the hospital on 10/9/18, for rectus sheath hematoma (accumulation of blood in the sheath of the rectus abdominis muscle) and returned to the facility on 10/12/18. Resident R246 was again transferred to the hospital on 11/10/18, for rectus sheath hematoma, atrial fibrillation, and thrombocytopenia and returned to the facility on 11/19/18. Resident R246 was again transferred to the hospital on 11/23/18, for increased pain and returned to the facility on 11/25/18. Resident R246 was again transferred to the hospital on 1/7/19, for colon fistula (narrow passage or duct formed by disease or injury) and returned to the facility on 1/11/19. Resident R246 was again transferred to the hospital on 1/16/19, directly from a doctor's appointment and returned to the facility on 1/21/19. Resident R246 was again transferred to the hospital on 2/20/19, for dehydration and pneumonia and returned to the facility on 2/25/19. The facility failed to provide documentation that they notified the Office of the State LTC Ombudsman.

Resident R16's clincal record revealed an admission date of 8/13/15, with diagnosis including but not limited to acute chronic heart failure, chronic obstructed pulmonary disease (difficulty breathing) and acute embolism (blood clot) and thrombosis (type of blood clot) of specified deep veins of unspecified lower extremity. Departmental notes indicated that Resident R16 was admitted to the hospital on 7/31/18, for chronic abdominal pain and returned to the facility on 8/3/18. The facility failed to provide documentation that they notified the Office of the State LTC Ombudsman.

Resident R100's clinical record revealed an admission date of 12/15/18, with diagnosis including but limited to retroperitoneal (presence of blood in lining of the stomach), acute apothem anemia (low blood cell count), and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (left side weakness due to a stroke). Departmental notes indicated that Resident R100 was transferred to the hospital on 1/17/19, for atherosclerotic heart disease and returned to the facility 1/21/19. Resident R100 was transferred to the hospital 1/24/19, with congestive heart failure (fluid collecting around the heart) and returned to facility 2/2/19. Resident R100 was again transferred to the hospital 2/4/19, for hypovolemia/ shock (low body fluids) and returned to facility on 2/12/19. The facility failed to provide documentation that they notified the Office of the State LTC Ombudsman.

Resident R150's clinical record revealed an admission date of 10/22/18, with diagnoses including but not limited to lung cancer, COPD (ongoing lung disease that causes obstructed airflow from the lungs), heart failure, and atrial fibrillation. Departmental notes indicated that Resident R150 was transferred to the hospital on 12/06/18, for acute respiratory failure. Resident R150 was then transferred to the hospital on 1/30/19, with tachycardia (extremely fast heart rate). Resident R150 was again transferred to the hospital on 2/26/18, with atrial flutter (abnormal heart rate) and fluid in her lungs. The facility failed to provide documentation that they notified the Office of the State LTC Ombudsman.

During an interview on 2/27/19, at 2:10 p.m. the Director of Nursing confirmed that the facility does not notify the Office of the State LTC Ombudsman of any discharges or transfers from the facility.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 9/14/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 9/14/18

28 Pa. Code 201.29(a) Resident rights


 Plan of Correction - To be completed: 04/15/2019

Preparation and/or evaluation of the following Plan of Correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the Statement of Deficiency. The Plan of Correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

Residents R54, R88, R246, R150, R16 and R100 have all returned to the facility.

The Pennsylvania Long-Term Care Ombudsman's Office (State Office) will be notified of all six (6) resident transfers per the regulatory requirement via email.

Completion Date: 03/15/19

The Pennsylvania Long-Term Care Ombudsman's Office (State Office) will be notified of all Resident Transfers for the month of February and monthly thereafter per Transfer Discharge Notice policy.

Completion Date: 03/15/19

The Director of Social Services will be trained on the Facility Transfer/Discharge Notice Policy.

Completion Date: 03/12/19

The Director of Social Services and/or designee will notify the Pennsylvania Long-Term Care Ombudsman's Office (State Office) monthly of all transfers via email per Facility Transfer Discharge Notice Policy.

Completion Date: 04/15/19

A Quality Assurance Monitor will be completed by the Administrator and/or designee regarding transfer and discharge notices to the Pennsylvania Long-Term Care Ombudsman's Office (State Office).
All transfers/discharges will be included in the monitor.

This monitor will be completed monthly for three (3) consecutive months then the monitor will be completed on a quarterly basis. The results of the monthly monitor will be reported at the monthly Quality Assurance meeting.

Completion Date; 04/15/19

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:


Based on review of clinical records and staff interviews it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for six of 39 residents reviewed (Residents R54, R88, R246, R150, R16, and R100)

Findings include:


Resident R54's clinical record revealed an admission date of 7/7/16, with diagnoses including but not limited to acute osteomyelitis (infection of bones) to left tibia and fibula (bones in legs), skin graft (transplanting skin from one area to another), bone graft (replacing missing bone) infection, and cutaneous (relating to the skin) abscess (tender mass filled with pus due to infection). Departmental notes indicated that Resident R54 was transferred to the hospital on 10/30/18, for surgical removal of the infected bone and returned to the facility on 11/5/18. Resident R54 was again transferred to the hospital on 1/4/19, for surgical procedure involving skin graft and returned to the facility on 1/7/19.
The clinical record lacked documentation indicating that Resident R54 and/or their representative was provided with a copy of the facility bed-hold policy within twenty-four hours of transfer.

Resident R88's clinical record revealed an admission date of 7/23/15, with diagnoses including but not limited to sepsis (infection in blood stream), atrial fibrillation (irregular heartbeat), diabetes, and chronic kidney disease. Departmental notes indicated that Resident R88 was transferred to the hospital on 11/29/18, for acute kidney injury, urinary tract infection, and pneumonia and returned to the facility on 12/5/18. The clinical record lacked documentation indicating that Resident R88 and/or their representative was provided with a copy of the facility bed-hold policy within twenty-four hours of transfer.

Resident R246's clinical record revealed an admission date of 6/16/17, with diagnoses including but not limited to atrial fibrillation, high blood pressure, osteoarthritis (inflammation of the joint), and thrombocytopenia (low platelets). Departmental notes indicated that Resident R246 was transferred to the hospital on 10/9/18, for rectus sheath hematoma (accumulation of blood in the sheath of the rectus abdominis muscle) and returned to the facility on 10/12/18. Resident R246 was again transferred to the hospital on 11/10/18, for rectus sheath hematoma, atrial fibrillation, and thrombocytopenia and returned to the facility on 11/19/18. Resident R246 was again transferred to the hospital on 11/23/18, for increased pain and returned to the facility on 11/25/18. Resident R246 was again transferred to the hospital on 1/7/19, for colon fistula (narrow passage or duct formed by disease or injury) and returned to the facility on 1/11/19. Resident R246 was again transferred to the hospital on 1/16/19, directly from a doctor's appointment and returned to the facility on 1/21/19. Resident R246 was again transferred to the hospital on 2/20/19, for dehydration and pneumonia and returned to the facility on 2/25/19. The clinical record lacked documentation indicating that Resident R246 and/or their representative was provided with a copy of the facility bed-hold policy within twenty-four hours of transfer.

Resident R16's clincal record revealed an admission date of 8/13/15, with diagnosis including but not limited to acute chronic heart failure, chronic obstructed pulmonary disease (difficulty breathing) and acute embolism (blood clot) and thrombosis (type of blood clot) of specified deep veins of unspecified lower extremity. Departmental notes indicated that Resident R16 was admitted to the hospital on 7/31/18, for chronic abdominal pain and returned to the facility on 8/3/18. The clincal record lacked documentation indicating that Resident R16 and/ or their representative was provided with a copy of the bed-hold policy within twenty-four hours of transfer.

Resident R100's clinical record revealed an admission date of 12/15/18, with diagnosis including but limited to retroperitoneal (presence of blood in lining of the stomach), acute apothem anemia (low blood cell count), and hemiplegia and hemiparesis following cerebral infarction affecting left dominant side (left side weakness due to a stroke). Departmental notes indicated that Resident R100 was transferred to the hospital on 1/17/19, for atherosclerotic heart disease and returned to the facility 1/21/19. Resident R100 was transferred to the hospital 1/24/19, with congestive heart failure (fluid collecting around the heart) and returned to facility 2/2/19. Resident R100 was again transferred to the hospital 2/4/19, for hypovolemia/ shock (low body fluids) and returned to facility on 2/12/19. The clincal record lacked documentation indicating that Resident R100 and/ or their representative was provided with a copy of the bed-hold policy within twenty-four hours of transfer.

Resident R150's clinical record revealed an admission date of 10/22/18, with diagnoses including but not limited to lung cancer, COPD (ongoing lung disease that causes obstructed airflow from the lungs), heart failure, and atrial fibrillation. Departmental notes indicated that Resident R150 was transferred to the hospital on 12/06/18, for acute respiratory failure. Resident R150 was then transferred to the hospital on 1/30/19, with tachycardia (extremely fast heart rate). Resident R150 was again transferred to the hospital on 2/26/18, with atrial flutter (abnormal heart rate) and fluid in her lungs. The clinical record lacked documentation indicating that Resident R150 and/or their representative was provided with a copy of the facility bed-hold policy within twenty-four hours of transfer.

During an interview on 2/27/19, at 2:10 p.m. the Director of Nursing confirmed that the facility does not provide residents or their representative with a written copy of the facility bed-hold policy upon or within twenty-four hours of transfer to the hospital.

28 Pa. Code 201.14(a) Responsibility of licensee
Previously cited 9/14/18

28 Pa. Code 201.18(e)(1) Management
Previously cited 9/14/18

28 Pa. Code 201.29(a) Resident rights







 Plan of Correction - To be completed: 04/15/2019

Residents R54, R88, R246, R150, R16 and R100 have all returned to the facility.

Residents R54, R88, R246, R150, R16 and R100, along with all residents that have been transferred to the hospital since 02/01/2019 will receive a copy of the Bed Hold Policy as well as the Resident Representative, if appropriate. Additionally, all current residents and their families will receive information about the Bed Hold Policy via a general letter of explanation.

Completion Date: 03/30/19

Pleasant Ridge Manor will continue to provide a copy of the Bed Hold Policy to all residents on Admission. The Bed Hold Policy indicates that a copy of the Bed Hold Policy will be sent with a resident when they are transferred to the hospital and/or on a Therapeutic Leave.

Completion Date: 03/30/19

An In-Service will be provided by the Nurse Educator and/or designee to all Licensed Nursing Staff and Ward Clerks regarding the Bed Hold Policy and the need to send a copy of the Bed Hold Policy with any Resident Transfer and/or Therapeutic Leave. Licensed Staff will document that they have send the Bed Hold Policy information.

Completion Date: 04/15/19

A Quality Assurance Monitor will be completed by the Director of Nursing and/or designee to assure that a written copy of the Bed Hold Policy is sent with all Resident Transfers and/or Therapeutic Leaves. This monitor will be completed monthly for three (3) consecutive months. If 100% compliance is achieved during the three (3) consecutive months then the monitor will be completed on a quarterly basis. The results of the monthly monitor will be reported at the monthly Quality Assurance meetings.

Completion Date: 04/15/19


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