Nursing Investigation Results -

Pennsylvania Department of Health
MANORCARE HEALTH SERVICES-POTTSTOWN
Patient Care Inspection Results

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MANORCARE HEALTH SERVICES-POTTSTOWN
Inspection Results For:

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MANORCARE HEALTH SERVICES-POTTSTOWN - 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 February 7, 2019, it was determined that Manorcare Health Services-Pottstown, 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:


483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to accurately complete an assessment to reflect the resident's current status for one of 25 sampled residents. (Resident 56)

Findings include:

Clinical record review revealed that Resident 56 had diagnoses that included Alzheimer's, psychotic disorder, and depression. Review of the Minimum Data Set (MDS) assessment dated December 4, 2018, indicated the resident utilized a physical restraint on a daily basis. Review of nursing documentation revealed that resident 56 did not utilize any kind of restraint.

In an interview on February 5, 2019, at 1: 45 p.m., the Director of Nursing stated that the use of the physical restraint was coded inaccurately on the assessment.

28 Pa. Code 211.5(f) Clinical records.


 Plan of Correction - To be completed: 03/25/2019

1. The Dec 4, 2018 MDS for resident number 56 was corrected.
2. An audit of the facility was conducted; no other residents were noted to have inaccurate restraint assessments.
3. RNACS have been educated by their regional director on proper coding of restraint assessments
4. Random audits of MDS assessments will be completed for new and current residents with restraints to validate accuracy. Weekly times four then monthly times two. By Registered nurse assessment coordinators, to ensure that they are completed and are reflective of the resident's current status. Results of audits will be submitted to QA committee for review and recommendations.


483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on observation, clinical record review and staff interview, it was determined that the facility failed to provide appropriate services to prevent further limitations with range of motion for one of 25 sampled residents with limited range of motion. (Resident 23)
Findings include:
Clinical record review revealed that Resident 23 had diagnoses that included spinal stenosis, muscle weakness and difficulty walking. The Minimum Data Set assessment dated November 20, 2018, indicated that the resident required extensive assistance from staff for most activities of daily living and had functional limitation in range of motion to her bilateral lower extremities. On May 31, 2017, the physician documented that the resident was to wear a leg brace to assist with ambulation and gait mobility and prevent mobility declines.
Observation on February 4, 2019 at 1:00 p.m. and February 5, 2019 at 12:30 p.m., revealed the resident out of bed without the brace applied.
In an interview on February 6, 2019 at 1:30 p.m., the Director of Nursing confirmed that the facility did not provide appropriate adaptive equipment for a resident with limitations in functional mobility.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 3/30/18


 Plan of Correction - To be completed: 03/25/2019

1. Resident # 23 leg brace was applied per physician orders
2. An audit of physician orders was conducted to identify residents that wear braces to ensure they are applied as per physician orders.
3. Current licenses nurses will be educated by the DON, or designee on brace application as per physician orders.
4. Random audits will be completed by nursing management and will be conducted weekly times four then monthly times two to ensure proper brace application per physician orders.


483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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.
483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on observation, it was determined that the facility failed to properly contain refuse.

Findings include:

Observation of the garbage compactor on February 4, 2019, at 10:05 a.m., revealed that on the ground surrounding the compactor was disposed soiled briefs, gloves, soiled washcloths, wound dressings, and medical waste.

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


 Plan of Correction - To be completed: 03/25/2019

1. The refuse was picked up and properly disposed of.
2. Like areas have been identified for potential disposal of refuse.
3. Housekeeping and dietary will be educated on keeping the compactor area clean
4. Random rounds of the garbage compactor will be done by Housekeeping and dietary. Weekly times four then monthly times two to ensure cleanliness.


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