Pennsylvania Department of Health
RENAISSANCE HEALTHCARE & REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RENAISSANCE HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

There are 96 surveys for this facility. Please select a date to view the survey results.

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RENAISSANCE HEALTHCARE & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to a complaint completed on February 27, 2024, it was determined that Renaissance Healthcare and Rehabilitation 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 related to the health portion of the survey process.

Plan of Correction:

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

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.

§483.45(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 observation, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for two of two units observed. (Unit One and Unit Two)

Findings Include:

Review of facility policy titled, "Storage of Medication" with a revision date of April 2007 states, "The facility shall store all drugs and biologicals in a safe, secure, and orderly manner". "7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrgiators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others."

During observation of unit one on February 27, 2024 at 10:50 a.m. revealed the medication cart used by Licensed Nurse, Employee E6 outside room 125 on unit one was left unattended and unlocked. Licensed Nurse, Employee E6 was outside room 125 preparing medications when she went into resident room 125 and left the cart unlocked. Two minutes (10:52 a.m.) after going into the resident's room and administering medications, Licensed Nurse E6 quickly came out of the room. When pointed out to the Licensed Nurse, Employee E6 that the cart was unlocked, she stated she was nervous and realized she had left the cart unlocked and unattended.

During observation of unit two on February 27, 2024 at 11:33 a.m. revealed the medication cart used by Licensed Nurse, Employee 7 outside room 228 on unit two was left unattended with a medication cup with poured there was a medication cart outside of room 228 towards the end of the hall. Five medication bottles out on the cart, a cup of poured medications out on the cart, and an unlocked cart with no licensed nurse in sight. License Nurse, Employee E7 came out of a resident's room and stated she was sorry another resident heard her voice, and she went in to talk with them. Licensed Nurse, Employee E7 confirmed she should have not left her cart with medication bottles and a poured cup of medications out of the cart unattended.

28 Pa. Code 201.14 (a) Responsibility of licensee

28 Pa. Code 211.12 (c) Nursing services

28 Pa. Code 211.12 (d)(1) Nursing Services

Plan of Correction - To be completed: 04/01/2024

Facility can not retroactively correct the deficient practice.

The Director of Staff Development or designee will re-inservice the RN and LPN staff regarding the Policy Storage of Medications with an emphasis on ensuring that the medication carts are locked when not in use and there are no medications stored unattended on the medication cart.

Random audits will be performed by the Director of Nursing or designee to ensure that medication carts are locked when not in use and there are no medications stored unattended on the medication cart. Results of the audits will be forwarded to the QAPI Committee for review and recommendations to determine the need for further audits and/or action plans.

483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records:

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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

§483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

§483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

§483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Observations:

Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to maintain the confidentiality of resident's medical information on two or two nursing units. (Unit one and Unit Two)

Findings Include:

Review of facility policy titled, "Resident Rights" last revised December 2016 states, "Employees shall treat all residents with kindness, respect, and dignity". "The unauthorized release, access, or disclosure of resident information in prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPPA Compliance Officer".

During observation of unit one on February 27, 2024 at 10:50 a.m. revealed the medication cart used by Licensed Nurse, Employee E6 outside room 125 on unit one was left unattended with the computer screen open with identifiable information so any passerby could see resident personal and confidential information. Licensed Nurse, Employee E6 was outside room 125 preparing medications when she went into resident room 125 and left the computer screen open and the cart unlocked. Two minutes after going into the resident's room and administering medications, Licensed Nurse E6 quickly came out of the room. When pointed out to the Licensed Nurse, Employee E6 that the information was up and the cart was unlocked, she stated she was nervous and realized she had left the information up on the screen.

During observation of unit two on February 27, 2024 at 11:33 a.m. revealed the medication cart used by Licensed Nurse, Employee 7 outside room 228 on unit two was left unattended with the computer screen open with identifiable information so any passerby could see resident personal and confidential information. There was no licensed nurse in sight. At 11:35 a.m.License Nurse, Employee E7 came out of a resident's room and stated she was sorry another resident heard her voice, and she went in to talk with them. Licensed Nurse, Employee E7 confirmed she should have not left her cart unattended with identifiable information up on the screen.

28 Pa. Code: 211.5(b) Clinical records

28 Pa. Code:210.29(i) Resident Rights

28 Pa. Code:211.12 (d)(3) Nursing Services

Plan of Correction - To be completed: 04/01/2024

Facility can not retroactively correct the deficient practice.

The Director of Staff Development or designee will re-inservice the RN and LPN staff regarding the Policy Resident Rights with an emphasis on ensuring that RN and LPN staff will maintain the confidentiality of residents' medical information by ensuring computer screens are not displaying resident information if the nurse is away from the cart.

Random audits will be performed by the Director of Nursing or designee to ensure that resident's confidentiality is maintained weekly x 4 and then monthly thereafter for 90 days. Results of the audits will be forwarded to the QAPI Committee for review and recommendations and to determine the need for further audits and/or action plans.

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