Nursing Investigation Results -

Pennsylvania Department of Health
ST. MARY CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ST. MARY CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

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ST. MARY CENTER FOR REHABILITATION & HEALTHCARE - 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 July 16, 2015, it was determined that St. Mary Center for 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.




 Plan of Correction:


483.10(b)(11) REQUIREMENT NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC):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.
A facility must immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications); a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or a decision to transfer or discharge the resident from the facility as specified in 483.12(a).

The facility must also promptly notify the resident and, if known, the resident's legal representative or interested family member when there is a change in room or roommate assignment as specified in 483.15(e)(2); or a change in resident rights under Federal or State law or regulations as specified in paragraph (b)(1) of this section.

The facility must record and periodically update the address and phone number of the resident's legal representative or interested family member.


Observations:

Based on clinical record review, it was determined that the facility failed to ensure that the physician was notified of changes in the resident's medical condition for one of two sampled residents. (Resident CR 1)

Findings include:

Clinical record review revealed that Resident CR1 was admitted to the facility on June 26, 2015, with diagnoses that included dementia and colon cancer. The resident was identified on admission as being at high nutritional risk due to a surgical wound and poor dietary intake. Review of the resident's meal completion from June 27, 2015, through July 4, 2015, revealed that on a daily basis, she consumed approximately twenty-five percent of all three daily meals. There was a lack of documentation to indicate that the physician was notified of the resident's poor meal completions.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/5/14


 Plan of Correction - To be completed: 09/10/2015

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
It is the practice of this facility to ensure that we notify the physician of changes in the medical condition of our residents. Resident CR1 has since discharged. Status of all current residents has been reviewed and clinical review was held with the Medical Director on 7/22/15. Policy for Change in resident status has been re-educated to all licensed Nursing. This will be monitored by the DON/Designee and reported at QA monthly for two quarters.

483.75(l)(1) REQUIREMENT RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE: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.
The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized.

The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.


Observations:

Based on clinical record review, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of two sampled residents. (Resident CR1)

Findings include:

Clinical record review revealed that resident CR1 was admitted to the facility on June 26, 2105, with diagnoses that included dementia and colon cancer. The resident was cognitively impaired and required staff assistance for fluid intake and meal completion. On July 1, 2015, a physician directed staff to place the resident on a hydration program, due to her risk for dehydration. There was a lack of documentation in the clinical record to indicate that resident was provided with fluids to meet her assessed fluid requirements. On July 7, 2015, the resident experienced a change in condition and was admitted to the hospital.

28 Pa. Code 211.5(f) Clinical records.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 12/5/14






 Plan of Correction - To be completed: 09/10/2015

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrong doing nor does it reflect agreement with the facts and conclusions stated in the Statement of deficiencies.
It is the practice of this facility to ensure that we maintain clinical records that are complete and accurately documented. Resident CR1 has since discharged. Registered Dietician will review all current residents on a Hydration program. Additional physician orders will be obtained as necessary. Hydration Monitoring Program has been re-educated to include documentation of fluid intake. This will be monitored by the Registered Dietician and reported at QA Monthly for two quarters.


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