Nursing Investigation Results -

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

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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 15, 2016, it was determined that St. Mary Center for Rehabilitation and HealthCare was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.75(l)(1) REQUIREMENT RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE: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.
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, and interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for three of four sampled residents (Residents CR1, R8, R61)

Findings include:

Clinical record review revealed that Resident CR1 was a long term resident with diagnoses that included hypertension and Parkinson's disease. On May 27, 2016, at 1:00 p.m. the physican documented that the resident had an elevated temperature (100 degrees Farhenheit). There was no documentation of the nursing assessment that described the resident's condition prior to the physican's examination and at what time that the low grade temperature was obtained. The resident medically declined during the day with a progress note by a nurse (LPN) written at 9:45 p.m., that revealed that the resident was congested and wheezing, that oxygen therapy was started and the supervisor was notified. There was no specific time of the actual decline in the resident's condition. There was no documentation of the supervisor's assessment of the resident's condition, throughout the shift. The resident expired at 11:55 p.m.

Clinical record review revealed that Resident R8 was admitted to the facility on December 20, 2015. On June 22, 2016, at 6:52 p.m., a nurse documented that a small lump was noted on the residents arm and there was no sign of pain. There was no further documentation about the lump until June 27, 2016, when there was a note that indicated that the resident was on antibiotics for a arm infection. In an interview on July 15, 2016, at 12;15 p.m., the resident's family and RN1 stated that the lump had become red, warm and hard to the touch (unable to remember the exact date). They both described the area as two inches long, one inch wide and about one half inch high. They both indicated that was the reason that the resident was ordered antibiotic therapy. There was no documentation in the clinical record that described these stated characteristic of the resident's skin condition.

Clinical record review revealed that Resident R61 was admitted on May 4, 2016. The resident was legally blind and had a significant hearing loss. The resident was also on antibiotic treatment for a urinary tract infection and pain management for end stage myeloma. On July 14, 2016, at 9:50 a.m., the physican documented that nursing had requested for the physican to see the resident. The physican's documentation noted that the resident had an acute episode of severe abdominal pain and was leaning over in the wheelchair due to the pain. The physican noted that the nurse stated that the resident had slept all morning and did not eat breakfast or lunch. There was no documentation by a nurse that described the series of events or the nursing assessment that lead to the request for a physican evaluation.

28 Pa. Code 211.12(d)(1) Nursing services.
28 Pa. Code 211.5(h) Clinical records.






 Plan of Correction - To be completed: 08/29/2016

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.
1. It is the practice of this facility to ensure that clinical records are complete and accurate. CR1 no longer resides at the facility. R8's arm has been assessed and clinical record has been updated. Nursing documentation was completed for R61 describing the series of events that led to the request for physician evaluation.
2. Director of Nursing /Designee will re-educate staff on maintaining accurate and complete clinical records.
3. Director of Nursing / Designee will complete random audits to ensure compliance.
4. Director of Nursing will report audit trends to QAPI Committee for review. QAPI Committee will determine compliance and need for further audits.

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 notify the responsible party of a change in condition for one of four sampled residents. ( Resident CR1)

Findings include:

Clinical record review revealed that Resident CR1 had diagnosis that included Parkinson's disease, dementia and high blood pressure. On May 27, 2016, at 1:00 p.m. the physican documented that the resident had an elevated temperature but was in no acute distress at that time. At 9:45 p.m. a nurse documented that the resident was congested and wheezing. The resident's oxygen saturation level was at 78 % and oxygen therapy was started. Review of the physician's orders revealed that the physician had ordered a transfer to the emergency room for further evaluation at 8:10 p.m. but that order was cancelled shortly thereafter and a chest xray was ordered. There was no documented evidence that the responsible party was notified of the resident's change in condition. Resident CR1 expired in the facility at 11:55 p.m.

28 Pa. Code 201.14(a) Responsibility of licensee.




 Plan of Correction - To be completed: 08/29/2016

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.
1. It is the practice of this facility to ensure that the facility inform the resident/ legal representative, physician of any significant change in condition. CR1 no longer resides at the facility.
2. Director of Nursing / Designee will re-educate staff to resident and family notification with change in condition.
3. Director of Nursing / Designee will complete random audits to ensure compliance.
4. Director of Nursing will report audit trends to QAPI Committee for review. QAPI Committee will determine compliance and need for further audits.


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