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 April 5, 2017, 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:


483.10(e)(3) REQUIREMENT REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES: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(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including:

(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on clinical record review, observation and resident interview, it was determined that the facility failed to ensure that call bells and a phone was within resident's reach for two of five resident's sampled. (Residents R4, R5)

Findings include:

Clinical record review revealed that Resident R4's current care plan directed staff to keep the call bell (device that is used by resident's to call for staff assistance) in reach due to to the resident being at risk to fall and incontinence. A sign above the resident's bed (family request) directed staff to place the resident's phone in reach. An Minimum Data Set (MDS) assessment dated February 6, 2017 identified that the resident was unable to walk and that the resident needed staff assistance to transfer between surfaces. On April 5, 2017 at 9:56 a.m., Resident R4 was in her room in bed without a call bell or phone within reach. Staff were not present in the room. When questioned, the resident was aware that the call bell was utilized to call staff for assistance. At 10:15 a.m., in the presence of the unit manager, the resident's call bell was located attached to the roommate's bed. The phone was found in the resident's lounge chair that was next to the bed and not within reach of the resident.

Clinical record review revealed that Resident R5's current care plan directed staff to keep the call bell in reach due to the resident being at risk to fall and incontinence. A MDS assessment dated February 21, 2017 identified that the resident was unable to walk and needed staff assistance to transfer between surfaces. On April 5, 2017 at 9:46 a.m., Resident R5 was in bed without staff being present. The call bell was not attached to her bed and was on the floor behind the bed out of reach of the resident. The resident was unable to locate the call bell when questioned and stated she would utilize the call bell if she needed staff assistance.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 12/16/16








 Plan of Correction - To be completed: 05/15/2017

The 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 call bells and phone are within reach. R4 and R5 have call bell and phone within reach.
2. Director of Nursing /Designee re-educated staff on ensuring call bells and phones are within reach of residents.
3. Director of Nursing / Designee will complete daily 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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