Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
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 a Abbreviated survey in response to two complaints completed on June 13, 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 Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

 Plan of Correction:

483.25(d)(1)(2)(n)(1)-(3) REQUIREMENT FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES: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.
(d) Accidents.
The facility must ensure that -

(1) The resident environment remains as free from accident hazards as is possible; and

(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

(n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

(1) Assess the resident for risk of entrapment from bed rails prior to installation.

(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

(3) Ensure that the bedís dimensions are appropriate for the residentís size and weight.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that safety measures were implemented and functional for one of four sampled residents. (Resident R4)

Findings include:

Clinical record review revealed that resident R4 had diagnoses that included hemiplegia (a weakness on one side of the body). The Minimum Data Set (MDS) assessment dated May 24, 2017, indicated that the resident had difficulty making himself understood but was not cognitively impaired and required extensive staff assistance for transfer and bed mobility. The ongoing care plan dated March 2, 2017, identified the resident at risk for falls and directed staff to implement ordered safety devices, such as a bed alarm. Review of the clinical record and other facility documentation revealed that on May 31, 2017, the resident fell from his bed. The investigation into the fall failed to identify whether the bed alarm had been placed and functioning at the time of the fall.

In an interview on June 13, 3017, at 1:30 p.m., the Director of Nursing stated that the resident's bed alarm had not been implemented and functional at the time of that incident.

CFR 483.25(d) Accidents
Previously cited 12/16/16

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

 Plan of Correction - To be completed: 06/19/2017

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 that safety measures are implemented and functional. R4 has bed alarm in place and functioning.
2. Director of Nursing /Designee re-educated staff on ensuring safety measures are in place and functioning.
3. Director of Nursing / Designee will complete random weekly 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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