Nursing Investigation Results -

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

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

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ST. JOHN NEUMANN 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 two complaints completed on March 9, 2019, at St. John Neumann Center for Rehabilitation and Healthcare, it was determined that St. John Neumann Center for Rehabilitation and Healthcare, was not in compliance with the following Requirements of 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.



 Plan of Correction:


483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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.
483.10(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 observation, review of clinical records, facility documentation, policy and procedure, interviews with residents and facility staff, it was determined, that the facility failed to provide incontinent care in a timely fashion for two of three residents (Residents R4 and R5).

Findings include:

Review of facility policy and procedure, titled, "Perineal Care", dated, December, 2018, indicated, "The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition".

Additional review of another facility policy and procedure, titled, "Accommodating Resident Needs", dated January, 2018, indicated, "Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being".

During the initial tour of the facility on March 9, 2019, from 10:30 - 1:30 p.m. Residents R4 and R5, were identified by Employee E1, Licensed Nurse, as being incontinent of bladder and bowel and were also alert and oriented.

Observation of Resident R4's resident room during the initial tour, revealed a strong odor of urine. An interview with Resident R4 on March 9, 2019, at 12:40 p.m. in the presence of Employee E1, indicated being incontinent of bladder and bowel. Resident R4 further indicated at the time of the observation, "Being soaked thru to the bottom bed sheet". Resident R4 also shared with the surveyor and Employee E1, that she had not received incontinent care since 8:00 a.m.. Employee E1, indicated that it is the facility policy and procedure that all residents that are incontinent of bladder and bowel are to receive incontinent care every two hours and as needed.

Further observation of Resident R4 during incontinent care, performed by Employee's E6 and E7, both Nurses Aide (NA), in the presence of Employee E1, Licensed Nurse, revealed that Resident R4's incontinent brief was heavily soaked with urine, observation of the protective blanket she was laying and the bottom bed sheet were completely urine soaked.

At the time of the observation Employee E6, NA, assigned to Resident R4, indicated that she last did incontinent care for Resident R4, at 8:00 a.m. as Resident R4 had indicated was the last time she had received incontinent care.

An interview with Employee E1, on March 9, 2019, at 12:55 p.m. confirmed that Resident R4, did not receive timely incontinent care.

Review of Resident R4's clinical record revealed a Careplan, dated August 7, 2018, related to frequent incontinent of bladder and bowel, due to decreased mobility and physical limitations. Further review of the Careplan indicated incontinence care on rounds and as needed.

Resident observation of Resident R5's room, during the initial tour of the facility, in the presence of Employee E1, also revealed a strong urine odor. Prior to the observation of Resident R5, Employee E1, had indicated Resident R5, was completely alert and oriented and was also incontinent of bladder and bowel.

During the resident interview, Resident R5, indicated, "Incontinent care was not so good". Resident R5, also indicated as did Resident R4, "Not having incontinent care since early in the morning".

Observation of incontinent care of Resident R5, completed by Employee's E8, Licensed Nurse and Employee E9, Nurse Aide, revealed that Resident R5 was heavily saturated with urine.

Again at the time of the observation Employee E1, confirmed that Resident R5, did
not receive incontinent care in a timely fashion.

Review of Resident R5's clincal record revealed a Careplan, about incontinent of bladder, which was dated, February 8, 2016, which indicated, Resident R5, is to receive incontinence care on rounds and as needed. Continued review of the clinical record revealed an incontinent assessment for Resident R5, dated, February 8, 2016, which also indicated, Resident R5, is incontinent of bladder and bowel.

Continued review of Resident R5's Careplan's revealed another Careplan, related to R5, having potential skin breakdown to the groin area, due to incontinence and moisture.

Interview with Administrator and Director of Nursing at approximately 3:00 p.m., confirmed that incontinence care is not being provided to residents in a timely fashion.

Facility failed to ensure that incontinent care was provided in a timely fashion to accomodate needs of residents.

F558 - Previously cited 12/18/18, 11/9/17 and 10/21/16

28 Pa. Code: 201.14(a) Responsibility of licensee
Previously cited 12/18/18, 10/29/18, 11/9/17, 8/4/17, 4/11/17, 2/10/17 and 10/21/16.

28 Pa. Code: 201.18(b)(1)(3) Management
Previously cited 12/18/18, 10/29/18, 11/9/17, 8/4/17, 4/11/17, 2/10/17 and 10/21/16.

28 Pa. Code: 201.18(e)(1) Management
Previously cited 12/18/18, 10/29/18, 11/9/17, 8/4/17, 4/11/17, 2/10/17 and 10/21/16.

28 Pa. Code: 211.11(d)Resident care plan
Previously cited 12/18/18, 10/29/18, 11/9/17, 8/4/17, 4/11/17, 2/10/17 and 10/21/16.

28 Pa. Code: 211.12(c)(d)(1)(5) Nursing services
Previously cited 12/18/18, 10/29/18, 11/9/17, 8/4/17, 4/11/17, 2/10/17 and 10/21/16.



 Plan of Correction - To be completed: 04/03/2019

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. Resident R4 and R5 were provided with incontinence care.
2. All residents who are incontinent have the potential to be affected by the deficient practice. Residents who require incontinence care were evaluated and incontinence care provided was deemed appropriate.
3. Nursing staff were in-serviced on the importance of providing timely incontinence care. Unit Managers or designee will conduct rounds on units at different times to verify residents have been provided with timely incontinence care. If incontinence care is required the unit manager or designee will ensure the care has been provided.
4. A designee will complete random audit of residents who require incontinence care to ensure care has been provided. The audit will be conducted weekly for four weeks. Results of the audit will be presented at the monthly QAPI meeting for review and correction.


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