Nursing Investigation Results -

Pennsylvania Department of Health
BRIGHTON REHABILITATION AND WELLNESS CENTER
Patient Care Inspection Results

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BRIGHTON REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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BRIGHTON REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health (DOH) on March 31, 2021. Brighton Rehabilitation and Wellness Center was in compliance with 42 CFR 483.73 related to E-0024(b)(6).








 Plan of Correction:


Initial comments:

Based on a COVID-19 Focused Infection Control Survey and Abbreviated Survey, in response to three complaints, completed on April 1, 2021, it was determined that Brighton Rehabilitation and wellness Center 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(e)(3) REQUIREMENT Reasonable Accommodations 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)(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 facility policy, observations, resident and staff interviews, it was determined that the facility failed to respond to resident call bells in a timely manner for 3 of 3 residents (Residents R14, R15 and R16) and make certain a call light was within reach for one of one resident (Resident R15).

Findings include:

The facility policy, "Flow of Care," last reviewed on 9/30/20, indicated that a call light is within reach and answered timely.

During an interview on 3/31/21, at 10:00 a.m. Resident R14, who was admitted to the facility who has a Brief Interview for Mental Status (BIMS- The residents cognitive status) of 14, stated she puts on her call bell and staff members come in and shut it off and leave. Resident R14 indicated that she is not checked and changed at all during the night and left soiled all night.

Review of the clinical record indicated that Resident R14 was admitted to the facility on 2/6/17, with respiratory failure requiring a tracheostomy and had been ventilator dependent. She is morbidly obese with a weight of 403 at 66 inches tall. Resident R14 cannot perform hygiene or bed mobility without total assistance and needs a total body lift out of bed. She has mobility of upper extremities but cannot reach call bell if out of arms length reach as she requires assistance of two with bed mobility. If she has any respiratory issues she cannot get help if call bell is out of reach, she is in a private room.

During an observation on 3/31/21, at 10:12 a.m. the call light illuminated above resident room 404, the call light was not responded to until 10:40 a.m. which was 28 minutes later with Resident R16 requesting to be bathed and get out of bed. Resident has a BIMS of 13.

Review of the clinical record indicated that Resident R16 was admitted to the facility on 3/4/21, with diagnoses which included kidney failure, diabetes, arthritis and malnutrition. She weighs 335 pounds and 64 inches tall. She requires assistance of two staff for all care. She cannot get out of bed without assistance of two and cannot reach for call bell if out of reach.

During an interview on 3/31/21, at 10:40 a.m. Licensed Practical Nurse Employee E9 confirmed that the call bell should have been responded to timely.

During an observation on 3/31/21, at 2:10 p.m. the call light above resident room 526 was illuminated. The surveyor walked to the doorway to find Resident R15, who has a BIMS of 10, lying on a soiled incontinence pad and stool all over her bed. The resident was tearful and said, "my call light is up there I could not reach it and she (pointing to her roommate) had to put the light on." The surveyor went to the nurses' station for the Registered Nurse (RN) Unit Manager Employee E10 to assist the resident. RN Unit Manager Employee E10 confirmed the call bell was out of reach and the call light should have been responded to more timely.

Review of the clinical record indicated that Resident R15 had been admitted to the facility on 2/26/18, with diagnoses which included a stroke, diabetes and anxiety. She is assistance of two staff for all care including bed mobility. She would not be able to call for help if call bell out of reach and her roommate had called for help for resident in tis case as Resident R15's call bell was found on a electrical box approximately three feet above residents head behind her on the wall. If Resident R15 had no roommate, she had no way of calling for help.

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

28 Pa. Code: 201.18(b)(1)(e)(1) Management.

28 Pa. Code: 201.20(a)(b)(c)(d) Staff development.

28 Pa. Code: 201.29(j) resident rights.

28 Pa. Code: 211.10(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.






 Plan of Correction - To be completed: 04/30/2021

R 14,15,16 call bells were placed within reach and were functional. R 14,15,16 was interviewed regarding call bell timeliness.

All residents we audited to make sure call bells were assessable and functional. All residents were asked about call bell response time.

Staff was educated on the importance of answering call bells timely and ensuring calls bells are functionable and within reach by the Director of Nursing.

The Director of Nursing or Designee will monitor that call bells are in reach and functioning 2 times a week for 4 weeks then monthly times 2 months and the Director of Nursing will, monitor call bell timeliness 2 times a week then monthly times 2 and report findings to QAPI.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observations and resident and staff interviews, it was determined that the facility failed to maintain a comfortable homelike environment for one of twelve nursing units observed (5 Main nursing unit).

Findings include:

During an observation on 3/31/21, at 11:00 a.m. of resident room 510 a blanket was taped with black tape above the window unit air conditioner over the open window space between the top and bottom window.

During an interview on 3/31/21, at 11:10 a.m. Maintenance Director Employee E11 indicated that the blanket should not be taped and did not provide a homelike environment for the residents of room 510.

During an observation on 3/31/21, at 11:16 a.m. a loud screeching noise was coming from resident room 526. Resident R15 indicated that it was the sink in her room. The sink is what the two residents in the room use to get their wash water from. Used for staff to wash hands after caring for these two residents. The observation showed a basin under the pipes of the sink 1/3 full with water, water leaking from the pipes and the faucet screeching. All the residents near the room indicated that the screeching has been going on for a while and the sink had not been repaired.

During an interview on 3/31/21, at 11:23 a.m. Maintenance Director Employee E11 confirmed that the sink was in disrepair he indicated that he had no idea how long the sink was in disrepair as he had not been in facility long. The noisy leaking faucet did not provide a homelike environment.

28 Pa. Code: 207.2(a) Administrator's responsibility.

28 Pa. Code: 201.29(j) Resident rights.







 Plan of Correction - To be completed: 04/30/2021

I hereby acknowledge the CMS 2567-A, issued to BRIGHTON REHABILITATION AND WELLNESS CENTER for the survey ending 04/01/2021, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

Items identified during survey ending 4/2/21 were corrected. Maintenance and Unit Directors will be reeducated on maintaining a home like environment for residents by director of nursing/designee. Facility will continue to report issues identified during ambassador rounds relating to resident care areas/homelike environment to administrator/designee during daily department head meeting. Findings will be reported to Quality Assurance and Performance Improvement committee for review.

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