Pennsylvania Department of Health
WEST CHESTER REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WEST CHESTER REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

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WEST CHESTER REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Findings of an Abbreviated Complaint Survey completed on January 17, 2024, at West Chester Rehabilitation and Healthcare Center, identified deficient practice, related to the reported complaint allegations, under the 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 as they relate to 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 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 observation, it was determined that the facility failed to ensure the call bell alerts were answered in a timely manner on one of two floors. (First Floor)

Findings include:

Observation conducted on January 17, 2024, at approximately 12:15 p.m., of the call bell alert unit at the first-floor nursing station, responsible for monitoring room 146, revealed that the room's call bell was on for 17 minutes.

Continued observation on January 17, 2023, from 12:15 p.m. through 1:00 p.m. revealed the call bell alert system continued to be activated for room 146.

Interview conducted on January 17, 2024, at approximately 1 p.m., with Resident R2, revealed that he/she pushed the call bell for staff assistance. R2 confirmed the call bell remained activated at time of the interview. R2 could not confirm the exact time call bell was initiated but stated it had been a while. R2 stated his/her bed was broken and was the reason he/she pushed the call bell for assistance. R2 stated that he/she informed staff the previous day and earlier that morning the bed was broken.

Additional observation conducted on January 17, 2024, at 2:31 p.m., revealed the call bell alert system was activated by lights inside the room and outside of the door and appeared to be operating properly.

Further observation of staff responded to a call bell alert within three minutes of activation, indicating the system was working properly at the nurse's station as well.

Additional observation conducted on January 17, 2024 revealed maintenance personnel taking a new bed towards R2's room.

Interview conducted on January 17, 2024, at approximately 3:35 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that they interviewed R2 and roommate R3 concerning the call bell alert system in their room. NHA and DON stated both residents denied activating the call alert system at anytime during the day. NHA and DON provided a signed statement from both R2 and R3 documenting neither activated the system. NHA and DON stated that nursing staff did go into the resident's room to provide medications during the time of observation.

Further interview with Administrator and Director of Nursing revealed in response to enquiry of reason the call bell system would remain activated at the nurse's station, the NHA and DON replied that the system was new and not fully operational.

28 Pa. Code 201.14(a) Responsibility of Licensee

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

28 Pa. Code 211.12(d)(1)(5) Nursing Services









 Plan of Correction - To be completed: 02/12/2024

· R2's call bell was answered, and assistance was provided for his request.

· The Administrator / Designee completed an audit to validate call bells are answered timely. Variances were addressed.

· The Administrator / Designee re-educated all staff on timely call bell response.

· The Administrator / Designee will complete an audit of call bell response time 5 times a week for 2 weeks, then weekly for 3 weeks, then monthly for 2 months. Results from the audits will be submitted to the quality assurance performance improvement committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on previous audit findings.
483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:


Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to implement the comprehensive care plan interventions to prevent pressure ulcer healing and discomfort for one of three resident reviewed (Resident R1).

Findings include:

Review of R1's records revealed a care plan dated December 24, 2023, documenting the resident has a pressure ulcer or has potential for pressure ulcer development related to disease process, immobility, sacral wound.

Interventions documented the need for staff to elevate/offload heels when in bed as tolerated using pillows, bootie, heel protectors or heel cushions.

Observation of R1 on January 17, 2024, at 12:30 p.m., revealed the resident lying in bed with resident's heels contacting a pillow. Observations also revealed resident wearing socks, with no heel booties, heel protectors or heel cushions. Further observation of resident's room revealed heel booties sitting on air conditioner unit.

Interview on January 17, 2024, at 12:35 p.m., with E3 revealed that R1 often refused to wear the heel booties because they were painful.

Observation of R1 on January 17, 2024, at 1:50 p.m., revealed that staff had put the heel booties on the resident, although it was known to staff that the resident did not like to wear them because they were painful. Interview with the resident confirmed they were painful, and the resident did not want to wear them.

Interview conducted on January 17, 2024, at approximately 3:30 p.m., with Nursing Home Administrator and Director of nursing, confirmed Resident R1 was care planned for pressure ulcers with interventions to include elevate/offload heels when in bed as tolerated using pillows, heel booties, heel protectors or heel cushions but the interventions were not implemented, as noted by observation.

The facility failed to implement Resident R1's comprehensive care plan which included interventions to offload heels to prevent pressure wounds.

28 Pa Code 211.10(d) Resident care policies

28 Pa Code 211.11(d) Resident care plan

28 Pa. Code 211.12(c) Nursing services



 Plan of Correction - To be completed: 02/12/2024

· R1's pillow was repositioned to offload her heels.

· The Director of Nursing / Designee completed an audit of residents who are care planned with interventions to elevate/ offload heels. No additional variances were identified.

· The Director of Nursing/ Designee re- educated nursing staff on elevating/ offloading heels as per care plan.

· The Administrator / Designee will complete an audit of residents who are care planned with interventions to elevate/ offload heels 5 times a week for 2 weeks, then weekly for 3 weeks, then monthly for 2 months. Results from the audits will be submitted to the quality assurance performance improvement committee monthly for further review and recommendations as needed. Further audit frequency will be determined based on previous audit findings.

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