Nursing Investigation Results -

Pennsylvania Department of Health
EDISON MANOR NURSING & REHAB CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
EDISON MANOR NURSING & REHAB CENTER
Inspection Results For:

There are  151 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
EDISON MANOR NURSING & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on December 10, 2021, it was determined that Edison Manor Nursing & Rehabilitation 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:


483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a baseline care plan was developed and implemented for two of two residents reviewed (Residents R1 and R2).

Findings include:

Review of Resident R1's clinical record revealed an admission date of 10/01/21, with diagnoses that included history of falling, high blood pressure, heart disease, chronic obstructive pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), difficulty walking, and Alzheimer's disease (a disease that destroys memory and other important mental functions).

Review of Resident R1's clinical record lacked evidence that a baseline care plan was developed and provided to the resident and/or resident's representative.

During an interview on 12/08/21, at 4:39 p.m. the Director of Nursing (DON) confirmed that a baseline care plan had not been developed and provided to the resident and/or resident's representative for Resident R1.


Review of Resident R2's clinical record revealed an admission date of 10/25/21, with diagnoses that included Dorsalgia (back pain), history of falling, chronic respiratory failure, and hyperlipidemia (high cholesterol and triglycerides in the blood).

Review of Resident R2's clinical record lacked evidence that a baseline care plan was developed and provided to the resident and/or resident's representative.

During an interview on 12/08/21, at 4:39 p.m. the DON confirmed that a baseline care plan had not been developed and provided to the resident and/or resident's representative for Resident R2.


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

28 Pa. Code 211.11(e) Resident care plan











 Plan of Correction - To be completed: 01/12/2022

Step 1
The two residents identified have discharged from the facility.

Step 2
Residents admitting to the facility have the potential to be affected. A baseline screen was completed on all residents admitted within the last thirty days to identify if documentation is present to verify that a presentation of a baseline care plan was given to the resident or responsible party.

Step 3
The NHA/DON or designee will be responsible for education of RNs, LPNs, and Social Worker regarding interim/baseline care planning policy.

Step 4
The NHA/DON or designee will be responsible for ongoing compliance monitoring. The facility will conduct baseline care planning audits to check for completion three times a week for four weeks and then two times per week for four weeks.. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

483.25(d)(1)(2) 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.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of facility policy and clinical records and staff interviews, it was determined that the facility failed to complete an incident/accident report and investigation regarding skin tears for one of thirteen residents reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed an admission date of 10/01/21, with diagnoses that included history of falling, high blood pressure, heart disease, chronic pulmonary disease (a lung disease that blocks airflow and makes it difficult to breathe), difficulty in walking, and Alzheimer's.

Review of a facility policy entitled "Incident/Accident Policy," dated 10/22/21 stated "An incident/accident is any occurrence which is not consistent with the routine care of a particular resident. An incident/accident can occur anywhere and be discovered by anyone (resident, visitor, employee, or volunteer). All incident/accidents involving residents will be analyzed and reported. The incident will be reported to the resident's responsible party as soon as practicably possible, including any known injury and provider orders."

Review of Resident R1's clinical record revealed that he/she had acquired several skin tears to bilateral upper extremities throughout his/her stay at the facility from 10/01/21 to 11/02/21. There was no evidence that incident/accident reports and investigation were completed for any skin tears during the time-period of 10/01/21 to 11/02/21 for Resident R1.

During an interview on 12/07/21, at 1:20 p.m. Registered Nurse (RN) Employee E1 indicated that when a resident encounters an injury such as a skin tear, an incident/accident report would be initiated immediately. RN Employee E1 indicated this report would contain an investigation of how the injury occurred or likely occurred, physician notification with orders and interventions to treat and prevent further injury to the resident, and resident and/or resident representative notification. RN Employee E1 verbalized on 12/07/21, at 1:20 p.m. that he/she was unaware of any skin tear incident reports initiated for Resident R1's bilateral upper extremities.

During an interview on 12/08/21, at 4:39 p.m. the Director of Nursing confirmed that there were no incident/accident reports with investigation completed for any of the skin tears to Resident R1's bilateral upper extremities during his/her stay at the facility from 10/01/21 through 11/02/21.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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










 Plan of Correction - To be completed: 01/12/2022

Step 1
Resident identified was discharged from the facility

Step 2
Residents sustaining an incident or accident have the potential to be affected. A baseline screen of incident/accidents occurring within the last thirty days will be reviewed to ensure documentation is present and investigation occurred.

Step 3
The NHA/DON or designee will be responsible for education for the RNs and LPNs regarding the incident/accident policy and the initiation/completion of incident reports and investigation.

Step 4
The NHA/DON or designee will be responsible for ongoing compliance monitoring. The facility will conduct Incident/Accident audits to check for completion of incident reports and investigation of incident three times a week for four weeks and then two times per week for four weeks.. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port