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

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MONROEVILLE REHABILITATION AND WELLNESS CENTER
Inspection Results For:

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MONROEVILLE REHABILITATION AND WELLNESS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated survey in response to a complaint completed on January 11, 2024, it was determined that Monroeville Rehabilitation and Wellness 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(f)(4)(ii)-(v) REQUIREMENT Right to Receive/Deny Visitors: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(f)(4) The resident has a right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident.
(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident's right to deny or withdraw consent at any time;
(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident's right to deny or withdraw consent at any time;
(iv) The facility must provide reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time; and
(v) The facility must have written policies and procedures regarding the visitation rights of residents, including those setting forth any clinically necessary or reasonable restriction or limitation or safety restriction or limitation, when such limitations may apply consistent with the requirements of this subpart, that the facility may need to place on such rights and the reasons for the clinical or safety restriction or limitation.
Observations:
Based on a review of facility documents and staff interviews, it was determined that the facility failed to ensure that the residents were aware of unrestricted visitation.

Findings include:

During an observation on 1/6/24, at 9:30 a.m. a stack of papers titled "Family/Visitor Information" were placed on the table with the visitor sign-in book. On this document was the following information:
Visitor Information:
Visitation Hours:
-Monday - Friday 8AM-8PM (Enter through the front doors)
-Saturday & Sunday 8AM-8PM (front doors lock at 1:00 PM; use ambulance entrance after hours).

Further review of the document failed to reveal information relating the availability of 24 hour visitation.

During an interview on 1/6/23, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that the residents were aware of unrestricted visitation.

28 Pa. Code 201.29(a) Resident Rights.


 Plan of Correction - To be completed: 02/20/2024

1. The family/visitor information was updated to reflect 24 hour unrestricted visitation.
2. Residents will be made aware the facility has 24 hour unrestricted visitation during resident council meeting. Activities Director/designee will provide a letter to all residents and post throughout the building and entrances that visitation is 24/7.
3. The facility staff will be re-educated on federal tag 563 regarding 24 hour unrestricted visitation hours at the facility by the Nursing Home Administrator/designee.
4. The Social Service Director/designee will interview five residents weekly for four weeks and monthly for three months to ensure they are aware the facility has 24 hour unrestricted visitation. . Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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.
§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:
Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for five of nine residents (Resident R1, R2, R3, R4, and R5).

Findings include:

Review of the clinical record indicated Resident R1 was admitted to the facility on 11/27/23.

Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/3/23, included the diagnoses of Myelodysplastic syndrome (group of cancers where immature blood cells do not mature or become healthy blood cells) and lymphedema (the build-up of fluid in soft body tissues) high blood pressure. Review of Section GG: Functional Abilities and Goals indicated that Resident R1 had range of motion impairments of one upper and one lower extremity. Review of Section M: Skin Conditions, indicated Resident R1 had three Stage II pressure ulcers (partial-thickness skin loss with exposed middle layer of skin).

Review of a physician's order dated 11/28/23, indicated for Resident R1 to have bunny boots (cushioned, heel protector booties) on while in bed, as tolerated.

Review of a physician's order dated 12/7/23, indicated for Resident R1 to have feet elevated while in bed.

Review Resident R1's care plan dated 12/15/23, indicated for staff to elevate feet when in bed every shift and to apply bilateral bunny boots while in bed as tolerated q shift for skin protection.

Review of the nurse aide Kardex (paper or electronic document that outlines the patients' activities of daily living - ADLs, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) indicated for staff to apply bunny boots and to assist with turning and repositioning as needed.

Review of the facility provided wound report dated 12/28/23 - 1/4/24, indicated under "Provider Recommendations," Resident R1should have side to side offloading every 2-3 hours while in bed.

On 1/6/24, observations of residents with wound orders began at approximately 10:25 a.m. (Observation 1), 11:45 a.m. (Observation 2), 1:00 p.m. (Observation 3), and 2:00 p.m. (Observation 4).

During observations completed on 1/6/23, the following was noted:
Observation 1: On back, feet flat on bed. No bunny boots observed.
Observation 2: On back, knees bent. No bunny boots observed.
Observation 3: Sitting up, eating. No bunny boots observed.
Observation 4: On left side, feet flat on bed. No bunny boots observed.

Review of the clinical record indicated Resident R2 was admitted to the facility on 11/27/23.

Review of the MDS dated 12/10/23, included the diagnoses of chronic kidney disease (gradual loss of kidney function) and heart failure (a progressive heart disease that affects pumping action of the heart muscles). Review of Section GG: Functional Abilities and Goals indicated that Resident R2 required "substantial/maximal assistance ("Helper does MORE THAN HALF the effort") to roll left and right in bed. Review of Section M: Skin Conditions, indicated Resident R2 had one deep tissue injury (DTI, an injury to a patient's underlying tissue below the skin's surface that results from prolonged pressure in an area of the body).

Review of a physician's order dated 6/5/23, indicated for Resident R2 to have bunny boots on while in bed, as tolerated.

Review of a physician's order dated 12/4/23, indicated for Resident R2 "keep left foot elevated no pressure on toes nothing is to touch toes."

Review Resident R2's care plan dated 12/4/23, indicated for staff to keep "left foot elevated , no pressure on toes. Nothing is to touch toes every shift."

Review of the nurse aide Kardex dated 1/6/24, failed to include directions for staff to apply bunny boots or to keep pressure off of the left foot.

Review of the facility provided wound report dated 12/28/23 - 1/4/24, indicated under "Provider Recommendations" soft heel boots to be worn at all times aside from ambulation. Nothing to touch left toes.

During all four observations completed on 1/6/23, the following was noted:
Resident R2 was on back, feet flat on bed, wearing bunny boots, with multiple blankets wrapped tightly over her feet.

Review of the clinical record indicated Resident R3 was admitted to the facility on 11/8/18.

Review of the MDS dated 12/22/23, included the diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and heart failure. Review of Section GG: Functional Abilities and Goals indicated that Resident R3 required "substantial/maximal assistance to roll left and right in bed. Review of Section M: Skin Conditions, indicated Resident R3 had one Stage III pressure ulcers (full-thickness loss of skin, in which fat is visible in the ulcer and granulation tissue slough and/or eschar may be visible).

Review of a physician's order dated 8/7/23, indicated for Resident R3 reposition side to side as tolerated.

Review Resident R3's care plan dated 5/11/23, indicated for Resident R3 "while in bed, reposition frequently as tolerated into side lying wedge."

Review of the nurse aide Kardex dated 1/6/24, indicated for Resident R3 while in bed, to reposition frequently as tolerated into side lying wedge.

Review of the facility provided wound report dated 12/28/23 - 1/4/24, indicated under "Provider Recommendations" side to side offloading every 2-3 hours while in bed with wedge.

During all four observations completed on 1/6/23, the following was noted: Resident R3 was on back, feet flat directly on a pillow, with no wedge.

During an interview on 1/6/23, at approximately 2:00 p.m. Nurse Aide (NA) Employee E1 confirmed that Resident R3 does not have a wedge in his room.

Review of the clinical record indicated Resident R4 was admitted to the facility on 3/22/23.

Review of the MDS dated 11/3/23, included the diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time) and heart failure. Review of Section GG: Functional Abilities and Goals indicated that Resident R4 required dependent level of assistance ("Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity") to roll left and right in bed. Review of Section M: Skin Conditions, indicated Resident R4 had one unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar).

Review of a physician's order dated 5/18/23, indicated for Resident R4 to be repositioned frequently into a right-side lying position using wedge and pillow placed under residual limb.

Review Resident R4's care plan dated 5/234/23, indicated for Resident R4 to be repositioned frequently into a right-side lying position using a wedge & pillow placed under residual limb.

Review of the nurse aide Kardex dated 1/6/24, indicated for Resident R4 to be repositioned frequently into a right-side lying position using a wedge & pillow placed under residual limb.

During all observations one, two, and three completed on 1/6/23, Resident R4 was on his back, feet flat on bed, and did not have a wedge. Resident R4 was receiving care during observation four.

Review of the clinical record indicated Resident R5 was admitted to the facility on 8/25/22.

Review of the MDS dated 12/30/23, included the diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and multiple sclerosis (a disease that affects central nervous system). Review of Section GG: Functional Abilities and Goals indicated that Resident R5 had a range of motion impairment to one lower extremity and required "substantial/maximal assistance to roll left and right in bed. Review of Section M: Skin Conditions, indicated Resident R5 had a risk of developing pressure ulcers.

Review of a physician's order dated 3/6/23, indicated for Resident R5 to reposition in bed frequently every shift, use wedge for side lying position.

Review Resident R5's care plan dated 8/21/23, indicated for Resident R5 to reposition in bed frequently every shift as tolerated, use wedge for side lying position every shift.

Review of the nurse aide Kardex dated 1/6/24, indicated for staff to assist with turning and repositioning frequently & as needed using wedge for side lying position.

During observations one, two, and three completed on 1/6/23, Resident R5 was on her back, feet flat on bed, without a wedge. Resident R4 was not in her room during observation four.

During a group interview on 1/6/23, at approximately 2:15 p.m. NAs Employees E1, E2, E3, and E4 were asked how they learn the assistance level for a resident, if they need to be turned and repositioned, and if they should have a wedge or bunny boots. All NAs indicated they would use the electronic charting system Kardex, and additionally they indicated there were paper documents at the nurses' station.

During an interview on 1/6/23, at approximately 2:30 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide prescribed treatment and services related to the care of pressure ulcers for five of nine residents.

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


 Plan of Correction - To be completed: 02/20/2024

1. Resident R1, R2, R3, R4, and R5 had skin assessments completed to ensure there were no identified issues from not having ordered treatments and services to care for pressure ulcers.
2. Current orders of residents with pressure ulcers were reviewed to ensure residents were provided the ordered treatments and services. Current resident care plans and kardexes were reviewed to ensure they reflect the current orders
3. Nursing staff will be re-educated by the Director of Nursing/designee on providing residents with the ordered treatments and services related to the care of pressure ulcers.
4. The Director of Nursing/designee will audit resident with pressure ulcers daily for two weeks, twice weekly for two weeks, weekly for two weeks and then monthly for three months to ensure ordered treatments are being provided. . Outcomes will be reported to the Quality Assurance Performance Improvement Committee for review and recommendations.

483.70(p)(1)(2) REQUIREMENT Qualifications of Social Worker >120 Beds: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.
§483.70(p) Social worker.
Any facility with more than 120 beds must employ a qualified social worker on a full-time basis. A qualified social worker is:

§483.70(p)(1) An individual with a minimum of a bachelor's degree in social work or a bachelor's degree in a human services field including, but not limited to, sociology, gerontology, special education, rehabilitation counseling, and psychology; and

§483.70(p)(2) One year of supervised social work experience in a health care setting working directly with individuals.
Observations:
Based on a review of facility documents, personnel records, and staff interview, it was determined that the facility failed to employ a qualified social worker for one of two employees (Employee E1).

Findings include:

Review of the facility policy "Social Services Administration" dated 6/1/23, indicated the following:
A qualified social worker is defined as an individual who meets, at a minimum, one of the following qualifications:
1. A bachelor's degree in social work, or
2. A bachelor's degree in human services field.
3. A bachelor's degree in social work or a bachelor's degree in a human services field including but not limited to sociology, special education, rehabilitation and counseling, and psychology.
4. One year of supervised social work experience in a health setting working directly with individuals.

Review of the facility provided job description for the Social Services Director included the educational requirement of a bachelor's degree in social work or a related field.

Review of the personnel record for Social Services Director (SSD) Employee E3 revealed that SSD Employee E3 did not have a bachelor's degree in any field of study as required and as stated in the Social Services Director's job description.

During an interview on 1/6/24, at 11:30 a.m. the Assistant Director of Nursing (ADON) reviewed the federal regulation, and confirmed that the requirement is for a bachelor's degree and one year of supervised social work experience in a health care setting working directly with individuals. The ADON confirmed that he had thought it was a bachelor's degree or a year of experience.

During interview with the Nursing Home Administrator on 1/6/24, at approximately 2:30 p.m. the Nursing Home Administrator confirmed that Employee E1 did not have a bachelor's degree in any field of study and confirmed that the facility failed to employ a qualified social worker for one of two employees.

Pa Code 211.16. Social Services.
Pa Code 201.14 (a)Responsibility of licensee.


 Plan of Correction - To be completed: 02/20/2024

The facility will ensure to provide consistent and ongoing consultation and oversite by a qualified social worker to the social services designee. The facility will have a Social Worker Consultant reviewing the work of our current Social worker until a qualified Social worker is hired.

The Nursing Home Administrator will re-educate the Human Resources Director on staff qualifications for Social Services regarding deficiency F0850.

The Facility is actively recruiting for a full time Social Services Director.
The Nursing Home Administrator will complete a weekly audit for four weeks, then monthly for 3 months to ensure Social Services Director's work was overseen by a qualified social worker and signed off on.

The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.


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