Nursing Investigation Results -

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

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WEATHERWOOD HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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

Based on an abbreviated complaint survey completed on October 1, 2019, it was determined that Weatherwood Healthcare and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(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, interviews with residents and facility staff it was determined the facility failed to provide housekeeping services to maintain a clean resident environment and care equipment on one of four resident units.

Findings include:

Observations of the third area nursing unit front shower room conducted at 10:25 AM on October 1, 2019, revealed a shower gurney (stretcher used to shower residents with limited mobility) with a build-up of flaky skin-like debris and dried particles on the mesh netting located under the removable pad of the gurney.

Observation of the same shower gurney at 2:00 PM in the presence of employee 1 (nurse aide) confirmed the build-up of flaky skin-like debris and dried particles on the mesh netting located under the removable pad of the gurney.

Interview with the nursing home administrator on October 1, 2019, at 2:45 PM confirmed the facility was to be maintained in a clean, comfortable and homelike manner.

28 Pa. Code 207.2 (a) Administrator's responsibility
Previously cited 6/14/19












 Plan of Correction - To be completed: 11/12/2019

Step 1- Facility shower stretcher that was identified to have debris and dried articles was cleaned immediately.
Step 2- The housekeeping supervisor or designee will conduct an initial audit of shower stretchers to verify they are clean.
Step 3- The housekeeping supervisor or designee with educate housekeeping and nursing staff to verify that shower stretchers are on a cleaning schedule and cleaned before use.
Step 4- The housekeeping supervisor or designee will conduct weekly audits for four weeks and then monthly for two months thereafter of shower stretchers to verify they are clean. The results of these audits will be reported to Quality Assurance Performance Improvement committee and will follow up as necessary.
Step 5- November 12, 2019

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observation, a review of select facility procedures and clinical records and resident and staff interview, it was determined that the facility failed to ensure cleaning and the implementation of maintenance schedule for a respiratory device, a bi-level positive airway pressure machine (BiPAP- a non-invasive ventilation machine capable of generating two adjustable pressure levels- Inspiratory Positive Airway Pressure (IPAP) high amount of pressure, applied when the patient inhales and a low Expiratory Positive Airway Pressure (EPAP) during exhalation as preferred by one of one residents sampled (Resident 5).

Findings include:

Review of the facility CPAP/BiPAP Support policy, no review date noted, revealed that the purpose was to promote resident comfort and safety. Preparation included to review and follow manufacturer's instructions for machine setup. Equipment and supplies include a large bore tubing (six-foot hose) and filter. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP (positive airway pressure) device. Filter cleaning includes to rinse the washable filter under running water once per week to remove dust and debris. Replace the filter at least once per year. Replace disposable filters monthly.

Review of the clinical record revealed that Resident 5, was cognitively intact. The resident had a current physician order initially dated, March 28, 2019, for the use of a BiPAP machine on at HS (bedtime) and off in the AM (morning) for a diagnosis of obstructive sleep apnea (collapse of the upper airway during sleep).

Interview with Resident 5 on October 1, 2019, at 10:45 AM revealed the resident had concerns over the consistency of staff in cleaning the BiPAP machine and if the six foot hose attached to the device should be changed periodically.

Observation at this time along with Employee 2 (LPN) revealed two filters in the back of the BiPAP device. The filters were dirty and covered with dust and debris at the time.

Interview with the director on nursing (DON) on October 1, 2019, at approximately 1:00 PM confirmed that filters should be free of dust and debris. The DON failed to provide documented evidence that the manufacturer instructions were followed to ensure supplies such as the hose and filters were on a schedule for replacement when required.

483.25 Respiratory/tracheostomy care and suctioning
Previously cited 6/14/19

28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services
Previously cited 6/14/19



 Plan of Correction - To be completed: 11/12/2019

Step1- The Bi-Pap machine and tubing for resident #5 that was identified was cleaned immediately.
Step 2- The Director of Nursing or Designee will conduct an initial audit to verify that Bi-pap machines and tubing were checked for cleanliness and changed as necessary.
Step 3- The Director of Nursing or Designee will educate licensed nursing staff for the process of Bi-pap cleaning maintenance.
Step 4- The Director of Nursing or Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify that Bi-pap machines are clean and changed as necessary. The results of these audits will be reported to Quality Assurance Performance Improvement committee and will follow up as necessary.
Step 5- November 12, 2019


483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on review of clinical records and grievances lodged with the facility and resident and staff interviews, it was determined that the facility failed to provide and/or deploy sufficient nursing staff in an efficient manner to consistently provide timely quality care and services to maintain the physical and mental well-being of one resident of 8 sampled (Resident 74).

Findings include:


A review of Resident 74's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 28, 2019, revealed that the resident was cognitively intact, with a BIMS score of 15 (brief interview for mental status a tool to assess cognitive function, a score of 13-15 indicates that the resident has intact cognition). Further review of the resident's MDS Assessment revealed that the resident required extensive assistance of two staff for bed mobility and was total dependent of two staff for transfers out of bed. The resident required extensive assistance of two staff for dressing and personal hygiene such as combing hair, brushing teeth, washing face and applying makeup.

A review of Resident 74's current plan of care indicated that she required a mechanical lift with the assist of two staff for transfers and assistance with daily hygiene, grooming and dressing.

Review of a grievance lodged with the facility dated September 17, 2019, at 1:00 PM indicated that on that date Resident 74 had been bed and activated her call at approximately 10 AM for assistance to get out of bed for the day. The grievance indicated that the call bell remained activated continuously from 10 AM and the resident continued to wait for staff assistance out of bed as of 1 PM when observed again by Employee 3, the COTA (certified occupational therapy assistant).

During an interview with Resident 74 on October 1, 2019, at approximately 2:00 PM, the resident stated that on that day (September 17, 2019) her call bell was on "for hours" and she waited to get out of bed for the day and "no one came in." According to Resident 74, the nursing staff had stated that they were "shorthanded."

Interview with Employee 3 on October 1, 2019, at approximately 2:00 PM revealed that Employee 3 had entered Resident 74's room on September 17, 2019, at approximately 9:45 AM to escort the resident to therapy and found the resident in bed and no AM care had been provided to the resident. Employee 3 stated that she activated the resident's call bell, left the resident's room and informed a nurse aide that the resident needed to get out of bed and required personal hygiene. Employee 3 then left the resident unit. Employee 3 stated that at this point the resident was pleasant and calm. Employee 3 explained that she then returned to Resident 74's room at approximately 11:10 AM and observed that the resident remained in bed, without AM care and the call light on. Employee 3 exited the resident's room and again informed a nurse aide that the resident needed to get out of bed and required personal hygiene before Employee 3 left the unit. Employee 3 said that Resident 74 was still pleasant and calm at this time However, Employee 3 again returned to Resident 74's room at approximately 12:50 PM and observed that resident was still in bed, without having received AM care and with the call light on. At this point Employee 3 said that Resident 74 was "emotional and teary eyed." Employee 3 exited the resident's room and informed the unit manager who obtained nursing staff to provide the necessary nursing care for the resident.

Interview with the Director of Nursing (DON) on October 1, 2019 at approximately 2:55 PM confirmed that nursing staff failed to provide timely nursing care and assistance to Resident 74 on the morning of September 17, 2019, resulting in the resident's emotional distress due to the lack of timely care and services



28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services
Previously cited: 10/28/18, 12/8/18, 1/4/19, 3/7/19, 6/14/19

28 Pa. Code 201.29 (j) Resident Rights
Previously cited:

28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management
Previously cited: 10/28/18, 3/7/19, 6/14/19













 Plan of Correction - To be completed: 11/12/2019

Step 1- Resident #74 was visited by Social Services to discuss call bell response times and provide emotional support.
Step 2- During non-clinical rounds any identified residents concerns or needs will be be addressed with resident and assigned staff member.
Step 3- Facility will hold daily staffing meetings to review staffing patterns in attempt to meet the needs of residents and deployment of nursing. The facility staff will receive education on process for answering resident call bells by DON/ Designee.
Step 4- The Director of Nursing or Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify call bell response times and interviews are appropriate. The results of these audits will be reported to Quality Assurance Performance Improvement committee and will follow up as necessary.
Step 5- Corrective action date is November 12,2019

483.40(d) REQUIREMENT Provision of Medically Related Social Service: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.
483.40(d) The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.
Observations:

Based on a review of clinical records and resident and staff interview it was determined the facility failed to provide medically-related social services to assist in obtaining durable medical equipment (equipment used to help complete daily activities such as walking) to ensure the physical, mental, and psychosocial well-being for one resident out of seven sampled (Resident 5).


Findings include:

A review of the clinical record revealed that Resident 5 was cognitively intact and had diagnoses, which included right-side hemiplegia (paralysis) and depression.

Interview with Resident 5 on October 1, 2019, at 10:45 AM revealed the resident had completed skilled therapy in August 2019. The resident voiced frustration because he needed a "special" walker to ambulate. The resident stated that he believed that therapy had made a request for the walker to the facility, but, to date, he never received it.

Interview with the social service director (SSD) on October 1, 2019, at approximately 12:30 PM confirmed that therapy had recommended a special neuro-walker (a walker with arm supports to provide stability). The SSD, responsible for coordinating the resident's need for durable medical equipment, stated that e-mails were exchanged with therapy and the business office regarding the walker, but a decision was not yet made.

A review of an e-mail dated August 13, 2019, confirmed therapy's request for the neuro-walker for the resident. An e-mail dated, August 22, 2019, noted there was a question regarding a security deposit for the walker. No further follow-up was provided to demonstrate the facility's efforts to obtain the walker for the resident.

Review of social service notes failed to provide documented evidence the resident was updated regarding the delay in obtaining the therapy recommended walker.

Interview with the administrator on October 1, 2019, at 2:00 PM failed to provide documented evidence of the timely provision of medically-related social services to Resident 5 in response to the resident's need for durable medical equipment.



28 Pa Code 201.29(a)(f) Residents Rights
Previously cited 6/14/19

28 Pa. Code 211.16(a) Social Services
Previously cited 6/14/19






 Plan of Correction - To be completed: 11/12/2019

Step 1- Resident #5 was reassessed by therapy for newer walker. Temporary walker was issued until new walker arrives, and new walker was ordered by facility therapy department.
Step 2- Director of Nursing will meet with the therapy director to verify there are no more outstanding recommendations for Durable Medical Equipment.
Step 3- Nursing Home Administrator or Designee will educate social worker and licensed nursing staff to verify that Durable Medical Equipment recommendations are followed through appropriately. Therapy recommendations will be discussed in morning meeting to verify adequate follow through.
Step-4 The Director of Nursing or Designee will conduct weekly audits for four weeks and then monthly for two months thereafter to verify there are no outstanding Durable Medical Equipment recommendations. The results of these audits will be reported to Quality Assurance Performance Improvement committee and will follow up as necessary.
Step 5- November 12, 2019



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