Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  104 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.
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on December 11, 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:

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Based on clinical record review, observations and resident interview it was revealed that the failed to provide safe and effective resident care equipment planned to maintain range of motion and functional mobility for one resident out of six sampled (Resident 3).

Findings include:

A review of Resident 3's comprehensive plan of care revealed the planned intervention of the use of bilateral hand splints initiated on February 16, 2018.

Observation of the resident on December 11, 2019 at 2:00 p.m., revealed that the resident was wearing the bilateral hand splints as planned. However, the velcro used to secure the splints and other areas of the splints were observed to be frayed and worn. The palm area of the splint on the resident's left hand was observed to be duct taped together. Along the sides of the duct tape, a piece of metal was observed protruding from beneath the fabric.

A review of the resident's MDS (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) Assessment dated November 25, 2019, revealed that the resident's cognition was intact.

Interview with the resident at the time of the observation on December 11, 2019, revealed that the resident stated that she had taped the splints herself "a while ago" due to the protruding metal piece.

Observations of the resident's wheelchair at this time also revealed that elastic exercise bands were wrapped around the inside metal wheel of the resident's chair. These bands were observed to be unraveling in areas from within the inside wheel, to the outer rubber tire of the wheelchair. There were extensive areas where there were no elastic bands. Further observations revealed that without the elastic bands, the smooth exposed areas, hindered the resident's ability to operate/self-propel the chair. When interviewed at that time, the resident stated that therapy had assessed her ability to manuver in the chair and had equipped the chair with these elastic exercise bands to improve her independence. She stated that when the bands begin to unravel she has difficulty moving the wheelchair.

A review of the resident's most recent occupational therapy notes dated August 10. 2019, revealed that the use of the elastic bands was one of the modifications made by therapy, to increase the resident's functional ability/independence.

The facility failed to ensure that the resident care devices, which were planned to maintain the resident's range of motion and ability to self-propel in the wheelchair was consistently maintained in a safe and effective manner.

28 Pa. Code: 211.12(a)(c)(d)(1)(3)(5) Nursing Services.
Previously cited: 11/13/19,10/1/19,6/14/19.

 Plan of Correction - To be completed: 12/27/2019

1. Resident #3's splints have been replaced. Her wheel chair has been repaired so that rubber hand grips are fixed and resident is able to self-propel.

2. The facility will conduct an audit of resident's that have splints to ensure they are clean and in good repair.

3. The DON/designee will re-educate nursing staff to alert therapy when a splint is in need of repair or cleaning

4. The facility will conduct random weekly audits x 4weeks, then monthly x 2months on splints to ensure they are clean and in good repair. Results of those audits will be brought to the facilities monthly QAPI meetings.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
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.

Based on observations and resident interviews it was determined that the facility failed to maintain clean resident care equipment for three residents out of six sampled ( Residents 1, 2 and 3).

Findings include:

Observations conducted throughout the day of survey on December 11, 2019, revealed that Resident 2 was observed seated in a Broda chair in front of the nurses station throughout the day tour of duty. The Broda chair in which the resident was seated was observed to be soiled with dried stains and liquids.

Observations conducted of Resident 1 throughout the day tour of duty on December 11, 2019, revealed that the resident was seated in a Broda chair in the hallway in front of the nurses station throughout the day. The chair in which the resident was seated, along with the cushion was observed to be soiled with dried stains. The resident was observed with blue padded pressure relief boots on both feet, which were soiled and stained on the outside and the inside where the resident's toes were positioned.

Observations of Resident 3's wheelchair on December 11, 2019 at 2:05 p.m. revealed dried stains on the sides of the chair.

28 Pa. Code: 201.29(j)(k) Resident Rights.
Previously cited: 10/1/19

28 Pa. Code 207.2(a) Administrator's responsibility
Previously cited: 10/1/19.

 Plan of Correction - To be completed: 12/27/2019

Submission of our plan of correction does not constitute an admission or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continually improve the quality of care for our residents and to comply with all applicable and state and federally regulatory requirements.

1. Resident #1's Broda chair and pressure relief boots were cleaned and washed. Resident #2's Broda chair was cleaned and washed. Resident #3's wheel chair has been cleaned and washed.
2. The facility will wash and clean resident's wheel chairs. The facility will complete an audit of the residents' who have pressure relief boots to validate they are in good condition.
3. The facility will initiate a wheel chair cleaning schedule. Nursing staff will receive education to replace heel protectors if soiled.
4. The facility will conduct random weekly audits of wheel chairs and pressure relief boots x4 weeks then monthly x2 months to ensure wheel chairs and pressure relief boots are clean. The results will be brought to the monthly QAPI meeting for review.

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