Pennsylvania Department of Health
WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Patient Care Inspection Results

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WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER
Inspection Results For:

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WINDBER WOODS SENIOR LIVING & REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a complaint survey completed on March 27, 2024, it was determined that Windber Woods Senior Living and 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:


483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based on review of facility policies, information provided to staff upon hire, investigation documents, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident's personal privacy was maintained for one of three residents reviewed (Resident 2).

Findings include:

The facility's abuse policy, dated December 14, 2023, included policies and procedures related to training, preventative measures, identifying, investigating, reporting, and protecting residents from exposure to abuse, neglect, mistreatment, and misappropriation.

The facility's cell phone usage policy, dated December 14, 2023, indicated that cell phones were not to be used in resident care units or carried on one's body while the employee was working. No staff member was allowed to photograph a resident or their surroundings and post it on social media of any kind. Even if a resident consented, and regardless of the resident's cognitive status, abuse will be presumed and investigated whenever there was a photograph or recording of a resident, or the manner that it was used (if it demeaned or humiliated a resident).

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 14, 2024, indicated that the resident was cognitively impaired, had verbal behaviors, was frequently incontinent of bowel and bladder, and had diagnoses that included dementia.

Review of information submitted by the facility, dated March 17, 2024, indicated that Nurse Aide 1 took a picture of Resident 2 on her cell phone while Resident 2 was sitting on the toilet with his pants pulled up almost the entire way, exposing a small portion of his upper leg. The picture of the resident was from the waist down and the resident's face was not in the picture. The picture showed the resident sitting on the commode with his pants pulled almost all the way up, exposing a small portion of his upper leg. The picture of the resident was then posted on social media.

Investigative interview statements from Nurse Aide 1, dated March 17, 2024, confirmed that she took a picture of Resident 2 while he was on the toilet.

Investigative interview statements from Nurse Aide 2, dated March 17, 2024, confirmed that she saw the picture on social media that Nurse Aide 1 took of Resident 2 sitting on the toilet.

Interview with the Nursing Home Administrator on March 27, 2024, at 11:04 a.m. confirmed that Nurse Aide 1 took a picture of Resident 2 on the toilet and posted it on social media, and revealed that employees were not to take any pictures of residents on their cell phones.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

28 Pa. Code 201.29(j) Resident Rights.







 Plan of Correction - To be completed: 04/29/2024


1. Corrective Action
- Resident #2 no longer resides in the facility and did not have adverse effects related to breech in privacy/confidentiality of records, free from mental abuse.
- Nurse aide 1 was terminated 3/17/2024.

2. Identifying other residents
- Current residents have the potential to be affected by the deficient practice.

3. Systemic Changes
- Director of Nursing (DON)/designee shall in-service all staff including agency staff regarding Personal Privacy/confidentiality of records which is provided in the Health Insurance Portability and Accountability Act (HIPAA) Basics education
- Staff across all department's will be audited for cell phone use in direct patient care areas and disciplined accordingly.

4. Monitoring
- DON/designee shall audit cell phone use in direct patient care areas on all staff daily x 1 week, then weekly x 4 weeks then monthly x 3 months or until compliance is achieved and maintained.
- Audit results shall be submitted to the Quality Assurance Performance Improvement (QAPI) Committee for analysis and to be addressed as appropriate.

5. Correction Date: 4-29-2024

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

483.12(a) The facility must-

483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:


Based on review of facility policies, clinical records and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from mental abuse for one of three residents reviewed (Resident 2).

Findings include:

The facility's abuse policy, dated December 14, 2023, included policies and procedures related to training, preventative measures, identifying, investigating, reporting, and protecting residents from exposure to abuse, neglect, mistreatment, and misappropriation.

The facility's cell phone usage policy, dated December 14, 2023, indicated that cell phones were not to be used in resident care units or carried on one's body while the employee was working. No staff member was allowed to photograph a resident or their surroundings and post it on social media of any kind. Even if a resident consented, and regardless of the resident's cognitive status, abuse will be presumed and investigated whenever there was a photograph or recording of a resident, or the manner that it was used (if it demeaned or humiliated a resident).

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 14, 2024, indicated that the resident was cognitively impaired, had verbal behaviors, was frequently incontinent of bowel and bladder, and had diagnoses that included dementia.

Review of information submitted by the facility, dated March 17, 2024, indicated that Nurse Aide 1 took a picture of Resident 2 on her cell phone while Resident 2 was sitting on the toilet with his pants pulled almost all the way up. The picture of the resident was from the waist down and the resident's face was not in the picture. The picture showed the resident sitting on the commode with his pants pulled up almost the entire way, exposing a small portion of his upper leg. The picture of the resident was then posted on social media.

Investigative interview statement from Nurse Aide 1, dated March 17, 2024, confirmed that she took a picture of Resident 2 while he was on the toilet.

Investigative interview statement from Nurse Aide 2, dated March 17, 2024, confirmed that she saw the picture on social media that Nurse Aide 1 took of Resident 2 sitting on the toilet.

Interview with the Nursing Home Administrator on March 27, 2024, at 11:04 a.m. confirmed that Nurse Aide 1 took a picture of Resident 2 on the toilet and posted it on social media, and revealed that employees were not to take any pictures of residents on their cell phones.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

28 Pa. Code 201.29(j) Resident Rights.






 Plan of Correction - To be completed: 04/29/2024

1. Corrective Action
- Resident #2 no longer resides in the home and did not suffer any injuries or adverse effects from the incident.
- Nurse Aide 1 was terminated.

2. Identifying other residents
- Current residents have the potential to be affected by the deficient practice.

3. Systemic Changes
- All staff including agency will be educated on Health Insurance Portability and Accountability Act (HIPAA) basics, Abuse Neglect and Exploitation, and the facilities Cellphone Usage Policy
4. Monitoring
- Director of Nursing (DON)/designee shall audit cell phone use in direct patient care areas on all staff daily x 1 week, then weekly x 4 weeks then monthly x 3 months or until compliance is achieved and maintained.
- Audit results shall be submitted to the Quality Assurance Performance Improvement (QAPI) Committee for analysis and to be addressed as appropriate.

5. Correction Date: 4-29-2024


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