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:

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SOUTHWESTERN VETERANS CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Abbreviated Survey in response to two complaints completed on January 2, 2020, it was determined that Southwestern Veterans Center had a deficiency that has the potential for minimal harm to residents as related to the 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:

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:Least serious deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Based on review of facility policy and clinical records and staff interview it was determined that the facility failed to provide the bed hold policy when transferred to the hospital for one of one residents reviewed (Resident CR1).

Findings include:

A review of "Emergency Transfer of Resident Via Ambulance" Policy, dated 5/4/2017, indicates that a photocopy of the Bed Hold policy was to be sent with the resident when transferred to the hospital.

A review of the clinical record indicated that on 10/31/19, Resident CR1 was transferred to the hospital. The clinical record did not include documentation that the Bed Hold policy was sent with the resident.

During an interview on 1/2/2020, at 2:10 p.m. the Director Of Nursing confirmed that the staff failed to document that the Bed Hold policy was sent with Resident CR1 on 10/31/19.

28. Pa. Code. 211.10(a) Resident care policies
28. Pa. Code. 211.12(d)(1)(2) Nursing Services.

 Plan of Correction - To be completed: 01/13/2020

I hereby acknowledge the CMS 2567-A, issued to SOUTHWESTERN VETERANS CENTER for the survey ending 01/02/2020, AND attest that all deficiencies listed on the form will be corrected in a timely manner.

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