Nursing Investigation Results -

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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WAYNESBURG HEALTHCARE AND REHABILITATION CENTER
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.


WAYNESBURG HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
A COVID-19 Focused Emergency Preparedness Survey was conducted by The Department of Health (DOH) on November 2, 2021 Waynesburg Healthcare and Rehabilitation was in compliance with 42 CFR 483.73 related to E-0024(b)(6).

Plan of Correction:

Initial comments:

Based on a COVID-19 Focused Infection Control Survey and an Abbreviated Survey in response to a complaint completed on November 2, 2021, it was determined that Waynesburg Healthcare 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 related to the health portion of the survey process.

Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in �483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in �483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in �483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

�483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in �483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under �483.15(c)(9).

Observations:
Based on a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to notify the representative for a change in condition for one of one residents (Resident R1)

A review of faciltiy policy "Change in a Resident's Condition or Status" reviewed May 2017, indicated the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/.mental condition and/or status.

A review of the clinical record revealed Resident R1 was admitted to the facility on 9/14/21, with diagnosis that included urinary tract infection and muscle weakness.

A review of Week 1 wound evaluation indicated the Left heel was a suspected deep tissue injury, treatment indicated 9/16/21, no notifications.

A review of the Week 3 wound evaluation indicated the Left heel was now a Stage 3 and that the Dietitian was notified.

There was no documentation in the clinical record that the representative was notified for the change in condition for Resident R1.

During an interview on 11/2/21, at 10:35 a.m., Employee E1 confirmed Resident R1 had a change in condition and the clinical record did not include documentation that the representative was notified.

28 Pa. Code 201.14(a) Responsibility of Licensee

Plan of Correction - To be completed: 12/07/2021

1.Resident R1 was evaluated by the wound nurse for left heel wound. Care plan, treatment records and wound sheets were updated according to evaluation. Family and physician were notified.
2.Facility residents were audited by the wound nurse to ensure that wound sheets, care plan and treatments were updated per policy and physician and family notified of any changes.
3.Wound nurse and licensed nursing staff were educated by the Director of Nursing or designee the policy regarding wound surveillance and notification of changes.
4.Audits will be performed by the Director of Nursing or designee weekly x 4, then monthly until next annual survey to ensure wound sheets and family/ physician notification are accurate. Audits will be reviewed at Quality Assurance and Performance Improvement Meetings. Trending to be found will be placed on a Performance Improvement Plan and followed through.
5.Date of compliance 12/7/2021

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

�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 facility policy and clinical records and staff interview, it was determined that the facility failed to monitor pressure ulcers as required for one of eight residents (Resident R2).

Findings include:

A review of facility policy "Prevention of Pressure Ulcer/Injuries" updated July 2017, indicated to assess the resident on admission for existing pressure ulcer/injuries, repeat assessment weekly and upon change in condition.

A review of the clinical record for Resident R2, indicated she was admitted to the facility on 10/12/21, current diagnosis included COVID-19 and muscle weakness.

A review of Resident R2's clinical record indicated she had a week one wound assessment on 10/13/21. It was described as a Stage 2 pressure wound on the Left & right gluteal fold.

A review of the current November pressure wound list indicated the wounds were now Stage 3.

A review of Resident R2's clinical record indicated only one weekly would assessment.

During an interview with Employee E1, at 10:30 a.m. on 11/2/21 confirmed that the facility failed to conduct weekly assessment of wounds as required for Resdient R2.

28 Pa. Code 211.12(d)(1)

Plan of Correction - To be completed: 12/07/2021

1.Resident R2 was evaluated by the wound nurse for pressure ulcer. Care plan, treatment records and wound sheets were updated according to evaluation. Family and physician were notified.
2.Facility residents were audited by the wound nurse to ensure that wound sheets, care plan and treatments were updated per policy and physician and family notified of any changes.
3.Wound nurse and licensed nursing staff were educated by the Director of Nursing or designee the policy regarding wound surveillance, weekly wound assessment completion and notification of changes.
4.Audits will be performed by the Director of Nursing or designee weekly x 4, then monthly until next annual survey to ensure weekly wound sheets and family/ physician notification are accurate. Audits will be reviewed at Quality Assurance and Performance Improvement Meetings. Trending to be found will be placed on a Performance Improvement Plan and followed through.
5.Date of compliance 12/7/2021

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

�483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

�483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

�483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to �483.70(e) and following accepted national standards;

�483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

�483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

�483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

�483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:
Based on facility policy and clinical records and staff interview, it was determined that the facility failed to provide surveillance data and analysis for one of three months (October 2021).

Findings include:

The facility policy entitled "Surveillance for Infections" reviewed September 2017, indicated the Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have subsdtantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions.

During the entrance conference on 11/2/21, at 8:45 a.m., the surveyor requested all infection control surveillance data and analysis for the prior six month period.

During an interview on 11/2/21, at 1:10 p.m. the Nursing Home Administrator confirmed that the facility was not able to provide infection tracking/surveillance records and analysis for October 2021 , a period of one month.

28 Pa Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 12/07/2021

1.Infection surveillance for month of October has been updated by the Assistant Director of Nursing.
2.The Director of Nursing or designee will educate the Infection Preventionist on the policy of maintaining a surveillance record for Healthcare Acquired Infections or other epidemiological significant infections/ that surveillance is accurate and updated according to resident changes.
3.The Director of Nursing or designee will audit the Infection Control Surveillance Records weekly for 4 weeks, then monthly until next annual survey, to ensure they are current.
4.Audits will be reviewed at Quality Assurance and Performance Improvement Meetings. Trending to be found will be placed on a Performance Improvement Plan and followed through.
5.Date of compliance 12/7/2021

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