Pennsylvania Department of Health
PROVIDENCE REHAB AND HEALTHCARE CENTER AT MERCY FITZGERALD
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PROVIDENCE REHAB AND HEALTHCARE CENTER AT MERCY FITZGERALD
Inspection Results For:

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PROVIDENCE REHAB AND HEALTHCARE CENTER AT MERCY FITZGERALD - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated survey in response to one completed on May 29, 2024, it was determined that Providence Rehab and health Care Center at Mercy was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirement for Long Term Care F and 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.90(g)(1)(2) REQUIREMENT Resident Call System:

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.

§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.

Observations:

Based on observation, review of facility policy, interview with resident and staff, it was determined that the facility failed to ensure that resident's call bells were within reach for four of 25 residents observed (Resident R1, R2, R3, and R4).

Findings include:

Review of facility policy on answering call light revealed the following: Under section. Purpose. The purpose of this procedure is to ensure timely responses to the resident's requests and needs. Under section General Guidelines. #4. Be sure the call light is plugged in and functioning at all times.

Observation of the First and Second floor unit conducted on May 29, 2024, from 8:15 a.m. to 9:54 a.m. revealed that Resident R4's call bell was hanging over her bedside table and out of reach of the resident.

Interview with Unit manager, Employee E3, conducted at the time of the observation confirmed that the call bell was hanging over resident's bedside table.

Observation of Resident R1' room (Rm 119-A) revealed that Resident R1's was not in her room. Further observation revealed that a call bell was clipped to Resident R1's bed. Further observation revealed that the call bell clipped to Resident R1's bed was plugged into Resident R2's call bell socket. Further observation revealed that the call bell's call red button was missing and did not work.

Further observation revealed that call bell plugged into Resident R1's call bell socket was hanging over Resident R1's bed side table and was not within reach from Resident R1's and Resident R2's bed

Interview with Resident R2 conducted at the time of the observation, revealed that she had not been able to use her call bell because its broken and that it has been broken for a week now. Further interview with Resident R1 revealed that her broken call bell was the one that was clipped to her roommates' bed.

Interview with first floor unit manager Employee E4 conducted at the time of the observation confirmed that Resident R1 and Resident R2's call bells were switched. Further Employee E4 also confirmed that resident R1's call bell was hanging over her bedside table and was not within reach from both Resident R1's bed and R2's bed.

Further Employee E4 also confirmed that the Resident R2's call bell button was missing the red button and that it was broken and cannot be used. Further Employee E4 also revealed that sometimes the call bell button breaks.

Further observation revealed that Room 118 Resident R3's call bell was hanging over her bed side table and was not within her reach.

Interview with Employee E4 conducted at the time of the observation confirmed that Resident R3's call bell was hanging over her bedside table and was not within her reach.

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(12)(3) Nursing services

Plan of Correction - To be completed: 06/17/2024

The statements made in this Plan of Correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To maintain compliance with all federal and state regulation, the facility has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the facilities allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated.
R2's call bell has been repaired. The call bells for R1, R2, R3, and R4 were placed within reach of each resident.
The facility has determined that all residents have the potential to be affected.
The maintenance director completed a house wide audit to ensure all call bells were functioning properly. In addition, a house wide audit was completed to ensure every resident's call bell was within their reach. Staff members will be in-serviced to ensure call bells are within a resident's reach.
The Director of Nursing/ Designee will conduct five random audits of a resident's call bell to ensure that it is functioning properly and that it is within the resident's reach. This audit will be conducted weekly for four weeks and monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.

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