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

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

There are  206 surveys for this facility. Please select a date to view the survey results.

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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 unannounced abbreviated survey in response to one complaint, completed on March 15, 2024, it was determined that Providence Rehab and Healthcare Center 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:


483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:
Based on review of facility policy, review of clinical records, interview with staff and residents, it was determined the facility failed to ensure that Resident records were complete and accurately documented regarding wound care treatments for one resident reviewed (Resident R1).

Findings include:

Review facility policy on Wound Care reveals that under section "Purpose": The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Under section "Documentation": The following information should be recorded in the residence medical record #1. the type of wound care given #2. date and time that wouldn't care was given #3. Position in which the resident was placed #4. The name and title of the individual performing the wound care #5. Any changes in residence condition #6. All assessment data (example wound bed collar size, drainage, etc.) obtained with inspecting the wound. #7. How the resident tolerated the procedure #8. and the problems are complaints made by the resident related to the procedure #9. If the resident refused the treatment and the reason why #10. Signature and title of the person recording the data.

Review of Resident's clinical r cord revealed that resident was admitted to the facility on December 13, 2023, with diagnoses of but not limited to Adult Failure to Thrive, Chronic Kidney Disease stage IV, Essential hypertension, muscle wasting and muscle weakness.

Review of physician's orders revealed an order for the following:
-Sacrum: cleanse sight with NSS (normal saline solution), pat dry, apply Desitin and foam dressing 2x daily every day and evening shift for wound care AND as needed for soiled/falling off. ordered December 15, 2023, and discontinued on December 27, 2023.
-Dakins (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to sacrum topically every day and evening shift for wound care Cleanse area with NSS, Pack with 1/4 strength Dakins soaked gauze, Cover with CDD (clean dry dressing) AND Apply to sacrum topically as needed for soiling or falling off Cleanse area with NSS, Pack with Dakins soaked gauze,-ordered December 28, 2023 and was discontinued on January 1, 2024.

Review of Resident R1's TAR (treatment administration record) for Sacrum: cleanse sight with NSS, pat dry, apply Desitin and foam dressing 2x daily every day and evening shift for wound care and as needed for soiled/falling off revealed that there was no nurse's initial entered on the TAR box for December 15, 2023, evening shift and December 22, 2023 evening shift revealed that there was no nurse's initial entered on the TAR box for December 15, 2023 evening shift and December 22, 2023 evening shift indicating that the treatment was not completed.

Review of Resident R1's TAR (treatment administration record) for Dakins (1/4 strength) External Solution 0.125 % (Sodium Hypochlorite) Apply to sacrum topically every day and evening shift for wound care Cleanse area with NSS, Pack with 1/4 strength Dakins soaked gauze, Cover with CDD AND Apply to sacrum topically as needed for soiling or falling off Cleanse area with NSS, Pack with Dakins soaked gauze revealed that there was no nurse's initial entered on the TAR box for December 28, 2023 evening shift indicating that the treatment was not completed.


28 Pa. Code 211.12(d)(1) Nursing services


 Plan of Correction - To be completed: 04/15/2024

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.

R1 is no longer a resident in the center.
The facility has determined that all residents have the potential to be affected.
Licensed staff will be in-serviced on ensuring resident records are complete and accurately documented on regarding wound care treatments.
Director of Nursing/ Designee will conduct five random audits of residents to ensure that their records are complete and accurately documented on regarding wound care treatments. 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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