§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.
§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.
§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
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Observations:
Based on clinical record review, resident interview, and observation, it was determined that the facility failed to provide timely assistance with care in a manner that maintained dignity for two of 24 sampled residents. (Residents 30, 86)
Findings include:
Clinical record review revealed that Resident 30 had mild cognitive impairment and required assistance from staff to get out of bed. According to the care plan, she also had depressed mood and would call out at times. The care plan indicated that staff was to respond to her requests for care and allow the resident to make decisions about her activities. On June 4, 2024, at 10:09 a.m., the resident was observed in bed and her call light was on. The resident stated, "I want to get out of bed." Between 10:09 and 10:38 a.m., the call light remained on, and several staff members walked by the room without assisting the resident. At 10:38 a.m., a staff member turned off the call light and left the room without assisting the resident. The resident began to call out, "Help me!" until staff assisted her at 11:07 a.m.
Clinical record review revealed that Resident 86 was incontinent of urine, was able to communicate her needs, and required assistance to use the toilet. According to the care plan, staff was to assist the resident to the toilet "frequently and upon request." On June 5, 2024, at 10:49 a.m., the resident turned on her call light. At that time she stated, "I need to use the bathroom." At 10:52 a.m., a nurse entered the room and turned off her call light without assisting her to the bathroom. Staff did not assist the resident until 11:30 a.m.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 07/08/2024
Department of Health Plan of correction for June 4th, 2024, preparation and /or execution of this Provider's Plan of Correction does not constitute admission or agreement of the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies as perceived by representatives of the Department of Health relative to the on-site survey concluded on June 6th, 2024. The provider's Plan of Correction is prepared solely because it conveys this sincere message of the governing body, as follow: All representative entities of Holy Family Manor("HFM") have been, are, and will be committed to providing the highest quality of care and services to the elderly, in accordance with, or exceeding all applicable local, state and/or federal laws/mandates regarding the operation of a Long-Term Care Facility in Pennsylvania. Representative entities of Holy Family Manor will evidentially substantiate compliance with all applicable local, state, and/or federal laws/mandates regarding operation of a Long-Term Care Facility in Commonwealth of Pennsylvania during the survey conducted subsequent to that concluded on June 6th, 2024.
All staff on the unit were immediately educated to respond to call bells in a timely manner. Resident(s) 30 and 86 were assisted and checked on after the observation on June 4th, 2024. Random call bell audits will be conducted on the unit three times a week for one month. Call bell timing will also be checked during our weekly managers walk-though. The Director of Nursing will report on the audit results during the Quality Assurance Performance Improvement meeting. This corrective action will be completed by July 8th, 2024.
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