Nursing Investigation Results -

Pennsylvania Department of Health
IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE
Inspection Results For:

There are  89 surveys for this facility. Please select a date to view the survey results.

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IMMACULATE MARY CENTER FOR REHABILITATION & HEALTHCARE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated Survey in response to two complaints, completed on September 13, 2019, it was determined that Immaculate Mary Center for Rehabilitation and Healthcare, was not in compliance with 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 as it relates to the health portion of the survey process.











 Plan of Correction:


483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:


Based on observation, review of clinical record, and review of manufacturer's instructions, it was determined that the facility failed to developed a care plan with measurables goal and objectives for the use of an assistive device for one of 39 residents reviewed. (Resident R28)

Findings include:

Review of Broda manufacturer's instructions revealed "Survey readiness guide-Broda durable medical equipment" stated "Review and document continued need of thigh belt at each care plan meeting following the placement of the thigh belt. All treatment, equipment, medication, etc. must be documented in the patient's individualized care plan prior to being given."

Review of the clinical record for Resident 28 revealed that resident was admitted to the facility on May 16, 2018 with diagnoses including but not limited to Huntington's disease (Disease of the central nervous system. Characterized by involuntary muscle movement.)

Observation of Resident R28 on September 11, 2019 at approximately 11:43 a.m. revealed that Resident R28 was seated on the Broda chair (a special type wheelchair to improve positioning and safety) with the thigh belt in place (a belt that is applied around upper thighs and buckled to the back of the Broda chair to prevent resident injury from falls).

Review of care plan for Resident R28 revealed no evidence that facility has developed and implemented a comprehensive care plan with measurable goals and interventions related to the use of thigh belt for Resident R28.

Interview with Director of Nursing on September 12, 2019 at approximately 2:00 p.m. confirmed that Resident R28's care plan contained no evidence that facility developed a comprehensive care plan related to the use of thigh belt.

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 08/12/19, 03/12/19, 03/21/19, 08/24/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/12/19, 03/21/19, 08/24/18

28 Pa. Code 211.10(d) Resident care policies
Previously cited 08/12/19, 03/21/19, 03/12/18

28 Pa. Code 211.11(a) Resident care plan

28 Pa. Code 211.11(d) Resident care plan






 Plan of Correction - To be completed: 10/22/2019

Resident R28 Comprehensive Plan of Care was reviewed and revised to reflect person centered objectives, goals and interventions as it relates to her assistive device/ Huntingdon's Broda durable medical equipment/ chair

A review of residents' comprehensive care plans was reviewed for measurable goals and objectives in regards to the use of an assistive device which revealed no deficient practice

Licensed staff was educated on developing and implementing comprehensive care plans with objectives, measurable person-centered goals and interventions related to assistive device use. Residents comprehensive care plan will be initiated and reviewed upon admission, quarterly, and with any changes in resident's status. Plan of care will be reviewed and revised and reflective of assistive device.

DON/Designee or designee will complete an audit of resident who utilize safety devices to ensure their care plan is comprehensive. Audits will be reviewed through the QAPI process to identify any trends and determine the need to continue audits

483.25 REQUIREMENT Quality of Care: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.
483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on observation, clinical record review and staff interview, it was determined that the facility failed to follow physcian's order related to the use of a wheelchair device for one of 39 residents reviewed. (Resident R28)

Findings reviewed:

Review of the clinical record for Resident 28 revealed that resident was admitted to the facility on May 16, 2018 with diagnoses including but not limited to Huntington's disease (Disease of the central nervous system. Characterized by involuntary muscle movement.) and depression (Major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or routine).

Review of clinical record for Resident R28 revealed a physician's order dated May 30, 2018 which stated, "When out of bed to the wheelchair, release leg strap every two hours and assess skin integrity every two hours for positioning."

Observation conducted of Resident R28 on September 11, 2019 at approximately 11:43 a.m. revealed that Resident R28 was seated on Broda chair (a special type wheelchair to improve positioning and safety) with the thigh belt in place (a belt that is applied around upper thighs and buckled to the back of the broda chair to prevent resident injury from falls).

Interview with the Registered Nurse Assessment Coordinator, Employee E on September 12, 2019 at approximately 12:00 p.m. confirmed that resident R28's physician's orders did not contain an order for thigh belt and Resident R28 was not wearing a leg strap as ordered by the physcian.

Interview with Director of Nursing on September 13, 2019 at approximately 9:00 a.m. confirmed that the physician's order for the leg strap for Resident R28 should have been clarified as thigh belt with the physician.

28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 08/12/19, 03/12/19, 03/21/19, 08/24/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/12/19, 03/21/19, 08/24/18

28 Pa. Code 211.10(d) Resident care policies
previously cited 08/12/19, 03/21/19, 03/12/18




 Plan of Correction - To be completed: 10/22/2019

Resident R28 physicians' orders were reviewed and revised to reflect manufacturers characteristics of Huntingdon's Broda Chair Package.

Review of resident's physician orders was completed regarding safety devices which revealed no deficient practice.

Staff educated on implementation of physician orders in regards to wheelchair devices / wheelchair packages per manufactures instructions. Unit Manager/Designee will monitor residents transport device orders routinely to ensure they are written in a manner that meets manufacturer characteristics.

DON/Designee will complete an audit of transport device orders to ensure they meet manufacturers characteristics weekly x 4. Audits will be reviewed through the QAPI process to identify any trends and determine the need to continue audits.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on observations, review of clinical records, staff interviews and review of manufacturer instruction, it was determined that the facility failed to conduct an assessment for the use of a thigh belt device for one of 39 residents reviewed. (Resident R28)

Findings include:

Review of Broda manufacturer instruction "Survey readiness guide-Broda durable medical equipment" stated "Written orders from the patients' Attending Physician, Physical Therapist, Nurse Practitioners or other qualified care providers are required prior to the order/placement or initiation of medical equipment, medicines and other treatments. Review and document continued need of thigh belt at each care plan meeting following the placement of the thigh belt. All treatment, equipment, medication, etc. must be documented in the patient's individualized care plan prior to being given."

Review of the clinical record for Resident 28 revealed that resident was admitted to the facility on May 16, 2018 with diagnoses including but not limited to Huntington's disease (Disease of the central nervous system. Characterized by involuntary muscle movement.) and depression (Major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or routine).

Observation of Resident R28 on September 11, 2019 at approximately 11:43 a.m. revealed that Resident R28 was seated on the Broda chair (a special type wheelchair to improve positioning and safety) with the thigh belt in place (a belt that is applied around upper thighs and buckled to the back of the Broda chair to prevent resident injury from falls).

Review of the entire clinical record for Resident R28 contained no evidence that facility conducted an initial assessment and on-going re-evaluations for the use of thigh belt device.

Interview with Director of Nursing on September 13, 2019 at approximately 9:00 a.m. confirmed that Resident R28's clinical record contained no evidence that facility conducted initial evaluation and on-going re-evaluations for the use of thigh belt.


28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 08/12/19, 03/12/19, 03/21/19, 08/24/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/12/19, 03/21/19, 08/24/18

28 Pa. Code 211.10(d) Resident care policies
previously cited 08/12/19, 03/21/19, 03/12/18











 Plan of Correction - To be completed: 10/22/2019

Resident R28 had an assessment initiated for the use of the thigh belt now characterized as Huntingdon's Broda Package.

House audit was completed to assess if any other residents were utilizing safety devices and the results of the audit concluded no other resident has a device.

Nursing staff were educated on safety device policy. Unit manager /designee will monitor the use of safety devices and routinely document the need for the device in the medical record.

DON/designee will audit safety devices and documentation weekly x 4 to ensure proper documentation is in place if applicable. Audits will be reviewed though the QAPI process

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 observation of medication administration, staff interview and review of facility's policy and procedures, it was determined that the facility failed to ensure proper hand washing during the administration of medications for four of four residents observed. (Residents R 155, R 217, R 219, R 221)


Findings include:

Reviewed the facility policy and procedure title "Hand Hygiene" revised 03/2019 revealed "All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to other personnel, residents and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap may also be utilized for washing/hand hygiene. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Observations conducted on September 11, 2019 at 8:27 a.m. duruing medication administration revealed licensed nursing staff, Employee E4 removed Resident R217's meal tray off the bedside table and place it in the food truck.

Licensed nursing staff, Employee E4 then returned to the medicine cart, documented the medicine given to Resident 217 then removed the blood pressure cuff from medicine cart and took Resident R219 blood pressure. After obtaining the blood pressure licensed nursing staff, Employee E4 did not wash hands or use hand sanitizer and proceeded to pour a medication for Resident R219.


The facility failed to ensure that the staff adhere to infection control procedures related to hand hygiene.



28 Pa. Code 211.12(d)(1) Nursing services
Previously cited 08/12/19, 03/12/19, 03/21/19, 08/24/18

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 03/12/19, 03/21/19, 08/24/18





 Plan of Correction - To be completed: 10/22/2019

Residents R155, R217, and R221 were Monitored closely for signs and symptoms of infection that may have been spread through the administration of medications by a nurse who failed to use the proper hand hygiene during her medication pass. The nurse who was observed administering medications to residents: R155, R217, and R221 without following the hand hygiene procedure received one to one training on proper hand hygiene with positive return demonstration.

Facility did not identify any further occurrences of the deficient practice that was observed during the medication pass including residents R155, R217, and R221.

Facility will be educating staff on the Hand Hygiene policy. All participants in the in-service education will return a positive demonstration of proper hand washing technique. Infection control preventionist or designee will monitor had hygiene routinely throughout the facility.

Random observations by the ADON and or designee will be conducted weekly X four weeks to ensure that the proper hand hygiene procedures are being followed. Results of the random audits will be discussed through QAPI to identify if there are any trends and to determine if the need to continue the random audits exists.


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