Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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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 March 26, 2021. Rehabilitation & Nursing Center at Greater Pittsburgh 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 a complaint survey completed on March 26, 2021, it was determined that Rehabilitation and Nursing Center of Greater Pittsburgh 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.

 Plan of Correction:

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Based on facility policy, clinical record review, and interview, the facility failed to follow a physcian's orders and facility policies for one of six residents (Resident R1).

A review of the facility policies "Prevention of Pressure Injuries" and "Pressure Injury Risk Assessment" dated 1/21/21, indicated the facility will provide structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries. The facility policy "Pressure Injury Risk Assessment" is to identify all risk factors and then to determine which can be modified and indicates risk factors include but are not limited to: under nutrition, impaired/decreased mobility, exposure of skin to urinary and fecal incontinence, end stage renal disease, thyroid disease and diabetes. The facility policy indicates that "repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition".

A review of the clinical record on 3/23/21, revealed that the resident R1 was admitted to the facility on 1/27/21, with diagnoses that included end stage renal disease (kidney disease) requiring dialysis, protein calorie malnutrition, congestive heart failure and diabetes. Review of the clinical record indicated resident R1 was incontinent and required extensive assistance with bed mobility (turning side to side and positioning in bed).

A review of the admission physician orders dated 1/21/21, indicated that Resident R1 was to have an initial pressure injury risk assessment (Braden assessment) to evaluate the risk of developing pressure injuries as well as weekly reassessment every Monday for an additional three weeks. Review of the Clinical record indicates it was completed on 1/28/21, and Resident R1 was determined to be at low risk for developing pressure injuries.

Facility records indicate the Braden scale was not completed on 1/25/21, or 2/1/21 as ordered. Facility records indicate on 2/4/21, Resident R1 was found to have a deep tissue injury to right heel, and orders to elevate heel off bed and treatments were instituted. Physician evaluation indicates this may or may not have been present at admission from the hospital. Additionally "excoriation" from moisture was noted on Resident R1's buttocks. Treatments were instituted but no Braden assessment was completed at that time. On 2/8/21, no weekly Braden assessment was completed as ordered.

Review of the clinical record dated 2/16/21, Resident R1 was noted to have additional skin alterations and breakdown of the left heel, and no Braden assessment was completed at that time.

During an interview on 3/23/21, at 4:14 p.m., the Nursing Home Administrator confirmed the facility failed to complete the Braden risk assessments as ordered, or based on the residents condition.

28 Pa. Code 201.14(a) Management.

28 Pa. Code 201.18(b)(1)(d)(1) Management.

28 Pa Code 211.5(f) Clinical records.

28 Pa Code 211.10(c)(d) Resident Care Policies.

 Plan of Correction - To be completed: 04/16/2021

Resident R1 has been discharged from this facility since 2/22/2021.

Braden assessment forms have been completed on all like residents residing in the facility. Orders were obtained for all residents within the facility to have a Braden assessment completed for the next three weeks to reflect four weeks of Braden evaluations. New admission orders were verified to have an initial Braden score established as well as three concurrent Braden Evaluations scheduled weekly.

Director of Nursing and/or facility designee will conduct audits of the Braden Form completion of ten residents weekly to ensure staff is complying with facility policy. These audits will be conducted on ten random residents twice weekly for four weeks, then once per month for two months or until 100% compliance is maintained.

The results of these audits will be presented to the Quality Assurance and and Quality Improvement program quarterly for one quarter for tracking, trending, and assessment of interventions.

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