Nursing Investigation Results -

Pennsylvania Department of Health
COUNTRY MEADOWS NURSING CENTER OF BETHLEHEM
Patient Care Inspection Results

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COUNTRY MEADOWS NURSING CENTER OF BETHLEHEM
Inspection Results For:

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COUNTRY MEADOWS NURSING CENTER OF BETHLEHEM - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Findings of an abbreviated survey in response to a complaint completed on December 13, 2021, at Country Meadows Nursing Center revealed that the facility 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 as they relate to the Health portion of the survey process.


 Plan of Correction:


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 clinical record review and staff interview, it was determined that the facility failed to ensure that safety interventions were implemented for one of four residents sampled. (Resident R1)

Findings include:

Clinical record review revealed that resident R1 had diagnoses that included atrial fibrillation and muscle weakness. On November 24, 2021, a physician directed staff to provide the assist of two staff members with all transfers of the resident from chair to bed. A note by a nurse on December 7, 2021, at 7:25 p.m., revealed that one staff member assited the resident with a transfer back to bed following toileting . Upon sitting on the bed, a large amount of blood was noted coming from a laceration on the resident's right lower extremity.

In an inteview on December 13, 2021, at 10:10 a.m., the Director of Nursing confirmed that the facility failed to ensure that two staff assited the resident with a transfer as ordered by the physician.

28 Pa. Code 211.12(d)(5) Nursing services.






 Plan of Correction - To be completed: 01/24/2022

I hereby acknowledge the CMS 2567-L issues to Country Meadows Nursing Center of Bethlehem for complaint survey ending 12/13/21 and attest that all deficiencies listed on the form will be corrected in a timely manner.
F0689 Free of Accidents
Bumpers were applied to bilateral side rails and underneath R1's bed to mitigate further injury. The staff member who transferred this resident was reeducated on transfer policies and procedures and given hands on education by the facility's DOR and DON on December 13, 2021. This staff member was also given progressive discipline and will be subject to termination if she fails to follow a resident's care plan or a physician's order in the future.
Nursing Administration will in-service staff regarding prevention of accidents and hazards with the importance following physician's orders for transfer status.
Nursing Administration will conduct observations weekly x4 weeks and monthly thereafter to ensure compliance with transfer orders. Non-compliance will be immediately addressed and remedied.
A written report will be submitted to the QAPI committee quarterly.
Subsequent reporting will be made to the Corporate Compliance Committee through the QAPI minutes.
Disclaimer:
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the department alleges are deficient under State and Federal regulations relating to long term care. This Plan of Correction should not be construed as either a waiver of the Facility's right to appeal and to challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violations of State and Federal regulatory requirements. I hereby acknowledge the CMS 2567-L issues to Country Meadows Nursing Center of Bethlehem for the complaint survey ending 12/13/21 and attest that all deficiencies


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