Nursing Investigation Results -

Pennsylvania Department of Health
WATSONTOWN REHABILITATION AND NURSING CENTER
Patient Care Inspection Results

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WATSONTOWN REHABILITATION AND NURSING CENTER
Inspection Results For:

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WATSONTOWN REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on April 8, 2022, it was determined that Watsontown Rehabilitation and Nursing Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 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, review of select policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate falls regarding alarm use for two of four residents reviewed (Residents CR1 and 3).

Findings include:

Review of the facility's current policy entitled "Quality of Care-Accidents" indicates that the facility will provide supervision and assistance devices to residents to avoid preventable accidents. When a resident experiences a fall, the facility will evaluate potential causal factors to aid in the development and implementation of relevant, consistent, and individualized interventions to reduce the likelihood of future occurrences.

Review of Resident CR1's closed clinical record revealed nursing documentation dated February 18, 2022, at 3:05 PM that indicated the facility was adding alarms to Resident CR1's bed and chair. The facility implemented this intervention in response to Resident CR1's previous fall.

Nursing documentation dated March 14, 2022, at 7:20 AM indicated that at 6:30 AM, Resident CR1 was noted to be lying in his bathroom. Resident CR1's bed alarm was not sounding. Review of the facility's investigation into Resident CR1's fall did not include documented evidence to indicate that the facility evaluated the reason behind his bed alarm not sounding.

Review of Resident 3's clinical record revealed nursing documentation dated February 3, 2022, at 6:38 PM that indicated he fell out of his wheelchair while seated in the dining room. The nursing note indicated that Resident 3's alarm did not sound after he fell onto the floor. Review of the facility's investigation into Resident 3's fall did not include documented evidence to indicate that the facility evaluated the reason behind his alarm not sounding.

Nursing documentation dated February 19, 2022, and again on March 4, 2022, indicated that Resident 3 was found on the floor by his bed. Review of the facility's investigations into Resident 3's falls from bed did not include documented evidence to indicate that the facility evaluated the reason behind his alarms not sounding.

Interview with the Administrator and Director of Nursing on April 8, 2022, at 12:45 PM confirmed the above findings.

28 Pa. Code 201.18 (e)(1) Management

28 Pa. Code 211.10(d) Resident care policies


 Plan of Correction - To be completed: 04/18/2022

F689
1. Resident CR1 no longer resides in the facility. At the time of post fall investigation, alarm checks were retimed to q 4hr.
Resident 3 was reviewed, alarms are functioning and alarm checks were retimed to q4hr before the date of compliance.
2. A 2 week look back of falls with alarms was conducted to ensure alarms were functioning and alarm checks were retimed for q 4 hr.
3. DON and NHA will be educated on investigation of accidents and hazards by regional director. Residents that experience a fall with an alarm enlisted as a fall prevention measure will have q 4 hr alarm checks completed.
4. DON or designee will audit falls with alarms to ensure proper investigation and intervention in place 3x/wk x 4wks then 1x/wk x 4 wks then monthly x1 results will be shared with the QAPI Committee.


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