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 September 25, 2019, 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(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on closed clinical record review, and staff interview, it was determined that the facility failed to initiate a restorative range of motion program and evaluate a strengthening program recommended by therapy for one of four residents reviewed (Resident CR1).

Findings include:

Interview with the Director of Nursing on September 25, 2019, at 2:00 PM revealed that the facility does not have a policy or procedure regarding the facility's restorative nursing programs.

Review of Resident CR1's closed clinical record revealed that physical therapy discontinued services for her on July 3, 2019. A review of the physical therapy discharge summary revealed that therapy recommended a restorative program of active range of motion to prevent a decline. There was no documented evidence in Resident CR1's closed clinical record to indicate that the facility initiated or carried out the recommendation of an active range of motion program from therapy.

Review of Resident CR1's "Rehab Discharge Program-Physical Therapy" form dated July 2, 2019, indicated that Resident CR1 was to be on a restorative program for lower range of motion and strengthening. The form designates that the exercise program is attached. The form was signed by two staff members, a nurse aide and a licensed nurse, indicating that they were trained on the program. Two pages of the strengthening program were signed by Resident CR1 and consisted of six exercises that were to be done daily.

There was no documented evidence in Resident CR1's closed clinical record to indicate that the strengthening program recommended by physical therapy was completed by Resident CR1 daily.

Nursing documentation dated August 16, 2019, at 1:21 PM revealed that Resident CR1 would not straighten her right knee. Nursing documentation dated August 17, 2019, at 10:24 revealed that Resident CR1 was, "still keeping right knee bent at a ninety-degree angle."

Interview with the Director of Nursing on September 25, 2019, at 1:30 PM, confirmed the above findings for Resident CR1.

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited 8/22/19


 Plan of Correction - To be completed: 10/02/2019

1. Resident CR1 no longer resides in the facility
2. The facility will initiate a restorative ROM program and evaluate a strengthening program as recommended by therapy. A 30 day look back of RNPs was competed to ensure residents who were affected by this alleged deficient practice had ROM programs and strengthening programs were put into task record.
3. Therapy and nursing staff will be educated on ROM and strengthening programs.
4. Audits to ensure ROM and strengthening programs recommended by therapy are in place and documented on will be performed by DON or designee 5x/week x 4 weeks, 3x/week x 4 weeks, then 1x/week x 4 weeks. Results will be presented at QAPI meetings for review and follow up as recommended.


483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to assess and monitor acceptable parameters of nutritional status for one of four residents reviewed for nutritional concerns (Resident CR1).

Findings include:

The policy entitled "Weight and Nutrition Guidelines," last reviewed without changes on December 27, 2018, indicates that the goal of the policy is to ensure that each resident maintains acceptable parameters of nutritional status and to ensure that residents with significant weight change and those at risk for weight loss are identified and an appropriate plan of care is developed. The policy does not indicate how a resident will be assessed for a significant weight loss, what interventions would be implemented, who should be notified of the weight loss, or if a reweight would be completed.

The policy also indicated that a resident who weighs 100 pounds or less will be weighed weekly unless the weight is within their usual body range and the resident is stable.

A nutritional note dated May 31, 2019, at 9:01 AM indicated that Resident CR1's goal was to maintain a body weight of 130 pounds plus or minus three percent.

Review of the closed record for Resident CR1's weights revealed that the facility weighed her on June 16, 2019 at 132.2 pounds. The facility weighed Resident CR1 again on July 3, 2019, at 95.8 pounds, a 27.5 percent severe weight loss in two weeks. There was no documented evidence to indicate that the facility completed a reweight or initiated weekly weights on Resident CR1, verifying the accuracy of Resident CR1's July 3, 2019 weight.

The facility did not weigh Resident CR1 again until August 1, 2019, at which time she weighed 112.6 pounds, which was a 14.6 percent significant weight loss in seven weeks. There was no documented evidence in Resident CR1's closed clinical record to indicate that the facility completed a nutritional assessment, notified her physician, or implemented any dietary interventions for her weight loss.

Interview with the Director of Nursing on September 25, 2019, at 1:32 PM, confirmed the above findings for Resident CR1.

28 Pa. Code 211.6(d) Dietary services
Previously cited 8/22/19

28 Pa. Code 211.10(c) Resident care policies
Previously cited 8/22/19

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 8/22/19


 Plan of Correction - To be completed: 10/02/2019

1. Resident Cr1 no longer resides in the facility
2. The facility will assess and monitor acceptable parameters of nutritional status. A 30 day look back was completed to ensure significant weight losses were reported to MD and dietitian and residents under 100 lbs were placed on weekly weights.
3. Dietitian and nursing staff will be educated on assessment and monitoring acceptable parameters of nutritional status.
4. Audits to ensure assessment and monitoring of weights will be completed by don or designee 3x/week x 4weeks, 1x/week x 4 weeks, then monthly x 1 month. Results will be presented at qapi meetings for review and follow up as recommended.


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