Nursing Investigation Results -

Pennsylvania Department of Health
THE PINES AT PHILADELPHIA REHABILITATIONANDHEALTHCARE CENTER
Patient Care Inspection Results

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THE PINES AT PHILADELPHIA REHABILITATIONANDHEALTHCARE CENTER
Inspection Results For:

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THE PINES AT PHILADELPHIA REHABILITATIONANDHEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to one complaint, completed on June 30, 2022, it was determined that The Pines at Philadelphia Rehabilitation and Healthcare Center 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 related to the health portion of the survey process.



 Plan of Correction:


483.21(a)(1)-(3) REQUIREMENT Baseline 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 Comprehensive Person-Centered Care Planning
483.21(a) Baseline Care Plans
483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility did not develop a person-centered baseline care plan related to pressure ulcer care within 48 hours of a resident's admission for two of seven records reviewed (Residents R2 and R5).

Findings include:

Review of facility policy titled "Care Plan" dated November 2021, revealed that it is the policy of the facility that "Baseline Care Plans for all new admissions will be initiated within 48 hours of admission," as well as including "initial goals, MD orders, medications, treatments, dietary orders, therapy orders, social services and PASARR recommendations."

Review of clinical documentation revealed that Resident R2 was admitted on June 4, 2022, with an unstageable pressure ulcer (where it is impossible to determine the level of tissue involvement due to wound characteristics) to his sacrum/coccyx (tailbone) area. He was readmitted following hospitalization on June 17, 2022. A nursing note dated June 4, 2022, stated that the patient had a "wound to coccyx." Orders were entered for "Santyl Ointment 250 Unit / Gram" on June 5, 2022, with instructions to "Apply to Sacral Wound topically every day shift for wound care." A nursing note dated June 17, 2022, stated "sacrum unstaged 1x1 utd center yellow slough." Also on June 17, 2022, orders were re-entered for the above treatment. As of June 30, 2022, no care plan had been developed for the care of the resident's sacral wound.

Review of clinical documentation revealed that resident R5 was admitted on June 24, 2022, with a stage 2 pressure ulcer (where the wound has gone through the top layer of skin exposing the lower layers of skin) to her sacrum. A nursing note dated June 25, 2022, stated "Resident's skin is noted with wound/skin breakdown as evidenced by pressure related skin impairment, treatment in progress, on turning and repositioning as per protocol." A treatment order was entered on June 24, 2022, stating "Dressing Change Sacrum clean with normal saline, pat dry apply medi- honey, cover with boarder gauze. one time a day for sacrum wound." As of June 30, 2022, no care plan had been developed for the care of the resident's sacral wound.

Interview with Director of Nursing and Nursing Home Administrator on June 30, 2022, at 1400 confirmed that a baseline care plan for wound care for these two residents should have been developed within 48 hours of their admission but was not.

28 Pa. Code 211.11(a)(b)(c)(d) Resident care plan.



 Plan of Correction - To be completed: 07/04/2022

F0655

1) Resident R2 and R5 suffered no ill effect from the deficient practice and no action could be taken due to both residents being discharged from the facility.
2) Any resident admitted with a pressure wound are at risk to be affected by the deficient practice. An audit was completed on all residents with a pressure ulcer to make sure all baseline care plans are in place.
3) The baseline care plan policy was reviewed and updated. All nurses were re-educated on the base line care plan policy with special focus on admissions with pressure ulcers.
4)All new resident's assessments will be audited by DON or designee within 48 hours of admission and special attention will be paid to admission skin assessments for 90 days and then random audits will continue. The results will be reported to QAPI for the next quarter.

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 clinical record review and interview with staff, it was determined that the facility did not develop a comprehensive care plan related to pressure ulcer care for two of seven records reviewed (Residents R1 and R4).

Findings include:

Review of facility policy titled "Care Plan" dated November 2021 revealed that it is the policy of the facility that care plans are to include "initial goals, MD orders, medications, treatments, dietary orders, therapy orders, social services and PASARR recommendations," and that they "will be updated timely and necessary revisions will be made."

Review of clinical documentation revealed that resident R1 was admitted to the facility on May 11, 2022 with a stage 4 pressure ulcer (which has gone through skin and fat and exposed the muscle or bone) to her sacrum. A nursing note dated May 11, 2022, stated "Sacral wound in place with eschar noted to wound bed." Orders were entered on May 11, 2022 stating "Sacrum every day shift cleanse with NSS, pat dry, apply no sting to periwound," (the area around a wound) "apply medihoney to wound bed, cover with Ca+ alginate," (an absorbent wound dressing which controls fluids and promotes healing) "and foam dressing." The resident was discharged on June 13, 2022. Review of the resident's care plan history revealed that no care plan was developed for the resident's wound care.

Review of clinical documentation revealed that Resident R4 was admitted to the facility on April 1, 2022. Facility acquired stage 3 pressure ulcers (which has gone through the skin and exposed the fat layer) of his left and right buttocks were identified in a wound consult note dated May 4, 2022. Orders were entered on May 4, 2022, stating "B/L" (bilateral- both sides) "buttock every day shift cleanse with NSS, pat dry, apply medihoney to wound bed; then Ca alginate and cover with CDD," (clean dry dressing) "until healed." The resident was discharged on May 30, 2022. Review of the resident's care plan history revealed that no care plan was developed for the resident's wound care.

Interview with Director of Nursing and Nursing Home Administrator on June 30, 2022, at 1400, confirmed that a care plan for wound care for these two residents should have been developed but was not.

28 Pa. Code 211.11(d) Resident care plan.



 Plan of Correction - To be completed: 07/04/2022

F0656

1)Resident R1 and R4 suffered no ill effect of the missing care plan because appropriate treatment was taking place. No additional action could be taken at the time of the survey due to both residents being discharged from the facility.
2)Any Resident admitted with a pressure wound are at risk to be affected by the deficient practice. An audit was completed on all residents with a pressure ulcer to make sure all comprehensive care plans are in place.
3)The comprehensive care plan policy was reviewed and updated. All nurses were re-educated on the comprehensive care plan policy with special focus on residents with pressure ulcers.
4)DON or designee will audit care plans of residents with identified wounds to make sure comprehensive care plan is in place weekly x 4 weeks, monthly x4 and then quarterly x 4.

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