Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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MARIAN MANOR CORPORATION - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint and an incident completed on March 26, 2024, at Marion Manor, it was determined that no deficiencies were identified under the 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 for 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.
Based on review of facility policy and investigative documents, it was determined that the facility failed to provide a safe environment for one of three residents reviewed for a resident getting a burn from a hot pack (Resident R1). This was identified as a past non-compliance.

Findings include:

Review of facility policy "Incident" dated 4/27/23, indicated " an unusual occurrence is defined as an undesirable event which is inconsistent with routine care of a particular resident."

Review of the clinical record indicated Resident R1 was admitted on 2/23/24.

Review of clinical documentation admit sheet indicated Resident R1 had diagnosis of diagnosis of displaced intertrochanteric fracture of left femur (type of hip fracture or broken hip), muscle weakness, and COPD (blocking air from lungs).

Review of facility documentation indicated: on 3/11/24, Resident R1 had an open area on left hip that appeared to be a burn. Resident R1 family reported to the facility that they put an instant hot pack on Resident R1's hip.

Review of facility documentation indicated that Resident R1's family received the instant hot pack from a staff member, they were offered a towel for the hot pack but declined, the order. Per documentation Resident R1 family member applied the hot pack directly to the skin and then left the room, upon returning Resident R1 stated that their hip was stinging.

During an interview on 3/26/24, at approximately 1:17 p.m., Resident R1's family member confirmed she applied the instant hot pack, that was requested and received from Nurse Aide (NA)Employee E1. Employee E1 offered them a towel for the instant hot pack but she declined the towel and put the instant hot pack to Resident R1's hip without a barrier.

Review of facility documentation indicated the following:

Treatment was ordered for the resident with no additional adverse effects noted to the resident.
Hot packs were received from the treatment rooms and staff education was provided by Assistant Director Of Nursing (ADON)/Designee. The aide was educated by agency employer with certificate provided of completion to facility, Verbal education provided to therapy as well, although they do not utilize.
On-going order reviewed if hot pack ordered by physician therapy will be notified for application and monitoring. If required for off shifts Director Of Nursing (DON)/ADON will be notified and process determined with supervisor.
Random checks of treatment rooms are observed during rounds to ensure heat packs are not located on nursing units.
Sign off sheets for training of Registered Nurse (RN)/Licensed Practical Nurse (LPN) and Nurse Aides were trained on the updated policy and procedure for using instant hot packs.
All instant hot packs were removed from the treatment rooms.
All corrective action was completed by 3/13/24.

Observations on all nursing units confirmed that the treatment rooms no longer contained instant hot packs.

During an interview on 3/26/24, at 12:55 p.m., NA Employee E1 confirmed that he/she was retrained on abuse/neglect/misappropriation, and the appropiate procedure for providing a hot pack to a resident.

During an interview on 3/26/24, at 2:50 p.m. Nursing Home Administrator (NHA) confirmed that Resident R1 had a burn on their hip from placement of an instant hot pack. The hot pack was requested by the family and placed on the resident by the family. The family was offered a towel place the instant hot pack in but refused. The family was re-educated regarding using an instant hot pack. Staff were re-educated about using an instant hot pack. The facility removed all the hot packs from the treatment rooms. Staff were re-educated about policy and procedure for using hot packs.

During an interview on 3/26/24, at 3:00 p.m. the NHA confirmed that the facility failed to provide a safe environment for Resident R1 who received a burn from an instant hot pack at the facility.

28 Pa. Code: 201/14(a) Responsibility of licensee.

28 Pa. Code: 211.12 (d)(1)(2)(5) Nursing services.

 Plan of Correction - To be completed: 04/02/2024

Past noncompliance: no plan of correction required.

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