Nursing Investigation Results -

Pennsylvania Department of Health
RIDGEVIEW HEALTHCARE & REHAB CENTER
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
RIDGEVIEW HEALTHCARE & REHAB CENTER
Inspection Results For:

There are  137 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
RIDGEVIEW HEALTHCARE & REHAB CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a revisit and abbreviated complaint survey completed on March 9, 2022, it was determined that Ridgeview Healthcare and Rehab Center corrected the federal deficiencies cited during the survey of December 10, 2021, and February 3, 2022, under the requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care, but continued to be out of compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.








 Plan of Correction:


201.14(e) LICENSURE Responsibility of licensee.:State only Deficiency.
(e) The administrator shall notify the appropriate division of nursing care facilities field office as soon as possible, or, at the latest, within 24 hours of the incidents listed in Section 51.3 and subsection (d).
Observations:

Based on review of the facility's COVID-19 line listing, select facility policy and clinical records and staff interview, it was determined that the facility failed to notify the State Licensing Agency (PA Department of Health) of Covid-19 infections and outbreak involving 11 residents (Residents B2, B3, B4, B5, B6, B7, B8, B9, B10, B11 and Resident B12).

Findings include:

The facility policy indicted that the facility will follow Centers for Disease Control (CDC), local and/or State reporting guidelines for any possible Covid-19 infections in staff or residents.

Review of the facility's Covid-19 line listing (comprehensive list of residents and staff with positive Covid-19 infection testing) indicated the following positive resident COVID-19 tests:

Resident B2 tested positive on February 22, 2022
Resident B3 tested positive on February 22, 2022
Resident B4 tested positive on February 22, 2022
Resident B5 tested positive on February 22, 2022
Resident B6 tested positive on February 22, 2022
Resident B7 tested positive on February 22, 2022
Resident B8 tested positive on February 22, 2022
Resident B9 tested positive on February 22, 2022
Resident B10 tested positive on February 22, 2022
Resident B11 tested positive on March 1, 2022
Resident B12 tested positive on March 1, 22, 2022

The State Licensing Agency, PA Department of Health, Division of Nursing Care Facilities, Scranton Field Office was not notified of these positive resident tests as of the time of the survey ending March 9, 2022.

During an interview on March 9, 2022, at 1:45 PM the Director of Nursing confirmed that the facility had not reported the positive test results for resident Covid-19 infections to the State Licensing Agency as required.

.




 Plan of Correction - To be completed: 03/23/2022

1. THE STATE LICENSING AGENCY, PA DEPARTMENT OF HEALTH, DIVISION OF NURSING CARE FACILITIES HAVE BEEN NOTIFIED OF RESIDENT B2, B3, B4, B5, B6, B7, B8, B9, B10, B11, AND B12 POSITIVE COVID TESTING.
2. THE FACILITY WILL AUDIT THE LAST 30 DAYS OF THE COVID 19 LINE LISTING TO ENSURE NOTIFICATION TO THE STATE LICENSING AGENCY IS COMPLETE.
3. ADMINISTRATION/NURSING MANAGEMENT WILL BE EDUCATED ON THE PROPER TIME FRAME FOR NOTIFICATION TO THE DIVISION OF NURSING CARE FACILITIES WITH COVID POSITIVE REPORTING.
4. NHA/DESIGNEE WILL AUDIT THE COVID 19 LINE LISTING DAILY x 4 WEEKS, THEN WEEKLY x4 TO ENSURE TIMELY REPORTING TO THE DIVISION OF NURSING CARE FACILITIES. RESULTS WILL BE REPORTED TO QAPI COMMITTEE.
5. DATE OF POC 03.23.2022

211.10(c) LICENSURE Resident care policies.:State only Deficiency.
(c) The policies shall be designed and implemented to ensure that each resident receives treatments, medications, diets and rehabilitative nursing care as prescribed.
Observations:

Based on clinical record and select policy review, observation and staff and resident interview, it was determined the facility failed to implement its resident care policy for medication administration for one resident (Resident A2) and bowel protocol for one resident (Resident B1) of six residents sampled.

Findings include:

A review of the current facility policy for Medication Administration, revealed that medications ordered for a particular resident may not be administered to another resident unless permitted by state law or facility policy. Self-administration of drugs is permitted only when approved by the attending physician and the interdiscilinary care planning team.

A review of current physicians orders for Resident A2, dated March 2022, revealed an order for Kenalog lotion (a steroid lotion, applied topically) 0.025%, apply to legs, daily for dermatitis.

An observation March 9, 2022, at approximately 1 PM, in room 215 B, revealed a container of Kenalog 0.025% lotion with no prescription label. During an interview at the time of the observation, Resident A1 stated that this was the medicated lotion staff puts on his skin. He stated that nursing staff leave the medicated lotion at his bedside "all the time."

During an interview on March 9, 2022, at approximately 1:30 PM, the Director of Nursing confirmed that Resident A2 is not able to self-administer the observed medicated lotion to himself. The DON also stated that physician ordered medications should have pharmacy labels on them and should be stored in the locked medication cart. She confirmed that medications should never be left at the resident's bedside and that the facility failed to follow their policy regarding medication administration.

A review of the facility policy entitled Bowel Protocol, no date as reviewed, revealed it was the policy of the facility to assure that the residents had adequate elimination and action is taken to prevent or relieve constipation.

The bowel protocol is initiated when a resident goes three days without having a bowel movement (BM). The procedure includes the following but is not limited to:

The nurse will check the bowel elimination record daily.

If the resident has not had a BM in three days the nurse will assess the abdomen and administer Milk of Magnesia 30 MLs by mouth and place the resident on the 24 hour report sheet.

If there is no result achieved the nurse will administer one Dulcolax suppository per rectum the next day.

If no result is achieved the nurse will administer a fleets enema per rectum the following day.

If no result is achieved from the enema the nurse will notify the physician for further direction.

The nurse will document any communications assessments and interventions in the medical record as needed.

A review of the clinical record revealed that Resident B1 was admitted to the facility on February 18, 2022, with diagnoses to include bladder stones.

A review of Resident B1's bowel elimination record revealed that the resident did have a bowel movement from February 23, 2022, until March 1, 2022, six days without bowel activity.

A review of her medication record for February 2022 and March 2022 revealed that no evidence that the bowel protocol, MOM, Dulcolax, Fleets enema, was administered according to the facility Bowel Protocol policy.

The resident was admitted to the hospital on March 2, 2022 with vomiting.

An interview with the Director of Nursing on March 9, 2022 confirmed the facility failed to implement their resident care policy for administering the bowel protocol to resident without a bowel movement for more than three days.






















































































































 Plan of Correction - To be completed: 03/23/2022

1. O QARESIDENT A2 DOES NOT HAVE MEDICATIONS STORED AT THE BEDSIDE. RESIDENT B1 IS NO LONGER A RESIDENT OF THE FACILITY.
2. DON/DESIGNEE WILL AUDIT RESIDENT ROOMS TO ENSURE NO MEDICATIONS ARE STORED AT THE BEDSIDE WITHOUT THE APPROPRIATE SELF ADMINISTRATION OF MEDICATION PROTOCOLS IN PLACE. THE BOWEL PROTOCOL WILL BE MONITORED TO ENSURE ADEQUATE ELIMINATION AND ACTION IS TAKEN TO PREVENT OR RELIEVE CONSTIPATION.
3. NURSING STAFF WILL BE EDUCATED ON THE POLICY FOR SELF ADMINISTRATION OF MEDICATIONS AND THE BOWEL PROTOCOL POLICY.
4. DON/DESIGNEE WILL AUDIT THE SELF ADMINISTRATION OF MEDICATIONS/RESIDENT ROOMS AND THE BOWEL PROTOCOL WEEKLY x 4, THEN MONTHLY X 4 . ALL RESULTS WILL BE REPORTED TPI.
5. DATE OF POC 03.23.2022

211.10(d) LICENSURE Resident care policies.:State only Deficiency.
(d) The policies shall be designed and implemented to ensure that the resident receives proper care to prevent pressure sores and deformities; that the resident is kept comfortable, clean and well-groomed; that the resident is protected from accident, injury and infection; and that the resident is encouraged, assisted and trained in self-care and group activities.
Observations:

Based on a review of select facility policy and clinical records and staff interview, it was determined that the facility failed to implement their resident care policy for resident shower/tub baths to ensure residents are clean and well-groomed for two of 6 sampled residents (Resident A1 and B1).

Findings include:

A review of a current facility policy for "Resident Showers/Tub bath revealed that the purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. Residents will have a showers or tub baths at least two times each week or more often if requested by the resident, Physician or if the condition warrants. Document any communications, assessments and interventions in the medical record, as needed.

Clinical record review revealed that Resident A1 was admitted to the facility on February 7, 2022, with diagnoses to include dementia.

Admission Physicians orders dated February 7, 2022 included a order of a Shower or tub bath twice a week on Monday and Thursday, during the 3 PM to 11 PM shift.

A review of shower records for the month of February 2022 and March 2022 indicated that Resident A1 received only one shower during the resident's stay, on March 5, 2022.

There was no documented evidence that the resident had been showered or had a tub bath from the time of admission on February 7, 2022, until March 5, 2022.

During an inteview March 9, 2022 at approximately 2 PM, the Director of Nursing (DON) confirmed that the facility policy and physician orders were not followed for showering Resident A1.

A review of the clinical record of Resident B1 revealed admission to the facility on February 18, 2022 and had a physician's order for showers on Tuesdays and Thursdays on the 7 AM to 3 PM shift. The resident was transferred to the hospital on March 2. 2022.

A review f the resident's activity of daily living record revealed that the only evidence of a bathing activity was completed on February 28, 2022, but it could not be determined if the resident had been showered or received a tub bath.

An interview with the DON on March 9, 2022 at 2:00 PM confirmed that there was no evidence that the resident was showered twice weekly as ordered and that the documentation failed to identify the type of bathing activity that had occurred on February 28, 2022.






 Plan of Correction - To be completed: 03/23/2022

1. RESIDENTS A1 AND B1 HAVE BEEN PROVIDED SHOWERS AS PER ORDER.
2. THE FACILITY WILL AUDIT SHOWER SCHEDULES WEEKLY TO ENSURE BATHING OCCURS AS SCHEDULED/ORDERED.
3. NURSING STAFF WILL BE EDUCATED ON THE POLICY FOR RESIDENT SHOWER/TUB BATHS.
4. DON/DESIGNEE WILL AUDIT SHOWER COMPLETION WEEKLY x 4 WEEKS, THEN MONTHLY x 4 MONTHS, THEN AS DEEMED NECESSARY BY THE QAPI COMMITTEE. ALL RESULTS WILL BE REPORTED TO THE QAPI COMMITTEE.
5. DATE OF POC.03.23.2022


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port