Nursing Investigation Results -

Pennsylvania Department of Health
PETER BECKER COMMUNITY
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


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PETER BECKER COMMUNITY
Inspection Results For:
There are 41 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.


PETER BECKER COMMUNITY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed on June 29, 2022, it was determined that Peter Becker Community 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 as they relate to the Health portion of the survey.

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 clinical record review and staff interview, it was determined that the facility failed to restorative ambulation services to maintain or improve mobility for two of 14 sampled residents. (Residents 16, 42)

Findings include:

Clinical record review revealed that Resident 16 had diagnoses that included difficulty in walking. The Minimum Data Set (MDS) assessment dated April 20, 2022, indicated that the resident was not cognitively impaired and required one person physical assistance to ambulate in the corridor. Review of the current care plan revealed that the resident was to receive a nursing restorative ambulation program to ambulate 100 to 150 feet with a wheeled walker and contact guard assistance from staff. During the Resident Council interview conducted on June 28, 2022, at 10:00 a.m., Resident 16 reported that she did not receive assistance with walking on a regular basis and that she would like to walk more. Documentation for the past 30 days on the nurse aide task sheets indicated that the resident was offered assistance walking in the corridor seven days and offered her restorative nursing program one day. There was a lack of evidence that she was offered assistance to walk on 22 of the past 30 days.

Clinical record review revealed that Resident 42 had diagnoses that included repeated falls. The Minimum Data Set (MDS) assessment dated June 9, 2022, indicated that the resident required one person physical assistance to ambulate in the corridor. On August 20, 2021, the physical therapist recommended that she receive a restorative nursing program for ambulation. Review of the current care plan revealed the resident was to receive a nursing restorative ambulation program to ambulate 90 to 100 feet with contact guard and a rolling walker. During the Resident Council interview conducted on June 28, 2022, at 10:00 a.m., Resident 42 reported that she did not receive assistance with walking on a regular basis and that she would like to walk more. There was a lack of evidence that the resident was offered her restorative ambulation program or assisted to walk in the corridor during the 30 day period prior to June 28, 2022.

During an interview on June 29, 2022, at 10:59 a.m., the Therapy Manager reported that residents on a restorative ambulation program should be assisted to walk daily.

28 Pa. Code 211.12(d)(1)(3) Nursing services.

Plan of Correction - To be completed: 07/29/2022

Plan of Correction:
Preparation and/or execution of this plan does not constitute admission or agreement by the provider that a deficiency exists. This response is also not to be construed as an admission of fault by the facility, its employees, agents or other individuals who draft or may be discussed in this response and plan of correction. This plan of correction is submitted as the Facility's credible allegation of compliance

Residents 16 and 42 did not have any complications from observation. Education to nursing staff on restorative ambulation program and documentation by 7/18/22.
Audits to be completed by DON/Designee on current residents who are on restorative ambulation program to ensure compliance, weekly times four then monthly times 4. Results will be presented at the QAPI meeting for further recommendations as indicated.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on facility policy review, observation, and staff interview, it was determined that the facility failed to ensure appropriate storage and timely disposition of expired medications on one of four nursing units. (Aster Avenue)

Findings include:

Review of the facility policy entitled, "Medication Storage in the Facility," revealed that outdated medications were to be immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order existed. When the original seal of a manufacturer's container or vial broken, the container or vial would be dated. The nurse should date the "do not use after" sticker on the medication.

Observation of the medication cart on Aster Avenue nursing unit on June 28, 2022, at 10:00 a.m., revealed a container of ipratropium-albuterol solution (a breathing treatment) that was open and not dated and a blister pack of hydrocodone acetaminophen (a pain medication) with an expiration date of April 30, 2022. During the same observation, the medication refrigerator in the medication room on Aster Avenue nursing unit contained a package of lorazepam (an antianxiety medication) that was open and not dated. In an interview during the observation, LPN 1, stated that the ipratropium-albuterol solution should have been dated after opening, the hydrocodone acetaminophen should have been destroyed, and the lorazepam should have been dated after opening.

28 Pa. Code 211.9(h)(i)Pharmacy services.

28 Pa. Code 211.12(d)(1)(2)(3)(5)Nursing services.

Plan of Correction - To be completed: 07/29/2022

No residents had complications from the observation.
Education to nursing staff regarding medication storage policy by 7/18/22.
Audits will be completed by DON/Designee on all medications to ensure that appropriate storage and timely disposition of expired medications is adhered to. Weekly audits times 4, then monthly times 4.
Results will be presented at the QAPI meetings for further discussion and or follow up.

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