Nursing Investigation Results -

Pennsylvania Department of Health
PHOENIX CENTER FOR REHABILITATION AND NURSING, THE
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
PHOENIX CENTER FOR REHABILITATION AND NURSING, THE
Inspection Results For:

There are  129 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.
PHOENIX CENTER FOR REHABILITATION AND NURSING, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an abbreviated survey completed on October 2, 2019 in response to two complaints at The Phoenix Center for Rehabilitation and Nursing 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 it relates to the health portion of the survey process.


 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on clinical record review, it was determined that the facility failed to provide appropriate interventions for the prevention of pressure ulcers and failed to timely identify a pressure ulcer resulting in actual harm to Resident CL5, who developed an unstageable pressure ulcer to the sacrum for one of 11 residents reviewed (Resident CL5).

Findings include:

Review of Resident CL5's clinical record revealed the resident was admitted to the facility on August 13, 2019 after sustaining a fall and a subsequent right femur fracture which required surgical repair.

Review of Resident CL5's Admission Minimum Data Set (MDS - periodic assessment of resident needs) dated August 20, 2019 revealed Resident CL5 had a Brief Interview for Mental Status Score of 8 indicating moderately impaired cognition, was frequently incontinent of bowel and bladder, and required extensive assistance from two staff members to reposition in bed. Further review of Resident CL5's Admission MDS also revealed the resident was at risk for developing pressure ulcers.

Review of Resident CL5's Physical Therapy Evaluation and Plan of Treatment dated August 13, 2019 identified the resident as needing moderate assistance for repositioning in bed.

Review of Resident CL5's care plan dated August 13, 2019 identified the resident as at risk for skin breakdown related to immobility with interventions including keep skin clean and dry, provide a pressure reducing mattress/air mattress when available and check the function every shift, and provide a well balanced diet. There were no interventions in place on the resident's risk for impaired skin breakdown addressing the resident's immobility and need for assistance with repositioning.

Review of Resident CL5's August 2019 Treatment Administration Record (TAR) revealed staff were documenting applying barrier cream to the resident's buttocks every shift starting on August 13, 2019.

Review of Resident CL5's admission assessment from August 13, 2019 identified the only skin concern as the resident's surgical incision to the right hip.

Review of Resident CL5's weekly skin assessment from August 20, 2019 identified no new skin concerns.

Review of Resident CL5's progress notes revealed a note dated August 26, 2019 which revealed Resident CL5 was now "noted with unstageable sacral wound measuring 3cm [(centimeters)] x 2.5cm x 0.1 cm with 100% slough [(separation of dead tissue from living tissue, yellow, tan, gray, green or brown)] noted at wound base. No drainage or odor noted. No complaint of pain at wound site. [Physician] and family aware. New orders noted. Air mattress to bed when available. Cleanse wound with [normal saline] apply santyl [(debriding agent)] and cover with dry dressing [daily], consult with wound care team, dietary consult." The resident's care plan dated August 13, 2019 indicated providing an air mattress when available, however 13 days later, on August 26, there was no air mattress in place and new orders for an air mattress were written on August 26, 2019.

Further review of Resident CL5's care plan revealed that the resident's plan of care for risk for impaired skin integrity was updated on August 26, 2019, the same day the sacral wound was discovered, with the intervention to encourage the resident to be out of bed during different intervals during the day and to encourage the resident to turn and reposition self every 2 hours. Prior to discovery of the sacral wound no interventions for repositioning were in place, despite Physical Therapy assessment which identified the resident as needing moderate assistance for repositioning in bed, and the MDS dated August 20, 2019 noting the resident's frequent incontinence of bowel and bladder, and that the resident required extensive assistance from two staff members to reposition in bed. .

The facility failed to provide appropriate interventions, including turning and repositioning, to prevent pressure ulcers from developing for Resident CL5, who was documented as needing moderate assisatance to extensive assistance with two staff members for bed mobility, and who was identified as being at risk for skin impairment due to immobility and frequent incontinence. The air mattress noted to be necesary on the care plan dated August 13, 2019 was not in place and was ordered again on August 26, 2019 when the unstagebale sacral wound was discovered, 13 days later. The facility also failed to identify and treat Resident CL5's sacral pressure ulcer before it became unstageable, even though staff documentation showed the application of barrier cream to the resident's buttocks area three times daily. This resulted in actual harm to Resident CL5 who developed an unstageable pressure ulcer to the sacrum.

The above information was conveyed to the Nursing Home Administrator and Director of Nursing on October 2, 2019 at approximately 3:15 p.m.

28 Pa. Code: 201.14(a) Responsibility of licensee
Previously cited 2/13/18, 8/28/18

28 Pa. Code: 201.18(b)(1) Management
Previously cited 8/28/18, 10/19/18, 2/22/19

28 Pa. Code: 211.5(f) Clinical records
Previously cited 2/22/19, 12/7/18, 10/19/18, 8/28/18, 2/13/18, 10/27/17

28 Pa. Code: 211.10(c) Resident care policies
Previously cited 3/15/18, 8/28/18, 10/19/18, 10/27/17

28 Pa. Code: 211.12(d)(1)(5) Nursing services
Previously cited 2/22/19, 8/28/18, 10/19/18, 4/16/18, 3/15/18, 2/13/18, 10/27/17, 10/5/17





 Plan of Correction - To be completed: 11/15/2019

Resident CL5 has discharged from the facility and no longer resides here.
All Residents who are incontinent and require assistance with mobility are at risk for acquiring pressure ulcers. The interdisciplinary team will meet to review residents. Appropriate injury prevention measures will be implemented for those identified to be at risk.
When a resident is admitted into the facility a skin assessment will be conducted. In-servicing will be provided to all Nursing Staff to reeducate them on identifying residents that are at risk for acquiring pressure ulcers, appropriate interventions as well as obtaining appropriate orders to prevent the development of pressure areas.
CNA's will be in-serviced on identifying potential areas that should have further assessment by the licensed nursing staff.
When a resident is admitted into the facility a skin assessment will be conducted. Residents identified as being at risk for skin injury will have a weekly skin assessment conducted by licensed nursing staff.
The DON or designee will conduct a monthly audit X4 to ensure that all Residents have the appropriate interventions. Findings will be reported at our QAPI meetings to make recommendations.
All corrective actions will be completed by 11/15/2019

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:
Based upon review of facility policy and procedure, clinical record review, facility documentation and staff interview, it was determined that the facility failed to thoroughly investigate injuries of unknown injury for one of 11 residents reviewed ( Resident R5).

Findings include:

Review of facility policy and procedure, titled The Phoenix Center - Abuse of Residents Policy and Procedure, revised date June 2019, includes policy for investigation of injury of an unknown source to include a completed designated report form and interviews of staff members on all shifts having contact with the resident during the period of the alleged incident.

Review of Resident R5's quarterly assessment, dated June 10, 2019, revealed diagnoses to include aphasia (loss of ability to understand or express speech, caused by brain damage) and dementia (a chronic or persistent disorder of the mental processes) . Further review revealed that the resident was totally dependent with two plus assistance for both bed mobility and transfer.

Review of nursing note dated July 24, 2019, revealed description of an "immeasurable bruise observed under the resident's right abdomen radiating between her legs, right thigh and inguinal groin region and pubic bone". Also described were "green appearing bruises noted to the resident's bilateral knee, bilateral lower and upper extremities, top of forehead and left cheek bone". Review of the facility report which initiated the investigation into the bruises indicated that the bruises were discovered by a nurse aide on the day shift on July 24, 2019 who reported the bruising to the licensed staff who wrote the aforementioned nursing note on July 24, 2019 and initiated the investigation and provided it to the abuse coordinator.

Further review of the investigation report and the statements from staff having contact with the resident prior to and at the time of the discovery of the bruises revealed a statement from another nurse aide indicating that she provided care to the resident on the night shift (11:00 p.m. to 7:00 a.m.) beginning July 23, 2019 and found bruising on the resident's right groin area and reported the bruising to the licensed staff on duty at that time who "came in and looked at the area and left". Review of the statements included in the investigation report revealed no evidence of a statement from that licensed staff nor did that licensed staff initiate an investigation or report the bruising to the abuse coordinator. Additional review of the investigation report revealed four blank witness statements which should have been completed by four other staff members having contact with the resident during the period of the alleged incident. Additionally, none of the statements addressed the bruising noted to the resident's bilateral knee, bilateral lower and upper extremities, top of forehead and left cheek bone.

Interview with licensed staff Employee E3 on October 2, 2019 at approximately 11:00 a.m. revealed that she was the licensed staff person who assessed the resident on July 24, 2019 after the nurse aide informed her of the discovery of bruising on the resident and that she wrote the aforementioned nursing note describing the bruises. Employee E3 stated that it was her responsibility, as the first licensed staff to observe the bruises, to initiate the investigation and report to the abuse coordinator who would ultimately be responsible for conducting the investigation. The interview with Employee E3 further revealed that the conclusion of the investigation was that the bruising to the resident's pelvic area was determined to be from contact with the Hoyer lift but that she was unaware of any conclusion related to the other bruising on the resident's body.

Interview with the nursing home administrator (NHA) on October 2, 2019 at approximately 2:00 p.m. confirmed that the investigation into the bruises on Resident R5's body was not a thorough and complete investigation conducted according to facility policy and procedure. The NHA also confirmed that the information concerning the incident was contradictory, the bruises on the resident's extremities and head were not addressed, statements were missing and that the licensed staff on the night shift from July 23 through July 24, 2019 should have initiated an investigation at that time.

The facility failed to conduct a thorough and complete investigation into injuries of unknown origin.

483.12(c)(2) Freedom from Abuse, Neglect and Exploitation

28 PA Code 201.14(a) Responsibility of Licensee

28 PA Code 201.18(b)(1)(3)(e)(1) Management
Previously cited 6/22/2019; 2/22/2019

28 PA Code 201.29(a)(j) Residents Rights

28 PA Code 211.5(f) Clinical Records
Previously cited 2/22/2019


 Plan of Correction - To be completed: 11/15/2019

Additional statements were collected from the staff to complete the investigation.
All Residents who might incur injuries of unknown origin are at risk of not having a complete and thorough investigation.
An in-service will be provided to all staff on the facilities Abuse Policy. The in-service will discuss the obligation to conduct a thorough and complete investigation including the staff providing statements as relating to the incident.
The NHA or designee will conduct a monthly audit X4 months to ensure that all such investigations have been completed thoroughly. Findings will be reported at our QAPI meeting to make recommendations.
All corrective actions will be completed by 11/15/2019


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