Nursing Investigation Results -

Pennsylvania Department of Health
PHOENIX CENTER FOR REHABILITATION AND NURSING, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PHOENIX CENTER FOR REHABILITATION AND NURSING, THE
Inspection Results For:
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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 February 7, 2020, in response to three complaints at Phoenix Center for Rehabilitation, it was determined that Phoenix Center for Rehabilitation 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 for the health portion of the survey process.

Plan of Correction:

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

�483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
�483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

�483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

�483.10(i)(3) Clean bed and bath linens that are in good condition;

�483.10(i)(4) Private closet space in each resident room, as specified in �483.90 (e)(2)(iv);

�483.10(i)(5) Adequate and comfortable lighting levels in all areas;

�483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81�F; and

�483.10(i)(7) For the maintenance of comfortable sound levels.

Observations:

Based on observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment, and maintain clean resident care equipment, on one of two units (the 300 unit) of the facility.

Findings include:

Observations during a tour of the 300 unit on February 5, 2020, at approximately 11:20 a.m., included the following:

Room 321- a large sharps container (used to safely hold used syringes, sharp objects), was very full.

Room 320- oxygen tubing connected to an oxygen concentrator and being used by resident, was laying on the floor, and the tubing was not dated. Soiled gloves were found in the bathroom.

Room 318- the trash receptacle in the room was overflowing with trash. On the hallway floor outside of the room, was soiled gauze padding, which was picked up by the Director of Nursing (DON) without wearing gloves.

Room 315- 2 linen containers with soiled bed linens, were being stored in resident's room. Paper and soiled gloves were found on the floor of the room.

Room 314- resident of this room was observed ambulating in the hallway with foley catheter tubing dragging on floor. A red bin in the room was overflowing with soiled linens.

Room 302 D- Oxygen tubing with no date was observed in the room.

Additional observation of the third floor of facility revealed that the footboard of beds in rooms 306 (next to window), and room 317 (middle bed) were detached from the bed frame and hanging down from the bed.

Interview with Resident R4 on February 2020, at approximately 11:30 a.m. stated that the bed has been broken for several months.

An additional tour of the the unit was conducted on February 5, 2020, at approximately 12:45 p.m., accompanied by the DON. Observations revealed the following:

Room 317- there were 2 large red bins, overflowing with soiled linens. A Geri chair (a medical recliner chair), in the hallway next to room 317 was found with numerous particles of dried food, dust, and an unknown dried substance on the side of chair and footrest. Further observation of resident care equipment located in the hallway next to room 312 revealed a Geri chair with large unknown brown substance in the cloth between the chair and footrest, as well as a wheelchair with numerous dust and dried food particles.
Observation of room 313 revealed soiled clothing on the floor of the bathroom. Further observation revealed a trash can containing food, trash, and soiled incontinence products, but without a trash can liner.

Observation of the shower/spa room on the third floor revealed a sit to stand lift with food particles, dirt, and dust on the foot pedestal. Further observation of the shower room revealed a black substance on the floor tiles extending up the wall next to the entrance door. Continued observation revealed the floor had discarded, used gloves, pieces of paper, and food pieces. Further observation of the shower room revealed a shower curtain with numerous unknown brown substance stains. Continued observations of shower room revealed food particles and dust noted on a roll-on weight scale.

An interview was completed on February 5, 2020, at approximately 3:00 p.m.,with the Director of Nursing, and all of the environmental observations were presented.

28 Pa Code 207.2(a) Administrator's Responsibility

Plan of Correction - To be completed: 03/16/2020

All items and trash identified were removed and cleaned out of the rooms. Catheter of resident R5 was re-secured to leg of resident. Shower room and all items in the shower room were thoroughly cleaned. Wheelchairs and Geri chairs were cleaned. Maintenance repaired broken beds. Linen containers were emptied out. All residents could potentially be affected. Administration conducted environmental audit rounds on all resident rooms and resident areas. Data from these rounds identified any other ares with environmental concerns. Nursing staff were in-serviced on proper handling of soiled linen and hazardous waste. Housekeeping was in-serviced to a cleaning schedule that was created for the shower rooms and wheelchairs. Facility staff was in-serviced to report maintenance concerns to director of maintenance in a timely fashion. Administrative environmental audits rounds will be ongoing to ensure compliance. Findings will be reported the the monthly Quality assurance committee.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

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.

�483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

�483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

�483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to �483.70(e) and following accepted national standards;

�483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

�483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

�483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

�483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on observation and staff interview, it was determined that the facility failed to ensure soiled linens and trash were stored in a sanitary manner, for one of two units observed (300 unit).

Findings include:

Observation of the 300 unit on February 5, 2020, at approximately 11:20 a.m., revealed in room 317, and 314, the red containers identified for infection control containment of bedding and waste were overflowing.

Observation on February 5, 2020, at approximately 11:30 a.m., revealed in room 315, two red containers overflowing with bagged linens and trash.

Observation on February 5, 2020, of Resident R5 walking in hallway with catheter tubing dragging on the floor.

Observation on February 5, 2020, at approximately 12:08 p.m., revealed the Director of Nursing picked up a soiled gauze padding from hallway floor without infection control protection gloves.

Interview occurred on February 5, 2020, at approximately 3:00 p.m,. with Director of Nursing when the above observations were presented.

28 Pa Code 201.18(b)(1) Management

Plan of Correction - To be completed: 03/16/2020

Staff removed overflowing red containers in identified rooms 317, 314, and 315, disposed the contents according to infection prevention guidelines, and replaced all container liners. All residents could be at risk from this deficiency. Staff rounded on all rooms to inspect all trash and linen containers. Containers were emptied as needed and contents disposed according to infection prevention guidelines. Leadership Rounds have been initiated and include weekly review of these infection prevention practices. Data collected during these rounds will identify any ongoing education or performance gaps on infection prevention practices, and interventions will be implemented as needed. Catheter of resident R5 was re-secured to leg of resident, tubing redirected, and privacy bag applied. Hand hygiene education and safe disposal of debris on floor will be conducted. Infection prevention topics will be included in all monthly staff meetings and in annual education for all staff. Monitor infection prevention data collected in Leadership Rounds will be reported in QAPI meetings.

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