Pennsylvania Department of Health
PHOEBE WYNCOTE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PHOEBE WYNCOTE
Inspection Results For:

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PHOEBE WYNCOTE - 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 a Civil Rights Compliance survey completed March 1, 2024, it was determined that Phoebe Wyncote 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 related to the health portion of the survey process.






 Plan of Correction:


483.10(h)(1)-(3)(i)(ii) REQUIREMENT Personal Privacy/Confidentiality of Records: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(h) Privacy and Confidentiality.
The resident has a right to personal privacy and confidentiality of his or her personal and medical records.

483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

483.10(h)(3) The resident has a right to secure and confidential personal and medical records.
(i) The resident has the right to refuse the release of personal and medical records except as provided at 483.70(i)(2) or other applicable federal or state laws.
(ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.
Observations:


Based facility policy, observation, and interviews, it was determined that facility failed to secure residents privacy relating to confidential medical records for 5 out of 42 residents reviewed. (Residents; R14, R28, R37, R11, and R1)

Findings include:

Review of the center for Disease Control and Prevention (CDC), Public health law titled the "Health Insurance Portability and Accountability Act of 1996 (HIPAA) revealed that HIPAA is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule which is a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services ("HHS") issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). The Privacy Rule standards address the use and disclosure of individuals' health information-called "protected health information.".

Review of the facility policy titled "Transmission-based Precautions" last revised June 20, 2023, revealed that the Infection preventionist will identify the type of transmission-based precautions and notification will be placed on the residents doors to which transmission based precaution is implemented, the selection and use of personal protective equipment (PPE), and the clinical conditions for which specific PPE should be used.

Observation of the facility Second floor nursing unit on February 27, 2023 at 10:40 a.m. revealed residents rooms: 404, 419, 420, 422, and 428 with a red colored sign hanging on the outside of the doors for everyone to see, which revealed the residents occupying those rooms were identified as being "covid positive."

Interview with Licensed nurse, Employee E18, at time of observation above, confirmed that the signs on these doors declared the residents diagnosis of covid positive.

28 Pa. Code 210.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1) Management






 Plan of Correction - To be completed: 04/30/2024

1. Isolation signs on identified rooms immediately removed and replaced with generic transmission-based precautions signs.
2. All + covid resident rooms were addressed by the removal of signs with +covid on the back on them and replaced with generic transmission-based precautions signs.
3. New transmission-based precautions signs created and are in use. Will educate nursing staff to use these signs only for residents requiring isolation.
4. DON/ADON will audit weekly x4 and then monthly x2 for compliance. Results will be presented in QAPI.
483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:


Based on observations of the daily meal preparation and delivery from the Food and Nutrition Department to the nursing unit for 41 of 46 residents reviewed and interviews with staff, it was determined that the facility failed to ensure that essential resident care equipment, for the food service operation was maintained in safe operating condition.

Findings include:

Observations on February 27, 2024 during the noon meal service revealed that the dietary staff was not using the plate warmer according to manufacturer's recommendations. There were no lids in place above the lowerator wells. The every day china plates were stacked above the food service equipment's warming mechanism; preventing proper heating of the dishware.

Observations on February 27 and March 1, 2024 during the plating of foods and beverages and assembly of meal trays; revealed that dietary staff were using opened slotted carts and opened push carts to deliver meals throughout the hallways on the nursing units and into each resident room.

Observations on February 27 and March 1, 2024 of the food service equipment being used to deliver the breakfast, lunch and dinner meals for the residents eating inside their rooms, revealed that the entire thermal set of food service equipment for plating, transporting and delivery of hot foods was not available for use. There were no metal pellets as specified by the equipment manufacturer for the dietary services.

Interview with the Director of Dietary, Employee E11 at 11:30 a.m., on February 27, 2024 and the dietary staff, Employees E5, E6 and E7 confirmed that the thermal heating equipment (pellets) manufactured to keep foods hot and safe during plating, transportation and delivery to each resident's room for breakfast lunch and dinner, were not being used according to manufacturer's recommendations and standards of the food service operation to ensure food service safety.

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management




 Plan of Correction - To be completed: 04/30/2024

1. Lowerator lids placed on plate warmer ensuring all plates covered and heat remains intact. Stacked china plates were removed from above the food service equipment's warming mechanism.
2. (same as above)
3. Dining staff to be educated to keep lids in place until use and to not stack china plates above the food service equipment's warming mechanism. Food is delivered in an enclosed plate, using a base and lid for each plate. Dining department has place order for the purchase of appropriate thermal heating tray delivery equipment. Completion date is pending no delay in delivery of equipment. Until equipment arrives, we will continue to encourage all residents to eat in the dining room. And plate food when ready for delivery to resident.
4. Dining Dir or designee will use checklist tool to document each meal and will continue to audit resident satisfaction a minimum of 3x per week. Results will be presented in QAPI x 3.



483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:


Based on clinical record reviews, interviews with staff, facility documentation, policy and procedure reviews and interviews with family members, it was determined that the facility failed to notify the resident's representative of a need to alter treatment significantly and failed to notify the resident's physician of an accident requiring physician intervention for two of 23 residents reviewed. (Residents R96 and R97)

Findings include:

A review of the facility policy titled Notification of Changes revealed that it was the responsibility of the facility to immediately inform each resident and/or resident representative of accidents that have the potential for physician intervention or significant changes in condition. The policy also indicated that it was the facility's responsibility to ensure that the physician was immediately notified of an accident that had the potential for requiring physician intervention. The policy said that the physician was to be notified immediately of a significant change in physical, mental and psychosocial status of the resident.

Clinical record review for Resident R96 revealed that this resident was admitted to the facility on February 10, 2024. The nursing progress note indicated that Resident R96 had poor cognitive status. The nurse indicated that the resident's diagnosis upon admisssion was CVA (cerebral vasculer accident) with right sisded weakness and aphasia (a loss or impairment of one's capacity to use or comprehend language, which is most commonly caused by injury to a specific area in the brain).

Clinical record review on February 13, 2024 indicated that Resident R96 received testing for the virus that causes COVID-19 and the test results were positive. The nursing progress note on February 13, 2024 indicated that interventions were significantly changed for Resident R96 to include taking transmission based precaustions when providing care or visiting this resident. The nursing progress note dated February 15, 2024 indicated that Resident R96 had a persistent cough.

Interview with Resident R96's responsible party/family member at 1:00 p.m., on February 27, 2024, revealed that the family member was not notified of the need to alter Resident R96's treatment and care due to the fact that Resident R96 was diagnosed as being positive for the virus that causes COVID-19 on February 13, 2024. The family member reported visiting the facility on February 14, 2024 and having to ask nursing staff, the medical status of Resident R96.

Interview with Employee E2, the Director of Nursing, at 9:00 on February 28, 2024 confirmed that the facility had no documentation to indicate that the responsible party for Resident R96 was notified of a significant change (postive results for COVID-19 testing) or change in medical status on February 13, 2024.

Clinical record documentation for Resident R97 indicated that this resident was admitted to the facility on January 9, 2024 and had diagnoses of osteoporosis (brittle bones), rheumatoid arthritis(autoimmune disease of joint swelling, redness or warmth) and infection of the internal fixation device of the ulna (forearm).

Clinical record review for Resident R97 revealed that the resident reported to the Licensed nurse on February 8, 2024 that she had fallen from the toilet, in the bathroom on February 7, 2024, at approximately 6:00 p.m. The nursing assistant responsible for this resident reported that she was clearing a path or clearing the room to the resident's bed, when she saw the resident fall in the bathroom.

Review of facility's investigation of alleged abuse, neglect and misappropriation of property dated February 8, 2024 indicated that the nursing assistant assigned to provide care to Resident R97 failed to report to the licensed nurse that Resident R97 experienced a fall on February 7, 2024. The fall occurred in the bathroom on February 7, 2024 for Resident R97. After the fall occurred, the nursing assistant responsible for Resident R97 asked another nursing assistant to assist the resident from the floor and they placed Resident R97 into the wheelchair and into bed on February 7, 2024.

Continued review of the faciltiy's investigation revealed that the resident's incident/accident was consequently not reported to the physician, by the licensed nurse, on February 7, 2024, for required intervention post fall. The investigation report form indicated that the facility was not aware of any incident/accident for Resident R97 until the resident reported the incident on February 8, 2024.

Interview with the Director of Nursing, Employee E2, on February 29, 2024 confirmed that lack of notification of the physician of an incident/accident (fall) involving Resident R97 on February 7, 2024. Employee E2, Director of Nursing also confirmed that the lack of notification of the physician, resulted in a delay of assessment, monitoring and potential treatment for Resident R97.

28 Pa. Code 211.10(d) Resident care policies

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








 Plan of Correction - To be completed: 04/30/2024

1. Family was immediately notified of resident's condition, + covid and need for isolation. Documentation completed. As soon as Nursing Management made aware of fall, MD notified, assessment done (no injury) and monitoring initiated.
2. Audit immediately done for all other residents with isolation need r/t + covid. Documentation shows that all families had been notified. Will review fall incidents for past 30 days to ensure notification to MD was done timely, with appropriate assessment and monitoring.
3. Licensed Nurses to be educated to notify families (as appropriate) with a resident's change in condition r/t + covid and need for isolation. CNAs are being educated to immediately report fall to licensed nurse and wait for nurse to assess before picking up resident. DON/ADON/Nursing Supervisor will review all incident reports to ensure timely notification. DON/ADON/Nursing Supervisor will review 24hr report to ensure the above.
4. DON/ADON will audit weekly x4 and then monthly x2 for compliance. Results will be presented in QAPI.
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.
Observations:


Based on clinical record reviews, interviews with staff and review of facility documentation, it was determined that the facility failed to ensure adequate supervision and assistive devices to prevent accidents for one of two residents reviewed with falls. (Resident R97)

Findings include:

Review of Resident R97's admission assessment dated December 27, 2023 indicated that the resident was able to make needs know with cognitively intact decision making. The resident was dependent on one staff member for toileting hygiene (ability to maintain perineal hygiene), substantial/maximal assistance to perform sit to stand, and partial to moderate assistance with walking ten feet. Continued review of the resident assesment revealed that the resident was frequently incontinent of bladder and bowel.

Review of clinical record documentation dated January 9, 2024 indicated that this resident had diagnoses that included: osteoporosis (brittle bones), rheumatoid arthritis s(autoimmune disease of joint swelling, redness or warmth) and infection of the internal fixation device of the ulna (forearm).

Review of Resident R97's care plan revealed that the resident was at risk for falls. Interventions included to provide Resident R97 with one person assist with all transfers (how a resident moves from surface to surface). The resident's care plan also indicated that Resident R97 required assistance of one staff member with bathroom needs and incontinence care of bowel and bladder.

Review of occupational and physical therapy documentation dated January 10, 2024 through February 6, 2024 indicated that Resident R97 required stand by assistance and safety cues to prepare for a transfer. The assessment also indicated that Resident R97 required the support of one person for standing from the sitting position and required care giver assistance to ambulate with the wheeled walker.

Interview with the Employee E3, a physical therapist, at 1:00 p.m., on February 29, 2024 confirmed that Resident R97 required stand by assistance to transfer and stand safely. The therapist also confirmed, during this interview, that Resident R97 required care giver hands on assistance for safe toileting.

Clinical record review for Resident R97 revealed that this resident reported to the licensed nurse on February 8, 2024 that she had fallen from the toilet, in the bathroom on February 7, 2024. The facility incident report indicated that the nursing assistant responsible for assisting Resident R97 with toileting, standing, transferring and ambulating on February 7, 2024 said that she was clearing a path or moving things out of the way, to the resident's bed, when she saw the resident fall.

Interview with employee E2, the Director of Nursing, at 9:00 a.m., on March 1, 2024 confirmed that the nursing assistant responsible for providing toileting, standing, transferring and ambulation assistance for Resident R97 on February 7, 2024; failed to provide this assistance as care planned for Resident R97. The Director of Nursing confirmed during this interview that the lack of proper assistance by the nursing assistance, during toileting, resulting in a fall for Resident R97 on February 7, 2024.

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

28 Pa. Code 201.18(b)(1) Management



 Plan of Correction - To be completed: 04/30/2024

1. CNA was clearing a path in the room for the oriented resident to return after toileting. CNA was educated to follow plan of care for resident.
2. Will review all residents identified as fall risk to ensure their plan of care includes level of assistance needed.
3. Will educate CNA staff to review plan of care for level of assistance needed at the beginning of their shift. DON/ADON will randomly have CNAs demonstrate knowledge of accessing plan of care.
4. DON/ADON will audit weekly x4 and then monthly x2 for compliance. Results will be presented in QAPI.
483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:


Based on facility policy, observation, interview with residents and staff and review of facility documentation, it was determined that the facility failed to ensure that all nursing staff possess the competencies and skill sets necessary to provide nursing and related services for three of twenty nine residents reviewed relating staff response to call bells, resident needs and nursing required skills. (Resident R16, Resident R39 and Resident R149)


Findings include:

Review of facility policy titled "Call System and Response" revised February 21, 2020, revealed that the facility will maintain a functional communication system from residents' rooms, bathrooms, and bathing areas. All resident call bells will be answered in a timely manner. Further review of this policy states that answering the call system is primarily the responsibilities of the certified nurse assistants. However, when a resident's call light is activated, the nearest available employee is to respond.

Interview with Resident R16 on February 27, 2024 at 10:40 a.m., revealed that his major concern and complaint of the facility that the call bell was not answered in a timely manner. He continued the interview with an example as recent as the same morning of the interview, Resident R16 activated his call bell in need of toileting and stated he waited an hour for an employee to respond to the call bell. At the time of this interview Resident R16 activated his call bell, there was no response to the call for a period of forty-four minutes. This time was also confirmed in a call bell audit provided by the Director of Nursing, Employee E2.

Interview with Resident R39 on February 28, 2024, at 11:30 a.m. revealed that Resident R39 was observed in gown. The resident expressed that she has been waiting since 6:30 a.m. to be cleansed and dressed. Resident R39 stated that she has requested to be assisted with these activities of daily living (ADLs) and was told "later". During this interview, Resident R 39 initiated her call bell, nurse aide, Employee E13 , responded and stated that
Resident R39 had to wait until physical therapy could assists in cleaning and dressing of this resident.

Interview with Physical therapist Employee E3 , February 28, 12:30 p.m. revealed that Resident R39 required a two person assists however did not need to wait for physical therapy to complete this tasks. Employee E3 revealed that any employee could assists with these tasks.

Review of the facility's job description of register nurses revealed that this position essential duties includes assess residents, plans, and implements care plans, receives reports, and relays information to nursing staff, informs physician of resident changes, orders medications as well as is performs resident treatments designed to be done by a licensed nurse, including wound care. Further review of this policy reveals that all supervisors are accountable for their own performance as well as the performance of their direct reports and are accountable to clearly communicate and reinforce department goals and individual job performance expectations.

Observation of Licensed nurse, Employee E18 providing wound care to Resident R149 on February 27, 2023, at 12:10 p.m. revealed that Employee E18 was unprepared and unknowledgeable of Resident R149. Licensed nurse, Employee E18 had limited information pertaining to this resident wounds and care needs. Licensed nurse, Employee E16 was unprepared needing to leaving the room twice for supplies, Licensed nurse, Employee E16 was unaware of location of wounds, condition, and proper wound care techniques. Interview with Licensed nurse, Employee E16 at time of observation revealed that this was her first day, she was not provided information or training of wound care.

Interview with Education Training Instructor, Employee E10 revealed that Licensed nurse, Employee E18 completed her orientation and skills needed for wound care would have been achieved on the floor training. This employee was not assigned to any resident that needed or were provided wound care during on the floor training, therefore was not instructed or provided any practice prior to provided Resident R149's wound care.

28 Pa. Code 201.20 (a)(6)(b) Staff development

28 Pa. Code 211.12 (c)(d)(1)(5) Nursing Services





 Plan of Correction - To be completed: 04/30/2024

1. Call bell audit was completed for Residents R16 and R39 on 2 consecutive days. Nurse cited has received wound care training.
2. Call bell audit was completed for all other residents on 2 consecutive days. Facility will ensure all nurses providing wound care review the treatment administration record in advance for familiarity of the wound to be treated and the supplies needed to conduct the treatment.
3. Staff to be educated on call bell policy, including anyone near resident's room at time of call bell activation should appropriately address. Weekly call bell audit to be done and non-compliance will be appropriately addressed. Will educate CNA staff to review plan of care at the beginning of their shift for the level of assistance that has been identified either by the licensed nurse or rehab. All licensed nurses will be trained for wound care. DON/ADON/Supervisor will observe wound care being provided to residents.
4. DON/ADON will audit weekly x4 and then monthly x2 for compliance. Results will be presented in QAPI.

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