Pennsylvania Department of Health
SCOTTDALE HEALTHCARE & REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SCOTTDALE HEALTHCARE & REHABILITATION CENTER
Inspection Results For:

There are 101 surveys for this facility. Please select a date to view the survey results.

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SCOTTDALE HEALTHCARE & REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a complaint survey completed on July 30, 2024, it was determined that Scottdale Healthcare and Rehabilition Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

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.

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure an assessment was completed by a professional (registered) nurse for a change in condition for one of five residents reviewed (Resident 1).

Findings include:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 20, 2024, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.

A nursing note for Resident 1, dated April 26, 2024, revealed that the resident was short of breath, breathing 44 times per minute with heavy diaphragmatic breathing (using stomach muscles to breath), skin was dusky color, and nail beds and lips were blue.

There was no documented evidence that Resident 1 was assessed by a registered nurse during or after his respiratory distress.

A nursing note for Resident 1, dated April 29, 2024, revealed that the resident's oxygen level was 72 percent (hypoxia - low blood oxygen) and that he was found without his oxygen on.

There was no documented evidence that Resident 1 was assessed by a registered nurse during or after his hypoxic episode.

A nursing note, dated May 1, 2024, revealed that the resident had shortness of breath, oxygen levels in the low in the 70's, and that he was being transferred to the emergency room where he was admitted with pneumonia and sepsis.

Interview with the Director of Nursing on July 30, 2024, confirmed that there was no documented evidence that a registered nurse assessed Resident 1 after he had respiratory distress and hypoxia, and there should have been a registered nurse assessment.

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

Plan of Correction - To be completed: 08/23/2024

1. Resident 1 was discharged from the facility.

2.Director Of Nursing or designee will conduct a house audit for all residents with a change in condition in the last two weeks to ensure that a registered nurse documented an assessment.

3. DON or designee will re-educate all registered nurses on RN assessment and documentation of assessments when there is a change in condition.

4.Director Of Nursing or designee will conduct weekly audits on all residents with changes in condition to ensure documentation of assessment x 4 weeks. Results will be reported at QAPI.

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