Nursing Investigation Results -

Pennsylvania Department of Health
ZERBE SISTERS NURSING CENTER, INC.
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
ZERBE SISTERS NURSING CENTER, INC.
Inspection Results For:

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ZERBE SISTERS NURSING CENTER, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey and State Licensure, and Civil Rights Compliance Survey completed on May 12, 2022, it was determined that Zerbe Sisters Nursing Center 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:


483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on facility policy review, clinical record review, and staff interview it was determined the facility failed to provide care for a Foley catheter for one of one resdient reviewed. (Resident 67)

Findings Include:

Review of facility policy titled Catheter Care, Urinary, dated April 2021, revealed "the following information should be documented in the residents clinical record: The date and time that catheter care was given. The name and titles of the individual giving the catheter care. All assessment date obtained when giving catheter care."

Review of Resident 67's physician orders revealed the resident was admitted to the facility on April 20, 2022, and had a order for the insertion of a Foley catheter (a thin, flexible tube placed in the bladder to drain the urine) dated April 28, 2022.

Review of Resident 67's care plan revealed no interventions for the care of the Foley catheter.

Review of Resident 67's entire clinical record revealed no documentation that catheter care had been completed since the insertion of the Foley catheter on April 28, 2022.

Interview with the nursing assistant Employee E3 assigned to Resident 67 on May 12, 2022, at 9:45 a.m. revealed she was only responsible for emptying the collection bag of Resident 67's Foley catheter.

Interview with the Licensed Nurse Employee E4 assigned to Resident 67 on May 12, 2022, at 9:50 a.m. revealed she was only responsible to make sure Resident 67's Foley catheter was in place and working.

Interview with the Director of Nursing on May 12, 2022 at 11:15 a.m. confirmed there was no documented evidence Resident 67, received foley care since the insertion of the Foley catheter on April 28, 2022.

28 Pa. Code 211.5 (f) Clinical record

28 Pa. Code 211.10 (d) Resident care policies

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











 Plan of Correction - To be completed: 06/22/2022





This POC does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. It is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements.

1. Resident #67 was identified as the only person to have an indwelling foley catheter. Resident #67 foley catheter care has been completed, properly documented and signed off by C.N.A.'s. Care plan for resident #67 has been updated to reflect foley care interventions.

2. A new foley care task has been created in Point Click Care which will be utilized for any future residents who have indwelling foley catheters to ensure foley care is properly completed and documented. This task includes indwelling foley care with cleansing instructions for every shift.

3. The DON/Designee shall provide education to the C.N.A's and licensed nurses on proper foley care.

4. Facility to complete weekly audit of foley care task completion every week for eight weeks.

5. Facility to review audit results at QAPI meeting for review and recommendation as needed.



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