Pennsylvania Department of Health
JOHN J KANE REGIONAL CENTER- ROSS TOWNSHIP
Patient Care Inspection Results

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JOHN J KANE REGIONAL CENTER- ROSS TOWNSHIP
Inspection Results For:

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JOHN J KANE REGIONAL CENTER- ROSS TOWNSHIP - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint, completed on April 2, 2024, it was determined that John J Kane Regional Center - Ross Township 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.



 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 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.
483.25(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, clinical record review, and interview, the facility failed to ensure that appropriate treatment and services were provided for six of six residents with an indwelling urinary catheter (Residents R1, R2, R3, R4, R5, and R6).

Findings include:

Review of facility policy "Catheter Care and Drainage Bags" dated 1/3/24, indicated the facility will safely and appropriately provide hygiene, monitor urinary output, and minimize the growth and transmission of pathogens for residents with indwelling urinary catheters (tube in bladder to drain urine), and the drainage bags are to be covered with a dignity bag.

Review of the Centers for Disease Control guidance "Guidelines for Prevention of Catheter-Associated Urinary Tract Infections" updated 6/6/19, indicated to keep the collecting bag below the level of the bladder at all times.

Review of facility policy "Catheter Urinary: Removal" dated 1/3/24, indicated physician orders discontinuation of catheter and any follow up treatments when condition is resolved (i.e.: as needed straight catheterization following discontinuation).

Resident R1 was admitted to the facility on 4/19/19. Review of the Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/29/24, indicated diagnoses of quadriplegia (a symptom of paralysis that affects all of a person's limbs and body from the neck down), bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and neuromuscular dysfunction of the bladder (lack of bladder control due to a brain, spinal cord or nerve problem). Section H indicated an indwelling catheter was present.

Review of physician order dated 2/2/24, indicated to change Resident R1's suprapubic (enters the body through an incision in the abdomen) catheter as needed for clogging or dislodgement, and to send to urologist every two weeks to change due to recurrent urinary tract infections.

Review of Resident R1's care plan dated 2/1/24, indicated to store collection bag inside a protective dignity pouch.

During an observation on 4/2/24, at 10:10 a.m., Resident R1 was in bed with his urinary drainage bag uncovered and laying on the floor.

Resident R2 was admitted to the facility on 7/19/23. Review of the MDS dated 1/24/24, indicated diagnoses of hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect arms, legs, and facial muscles), suprapubic catheter, and vascular dementia (brain damage caused by multiple strokes). Section H indicated an indwelling catheter was present.

Review of physician order dated 3/27/24, indicated to change Resident R2's suprapubic catheter monthly on the 18th.

Review of Resident R2's care plan dated 1/26/24, indicated do not allow tubing or any part of the drainage system to touch the floor.

During an observation on 4/2/24, at 10:14 a.m., Resident R2 was in bed with his urinary drainage bag uncovered and laying on the floor.

Resident R3 was admitted to the facility on 3/22/24. Review of the Continuity of Care document dated 4/2/24, indicated diagnoses of spina bifida (a birth defect in which a developing baby's spinal cord fails to develop properly), heart failure (heart doesn't pump blood as well as it should), and neuromuscular dysfunction of the bladder. Section H indicated an indwelling catheter was present.

Review of Resident R3's care plan dated 3/25/24, indicated resident requires a suprapubic catheter, chronically leaks, related to neurogenic bladder. Keep system as closed as possible.

During an observation on 4/2/24, at 10:17 a.m., Resident R3 was in bed with his urinary drainage bag uncovered and laying on the floor.

Review of Resident Council Minutes dated 2/29/24, and 3/28/24, indicated Resident R4 had a concern in relation to nursing staff's ability to change her foley catheter, and a concern for nail length of agency staff.

Resident R4 admitted to the facility on 1/27/23. Review of the MDS dated 3/21/24, indicated diagnoses of paraplegia, cervicalgia (neck pain), and neuromuscular dysfunction of the bladder. Section H indicated an indwelling catheter was present.

Review of Resident R4's care plan dated 3/22/24, indicated antibiotics to prevent urinary tract infections, and urinary catheter related to paraplegia. Provide catheter care every shift.

During an observation on 4/2/24, at 11:20 a.m., Resident R4 was in the wheelchair with the urinary drainage bag in place and covered.

Interview on 4/2/24, at 11:20 a.m. Resident R4 indicated "They don't know how to care for my catheter. They don't know how to run the bag through my pants when they dress me. One nurse aide said she can't empty my catheter because her nails are too long, so I have to open the tube for her. I made a complaint about it."

Interview with the Nursing Home Administrator on 4/2/24, at 11:22 a.m. confirmed Resident R4 filed a grievance relating to nail length and agency aides not knowing how to take care of her catheter.

Resident R5 was admitted to the facility on 3/1/24. Review of the MDS dated 3/5/24, indicated diagnoses of hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect arms, legs, and facial muscles), suprapubic catheter, and vascular dementia (brain damage caused by multiple strokes). Section H indicated an indwelling catheter was present.

Review of Resident R5's care plan dated 3/2/24, indicated resident requires a urinary catheter, and will not exhibit signs of a urinary tract infection. Keep system as closed as possible.

During an observation on 4/2/24, at 11:25 a.m., Resident R5 was in bed with the urinary drainage on the bed between her feet and above the level of the bladder.

Interview on 4/2/24, at 11:25 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R5's bag was not placed properly on bed frame to allow proper drainage as required.

Resident R6 was admitted to the facility on 2/5/24. Review of the MDS dated 2/11/24, indicated diagnoses of stroke (damage to the brain from an interruption of blood supply), urinary tract infections, and repeated falls. Section H indicated an indwelling catheter was present.

Review of Resident R5's care plan dated 3/27/24, indicated resident was positive for a urinary tract infection.

During an observation on 4/2/24, at 11:30 a.m., Resident R6 was in bed and did not have an indwelling catheter.

Review of progress notes dated 2/12/24, indicated indwelling catheter was discontinued at 2:52 p.m. and staff were to bladder scan (machine that uses ultrasonic reflections within the body to differentiate urinary bladder from surrounding tissues to determine the need for catheterization) every eight hours for three days.

Review of the clinical record failed to include any documentation of bladder scan results being completed.

Interview with the Acting Director of Nursing on 4/2/24, at 1:41 p.m. confirmed the bladder scans were never completed, and the catheter bags were not covered appropriately.

Interview with the Nursing Home Administrator on 4/2/24, at 2:00 p.m. confirmed the facility failed to ensure that appropriate treatment and services were provided for six of six residents with an indwelling urinary catheter. (Residents R1, R2, R3, R4, R5, and R6).

28 Pa. Code: 201.14(a) Responsibility of licensee.

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

28 Pa. Code: 201.20(a)(b)(c)(d) Staff development.

28 Pa. Code: 201.29(j) Resident rights.

28 Pa. Code: 211.10(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.



 Plan of Correction - To be completed: 04/12/2024


1) All residents with indwelling catheters were immediately checked by ADON and the foley bags were covered and all were in proper position.
2) Residents with supra pubic catheter and indwelling catheter were checked by DON/ADON on 4/4/24 for proper placement and covers according to facility policy. Audits completed to ensure current active dx for indwelling catheters.
3) One resident requires bladder scanning, audit completed for proper documentation of residual urine, and reporting to Physician.
4) ADON/DON/Staff Educator to educate nursing staff on policy of proper care of the resident with a foley, or suprapubic catheter. ADON/DON/Staff Educator to educate nurses on protocol for performing bladder scans and documentation following bladder scanning.
5) Audits will be completed weekly X4 Bimonthly X 2. Results will be presented to the Quality Improvement Committee.


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