Pennsylvania Department of Health
MONTGOMERYVILLE SKILLED NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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MONTGOMERYVILLE SKILLED NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  156 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MONTGOMERYVILLE SKILLED NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Findings of an Abbreviated survey in response to a complaint completed on April 3, 2024, at Montgomeryville Skilled Nursing and Rehabilitation Center, revealed that the facility 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 as they relate to the Health portion of the survey process.



 Plan of Correction:


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 review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that safety interventions were implemented during a transfer from bed to chair for one of four sampled residents. (Resident 1)

Findings include:

Clinical record review revealed that Resident 1 was admitted to the facility on April 13, 2021, with diagnoses that included brain bleed, stroke, and bipolar disorder. The Minimum Data Set assessment dated March 3, 2024, revealed that the resident was non-ambulatory, dependent upon staff for care, and required the assistance of two staff with the use of a lift for transfers out of bed.

The resident's care plan dated March 23, 2024, directed staff to provided full assistance of two staff members with the use of a lift for all transfers out of bed.

Nursing documentation dated March 28, 2024, at 11:00 a.m., indicated that the resident was heard yelling for staff while seated in her wheelchair in her room. The resident stated that her head got bumped while being transferred out of bed with the lift. Review of the facility investigation revealed that only one staff member had used the lift to transfer the resident out of bed.

In an interview on April 3, 2024, at 10:00 a.m, the Director of Nursing confirmed that the nursing assistant failed to ensure that the assistance of two staff members was provided during the transfer of Resident 1 from the bed to the wheelchair on March 28, 2024.

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




 Plan of Correction - To be completed: 04/24/2024

F0689
SS=D

Resident 1's CNA was immediately re-educated regarding the need to follow the transfer orders indicated in her plan of care. The employee also received disciplinary action for failure to follow the plan of care.

All staff will be re-educated regarding following the transfer orders indicated in the plan of care.

The Director of Nursing or designee will audit care plans to ensure that transfer status is accurate for all residents.

The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days, to ensure all transfers are occurring as indicated in the plan of care.

Results of the audits will be presented to the monthly QAPI meeting for review and recommendations.



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