Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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LECOM AT VILLAGE SQUARE, LLC - 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 January 22, 2020, it was determined that LECOM at Village Square, LLC. was not in compliance with the 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:

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Based on review of facility documentation, policy and procedure, and clinical records, and staff interview, it was determined that the facility failed to ensure residents received adequate bathing for one of four residents reviewed. (Resident R12)

Findings include:

A facility policy/procedure entitled "Bath,Shower," indicated that the purpose of providing resident bathing was to cleanse and refresh the resident, observe for skin breakdown, provide increased circulation, to assess the degree to which the resident participated and the amount of assistance the resident required.

The Face Sheet and Diagnosis Report revealed that Resident R12 was admitted to the facility on 12/6/19, with diagnoses that included Alzheimer's dementia and back problems

The bathing schedule for Resident R12 directed that the resident was to receive bathing/showers every Wednesday and Sunday of each week, a period of every four days. Resident R12's bathing documentation from 12/6/19, through 1/21/20, revealed the following:

Offered bathing Thursday 12/12/19, six days after admission
Offered and refused Thursday 12/19/19, seven days later
Offered bathing Monday 12/23/19
Offered bathing Thursday 12/26/19
Offered bathing Thursday 1/2/20, seven days later
Offered bathing Thursday 1/9/20, seven days later

Resident R12 was offered/received bathing services, less than twice weekly as scheduled from 12/6/19, through 1/21/20.

During an interview on 1/22/20, at 1:20 p.m. the Director of Nursing confirmed that Resident R12 was to have received bathing opportunities at least twice weekly and that there was no indication that the resident was offered this assistance as required.

28 PA Code 211.12(d)(1)(5) Nursing services
Previously cited 7/11/19

 Plan of Correction - To be completed: 03/17/2020

1.Resident R12 was discharged to another facility.
2.The bathing schedule was evaluated and adjusted to ensure all residents are being offered a shower/bath at least twice a week.
3.Shower sheets will be completed and signed with every shower by the certified nursing assistant and co-signed by the wing nurse. Shower schedules will be added to the treatment record and signed off by the wing nurses.
4.All staff will be in-serviced on offering showers/baths at least twice a week, completing shower sheets and signing off on treatment records by February 17, 2020.
5.The director of nursing/designee will audit the shower sheets and treatment records twice a week for eight weeks, then weekly ongoing. All audits will be reported at the monthly Quality Assurance meeting.
6.Showers for all new admissions will be offered within 48 hours. This process will have a separate biweekly ongoing audit.

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