Nursing Investigation Results -

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

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POTTSVILLE REHABILITATION AND NURSING CENTER
Inspection Results For:

There are  137 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.
POTTSVILLE REHABILITATION AND NURSING CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on June 28, 2022, it was determined that Pottsville Rehabilitation and Nursing 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 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on a review of clinical records and facility provided documentation, and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for skin treatment for one resident out of six sampled (Resident A1).

Findings include:

A review of the clinical record revealed that Resident A1 was most recently admitted to the facility on May 8, 2022, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), diabetes, end stage renal disease, renal dialysis, peripheral vascular disease (PVD - a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel can cause PVD), gastro - esophageal reflux disease (GERD), gout (a common form of inflammatory arthritis that is very painful), muscle wasting and atrophy.

A review of a Quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 15, 2022, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 15 (13 - 15 represents cognitively intact) and required extensive assist of 2 staff members for bed mobility, transfers, dressing, toileting, personal hygiene (combing hair, brushing teeth) and with 2 person physical help with bathing.

A physician order dated May 19, 2022, was noted to provide a treatment for the sacrum (the triangular bone just below the lumbar vertebrae - at the base of your spine) of cleanse with wound cleanser, apply medihoney (a wound gel treatment), cover with 4 x 4 dressing (rest against, do not secure) every shift for pressure.

A nursing note dated June 1, 2022, at 10:03 PM, indicated that during the shift a nurse aide notified the nurse that the resident had a different treatment on his bottom. The nurse noted an Island dressing on Resident A1's bottom. The treatment noted on the resident's Treatment Administration Record (TAR) is for a 4 x 4 piece of gauze with medihoney to rest against resident's sacrum. Upon staff removing the Island dressing, the resident's skin was too fragile, at the location he island dressing attached to the resident's skin and the resident sustained skin tears. On the right buttock a 3.0-centimeter (cm) x 1.0 cm skin tear was observed. On the left buttock a 1.5 cm x 0.2 cm skin tear observed. The resident stated "The nurse on 7-3 shift put this on me, I didn't notice it was a bandage until you pointed it out." This nurse changed the resident's treatment to the correct treatment. A 4 x 4 gauze with Medihoney to sacrum, bacitracin was applied to skin tears and 4 x 4 gauze placed over the skin tears.

The intervention in response to this error was to provide nursing education on how to read the TAR for proper treatment instructions.

A review of facility provided document and incident report, dated June 1, 2022, 9:38 P.M., also noted the incident above. The immediate action taken was that the nurse corrected the treatment, and that nursing education on how to read the TAR for proper treatment instructions.

An outside -community based, wound consultant, initial wound evaluation and management, for the skin tear - abrasion on the left and right buttocks on June 2, 2022, at 3:39 P.M., indicated that the left buttock abrasion (Length x Width x Depth) cm was 1 x 0.3 x 0.1, with no exudate (drainage - fluid that has seeped out of blood vessels or an organ), but was tender. The right buttock abrasion measured 1 x 0.3 x 0.1 with no exudate, with tenderness.

The wound consultant documentation dated June 16, 2022, at 12:19 P.M., indicated that the resident's left buttock abrasion measured 0.4 x 0.3 x 0.1 without exudate with tenderness. The right buttock abrasion was resolved.

A wound consultant documentation dated June 23, 2022, at 5:47 P.M., indicated that the resident's left buttock abrasion measured 0.2 x 0.2 x 0.1 without exudate with tenderness.

During an interview on June 28, 2022, at approximately 2:00 PM, with the Nursing Home Administrator (NHA), he NHA verified the incident during which the physician orders had not been followed resulting in skin tears to the resident. The NHA verified that there was no documented evidence of the nursing education, and/or discipline, and or competency evaluation provided to the nurse who applied the incorrect treatment at the time of the survey ending June 28, 2022.



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







 Plan of Correction - To be completed: 08/09/2022

What corrective actions will be accomplished for those residents found to have been affected by the deficient practice?

An incident report was competed at the time of the original occurrence. Resident A1's physician's orders were immediately reviewed, and the correct treatment was applied. Resident A1 no longer resides at the facility.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

Current facility residents with wound treatments have been assessed and reviewed for treatment accuracy.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

The facility policy and procedure for Treatment Administration will be reviewed/revised. Current facility licensed staff will be educated by DON/designee on the policy changes. DON/designee will complete Treatment Competencies with current licensed staff.


How the corrective action will be monitored to ensure that the deficient practice will not recur?

To ensure the deficient will not recur, the facility will audit 5 wound treatments and orders for accuracy weekly X 4 weeks, bi-weekly X 1 month then monthly X 1 month. Audit results will be reviewed at the monthly QAPI meeting.

Dates of when the corrective action will be completed: August 9, 2022



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 a review of clinical records and select facility incident reports and staff interview, it was determined that the facility failed to implement effective interventions, to promote resident safety and prevent repeated falls for one resident (Resident CR1) of 3 sampled residents.

Findings include:

A review of the clinical record revealed that Resident CR1 was admitted to the facility on April 20, 2022. The resident had diagnoses that included cerebral infarction (stroke).

Review of an admission nursing assessment dated April 20, 2022 revealed that the resident was at high risk for falls related to weakness and poor cognition.

Review of the resident's care plan, initially dated April 20, 2022, indicated that the resident is at high risk of falls related to weakness and poor cognition, history of falls, and confusion. Interventions to keep the resident free of injury included the resident's bed in lowest position, orient the resident to the surroundings, place call bell and frequently used items within reach and encourage calling for assistance if needed. Ensure resident is wearing non-skid socks when ambulating or mobilizing in wheelchair.

Review of an incident report dated June 8, 2022, at 11:00 PM revealed that the resident was found lying on the floor on her right side, on the floor beside her bed, parallel to the wall. The resident had bowel movement on her sheets and the outside of her brief. The resident was screaming "please get me back to bed." The bed was noted to be in the low position at the time of the fall. The resident was unable to give description of what happened. The resident was assessed, and no injuries were noted. The resident was washed up and put into a new brief. The new intervention, which was then added to the resident's care plan, was for the use of a body pillow. There was no description of which side of bed body pillow was to be placed.

Review of an incident report dated June 10, 2022 at 12:30 PM revealed that the resident was observed face down on the floor on the door side of the bed with left arm underneath her body. The registered nurse assessed the resident and a 0.1 cm by 0.5 cm cut to the bridge of the nose with bruising; 2 cm by 2 cm bump to the middle of the forehead; 5 cm by 5 cm bruise to the left knee; and 4 cm by 5cm bruise to the right knee were noted. The resident's nose was actively bleeding, and the resident's dentures were broken on the floor. Immediate actions taken were x-ray left hip/shoulder and face, neuro checks initiated, and every one-hour safety checks. The physician and responsible party were notified.

Further review of the incident report revealed that Predisposing physiological factors included the resident's behavior. Predisposing Situation Factors were noted to be the resident's non-compliance with care and that the resident transfers self.

Review of witness statements revealed that the resident's non-skid socks were not on her feet. The resident's socks were in the bed. Further review of the investigation revealed no documented evidence of planned safety interventions that were in place at the time of the fall. There was no documented evidence that the body pillow, which was put in place after the resident's fall from bed on June 8, 2022, was implemented and in use at the time of this fall.

Review of an incident report dated June 10, 2022 at 8:00 PM (seven hours and thirty minutes after the previous fall out of bed) revealed the resident was found lying on the floor in her room parallel to the bed and between the bed and wall. The resident was noted to be calling out all day, anxious per shift report, and all the 3:00 PM to 11:00 PM shift. The bed was in low position. The family had just stepped out of the room a few minutes before the incident. The resident was unable to give a description of the incident.

The resident was assessed for injuries and noted to have a hematoma to the right eye and forehead, pea-sized abrasion noted to the left knee, and small amount of blood dripping from her nose. No change in range of motion was noted, moving all extremities. A new order was noted to send the resident to the emergency room for evaluation and treatment. The facility noted that upon return, fall mats will be placed at the bedside as an intervention.

Further review of the incident report revealed that Predisposing Physiological factors included the resident's behavior, the resident was confused and impaired memory.

Further review of the incident report failed to provide documented evidence that the facility had implemented effective interventions and provided adequate supervision based on the resident's noted behaviors and confusion to prevent the resident from experiencing repeated falls from bed.

Interview with the Nursing Home Administrator (NHA) on June 28, 2022, at approximately 1:00 PM, failed to provide evidence that the facility provided safety measures to protect a resident who was at risk for falls from falling out of the bed twice in the same day.



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

28 Pa. Code 211.11(d) Resident care plan






 Plan of Correction - To be completed: 08/09/2022

What corrective actions will be accomplished for those residents found to have been affected by the deficient practice?

Resident CR 1 has been discharged from the facility.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Current facility residents identified as a fall risk, will have their care plans reviewed for fall interventions.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?


Facility policy and procedure for Fall interventions will be reviewed and revised. DON/designee will educate current licensed staff on fall risk assessment policy/procedure identifying and implementing fall interventions. New fall interventions will be monitored daily through the facility clinical stand-up process to ensure they are in place and on the resident's plan of care.

How the corrective action will be monitored to ensure that the deficient practice will not recur?

New fall interventions will be audited weekly X 4 weeks, bi-weekly X 1 month and monthly X 1 month. Audit results will be reviewed at the monthly QAPI meeting.

Dates of when the corrective action will be completed: August 9, 2022


483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

483.55(b) Nursing Facilities.
The facility-

483.55(b)(1) Must provide or obtain from an outside resource, in accordance with 483.70(g) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:

Based on review of clinical records, select facility incident reports, and payor source data, and staff interview, it was determined that the facility failed to promptly refer a resident with broken dentures for dental services for one Medicaid payor source residents (Resident CR1) out of six sampled residents.

Findings include:

A review of the clinical record revealed that CR1 was admitted to the facility on April 20, 2022 and discharged to home on June 22, 2022.

Review of an incident report dated June 10, 2022 at 12:30 PM revealed that the resident was observed face down on the floor, on the door side of the bed, with her left arm underneath her body. The resident's dentures were broken on the floor as the result of the fall.

The resident was transferred to the emergency room and was admitted to the hospital on June 10, 2022, at 11:30 PM. The resident was readmitted to the facility on June 17, 2022 at 2:54 PM.

There was no documented evidence at the time of the survey ending June 28, 2022, of the facility's efforts to obtain new dentures for the resident in a timely manner after this fall and resident's readmission to the facility on June 17, 2022.

Interview with the Nursing Home Administrator on June 28, 2022 at 2:00 PM failed to provide evidence that the facility attempted to refer the resident for dental services for replacement dentures.



28 Pa Code 211.12 (c)(d)(3)(5) Nursing services

28 Pa. Code 211.15(a) Dental services.








 Plan of Correction - To be completed: 08/09/2022

What corrective actions will be accomplished for those residents found to have been affected by the deficient practice?

Resident CR 1 has been discharged from the facility.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

Current facility residents with dentures will be reviewed to ensure their dentures are in good working order and are not in need of repair. Any identified repair needs will be referred to facility dentist.

What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
Current facility staff will be educated on facility dental consult practice. Residents requiring dental consults for dentures issues will be monitored and identified via the facilities clinical stand-up process for further intervention.

How the corrective action will be monitored to ensure that the deficient practice will not recur?

A random sample of 5 current facility residents will be audited weekly X 4 weeks, bi-weekly X 1 month and monthly X 1 month, to ensure dentures are in working condition.


Dates of when the corrective action will be completed. August 9, 2022



201.18(b)(1)-(3) LICENSURE Management.:State only Deficiency.
(b) The governing body shall adopt and enforce rules relative to:

(1) The health care and safety of the residents.

(2) Protection of personal and property rights of the residents, while in the facility, and upon
discharge or after death.

(3) The general operation of the facility.
Observations:

Based on a review of clinical record and staff interview, it was determined that the facility failed to account for the disposition of personal property upon discharge for one resident out of three reviewed (Resident CR1).

Findings include:

A review of the clinical record of Resident CR1 revealed the resident was admitted to the facility on April 20, 2022 and discharged to home on June 22, 2022.

A review of the resident's Personal Effects Inventory sheet revealed the sheet was not dated or signed by whomever had completed/updated the inventory sheet to verify when the sheet was completed and if it was updated throughout the resident's stay at the facility.

Written at the bottom of the sheet was a list of items which included "right side hearing aid". On the back of the form the responsible party indicated items that were missing and included: a left and right hearing aid, two nightgowns, blue silk and black silk blouse, and black leggings.

Interview with the administrator on June 28, 2022 at 2:00 PM confirmed the the resident's inventory sheet was not completed in a manner to ensure an accurate inventory of the resident's personal property.









 Plan of Correction - To be completed: 08/09/2022

What corrective actions will be accomplished for those residents found to have been affected by the deficient practice?

Resident CR 1 has been discharged from the facility.


How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?

Current facility residents inventory sheets will be reviewed for accuracy and updated if needed.


What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?

The Admissions Director and Nursing Supervisor will be educated on the policy/procedure for completing an accurate inventory checklist.

How the corrective action will be monitored to ensure that the deficient practice will not recur?

A random sample of 5 current facility residents inventory checklists will be audited weekly X 4 weeks, bi-monthly X 1 month and monthly X 1 month. Results to QAPI monthly.

Dates of when the corrective action will be completed: August 9, 2022



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