Nursing Investigation Results -

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

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SOUTHWESTERN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  197 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.
SOUTHWESTERN NURSING AND REHABILITATION CENTER - 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 6/30/22, it was determined that Southwestern Nursing and Rehabilitation 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.



 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on review of clinical records, facility policy, and staff interview, it was determined that the facility failed to notify the family or responsible party for a change in condition or need to transfer resident out of the facility for treatment for one of two residents (Resident R1)

Findings include:

A review of the facility policy "Change in a Resident's Condition or Status" dated 2/1/21, indicated the facility will notify the resident's representative when there is a significant change in the resident's physical, mental, or psychosocial status, and if it is necessary to transfer the resident to a hospital/treatment center.

Review of clinical record revealed that Resident R1 was admitted on 3/10/22, with diagnoses that include peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), dementia, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).

A review of the quarterly Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 6/19/22, indicated the diagnoses remain current.

Review of clinical record for Resident R1 revealed documentation present from consulted Wound Care Certified Registered Nurse Practitioner (CRNP) dated 2/24/22. This documentation stated that Resident R1 was found to have an unstageable pressure injury (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or a scab) on the right heel during an exam performed on 2/24/22.

The clinical record did not include documentation that the responsible party was notified of the change in condition for Resident R1.

Review of the clinical record reveals the Resident R1 was transferred to a Surgery Center on 5/16/22 to receive an angiogram (an xray of the heart's blood vessels).

The clinical records did not include documentation that the responsible party was notified of the need to transfer to a Surgery Center or of the need for the angiogram.

During an interview on 6/29/22, at 5:52 p.m. the Director of Nursing confirmed that Resident R1 had changes in physical condition and had been transferred out of the facility for treatment and the clinical record did not include documentation that the family or responsible party was notified.

28 Pa. Code 201.14(a) Responsibility of Licensee.

`



 Plan of Correction - To be completed: 07/11/2022

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.

F 580 Notification
1. Failure to notify R#1 family or responsible party of a change in condition or need to transfer out of the facility for treatment cannot be retroactively corrected.
2. Audit will be completed of current residents' last 2 weeks of appointments and progress notes to validate that resident/residents' representatives are notified of the appointment/s and or changes in condition. Audit will be completed by Director of Nursing/designee
3. Education will be completed with licensed nursing staff on proper notification to residents/resident representatives when a resident has a physician ordered external appointment. Any nurses not on schedule will have education on next scheduled shift. Education will be completed by the Director of Nursing/Designee.
4. Audit will be completed for documentation new orders for external appointments and notification of changes in condition daily for 5 days then weekly for 3 weeks then monthly for 3 months. Audits will be completed by Director of Nursing/Designee
5. Results of audits will be reviewed with the Quality Assurance Performance Committee monthly or until substantial compliance is met.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer: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(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on review of clinical records, and staff interviews, it was determined that the facility failed to provide necessary treatment and services to promote healing of pressure ulcers and follow consulted wound care practitioner's orders for pressure ulcers for one of three residents (R1).

Findings include:

Review of clinical record revealed that Resident R1 was admitted on 3/10/20 with diagnoses that include peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), dementia, and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).

A review of the quarterly Minimum Data Set assessment (MDS-a periodic assessment of resident care needs) dated 6/19/22, indicated the diagnoses remain current.

Review of clinical record for Resident R1 revealed documentation present from consulted Wound Care Certified Registered Nurse Practitioner (CRNP) dated 2/24/22. This documentation stated that Resident R1 was found to have an unstageable pressure injury (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or a scab) on the right heel during an exam performed on 2/24/22.

Review of Wound Care Certified Nurse Practitioner (CRNP) notes on 2/24/22, 3/3/22, 3/10/22, 3/24/22, and 4/7/22 include recommendations to provide treatments that included the use of skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction) to the right heel.

Review of Treatment Administration Records (TARs), and Medication Administration Records (MARs), from February 2022, March 2022, and April 2022, indicate that the facility failed to provide this treatment.

During an interview on 6/30/22, at 12:53 p.m. with Director of Nursing Employee, it was confirmed that Resident (R1) did not receive the skin prep treatment that was recommended.

28 Pa. Code 201.14(a) Responsibility of Licensee.
Previously cited 2/7/22.

28 Pa. Code 201.18(b)(1) Management.
Previously cited 2/7/22.

28 Pa. Code 211.12 (d)(1)(5) Nursing Services.
Previously cited 11/18/21.

28 Pa. Code 211.12 (d)(2)(3) Nursing Services.



 Plan of Correction - To be completed: 07/11/2022

1. Facility will review R#1 wound care consultant progress notes from June 29, 2022, to validate any new wound care recommendations have been followed up on with the attending physician
2. Residents with pressure injury wound notes from most recent wound care consultant visit will be audited to validate those recommendations for treatments/changes were reviewed with the attending physician. Audit will be completed by the Director of Nursing/Designee
3. Education will be completed with current licensed nurses on review of wound consultant recommendations with attending physician. Nurses not scheduled on that day will be educated on next scheduled shift. Education will be completed by Director of Nursing/Designee
4. Audit will be completed of wound consultant progress notes for any recommended treatment changes and applicable attending physician follow up weekly for 4 weeks, then monthly for 2 months. Audit will be completed by Director of Nurse/designee.
5. Results of audits will be reviewed with the Quality Assurance Performance Committee monthly or until substantial compliance is met



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port