Nursing Investigation Results -

Pennsylvania Department of Health
WESTERN RESERVE HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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WESTERN RESERVE HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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WESTERN RESERVE HEALTHCARE AND REHABILITATION 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 Western Reserve Healthcare and Rehabilitation Center was not in compliance with the following requirements of the 28 PA Code, Commonwealth of Pennsylvania Long Term Licensure Regulations.




 Plan of Correction:


211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:

Based on review of nursing schedules and staff and resident interviews, it was determined that the facility failed to provide the minimum number of general nursing care hours of 2.7 hours of direct resident care hours per resident in a twenty-four hour period for one of 21 days reviewed (5/14/22).

Findings include:

Interviews with alert and oriented residents (Residents R1, Resident R2, and Resident R3) revealed that it is common to wait for an hour for care by nursing staff when they put their call bell on, especially in the evening and midnight hours.

During a review of nursing schedules between 4/17/22 through 4/23/22, 5/12/22 through 5/18/22, and 6/20/22 through 6/26/22, it was identified that the hours of direct resident care was below the 2.7 minimum per patient day (PPD) on the following date:

5/14/222.68 PPD

During an interview on 6/28/22, 3:45 p.m. the Nursing Home Administrator confirmed that the facility did not meet the 2.7 minimum hours of direct resident care on the 5/14/22.





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

1.No residents identified

2. All residents have the potential to be affected by less than a minimum of 2.7 hours of direct resident care for each resident. Daily schedules, as well as biweekly schedules will be reviewed to ensure sufficient staff are in the facility at all times.

3.Current open positions have been placed advertising for nurses as well as CNAs. The hiring of additional CNAs and nurses has and continues to be ongoing. Education being provided to nursing staff on the Attendance Policy and correctly reporting a call in with correct time frame. Open shifts posted for current staff to fill. Referral bonuses for current employees to refer potential new hires.

4.The NHA, Director of Nursing or Designee will review daily schedule to ensure appropriate nursing service hours of a minimum of 2.7. The NHA, DON or designee will audit 3 times a week for 2 weeks, 1 time a week for 2 weeks and monthly thereafter to ensure that sufficient staff are in place.

5.The results of these audits will be reviewed in QAPI. Schedules will have projected hours above 2.7 in case of call offs to help maintain the 2.7

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