Pennsylvania Department of Health
SELECT SPECIALTY HOSPITAL - MCKEESPORT, INC.
Patient Care Inspection Results

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SELECT SPECIALTY HOSPITAL - MCKEESPORT, INC.
Inspection Results For:

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SELECT SPECIALTY HOSPITAL - MCKEESPORT, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of an unannounced onsite complaint investigation, CHL24C244P, completed on April 1, 2024, at Select Specialty Hospital- McKeesport. At the time of the investigation, the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.




 Plan of Correction:


109.36 LICENSURE NURSING NOTES:State only Deficiency.
109.36 Nursing notes

Nursing records and reports which reflect the progress of each patient and the nursing care planned shall be maintained. They shall be pertinent, accurate, and concise so that they contribute to the continuity of patient care. Nursing records and reports shall become part of each patient's medical record.
Observations:
Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined that the facility failed to consistently document turning and positioning for a "bedfast" patient with a sacral wound in one of one medical record reviewed(MR1).


Findings include:


On April 1, 2024, Policy S05-G, "Guidelines and Protocols, Clinical " (Last Revised: October 1, 2023) was reviewed and revealed the following: "To ensure quality patient care, certain standards of care must be upheld. The following table outlines basic tasks and designates the minimum frequency with which these tasks must be performed to maintain quality care ...Activity/Mobility: Bedfast patients turned. Frequency: Every 2 hours."


On April 1, 2024, a review of MR1 revealed that the patient was admitted on February 19, 2024 with a sacral wound measuring 9cm x 5 cm x 3cm (135cm3- surface area). Turns and re-positioning were not documented on a "bedfast" patient for the following:

On February 20, 2024, MR1's documented position remains "pillow support" from 2:00 AM to 7:00 AM without documentation/evidence of MR1's position in bed or any change of position for 5 hours. From 8:00 AM until 1:00 PM, MR1's position is documented as right side without evidence of change in position for 5 hours. At 5:37 PM, MR1 is repositioned from right side to left side. From 7:00 PM to 10:00 PM, MR1's position is documented as "pillow support" without documentation/evidence of MR1's position in bed or any change of position for 4 hours and 23 minutes.


On February 21, 2024, MR1's documented position remains "pillow support" from 12:00 AM to 8:00 AM without documentation/evidence of MR1's position in bed or any change of position for 8 hours. At 6:51PM, MR1 was dangled at the bedside. From 7:00 PM to 11:00 PM, MR1's position is documented as "pillow support" without documentation/evidence of MR1's position in bed or any change of position for 4 hours.


On February 22, 2024, at 4:33 PM, MR1's position in bed is documented as left side. From 6:00 PM to 10:43 PM, MR1's position is documented as "pillow support" without documentation/evidence of MR1's position in bed or any change of position for 6 hours and 10 minutes.


On February 24, 2024, MR1 was out of bed (OOB) to a chair from 11:00 AM to 5:00PM. MR1's position is documented as "OOB with pillow support" without documentation/evidence of any change of position for 7 hours.


On February 25, 2024, MR1's documented position remains "pillow support" from 12:00 AM to 8:00 AM without documentation/evidence of MR1's position in bed or any change of position for 8 hours.


On February 26, 2024, MR1's documented position remains "pillow support" from 12:00 AM to 11:00 AM without documentation/evidence of MR1's position in bed or any change of position for 11 hours.


On April 1, 2023 the above findings were confirmed by EMP2 at 11:50 AM.












 Plan of Correction - To be completed: 04/19/2024

To ensure that nursing notes and records reflect the progress of each patient in accordance with 109.36 LICENSURE NURSING NOTES, the Chief Nursing Officer (CNO), and/or designee, will provide education to clinical nursing staff on Clinical Services Policy and Procedure Number S05-G, "Guidelines and Protocols, Clinical," with emphasis on, documentation in the medical record of turns and repositioning with evidence of change in position every 2 hours. Education will be completed no later than May 1, 2024. As of May 1, 2024, any nursing staff members that have not completed this education will do so prior to working their next scheduled shift.
Compliance with the above plan will be monitored by the CNO, or designee. To ensure documentation in the medical record of turns and repositioning with evidence of change in position every 2 hours, the CNO, or designee, will audit 5 medical records a day. This will continue until 90% compliance has been achieved and sustained. At that time, monitoring will be part of the hospital's ongoing Quality Assurance Process Improvement (QAPI) Plan via random audits. Findings will be reported monthly to the QAPI Team, and quarterly to the Organization Improvement Committee (OIC), Medical Executive Committee (MEC) and Governing Board (GB). Staff members who are noted to be non-compliant will be subject to disciplinary action, up to and including termination, per HR policies and procedures.


The Chief Nursing Officer is ultimately responsible for ensuring the plan of correction is implemented and that compliance is achieved and maintained.


The hospital will be in full compliance with the above by June 1, 2024


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