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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

YORK NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 191 surveys for this facility. Please select a date to view the survey results.

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YORK 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 two complaints completed March 8, 2024, it was determined that York Nursing and Rehabilitation Center 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 related to the health portion of the survey process.

Plan of Correction:

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on observation, clinical record review and interviews with staff, it was determined that the facility failed to administer oxygen therapy in accordance with professional standards of practice and failed to obtain physician orders for oxygen therapy for one of one resident reviewed. (Resident R1)

Findings Include:

Review of Resident R1's care plan dated December 6, 2023, revealed that the resident had a diagnosis of pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred. This thickened, stiff tissue makes it harder for the lungs to work properly), sarcoidosis (disease characterized by the growth of tiny collections of inflammatory cells) and respiratory illness which required the resident to need oxygen therapy.

Observation on March 8, 2024 at 9:40 a.m. revealed resident sitting on the side of the bed, wearing oxygen with a nasal cannula at 4 liters/min with a humidification bottle. Humidification bottle and oxygen tubing noted to have no date or time on them.

Interview with Resident R1 on March 8, 2024 revealed that he fills up his humidification bottle with water from the sink at times because staff take too long to bring the water to refill it. Resident stated he is supplied oxygen tanks by the facility when attending appointments.

Interview with Staff Educator, Employee E3 on March 8, 2024, confirmed that the resident was on oxygen at 4 liter/minute. Staff educator confirmed that there was not an order for oxygen therapy or indication of what setting the concentrator should be set to in resident's clinical record. Staff educator confirmed that it is the facility policy to have a physician order for oxygen. It was also confirmed that it is not facility policy to fill the humidification bottle with tap water and that they should be filled with distilled water by nursing staff.

Interview with Assistant Director of Nursing (ADON), Employee E2 on March 8, 2024 revealed resident had an order for Oxygen 2 liter/min which 'fell off' in February 2024. ADON unsure why this happened. ADON stated order should be reactivated.

28 Pa. Code 211.10 (c) Resident Care Policies

28 Pa. Code 211.12 (d)(5) Nursing services

Plan of Correction - To be completed: 04/10/2024

1) Physician order obtained for Oxygen therapy and initiated for R1 and Oxygen tubing replaced with date and time.

2) Facility wide audit completed for all residents requiring oxygen therapy to ensure accuracy of orders with proper date/labeling on tubing.

3) Nursing staff will be educated on ensuring Oxygen orders are obtained and in place for all residents requiring continuous oxygen, ensuring proper use of humidification water bottles as per MD orders and proper date/labeling of oxygen tubing.

4) DON/designee will conduct audits weekly x4, to ensure accuracy of oxygen orders, date labeling of oxygen tubing and ensuring proper use of humidification water bottles as per MD orders as per facility protocol. All results will be presented at QA for further review

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