Pennsylvania Department of Health
PROVIDENCE HEALTH & REHAB CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PROVIDENCE HEALTH & REHAB CENTER
Inspection Results For:

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PROVIDENCE HEALTH & REHAB CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to three complaints, completed on March 21, 2024, it was determined that Providence Health and Rehab Center was not in compliance with the 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:

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of two residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a fracture of the distal right tibia (fracture of the shin bone near the ankle). This deficiency is cited as past non-compliance.

Findings include:

Review of facility policy entitled "Pennsylvania Resident Abuse", dated 1/19/24, indicated that the facility will not tolerate abuse, neglect, mistreatment, exploitation of residents, and misappropriation of resident property by anyone. It is the facilities policy to investigate all allegations, suspicions and incidents of abuse, neglect, involuntary seclusion, intimidation, exploitation of residents, misappropriation of resident property and injuries of unknown source. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of Resident R1's admission record indicated that Resident R1 was admitted to the facility 4/5/23.

Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated 1/3/24, indicated diagnoses of hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation (disease of the heart characterized by irregular or often faster heartbeat). Further review of MDS indicated that Resident R1 is dependent for chair/bed-to-chair transfers in which helper does all of the effort; resident does none of the effort to complete the activity; Or the assistance of two or more helpers is required for the resident to complete the activity. Further review of MDS indicated BIMS score of 15 "cognitively intact".

Review of active physician orders indicated that on date 6/28/23, Resident R1 was ordered a Transfer status: full body mechanical lift every shift.

Review of Resident R1's care plan with an identified Problem focus category "ADL's Functional Status/Rehabilitation Potential", with an initiated date of 10/19/23, indicated under approach, Resident R1 is to be provided full body mechanical lift assistance for transfers. An additional approach initiated 11/29/23, indicated Resident R1's transfer status hoyer lift (a device that helps caregivers transfer patients with limited mobility from one place to another).

Review of current Resident Profile (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 10/19/23, Resident R1 is to be provided full body mechanical lift assistance for transfers; further indicated that on 11/29/23, Resident R1's transfer status hoyer lift.

Review of Resident R1's clinical record revealed a nursing note dated 3/13/24, at 12:29 p.m., which revealed her complaining about her right leg and how it was hurting. Right shin was found to be shiny, red, edematous (swelling) and warm to touch. Patient (Resident R1) states it was hit last night being put to bed.

Review of Resident R1 nursing note dated 3/13/24, at 4:15 p.m., revealed resident was assessed by a Registered Nurse (RN) Employee E1 due to complaints of right lower extremity pain. Resident R1 was found to have a 10x6 cm (centimeter) raised area that was firm to touch and painful to palpitation and movement. Per note, physician was made aware with new order for stat x-ray (diagnostic test that captures images of the structures inside the body).

Review of Resident R1 nursing note dated 3/14/24, at 12:28 a.m., revealed that x-ray results received identified a comminuted nondisplaced fracture of the distal right tibia. Per note, new order by physician to make appointment with Orthopedics (branch of medicine dealing with the correction of deformities of bones or muscles) as soon as possible for 3/14/24.

Review of Resident R1 nursing note dated 3/15/24, at 12:51 p.m., Resident R1 consulted with Orthopedic physician, follow-up in one week, and that short leg cast applied at visit.

Review of facilities investigation revealed that on 3/14/24, at 4:00 p.m., Resident R1 was interviewed by the Director of Nursing stating that one "lady" lifted her from her wheelchair to the bed "mangled" my leg "hit it on something done there" as she motioned to the bed frame below her. An additional interview was conducted with Resident R1 at 9:45 p.m., by the DON, who stated a women was putting her (Resident R1) to bed. She (NA Employee E2) just grabbed me up and she (Resident R1) told her (NA Employee E2) she couldn't walk. She (NA Employee E2) put my (Resident R1) feet on top of hers and moved me. Then she (NA Employee E2) bumped her (Resident R1) right leg off of the bed.

Review of the facility's investigation revealed that on 3/15/24, at 2:45 p. m., the Nursing Home Administrator (NHA) interviewed Resident R1 who stated that a woman (Employee E2) tried to put me in bed without a hoyer. She (NA Employee E2) got in front of her (Resident R1), picked her up, and told her (Resident R1) to hold her (NA Employee E2) around the neck. Resident R1 further stated that the bed was not at the right height and my leg hit the bed.

Review of the facility's investigation revealed an interview with Employee E2 was conducted on 3/14/24, at 9:01 p.m., by the NHA and DON, indicated which unit she (NA Employee E2) was working on (1B), was using the sit-to-stand (a type of mobility device) with Resident R1, without assistance, and that she (Resident R1) complained of her legs hurting. NA Employee E2 further stated in interview that who she took report from said she (Resident R1) was a sit-to-stand, and that her (Resident R1) transfers change all the time, and that she (NA Employee R2) doesn't think she bumped her (Resident R1) leg at all.

Review of the facility's investigation witness statement dated 3/15/24, NA Employee E3 stated that she did give NA Employee E2 report, but doesn't recall giving report of specific transfer status for Resident R1, and that she (NA Employee E3) has always only transferred Resident R1 with a hoyer lift.

Review of documentation submitted by the facility dated 3/14/24, revealed that the facility initiated an investigation, regarding resident abuse on 3/13/24. The investigation revealed that NA Employee E2 was terminated.

Interview conducted with NHA on 3/20/24, at 3:40 p.m., confirmed that NA Employee E1 failed to transfer a resident properly who required full body mechanical lift assistance with a hoyer lift.

The facility failed to ensure that Resident R1 was free from neglect resulting in actual harm of a fracture of the distal right tibia from the improper transfer which required the use of a hoyer lift.

This deficiency is cited as past non-compliance.

On 3/15/24, the facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and NA's to ensure that resident transfers are performed per resident care plans. This plan included the following:

Termination of Employee E2 on 3/15/24.

Immediate education regarding abuse, neglect, and exploitation, in addition to following proper transfer protocol was provided to nursing staff which included RN's, LPN's, and NA's, which occurred on 3/14/24, through 3/15/24. Education included how to access Care plan and Resident Profile to review transfer status prior to transfers.

Immediate NA competency questionnaire was obtained and re-education was provided for those NA's who were identified as having concerns related to location of residents transfer status, or concerns regarding their level of comfort with transfers protocols, which occurred 3/14/24, through 3/15/24.

Review of all resident transfer status compared with resident care plan and Resident Profiles was completed on 3/15/24.

Interview questionnaire with alert and oriented residents was conducted regarding abuse, care needs being met, witnessing and reporting abuse, and how transferred from bed to chair, which occurred 3/14/24.

Facility conducted whole house skin checks/audits to determine any other injuries due to improper transfers, which occurred 3/14/24.

Interviews with LPN Employees E4, E5, and E6 and Na Employees E3, E7, E8, E9, E10, and E11 on 3/20/24, confirmed that the facility initiated education on 3/14/24, which included reporting abuse, neglect, and exploitation timely, following proper transfer protocols, and how to check a residents current transfer status.

Audits were conducted to ensure residents are transferred per their care plan/Resident Profile which occurred on 3/15/24, through 3/20/24. Per interview with the NHA these audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee meeting and will continue until determined otherwise by the QAPI committee.

During an interview with the NHA 3/21/2024 at 1:15 p.m. and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from neglect regarding transfer status of residents and had achieved substantial compliance as of 3/16/24.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(1) Management

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(3) Nursing services

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

Plan of Correction - To be completed: 04/02/2024

Past noncompliance: no plan of correction required.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§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 review of facility policy, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide adequate supervision and implement effective transfer interventions as per physician order to promote resident safety, resulting in a preventable accident and actual harm when the resident received a fracture of the distal right tibia, one of two residents reviewed (Resident R1). This deficiency is cited as past non-compliance.

Findings include:

Review of facility policy entitled "Incident/Accident Policy", dated 1/19/24, indicated an incident/accident is any occurrence which is not consistent with the routine care of a particular resident. An incident/accident can occur anywhere and be discovered by anyone (resident, visitor, employee or volunteer). All incident/accidents involving residents will be analyzed and reported.

Review of facility policy entitled "Mechanical Lift Policy", dated 1/19/24, indicated a mechanical lift may be used for transferring residents that cannot be safely transferred by themselves or with staff assistance. Lift devices are available for general nursing care units and may be utilized by staff that have demonstrated competency. Residents ' transfer status will be assessed on admission, quarterly and as needed with any change in the resident ' s transfer ability. It will be determined if a mechanical lift and which type of lift is required. The decision will be based on nursing judgement and/or therapy evaluation and recommendation. Two staff person assist/oversight is required for total body lifts while one person assist is satisfactory for sit-to-stand lifts.

A review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019 indicated that a Brief Interview for Mental Status ("BIMS", a screening test that aides in detecting cognitive impairment ). The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of Resident R1's admission record indicated that Resident R1 was admitted to the facility 4/5/23.

Review of Resident R1's Minimum Data Set (MDS - an assessment tool used to facilitate the management of care) assessment dated 1/3/24, indicated diagnoses of hypertensive heart and chronic kidney disease with heart failure, and atrial fibrillation (disease of the heart characterized by irregular or often faster heartbeat). Further review of MDS indicated that Resident R1 is dependent for chair/bed-to-chair transfers in which helper does all of the effort; resident does none of the effort to complete the activity; Or, the assistance of two or more helpers is required for the resident to complete the activity. Further review of MDS indicated BIMS score of 15 "cognitively intact".

Review of active physician orders indicated that on date 6/28/23, Resident R1 was ordered a Transfer status: full body mechanical lift every shift.

Review of Resident R1's care plan with an identified Problem focus category "ADL's Functional Status/Rehabilitation Potential", with an initiated date of 10/19/23, indicated under approach, Resident R1 is to be provided full body mechanical lift assistance for transfers. An additional approach initiated 11/29/23, indicated Resident R1's transfer status hoyer lift (a device that helps caregivers transfer patients with limited mobility from one place to another).

Review of current Resident Profile (an easy reference of resident care needs for the nursing assistants to reference), indicated that on 10/19/23, Resident R1 is to be provided full body mechanical lift assistance for transfers; further indicated that on 11/29/23, Resident R1's transfer status hoyer lift.

Review of Resident R1's clinical record revealed a nursing note dated 3/13/24, at 12:29 p.m., which revealed her complaining about her right leg and how it was hurting. Right shin was found to be shiny, red, edematous (swelling) and warm to touch. Patient (Resident R1) states it was hit last night being put to bed.

Review of nursing notes dated 3/13/24, at 4:15 p.m., revealed Resident R1 was assessed by a Registered Nurse (RN) Employee E1 due to complaints of right lower extremity pain. Resident R1 was found to have a 10x6 cm (centimeter) raised area that was firm to touch and painful to palpitation and movement. Per note, physician was made aware with new order for stat x-ray (diagnostic test that captures images of the structures inside the body).

Review of nursing notes dated 3/14/24, at 12:28 a.m., revealed that x-ray results received identified a comminuted nondisplaced fracture of the distal right tibia. Per note, new order by physician to make appointment with Orthopedics (branch of medicine dealing with the correction of deformities of bones or muscles) as soon as possible for 3/14/24.

Review of nursing note dated 3/15/24, at 12:51 p.m., Resident R1 consulted with Orthopedic physician, follow-up in one week, and that short leg cast applied at visit.

Review of the facility's investigation revealed that on 3/14/24, at 4:00 p.m., Resident R1 was interviewed by the Director of Nursing stating that one "lady" lifted her from her wheelchair to the bed "mangled" my leg "hit it on something done there" as she motioned to the bed frame below her. An additional interview was conducted with Resident R1 at 9:45 p.m., by the DON, who stated a women was putting her (Resident R1) to bed. She (NA Employee E2) just grabbed me up and she (Resident R1) told her (NA Employee E2) she couldn't walk. She (NA Employee E2) put my (Resident R1) feet on top of hers and moved me. Then she (NA Employee E2) bumped her (Resident R1) right leg off of the bed.

Review of the facility's investigation revealed that on 3/15/24, at 2:45 p.m., the Nursing Home Administrator (NHA) interviewed Resident R1 who stated that a women (Employee E2) tried to put me in bed without a hoyer. She (NA Employee E2) got in front of her (Resident R1), picked her up, and told her (Resident R1) to hold her (NA Employee E2) around the neck. Resident R1 further stated that the bed was not at the right height and my leg hit the bed.

Review of the facility's investigation revealed an interview with Employee E2 was conducted on 3/14/24, at 9:01 p.m., by the NHA and DON, indicated which unit she (NA Employee E2) was working on (1B), was using the sit-to-stand (a type of mobility device) with Resident R1, without assistance, and that she (Resident R1) complained of her legs hurting. NA Employee E2 further stated in interview that who she took report from said she (Resident R1) was a sit-to-stand, and that her (Resident R1) transfers change all the time, and that she (NA Employee R2) doesn't think she bumped her (Resident R1) leg at all.

Review of the facility's investigation witness statement dated 3/15/24, NA Employee E3 stated that she did give NA Employee E2 report, but doesn't recall giving report of specific transfer status for Resident R1, and that she (NA Employee E3) has always only transferred Resident R1 with a hoyer lift.

Review of documentation submitted by the facility dated 3/14/24, revealed that the facility initiated an investigation, regarding resident abuse on 3/13/24. The investigation revealed that NA Employee E2 was terminated.

Interview conducted with NHA on 3/20/24, at 3:40 p.m., confirmed that NA Employee E1 failed to transfer a resident properly who required a total/full body mechanical lift assistance with a hoyer lift, which requires assistance of 2 staff members.

The facility failed to ensure that Resident R1 was provided adequate supervision and implement effective transfer interventions and was free from an avoidable accident/injury resulting in actual harm of a fracture of the distal right tibia from the improper transfer which required the use of a hoyer lift, with assistance of 2 staff members.

This deficiency is cited as past non-compliance.

On 3/15/24, the facility initiated education for all nursing staff including Registered Nurse's (RN's), Licensed Practical Nurses (LPN's), and NA's to ensure that resident transfers are performed per resident care plans. This plan included the following:

Termination of Employee E2 on 3/15/24.

Immediate education regarding abuse, neglect, and exploitation, in addition to following proper transfer protocol was provided to nursing staff which included RN's, LPN's, and NA's, which occurred on 3/14/24, through 3/15/24. Education included how to access Care plan and Resident Profile to review transfer status prior to transfers.

Immediate NA competency questionnaire was obtained and re-education was provided for those NA's who were identified as having concerns related to location of residents transfer status, or concerns regarding their level of comfort with transfers protocols, which occurred 3/14/24, through 3/15/24.

Review of all resident transfer status compared with resident care plan and Resident Profiles was completed on 3/15/24.

Interview questionnaire with alert and oriented residents was conducted regarding abuse, care needs being met, witnessing and reporting abuse, and how transferred from bed to chair, which occurred 3/14/24.

Facility conducted whole house skin checks/audits to determine any other injuries due to improper transfers, which occurred 3/14/24.

Interviews with LPN Employees E4, E5, and E6 and Na Employees E3, E7, E8, E9, E10, and E11 on 3/20/24, confirmed that the facility initiated education on 3/14/24, which included reporting abuse, neglect, and exploitation timely, following proper transfer protocols, and how to check a residents current transfer status.

Audits were conducted to ensure residents are transferred per their care plan/Resident Profile which occurred on 3/15/24, through 3/20/24. Per interview with the NHA these audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee meeting and will continue until determined otherwise by the QAPI committee.

During an interview with the NHA 3/21/24 at 1:15 p.m. and review of the facility's immediate actions, education, audits, and QAPI monitoring process to sustain solutions, it was verified that the facility had implemented a plan of correction to ensure residents are free from accidents/incidents regarding transfer status of residents and had achieved substantial compliance as of 3/16/24.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(1) Management

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(3) Nursing services

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

Plan of Correction - To be completed: 04/02/2024

Past noncompliance: no plan of correction required.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Plan of Correction - To be completed: 04/09/2024

Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under the state and federal laws.
Facility Administration will ensure one nurses aide per twelve residents during day shift, one nurses aide per twelve residents during evening shift and one nurse's aide per 20 residents during the night shift.
The facility staffing schedule was reviewed to ensure that it provided the necessary coverage per regulation of nursing assistance.
To prevent this from happening again the NHA, DON and scheduler will meet during the staffing meeting five times a week to ensure staffing ratios are maintained.
Regional Director of Clinical Services will educate the facility NHA, DON and scheduler on the nurse aide staffing ratios implemented on 07/01/2023.
To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two months.

Results will be taken to the QAPI for review and revision as needed.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Plan of Correction - To be completed: 04/09/2024

Facility Administration will ensure a minimum of one license practical nurse per 25 residents during day shift and 30 residents during the evening shift.
The facility staffing schedule was reviewed to ensure that it provided the necessary coverage of License practical nurses per regulation.
To prevent this from happening again the facility Administrator, Director of Nursing and Scheduler will conduct a staffing meeting to review staffing ratios weekly times four weeks then monthly times two month.
Regional Director of Clinical Services will educate the facility Administrator, Director of Nursing and scheduler on the LPN staffing ratios implemented on 07/01/2023.

To monitor and maintain ongoing compliance the Director of Nursing/designee will audit staffing weekly times four weeks then monthly times two months.

Results will be taken to the QAPI for review and revision as needed

§ 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, 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 2.87 hours of direct resident care for each resident.

Observations:
Based on review of nursing time schedules, and staff interviews, it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on two of twenty-one days (3/16/24 and 3/17/24).

Findings include:

Nursing time schedules for the time period of 2/28/24, through 3/19/24, revealed that the facility failed to maintain 2.87 hours of general nursing care to each resident in a 24 hour period on the following date:

3/16/24 - 2.70 PPD
3/17/24 - 2.65 PPD

During an interview on 3/21/24, at 1:15 p.m., Nursing Home Administrator (NHA) confirmed that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on two of twenty-one days (3/16/24 and 3/17/24).

Plan of Correction - To be completed: 04/09/2024

Facility Administration will ensure the total number of hours of general nursing care provided for each 24-hour period when totaled will be a minimum of 2.87 hours of direct resident care for each resident.
The facility staffing schedule was reviewed to ensure that it provided the necessary coverage per regulation of general nursing care.
To prevent this from happening again the NHA, DON and scheduler will meet during the staffing meeting five times a week to ensure the general nursing care hours are maintained.
Regional Director of Clinical Services will educate the facility NHA, DON and scheduler on the total number hours of general nursing care provided in each 24-hour period and the minimum number of 2.87 hours of direct care for each resident.
To monitor and maintain ongoing compliance the DON or designee will audit staffing weekly x4 weeks then monthly for two months.

Results will be taken to the QAPI for review and revision as needed.

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