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P2170

Failure to Provide Admission Orientation Materials

Pittsburgh, Pennsylvania Survey Completed on 02-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was sufficiently oriented to the facility upon admission, as required by their admission policy. The policy mandates that a Resident handbook and/or Facility Orientation material should be provided to the resident or family prior to or upon admission. However, a review of Resident R212's clinical record indicated that these materials were not provided upon their admission on February 9, 2025. Resident R212, who was admitted with diagnoses including breast cancer, high blood pressure, and anxiety disorder, confirmed during an interview that they did not receive the necessary orientation materials. Further investigation revealed that the Admission Director, Employee E13, confirmed the absence of evidence in Resident R212's clinical record regarding the provision of admission information. Additionally, the Director of Nursing (DON) acknowledged that the facility failed to ensure the resident was sufficiently oriented to the facility upon admission. This deficiency was identified through staff interviews and a review of facility policy and clinical records.

Plan Of Correction

The facility orientation handbook was developed for Squirrel Hill Wellness and Rehab. It was determined that not having the orientation could affect the new residents. The handbook was given to Resident 212. The Admissions Director was educated in giving the handbook to new residents. The Director of nursing will interview 2 new admissions per week to see if they have received a copy of the handbook. Once a week for 2 weeks, then every 2 weeks for 2 weeks, then monthly for 2 months. The findings will be reported to the quality assurance and performance improvement committee.

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