Nursing Investigation Results -

Pennsylvania Department of Health
FELLOWSHIP MANOR
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
FELLOWSHIP MANOR
Inspection Results For:

There are  33 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
FELLOWSHIP MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and Civil Rights Compliance survey completed March 8, 2019, it was determined that Fellowship Manor was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health process of the survey process.



 Plan of Correction:


483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences: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.
483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on clinical record review, observations, and staff interview it was determine that the facility failed to accomodate resident needs regarding the accessibility to call bells for three of 23 sampled residents. (Residents 33, 37, 55)

Findings include:

Clinical record review revealed that Resident 33 was admitted to the facility on April 11, 2018 with diagnoses that included dementia and depression. Review of the Minimum Data Set (MDS) assessment dated January 2, 2019, revealed that Resident 33 was alert and oriented and required extensive assistance from staff for toileting and bed mobility. On March 5, 2019 at 10:07 a.m., Resident 33 was observed attempting to get up from his bed. Resident stated he needed to use the bathroom. The resident further stated "my call bell is not near me, and I can't reach it". The care plan dated January 9, 2019, identified that the resident was at risk for falls and directed staff to have the resident's items within reach including his call bell.

Clinical record review revealed that Resident 37 was admitted to the facility on December 31, 2018 with diagnoses that included dementia and depression. Review of the MDS assessment dated January 7, 2019, revealed that Resident 37 was cognitively impaired, was at risk for falls and required extensive assistance from staff with activities of daily living. The care plan dated February 27, 2019, identified that the resident was at risk for falls and directed staff to have the resident's items within reach that included his call bell. Observation on March 5, 2019 at 9:15 a.m, revealed that the resident was out of bed in his wheelchair with his call bell behind him and on the floor and not within reach.

Clinical record review revealed that Resident 55 had diagnoses that included stroke, paraplegia, and impaired vision. The MDS assessment dated January 21, 2019, revealed that Resident 55 was cognitively impaired and required total assistance from staff for transfers. Observation on March 6, 2019 at 1:09 p.m., revealed that the resident was out of bed seated in his wheelchair but his call bell was behind him out of reach.

In an interview on March 7, 2019 at 1:00 p.m, Director of Nursing confirmed that the residents did not have access to their call bells.

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











 Plan of Correction - To be completed: 03/18/2019

It is the policy of Fellowship Manor to assure that all residents have a call bell or acceptable alternative device within reach of each resident at all times.
On March 7, 2019 the ADON conducted an investigation of the circumstances surrounding the event with Resident 33. The CNA caring for the resident on March 5, 2019 was interviewed as to the placement of the call bell on that day. The CNA indicated that she had placed the call bell with in this residents reach after giving care and she feels that call bell was displaced when the resident attempted to sit up at the side of the bed. On this same day it was decided that due to resident 33's cognitive /dexterity issues that a tap bell would be more appropriate. An order was obtained and the comprehensive care plan was updated to reflect the change.
On March 7, 2019 after becoming aware of the observation that resident 37's call bell was not in reach an investigation was conducted by the ADON with the CNA responsible for resident's care. The CNA indicated that this residents wife was in to visit and most likely returned the resident to the room without making the staff aware and as a result the call bell was not placed in reach. This may be plausible but could not be confirmed. On this same day the resident's wife was educated by the ADON as to her responsibility in assuring that the staff is aware when she returns the resident to his room. The staff on the unit were made aware of the observed situation and education was given to reinforce that call placement within the reach of the resident is required at all times without exception and is the direct caregiver's responsibility.

On March 7, 2019 after becoming aware of the observation that resident 55's call bell was not in reach an investigation was conducted by the ADON with the CNA responsible for resident's care. The CNA assigned to the resident indicated that the private companion had returned the resident to the room and did not place call bell within reach. CNA was counseled as to the fact that although there is a companion with the resident the nursing staff is accountable to assure that call bells are within reach.
On March 7, 2019 a "Read and Sign" education was provided to the staff to reinforce the call bell placement requirements. The ADON verbally spoke with the companion regarding call bell placement on March 8, 2019. On March 8, 2019 the DON also sent an e-mail to all staff reinforcing their responsibility to inform family and companions to report when resident s is placed back in their rooms.

Beginning March 18, 2019 the DON/designee will conduct a random sampling audit to assess compliance to call bell placement. Sample size will include 10 residents on each shift 5 days a week for two weeks and then beginning April 1, 2019 weekly thereafter. Any noted concerns with non-compliance will be addressed immediately. Results of the auditing process will be reported at least quarterly to the Quality Council. Auditing will continue until substantial compliance is achieved.



483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility: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(c) Mobility.
483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Observations:

Based on observation, clinical record review and staff interview, it was determined that the facility failed to provide appropriate services to prevent further decrease in range of motion for two of five sampled residents with limited range of motion. (Resident 82, 162)Findings include:

Clinical record review revealed that Resident 162 had diagnoses that included stroke, dementia, and aphasia (an inability to understand or express speech). The Minimum Data Set (MDS) assessment dated December 7, 2018, indicated that the resident was cognitively impaired, had functional limitation in range of motion, and required extensive assistance from staff for most activities of daily living. The ongoing care plan dated March 1, 2019, revealed that the resident was at risk for skin integrity breakdown related to a decrease in mobility and impaired cognition, and staff would provide a palm guard to the right hand and a "therapy carrot" to the left hand to prevent further contractures. Review of an occupational therapy discharge summary dated October 24, 2018, was for staff to provide bilateral hand devices due to increased tightness of the right hand and contracture of the left hand. Observations on March 5, 2018, from 10:00 a.m. to 2:00 p.m., revealed that the resident was out of bed without his recommended bilateral hand devices applied.

Clinical record review revealed that Resident 82 had diagnoses that included weakness on one side of the body and dementia. The MDS assessment dated February 6, 2019, indicated that the resident was cognitively impaired, had functional limitation in range of motion on one side of the upper and lower extremities, and required extensive assistance from staff for most activities of daily living. An Occupational Therapy discharge summary dated on April 6, 2018, revealed that staff were to apply a left resting hand splint daily. On February 14, 2019, the physician ordered left resting hand splint to be applied from 11:00 a.m. through 4:00 p.m. daily.Observations on March 6, 2019, from 12:23 p.m. through 1:13 p.m., revealed that the resident was seated in his wheelchair without the left hand splint applied. A second observation on March 7, 2019 at 12:12 p.m., revealed that the resident was again seated in his wheelchair without the left hand splint applied.

In an interview on March 7, 2019 at 12:33 p.m., the Director of Nursing confirmed that staff failed to provide appropriate services for the resident.

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





 Plan of Correction - To be completed: 03/18/2019

It is the policy of Fellowship Manor to assure that all residents with limited mobility receive appropriate services, equipment and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.
Resident 162 had therapy orders to place a palm guard to the right hand and a "Therapy Carrot" to the left hand to prevent further contractures. The resident was out of bed on March 5, 2019 without the recommended bilateral hand devices applied. Follow up investigation revealed that this resident had been readmitted from a hospitalization on March 1, 2019 and placed on hospice. The OT recommendation for the bilateral hand devices did not get re-ordered to align with the care plan. When the oversight was called to the attention of the DON/ADON an order was immediately obtained and the devices were applied as ordered.
Resident 82 had an order for a resting hand splint to be applied between 11am 4pm daily. After being informed on March 7, 2019 of this oversight the staff were made aware of the need to follow the order as written on the care plan. The devices were applied per order. In addition, on this same day all residents with orders for splint type devices were assessed to assure that routines for application were being followed.
On March 7, 2019 the DON/ADON met with the nursing leadership team and a decision was made to assign splint application therapy to the licensed nursing staff versus the current process of having CNAs responsible. The licensed staff are now applying splints and documenting on the E-tar when ordered routines are being carried out. On March 7, 2019 a mandatory "Read and Sign" education was provided to all appropriate staff on this new process for splint application and documentation.
Beginning on March 18, 2019 an audit of compliance to splint applications and supporting documentation will be conducted by DON/designee on a daily basis for two weeks and then beginning on April 1, 2019 audits will be conducted on a weekly basis on all applicable shifts. Any noted concerns with non-compliance will be addressed immediately. Results of the auditing process will be reported at least quarterly to the Quality Council. Auditing will continue until substantial compliance is achieved.


Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port