Nursing Investigation Results -

Pennsylvania Department of Health
OXFORD HEALTH CENTER
Patient Care Inspection Results

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OXFORD HEALTH CENTER
Inspection Results For:

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OXFORD HEALTH CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on January 9, 2019, in response to a complaint at Oxford Health Center, it was determined that the facility was not in compliance with the following requirements of the 42 CFR part 483, Subpart B, Requirements for Long Term Care and the PA 28 Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.















 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility failed to assess a resident after a change in condition in a timely manner for one out of three residents reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed the following diagnoses not limited to history of breast and lung cancer.

Review of Certified Registered Nurse Practitioner's note dated October 30, 2018 revealed that the resident was being seen for right lower quadrant abdominal lump. Resident R1 stated that she had a hard area on right side of the abdomen and it has been there about a month. The resident denied injury to right side. Further documentation stated that a scheduled CT scan (combination of X-rays and a computer to create pictures of the organs, bones, and other tissues of the abdomen was scheduled for the next day and the findings were going to be evaluated at that time.

Further review of Resident R1's clinical record revealed that on October 31, 2018, the resident went for a CT scan of the chest without contrast (without the use of a special dye). The CT scan had been previously scheduled by the oncologist. The findings indicated that the upper abdomen was viewed. There was no evidence that the resident's right lower quadrant of the abdomen was viewed in the CT scan.

Further review of Resident R1's clinical record revealed that there was no further documentation of the right lower quadrant of the abdomen concerns until November 28, 2018 when the resident was seen by a surgeon for another medical condition and an ultrasound of the abdomen was performed at this time.

An interview was conducted on January 9, 2019, at approximately 2:00 p.m. with the Nursing Home Administrator and the Director Nursing confirming that no addition diagnostic testing of the lump of the right lower quadrant of the abdomen was done from October 30, 2018 until November 28, 2018.

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.10(c) Resident care policies

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services




 Plan of Correction - To be completed: 02/24/2019

- Resident R1 has been assessed for any change in condition

- Current resident progress notes will be reviewed for the past 5 days to assure that residents have been assessed following a change in condition and physician has addressed

- MD and CRNP have been educated on the Change in Condition Policy and the importance of communication to the Health Center Nursing Team when there is a change in condition- this will ensure follow-up is completed timely
- An audit of 5 resident charts will be completed weekly for 4 weeks and then monthly for 2 months to ensure timely follow-up has taken place after a change in condition. Audit results will be forwarded to the QAPI committee for review and recommendations


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