Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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CAMBRIA CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a complaint survey completed on March 4, 2020, it was determined that Cambria Care 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.

 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.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician orders were followed regarding the indwelling catheter size for one of the three residents reviewed (Resident 2).

Findings include:

A diagnosis record for Resident 2, dated August 29, 2019, revealed that the resident had diagnoses that included stroke and neuromuscular dysfunction of the bladder (bladder problems due to disease or injury of the central nervous system).

Physician's orders for Resident 2, dated August 9, 2019, included an order for the resident to have an indwelling urinary catheter (tube inserted and held in the bladder to drain urine), 30 French (catheter size) with a 75 cubic centimeter (cc) balloon (located on the end of the catheter and inflated to hold the catheter in place). Physician's orders dated July 24, 2019, included an order to change the indwelling catheter every month.

A nursing note for Resident 2, dated January 25, 2020, indicated that the resident's catheter was changed and that a 28 French with a 75 cc balloon was inserted. The resident's treatment record for February 2020 indicated that a routine monthly catheter change was completed on February 15, 2020.

Interview with Registered Nurse 1 on March 4, 2020, at 2:40 p.m. confirmed that Resident 2 currently had a 28 French catheter with a 75 cc balloon in place, instead of a 30 French as ordered by the physician.

Interview with the Assistant Director of Nursing on March 4, 2020, at 3:10 p.m. revealed that a physician's order was required to change a resident's catheter size. She was not aware of why a different size catheter was inserted for Resident 2, and indicated that if the size ordered was unavailable the order should have been clarified with the physician.

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

 Plan of Correction - To be completed: 03/24/2020


The following is submitted for plan of correction purposes only and is not to be construed as an admission

Residents 2 continues to reside in this facility. Resident 2 had indwelling urinary catheter size clarified with the physician on 3/4/2020. Resident 2 had a urology consult 3/11/20. Urology recommendations reviewed with physician and order was received to discontinue indwelling urinary catheter on 3/12/2020.

Current residents who are ordered indwelling catheters will be reviewed to ensure that they have the correct size catheter as per physician's order.
The policy for indwelling urinary catheters was reviewed and remains appropriate
The policy for indwelling Urinary Catheters was reviewed and revised to reflect the need to verify the Physician's order prior to insertion to ensure the proper size is available and utilized.

The Director of Nursing/Designee will educate licensed nursing staff on federal regulation 684 and the importance of ensuring physician's orders are followed regarding the indwelling catheter size. Licensed staff will also be educated on the revised catheter policy. Agency Nurses will be educated prior to the provision of care in the facility.
The Director of Nursing/Designee will complete random audits daily for two weeks, weekly for two weeks, monthly for two months, then randomly thereafter to ensure physician's orders are followed regarding the indwelling catheter size. Results of these audits will be reviewed during the facility's Quality Assurance Performance Improvement committee for further recommendations to ensure sustained compliance.

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