Nursing Investigation Results -

Pennsylvania Department of Health
CONESTOGA VIEW
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
CONESTOGA VIEW
Inspection Results For:

There are  150 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.
CONESTOGA VIEW - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated revisit survey, state monitor and complaint investigation survey completed on October 1, 2019, it was determined that Conestoga View corrected all deficiencies cited during the Medicare/Medicaid Recertification Survey and State Licensure survey of August 8, 2019, but continues to be in non compliance with the following requirements of 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 the clinical record review and interviews with staff it was determined that the facility failed to follow physician orders for one of three residents reviewed (Resident R2).

Findings include:

Review of Resident R2's clinical record revealed an admitting date of September 5, 2019, with the following diagnosis: malignant neoplasm of the brain, urostomy, (a surgical procedure that creates an artificial opening for the urinary system), nephrostomy (an artificial opening created between the kidney and the skin ) and colostomy (an opening in the large intestine that provides an alternative channel for feces to leave the body).

Review of the physician orders revealed an order dated September 5, 2019 to flush Nephrostomy Tube with 10cc NSS twice weekly every Wednesday and Sunday and every night shift every Tuesday, and Saturday. Further review of the Treatment Administration Record (TAR) found this was not done on September 10, 14, and 21, 2019.

Further review of the physician orders revealed an order dated September 5, 2019 to empty and measure urine for right nephrostomy tube and document in medical record every shift. A review of the Treatment Administration Record (TAR) found this was not done on September 7 (day shift), September 10 (day shift), September 28 (night shift), and September 30, 2019 (Night shift).

Further review of the physician orders revealed an order dated September 5, 2019 for Urostomy care; empty and
measure urine at the end of shift and document in the medical record every shift. Further review of the Treatment Administration Record (TAR) found this was not done on September 7 (day shift), September 10 ( day and evening shift, September 28, (night shift) and September 30, 2019 (night shift).

An interview was conducted on October 1, 2019, with the Executive Director, at approximately 2:00 p.m. and no further documentation was provided for these dates.

28 Pa. Code 211.10(c) Resident care policies
Previously cited 8/8/2019

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Previously cited 2/5/19, 4/25/19, 7/2/19




 Plan of Correction - To be completed: 10/21/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

1. Resident #2 no longer resides in the facility.
2. An audit was be completed of current resident treatment administration records for the last 14 days to determine if treatments were documented as appropriate and findings will be reviewed with the facility Medical Director or designee.
3. Director of Staff Development or designee will provide re-education to licensed nursing staff that treatments need to be administered as per physician orders as appropriate. This education will be completed prior to the completion of nursing staff next scheduled shift.
4. Director of Nursing or designee will audit random resident treatment administration records 3 times a week for 4 weeks and then monthly for 2 months to ensure treatments were administered as ordered/appropriate.
5. A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for dignified care being provided to the residents. Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or monitoring.

483.35(a)(1)(2) REQUIREMENT Sufficient Nursing Staff: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.
483.35(a) Sufficient Staff.
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at 483.70(e).

483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:
(i) Except when waived under paragraph (e) of this section, licensed nurses; and
(ii) Other nursing personnel, including but not limited to nurse aides.

483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.
Observations:

Based on a review of facility documentation and resident interview, it was determined that the facility failed to provide sufficient nursing staff to promote the physical and mental well-being and meet the needs of one of one resident reviewed (Resident #132).

Review of Resident #132's diagnosis list revealed diagnoses of Quadriplegia (Paralysis of all four extremities, including the trunk), injury of the cervical spinal cord, Stage four right hip pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone).

Review of Resident #132's Minimum Data Set (MDS- An assessment tool used to facilitate the management of care) dated September 23, 2019, revealed that Resident #132 was cognitively intact. Further review of the same MDS revealed that Resident R1 required extensive with two-person assistance in toileting.

Interview with Resident #132 on October 1, 2019, at approximately 11:00 a.m., revealed that on August 9, 2019, on the three to eleven shift, Resident #132 had a bowel movement in bed, Resident #132 called for help by pressing the call bell. Resident #132 stated that she/he waited for a long time, "almost two hours" but nobody showed up. The resident further stated that she/he called her/his son. Resident #132's son called the facility to inform them that Resident #132 was calling for help to get changed. Resident #132 stated that a nurse aide and a nurse showed up in her/his room and was changed. Resident #132 stated that there were other times that she/he had to wait for a long time to get changed and it usually happened during the evening shift.

Review of the facility documentation revealed a witness statement from the Assistant Director of Nursing (ADON) dated August 9, 2019, which stated "At about 10:20 p.m., I was informed by a nurse assistant that Resident #132 was ringing since 9:00 p.m., myself and the nurse assistant went in immediately to assist the resident".

The above was discussed with the Nursing Home Administrator (NHA).

The facility failed to provide sufficient staff with regard to meeting Resident #132 incontinence needs.


28 Pa Code 211.12 (a) Nursing services

28 Pa Code 211.12 (c) Nursing services
Previously cited 7/2/19, 8/8/19

28 Pa Code 211.12 (d)(3)Nursing services
Previously cited 2/5/19, 8/8/19

28 Pa Code 211.12 (d)(1)(5) Nursing services
Previously cited 2/5/19, 4/25/19, 7/2/19,8/8/19













 Plan of Correction - To be completed: 10/21/2019

1. Social services followed up with affected resident and a psychosocial note or statement was completed. Grievance process was started on 8/9/19 for this concern, no negative impacts on resident skin condition.
2. An audit will be completed of grievance logs for the last 14 days to determine if any resident expressed concerns related to incontinence care and determine if it was addressed adequately.
3. Staff Development Director or designee will provide re-education to facility nursing staff that incontinence care needs to be provided in a reasonable manner to acknowledge the resident needs. This education will be completed prior to the completion of nursing staff next scheduled shift.
4. Facility leadership team will complete random interviews of residents with Brief Interview Mental Status scores of 10 or higher 3 times a week for 4 weeks then monthly to ensure incontinence care is being provided in a reasonable timeframe. Executive Director or Designee will audit grievance log weekly for 4 weeks then monthly for 2 months to review any grievance related to incontinence care and if concern was related to staffing levels.
5. A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for dignified care being provided to the residents.
Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or monitoring.


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