Nursing Investigation Results -

Pennsylvania Department of Health
WESTMINSTER WOODS AT HUNTINGDON
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
WESTMINSTER WOODS AT HUNTINGDON
Inspection Results For:

There are  44 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.
WESTMINSTER WOODS AT HUNTINGDON - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on September 9, 2019, it was determined that Westminster Woods at Huntingdon 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:


483.12(b)(1)-(3) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
483.12(b) The facility must develop and implement written policies and procedures that:

483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

483.12(b)(3) Include training as required at paragraph 483.95,
Observations:


Based on review of policies, clinical records and grievance documents, as well as staff interviews, it was determined that the facility failed to follow its policy for thorough investigation of allegations of possible neglect and/or abuse for one of five residents reviewed (Resident 5).

Findings include:

The facility's policy regarding abuse, neglect or exploitation, dated August 19, 2019, indicated that any complaints of abuse or neglect, expressed verbally or in writing, were to be investigated thoroughly.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated June 25, 2019, indicated that the resident was cognitively intact, continent of bowel, and occasionally incontinent of urine. Physician's orders, dated May 16, 2019, included an order for the resident to receive 1 milligram (mg) of Bumex (a diuretic - to help the body excrete excess fluid, resulting in increased voiding) daily in the a.m. and at bedtime.

A grievance document for Resident 5, dated July 6, 2019, indicated that the resident reported that she rang her call bell and the staff just turned it off and decided to have her wait until her nurse aide came back from break to take her to the bathroom. The grievance also indicated that the nurse scolded her for having to go to the bathroom at 9:00 p.m. and then again before bedtime.

There was no documented evidence that a thorough investigation was completed into Resident 5's allegation of possible neglect related to staff not assisting her to the bathroom.

Interview with the Nursing Home Administrator on September 9, 2019, at 8:50 p.m. revealed that that there was no documented evidence that an investigation was completed to determine which staff failed to provide assistance for Resident 5 to use the bathroom when she rang her call bell.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 8/22/19.



 Plan of Correction - To be completed: 10/01/2019

1. Resident 5 did not suffer any ill effects from her call bell being turned off and not being assisted to the bathroom at that moment. There were no episodes of incontinence documented for Resident 5 at the time noted. The investigation documentation has been updated to reflect the nurse who turned off the call bell.

2.Grievance forms for the past two months were reviewed and updated to reflect identification of the staff member involved in allegations of abuse or neglect and to ensure that a thorough investigation was completed.

3.Education was completed and the abuse and neglect investigation policy was reviewed with nursing staff and the interdisciplinary care team.


4.Audits of grievances for proper identification of staff involved in alleged abuse or neglect allegations and to ensure that a thorough investigation was completed. will be completed every week x 4 weeks and every month x 2. Identified trends will be investigated. Results will be reported to the Quality Assurance committee.

Yes, the NHA will review all grievances with the appropriate department director or designee to collaboratively determine if more statements are needed from staff, residents, or families to ensure investigations are thorough and complete.
483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information: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.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that clinical records were complete and accurately documented for one of five residents reviewed (Resident 2).

Findings include:

The facility's policy regarding medication administration, dated August 19, 2019, revealed that the facility had flexible times for the administration of daily medications, but that due to computerization, a specified administration time would be entered on the Medication Administration Record (MAR) (such as 9:01 a.m. for morning medications).

A nursing note, dated July 8, 2019, at 8:30 p.m. revealed that Resident 2 was sent to a surgical center to have surgery and the resident's family member notified the facility that the surgical center did not complete the surgery and they were sending the resident to the emergency room for evaluation of stroke-like symptoms. The resident's family member called and informed the facility that they decided not to send the resident to the emergency room due to becoming increasingly agitated and aggressive and requesting to return home. The resident returned to the facility, was noted to be her usual self, was alert with clear speech, and was able to be understood.

A physician's progress note for Resident 2, dated July 8, 2019, indicated that the resident was seen for an episode of troubled speech that occurred the prior day, and on the day of examination she had some increased confusion. The diagnoses included aphasia (trouble understanding, speaking, reading, or writing) following unspecified cerebrovascular disease and the plan was to treat her with aspirin. A physician's order, dated July 9, 2019, included an order for the resident to receive 81 milligrams (mg) of enteric coated (delayed release) aspirin every morning.

Resident 2's Medication Administration Record (MAR) for July 2019 revealed that aspirin was scheduled to be administered on July 9, 2019, at 9:01 a.m., and the aspirin was signed by staff as being administered. A medication administration log report indicated that the aspirin was administered at 12:57 p.m.; however, a nursing note dated July 9, 2019, at 12:45 p.m. indicated that the resident refused the aspirin. There was no documented evidence on the MAR that the resident refused the aspirin.

Interview with the Assistant Director of Nursing on September 9, 2019, at 9:33 p.m. revealed that Resident 2 refused aspirin at 12:45 p.m. on July 9, 2019; however the nurse re-approached the resident at 2:30 p.m. and the resident took the aspirin. He confirmed that there was no documentation on the resident's MAR that the resident refused the aspirin at 12:45 p.m., and no documented evidence that aspirin was administered at 2:30 p.m.

28 Pa. Code 211.5(f) Clinical records.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 8/22/19.




 Plan of Correction - To be completed: 10/01/2019

1. Resident 2 did not suffer any ill effects from the medication not being documented as refused at the time of refusal and not documented as administered at the time that it was administered.

2.Observation of licensed nurses and/or verbal statements of proper procedure for documenting administration and refusal at the time of action was completed

3.Education was completed for licensed nurses regarding documentation of administration and refusal of medications at the time of action.



4.Audits of proper documentation of refusal and administration of medications for 5 nurses will be completed every week x 4 weeks and every month x 2. Identified trends will be investigated. Results will be reported to the Quality Assurance committee.

Yes, new licensed staff will be educated on this issue as part of the new hire orientation process.


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