Pennsylvania Department of Health
PINE VIEW HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PINE VIEW HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

There are 178 surveys for this facility. Please select a date to view the survey results.

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PINE VIEW HEALTHCARE AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Findings of an Abbreviated Complaint Survey completed on March 19, 2024, at Pineview Healthcare and Rehabilitation Center, identified a deficient practice, related to the reported complaint allegations, under the 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 as they relate to 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 records review, and interviews with resident and staff interviews, it was determined that the facility failed to ensure an order for NPO (nothing per mouth) before a procedure was followed for one of the two residents reviewed (Resident R1).

Findings include:

Review of Resident R1's clinical record revealed Resident R1 was admitted to the facility with a diagnosis of Atrial Fibrillation (irregular heartbeat), awaiting hip surgery, and Intellectual disability.

Review of Resident R1's Admission Minimum Data Set (MDS- A standardized assessment tool that measures health status in long-term care residents) dated January 3, 2024, revealed resident's cognition was intact.

Review of the nursing progress notes dated February 22, 2024, at 2:39 p.m., revealed resident returned from a Cardiologist (A physician who specializes in heart conditions) appointment. The note revealed that the resident was scheduled for a Transesophageal Echocardiogram (TEE- An ultrasound that provides highly detailed images of the heart and its internal structure) on February 28, 2024, at [Hospital Name]. NPO 12 hours before the procedure.

Review of the physician's order dated February 23, 2024, revealed an order for NPO at midnight, may take all morning medications on February 28, 2024, with water every shift until 10:00 a.m.

review of the nursing progress notes dated February 28, 2024, at 3:35 p.m., revealed resident's echocardiogram will be rescheduled, nurse practitioner is aware.

Interview with Resident R1 was conducted on March 19, 2024. Resident R1 reported that on the morning of February 28, 2024, a female staff came to her/his room and provided her/him with a breakfast tray. Resident R1 reported that she/he consumed a cup of orange juice and 2-3 spoons of cereal when the nurse came and told her/him about the NPO order. Resident R1 reported that she was previously made aware of the NPO order but forgot about it on the day of the procedure.

Interview with licensed nurse Employee E3 was conducted on March 19, 2024. Employee E3 reported that she/he was the nurse working on the morning of February 28, 2024. Employee E3 reported that at around 7:00 a.m. while receiving a report from the previous shift, an agency nurse aide provided Resident 1 a breakfast tray. Employee E3 reported talking to the resident and was informed that she/he consumed a few sips of orange juice. The doctor/procedure place was notified and ordered to reschedule the echocardiogram.

interview with the Director of Nursing was conducted on March 19, 2024. The DON reported that for NPO orders, a communication form is sent to the kitchen. The facility was unable to provide documented evidence that a communication form was sent to the kitchen informing Resident R1 was NPO on February 28, 2024, until 10:00 a.m.

The facility failed to ensure the NPO order was followed resulting in delay of Resident1's TEE procedu

28 Pa. Code 211.5(f) Clinical records

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

Plan of Correction - To be completed: 04/03/2024

1) Resident R 1 orders were followed and she received echocardiogram on 3/5/24.
2) All residents' orders were reviewed to identify any other resident with a NPO status to ensure MD orders were being followed.
3) Nursing staff was educated as of 3.22.24 on proper procedures and process for following physician order of NPO.
4) NHA / designee will audit weekly x4 and then monthly for 3 months any resident who has an NPO order to ensure compliance is being maintained and that the proper procedures are being followed The Administrator and/or designee will report the findings of these audits to the Performance Improvement Committee each month for three months and quarterly for one year. The Interdisciplinary team will develop an additional plan of correction if issues are found.

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