Nursing Investigation Results -

Pennsylvania Department of Health
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
Inspection Results For:

There are  128 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.
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey and a COVID-19 Focused Infection Control Survey completed on December 10, 2021, it was determined that Abington Crest Healthcare and Rehabilitation 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. The facility was in compliance with 42 CFR 483.80 Subpart B Requirements for Long Term Care Facilities infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

 Plan of Correction:

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(b) Skin Integrity
483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Based on review of facility policy and clinical record and staff interviews, it was determined that the facility failed to ensure that residents were monitored, adequately assessed, and preventative measures were implemented to prevent new ulcers from developing, resulting in actual harm of an Unstageable (full-thickness skin and tissue loss) pressure ulcer development of the coccyx (small triangular bone at the base of the spinal column) for one of two residents reviewed (Resident R1).

Findings include:

Review of facility policy entitled "Prevention of Pressure Ulcers/Injuries" dated 7/29/21, revealed that the facility would "Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable" and "Assess the resident on admission (within eight hours) for existing pressure ulcer/ injury risk factors. Repeat the risk assessment weekly and upon any changes in condition."

Review of Resident R1's clinical record revealed an admission date of 8/9/21, with diagnoses that included non-traumatic cerebral hemorrhage (brain bleed), dysphagia (difficulty swallowing) and diabetes (uncontrolled blood sugar level).

Review of hospital documentation from a local hospital entitled "Transfer Report" with discharge date 8/9/21, stated "The pts (patient's) condition requires frequent changes in body positioning and/or has an immediate need for change in body positioning. Pts condition requires positioning not feasible with an ordinary bed and is also needed to alleviate pain. Pt also requires an alternating pressure pad/pump as pt is completely immobile; cannot make changes in body position without assistant."

Review of an Admission / Readmission Evaluation completed on 8/9/21, at 6:55 p.m. by Registered Nurse (RN) Employee E2 indicated "no" for the question "Are there any current skin breakdown or skin conditions present." A Braden Scale (assessment used to assist in identifying risk of developing a pressure ulcer) was completed as part of the admission assessment which revealed a total score of 9, indicating Resident R1 was at a very high risk for developing pressure ulcers due to Resident R1's limited sensory perception (ability to feel or communicate discomfort), incontinence, being bedridden, poor nutrition, risk for friction and shear (sliding on sheet causing skin irritation), and having limited mobility or inability to make frequent changes in position.

Review of a Braden Scale completed on 8/17/21, revealed that Resident R1 was at high risk for developing pressure ulcers and additional Braden Scales completed 8/31/21, and 10/25/21, revealed Resident R1 was at moderate risk for developing pressure ulcers. Admission / Readmission Evaluation also revealed Resident R1 was incontinent of bowel and bladder, required assistance with moving up in bed and turning, required assistance with lateral moves, and had fragile skin.

Review of Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), with an Assessment Reference Date (ARD) of 8/16/21, section G0100A entitled "Activities of Daily Living (ADL) Assistance - Bed Mobility (move to and from lying position, turn side to side, and position body while in bed)" was coded as requiring extensive assistance of staff to complete task. Section M0100A entitled "Determination of Pressure Ulcer Injury or Risk - Resident has a pressure ulcer / injury ...." was coded as "No". Section M0150 entitled "Risk of Pressure Ulcer / Injuries - Is this Resident at risk for developing pressure ulcers/injuries" was coded as "Yes". Section M1200C entitled "Skin and Ulcer/Injury Treatments - Turning and Repositioning program" was coded as "No."

Review of Resident R1's physician's orders dated 8/11/21, indicated that weekly body audits were to be completed every dayshift on Wednesday. Physician's orders lacked any other interventions to aide in prevention of a pressure ulcer developing.

Review of facility documentation revealed that a "Pressure Ulcer Investigation" was completed on 10/25/21, at 9:08 p.m. by Licensed Practical Nurse (LPN) Employee E4 indicating the nurse aide reported an open area to the coccyx. Upon assessment completed by LPN Employee E4 the area measured 3.5 centimeters (cm) x 1.0 cm and was Unstageable. The wound was described as draining serosanguineous fluid (watery and bloody fluid) and covered with slough (loose dead skin) preventing visualization of the wound bed. A physician's order was obtained and to cleanse area with normal saline solution, apply z-guard (skin protectant cream containing zinc oxide) and cover with optifoam (foam dressing that absorbs drainage and provides a cushion).

Review of Resident R1's clinical record lacked evidence that the physician ordered weekly body audits were completed for 9/29/21, 10/6/21, and 10/20/21, resulting in a twelve-day lapse from the last completed weekly body audit dated 10/13/21, to the time the Unstageable pressure ulcer was discovered.

Review of the clinical record revealed that on 11/9/21, a wound consultant assessed Resident R1's coccyx wound as Unstageable and measured 5.0 cm x 6.0 cm x <0.1 cm. and obtained orders to change the dressing orders to Santyl (prescription medication that removes dead tissue from the wound allowing it to start to heal), Calcium Alginate (substance that when combined with wound drainage it forms a gel to help with wound healing by limiting secretions and bacteria), and cover with optifoam.

Review of Resident R1's clinical record revealed that the resident was at high risk for pressure ulcer development, there was no care plan developed to address any interventions until 10/26/21, one day after the Unstageable pressure ulcer was identified. A turning and repositioning program was not implemented until 11/9/21, seventy-seven days after admission and fifteen days after development of the pressure ulcer. A low air loss mattress was not ordered until 11/10/21, seventy-eight days after admission and sixteen days after development of the pressure ulcer.

The facility failed to ensure that Resident R1 had appropriate interventions in place and was monitored for skin integrity adequately to prevent the development of harm of an Unstageable pressure ulcer wound.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.12(d)(1)(2)(5) Nursing services

28 Pa. Code 211.5(f) Clinical records

 Plan of Correction - To be completed: 01/05/2022

Resident R1 is not currently residing at the facility. Interventions to promote wound healing were in place prior to discharge.

DON/designee completed an audit on 12/14/21 of current residents to ensure care plans and interventions are in place to match risk factors and reduce potential for skin impairment.

DON/designee will reeducate nursing staff by 12/20/21 on prevention of skin breakdown, care plans for new admissions, and associated documentation.

DON/designee will audit 20% of residents for completion of weekly body audits 3 times a week for four weeks then monthly for 3 months.

DON/designee will audit new admissions for risk related to skin breakdown, care plans, and corresponding interventions in place to prevent skin breakdown twice weekly for four weeks then monthly for 3 months.

Findings will be summarized and reported to the Quality Assurance Performance Improvement Meeting. Quality Assurance Performance Committee will determine the need for further audits and/or recommendation.

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