Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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SPANG CREST MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on March 14, 2024, it was determined that Spang Crest Manor 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(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.

Based on clinical record review, policy review, and staff interview, it was determined that the facility failed to assess bladder incontinence and provide services to restore bladder function as much as possible for one of five sampled residents. (Resident CL1)

Findings include:

Review of the facility policy entitled, "Resident Bladder/Bowel Program," last reviewed April 28, 2023, revealed that facility staff was to complete an incontinence assessment within seven days of admission using the admission nursing assessment, incontinence risk assessment, and a three day bowel/bladder pattern record. After completion of the bladder/bowel incontinence assessment and the three day bowel/bladder pattern record, an assessment would be completed to determine if there was a pattern present, what type of incontinence, and then determine which incontinence program would be appropriate. The program was to be documented on the care plan.

Clinical record review revealed that Resident CL1 was admitted to the facility on February 4, 2024, with diagnoses that included dementia and hypertension. According to the Minimum Data Set assessment, dated February 10, 2024, the resident needed assistance from staff for toileting. The assessment further indicated that the resident was incontinent of urine and was not on a toileting program. Review of the current care plan revealed that Resident CL1's type of urinary incontinence was not identified and there were no specific interventions developed to address CL1's urinary incontinence. There was no documented evidence that an incontinence risk assessment, and an assessment to determine the type of incontinence and an appropriate incontinence program were ever completed.

In an interview on March 14, 2024, at 1:52 p.m., the Nursing Home Administrator confirmed that there was no documented evidence that Resident CL1's urinary incontinence had been assessed per facility policy.

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

 Plan of Correction - To be completed: 04/16/2024

1. Resident CL1 has discharged from the facility so specific toileting interventions can not be implemented retroactively.

2. Current residents with urinary incontinence will be reviewed for appropriate toileting program/interventions.

3. Licensed staff will be re-educated on Bowel/Bladder Policy.

4. Random audits of resident toileting programs will be completed weekly x4 weeks and then monthly x 2 months. Findings will be reported to QAPI for Committee for review, recommendations and continued auditing.

5. April 16th, 2024.

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