Pennsylvania Department of Health
VINCENTIAN HOME
Patient Care Inspection Results

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VINCENTIAN HOME
Inspection Results For:

There are  119 surveys for this facility. Please select a date to view the survey results.

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VINCENTIAN HOME - 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 February 9, 2024, it was determined that Vincentian Home 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 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 observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents received treatment and care in accordance with standards of practice and physicians' orders regarding surgical site care which resulted in a failure of timely care for three of five residents (Residents R1, R2, and Closed Record CR1).

Findings Include:

A review of the facility policy, "Skin Assessment" dated 4/26/23, indicated:
-Non-pressure related skin conditions include but is not limited to skin tear, arterial ulcer, venous ulcer, foot problem, surgical wound, rash, cut, laceration, open lesion, or burn.
-The licensed nurse will complete a head to toe skin assessment within two to six hours of admission/readmission to identify the presence of any skin issue.
-If a non-pressure area is identified, will document a complete assessment on the N. Adv Skin Only Evaluation and reassess weekly until healed.
-Describe the treatment order and response to treatment.

Review of admission record indicated Resident R1 was admitted to the facility on 1/25/24.

Review of Resident R1's Minimum Data Set (MDS- a periodic assessment of care needs) dated 1/31/24, indicated diagnoses of heart failure (a condition in which the heart doesn't pump blood as well as it should), high blood pressure, and left hip fracture. Section C indicated a Brief Interview for Mental Status (BIMS) score of 13 - cognitively intact.

Review of Resident R1's "Skin Only Evaluation" dated 1/25/24, indicated post-surgical (after an operation) Aquacel (wound dressing) intact to left hip.

Review of Resident R1's "Skilled Evaluation V6.3" dated 2/1/24, indicated no skin issues.

Review of Resident R1's "Hospital Final Report" document dated 1/25/24, indicated Aquacel dressing until post-op day seven. May shower. After post-op day seven clean wound with alcohol and apply 4x4 dressing and tape. Must cover for showers.

Review of Resident R1's Treatment Administration Records (TAR) dated January and February 2024, failed to include physician orders for care and treatment of the left hip surgical wound.

Review of Resident R1's admission "Physician's Order Summary" dated 1/25/24, failed to include physician orders for care and treatment of the left hip surgical wound.

Interview on 2/8/24, at 12:15 p.m. Resident R1 indicated she had surgery on her left hip and they haven't changed the heavy plastic on her left hip since she arrived on 1/25/24.

Observation on 2/8/24, at 12:16 p.m. Resident R1 pulled her trouser down an inch along the left hip displaying the top of the Aquacel dressing.

Interview on 2/8/24, at 12:20 p.m. Registered Nurse (RN) Employee E1 indicated there was no order for the Aquacel dressing on Resident R1's hip and that it should have been removed seven days post-op around January 31, 2024, but there was no order put in for it.

Review of the admission record indicated Resident R2 was admitted to the facility on 1/30/24.

Review of Resident R2's Diagnosis Report dated 1/30/24, indicated the diagnoses of right hip fracture, heart failure, and repeat falls.

Review of Resident R2's "Clinical Admission" document dated 1/30/24, indicated no skin issues.

Review of Resident R'2's "Hospital Discharge Summary" dated 1/30/24, indicated to keep incision covered with clean, dry, occlusive (an air and water tight medical dressing).

Review of Resident R2's admission "Physician order summary" dated 1/30/24, indicated keep right hip incision clean, dry with an occlusive dressing (dry gauze/opsite clear dressing) every morning.

Review of Resident R2's TARs dated January and February 2024, failed to include physician orders for care and treatment of the right hip surgical wound.

Interview on 2/8/24, at 12:35 p.m. the Director of Nursing indicated they failed to click the drop down box and schedule the order, therefore it did not show up on the TAR for the nurses to see.

Review of the admission record indicated Resident Closed Record CR1 was admitted to the facility on 1/2/24.

Review of Resident CR1's MDS dated 1/5/24, indicated the diagnoses of heart failure, diverticulitis (inflammation or infection in small pouches in the digestive tract), and open wound of the abdomen.

Review of Resident CR1's "Skin Only Evaluation" dated 1/2/24, indicated a 0.5 cm (centimeter) round open area on left lower quadrant draining a copious amount of brown, murky drainage. No odor.

Review of Resident CR1's "Hospital Final Report" dated 1/2/24, indicated wound care/ostomy (surgical opening that allows bodily waste to pass through an opening on the skin) Discharge Recommendations: twice a day - left lower abdominal old JP (Jackson Pratt -surgical drain) drainage wound site. Cleanse with soap and water. Dry thoroughly.
Apply critic aid clear (barrier paste) to surrounding wound. Apply a dry 4x4 gauze and Medipore (flexible type of tape) tape to hold in place.

Review of Resident CR1's TAR dated January 2024, indicated the physician ordered treatment dated 1/6/24, of wound care for left lower abdominal old JP drainage wound site. Cleanse with soap and water. Dry thoroughly.
Apply critic aid clear (barrier paste) to surrounding wound. Apply a dry 4x4 gauze and Medipore (flexible type of tape) tape to hold in place.

Review of Resident CR1's progress note dated 1/9/24, indicated the order for the dressing changes was entered into the system on January 5, 2024. Prior to that, Resident CR1 would regularly ask us to change the dressing.

Interview with the Director of Nursing on 2/8/24, at 2:02 p.m. indicated that the order was not put in timely upon admission to the facility on 1/2/24, and that it was ordered on 1/6/24.

Interview with the Director of Nursing and Nursing Home Administrator on 2/8/24 at 3:30 p.m. confirmed the facility failed to ensure that residents received treatment and care in accordance with standards of practice and physicians' orders regarding surgical site care which resulted in a failure of timely care for three of five residents (Residents R1, R2, and Closed Record CR1).

28 Pa Code: 201.29 (i) Resident rights.
28 Pa Code: 201.18 (b)(1)(3) Management.
28 Pa Code: 211.10 (c ) Resident care policies.
28 Pa Code: 211.12 (a )(d)(1)(2)(3)(5) Nursing services.



 Plan of Correction - To be completed: 03/20/2024

Resident R1- continues to reside in the facility. The physician order to remove the Aquacel dressing was added and placed on the Treatment Administration Record (TAR). The Aquacel dressing was removed on 2/8/2024.

Resident R2 – continues to reside in the facility. The physician order was revised to indicate the treatment to appear on the Treatment Administration Record (TAR).

Resident CR1 – has been discharged from the facility.

The facility will act to protect residents in similar situations by conducting reviews of current residents' admission orders to include all physicians'treatment orders for surgical site care on the Treatment Administration Record (TAR).

Measures the facility will take to ensure practice does not recur will include educational inservices by the DON/ADON/Designee to the licensed nurses. Educational inservices will include that residents' admission orders be reviewed to include all physicians' orders regarding surgical site care be recorded on the Treatment Administration Record (TAR).

Performance will be monitored by conducting audits of residents' admission orders to include all physicians' orders regarding surgical site care be recorded on the Treatment Administration Record (TAR). Four audits will be conducted weekly for a period of four weeks, then monthly thereafter for a period of three months. Audits will be conducted by DON/Designee and results will be reported to the quarterly Quality Assurance Committee Meeting.


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