Pennsylvania Department of Health
ABINGTON MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ABINGTON MANOR
Inspection Results For:

There are 106 surveys for this facility. Please select a date to view the survey results.

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ABINGTON MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an abbreviated complaint survey completed on February 8, 2024, at Abington Manor it was determined that there were no federal deficiencies identified under the requirements of 42 CFR Part 483 Subpart B as related to the health portion of the survey process, but the facility was not in compliance with the following requirements of the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

§ 211.12(d)(5) LICENSURE Nursing services.:

(5) General supervision, guidance and assistance for a resident in implementing the resident ' s personal health program to assure that preventive measures, treatments, medications, diet and other health services prescribed are properly carried out and recorded.

Observations:

Based on clinical record review and staff interviews it was determined that the facility's nursing staff failed to ensure that preventative measures and other planned resident care were properly carried out and recorded for one resident (Resident 1) of 10 sampled.

Findings included:

A review of Resident 1's clinical record revealed the resident was admitted to the facility on August 22, 2019, with diagnoses which included type 2 diabetes.

A review of the resident's current plan of care dated September 14, 2021, revealed that the resident has bowel incontinence related to impaired mobility with a planned intervention for staff to check and change the resident for incontinence every two hours.

A review of the resident's current Kardex (a nursing worksheet that includes a summary of patient information, such as prescribed medications, clinical follow-ups, and daily care schedules for direct care staff) conducted on February 8, 2024, revealed that the task of performing the 2 hour check and change of the resident was noted on the resident's Kardex to alert staff of the care to be provided to the resident.

A review of the resident's clinical record, conducted during the survey ending February 8, 2024, revealed no documented evidence that staff were completing the task of checking and changing the resident for incontinence, every two hours, according to the resident's care plan and Kardex.

An interview with the Director of Nursing on February 8, 2024, at approximately 2:00 PM confirmed that there was no documented evidence in the resident's clinical record that nursing staff were checking and changing the resident for incontinence every two hours as planned.

Plan of Correction - To be completed: 04/02/2024

1. Resident 1- Task record updated to reflect documented evidence in clinical record.

2. A facility house audit will be conducted to identify all residents scheduled on a check and change plan and task record will be updated to reflect documented evidence of completion.

3. DON/designee with educate all staff on Urinary Continence and Incontinence- Assessment and Management Policy.

4. DON/designee will audit new residents, any residents with a change in bladder/bowel patterns weekly x3. DON/designee will review residents' tasks to ensure documented evidence of the task is in the clinical record. Results of the audit will be presented at the monthly QAPI meeting for review and recommendations.

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nurse staffing and staff interview, it was determined that the facility failed to ensure the minimum nurse aide staff to resident ratio was provided on each shift for 3 shifts out of 6 reviewed.

Findings include:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide minimum nurse aide staff of 1:12 on the evening shift and 1:20 on the night shift based on the facility's census.

February 6, 2024 - 8.65 nurse aides on the evening shift, versus the required 8.75 for a census of 105.
February 6, 2024 - 4.69 nurse aides on the night shift, versus the required 5.25 for a census of 105.
February 7, 2024 - 4.33 nurse aides on the night shift, versus the required 5.25 for a census of 105.

An interview with the Nursing Home Administrator on February 8, 2024, at approximately 3:00 PM, confirmed the facility had not met the required nurse aide to resident ratios on the above dates.

Plan of Correction - To be completed: 04/02/2024

1. The facility will provide staffing at a minimum of 1 nurse aid per 12 residents during the day, 1 nurse aid per 12 residents during the evening, and 1 nurse aid per 20 residents overnight to meet the needs of the residents. The facility Administrator, Director of Nursing, and Nursing Scheduler will review the nursing schedule and deployment sheets daily Monday-Friday, to include projected weekend ratios, to validate appropriate direct resident care ratios. Adjustments will be made as necessary.

2. Schedule is completed daily and staffed with a minimum of 1 nurse aid per 12 residents during the day, 1 nurse aid per 12 residents during the evening, and 1 nurse aid per 20 residents overnight. When absences occur, every effort is made to replace staff.

3. The Administrator, the Nursing Management team, and the nursing scheduler will be re-educated concerning minimum CNA ratios and the appropriate response to unplanned variations in ratios. Ratios will be audited by the Nursing Home Administrator/designee during the daily review of nursing schedules and deployment sheets to ensure that correct CNA ratios are maintained.

4. The Administrator/designee will present the results of these audits at the Quality Assurance and Performance Committee monthly for further review and recommendations.

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