Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

There are  146 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.
CONESTOGA VIEW - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on July 2, 2019 in response to two complaints at Conestoga View, it was determined that Conestoga View was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the health portion of the survey process.

 Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):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.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident

Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).

Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident's responsible party of the need to initiate new treatment for one of three residents reviewed (Resident R1).

Findings Include:

Review of facility policy titled "Notification of Responsible party/family" with a review date of March 2019 indicated "it is the policy of this facility to notify the resident's responsible party/family when there is a significant change in the resident's condition".

A review of the clinical record revealed Resident R1 was admitted to the facility on December 17, 2018 with diagnoses including but not limited to following: Malignant neoplasm of large intestine, rectum and lung (cancer); Muscle Wasting/Atrophy; Epilepsy (Seizure disorder); and Dysphagia (inability/difficulty swallowing).

Review of Resident R1's January 2019 physician orders revealed an order dated January 13, 2019 indicating "for open area to right buttock-clean area with wound cleanser, dry area, prep peri-wound, cover with foam border one time a day daily and PRN (as needed).

A review of Resident R1's clinical record including nursing progress notes revealed note dated January 15, 2019 indicating "Resident with an open area to the right buttock 2 cm(centimeters) x 1.5 cm x 0 cm. There is no drainage or bleeding. It is tender to the touch. Treatment in place and wound consult sent."

Further review of Resident R1's progress notes revealed a note dated January 28, 2019 indicating, "Resident with open areas on buttocks - MASD (Moisture Associated Skin Damage). Both areas are red and blanchable. Denuded area on R (right) buttock measures 4 cm x 1cm x 0cm. there are 2 open areas on the L (left) buttock. One measures 2cm x 2 cm x 0cm and is round. The other measures 6 cm x 4 cm x 0cm."

There is no documented evidence in Resident R1's clinical record that the responsible party was notified of the discovery of the open wounds or physician recommendations.

Interview on July 1, 2019 at approximately 3:19 p.m. with the Nursing Home Administrator confirmed that there is no documented evidence that resident's power of attorney was notified of Resident R1's change in condition of discovery of open wounds to buttock area.

28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
Previously cited on 04/25/19, 02/05/19, and 09/13/18

 Plan of Correction - To be completed: 07/17/2019

Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law.
1. Resident #1 wound resolved in February of 2019.
2. An audit will be completed of residents who are were identified with new wounds or skin alterations for the previous 30 days to verify notification was completed to responsible party.
3. Director of Staff Development or designee will provide re-education to facility nursing administration and licensed nursing staff that when a wound or skin alteration is identified family or responsible party notification needs to occur at time of identification.
4. Director of Nursing or designee will audit random residents that identified with new wounds or skin alterations weekly for 4 weeks and then monthly for 2 months to ensure notifications of responsible party or family occurred at time of identification.
5. A Quality Assurance/Performance Improvement plan will be developed and utilized to monitor for appropriate notification to responsible parties. Findings of the audits will be reported to the facility Quality Assurance Performance Improvement committee to determine need for additional actions and or monitoring.

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