Nursing Investigation Results -

Pennsylvania Department of Health
CONESTOGA VIEW
Patient Care Inspection Results

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CONESTOGA VIEW
Inspection Results For:

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

Based on an abbreviated survey completed on February 11, 2020, in response to five complaints at Conestoga View, it was determined that the facility was not in compliance with the following requirements of the 42 CFR part 483, Subpart B, Requirements for Long Term Care and the PA 28 Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.




















 Plan of Correction:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
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.
Observations:

Based on clinical record review, resident interview, and staff interview, it was determined that the facility failed to provide appropriate interventions for the prevention of a pressure ulcer for two of two residents reviewed (Resident R5 and Resident R6).

Findings include:

Review of Resident R5's clinical record, revealed diagnoses including Parkinson's disease (a chronic and progressive movement disorder), rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), contracture (a permanent shortening of a muscle or joint) of the right hip, contracture of the left hip, contracture of the right knee and contracture of the left knee.

Review of Resident 5's Quarterly Minimum Data Set dated January 2020, states that the resident is a 13 out of 15 for cognitive function meaning they are mildly impaired.

Review of Resident R5's clinical record revealed a physician's order dated February 25, 2019, for heel boots on every shift. Further review revealed a physician's order dated October 25, 2019, for the right medial ankle to cleanse, apply skin prep, cover with foam dressing, change daily and as needed every night shift for preventative care.

Further review of Resident R5's clinical record revealed a note from the wound team dated January 20, 2020, that stated a new pressure injury was noted to the right medial ankle identified on their rounds. Pressure injury is a Stage 3 (full-thickness loss of skin, in which fat is visible and rolled wound edges are often present) measuring 0.9 cm x 0.8 cm x 0.1 cm. Orders are to cleanse site and apply skin prep around the wound; apply nickel thickness Santyl ointment to wound base every day and as needed; cover with calcium alginate foam dressing and to off-load pressure on area, use heel boot please.

An interview with the Medical Director on February 11, 2020, at approximately 1:10 p.m. revealed that she is not sure why the pressure ulcer developed if preventative measures were in place.

Observation of Resident 5's treatment to the right ankle on February 11, 2020, at approximately 1:15 p.m. revealed that the resident did not have heel boots on as per physician order. Resident was interviewed at this time and stated she does not remember the last time someone put her boots on.


Review of Resident R6's clinical record diagnosis list, revealed diagnoses including major depressive disorder (loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and or daily routine) and ambulatory dysfunction.

Review of the Resident R6's clinical record revealed a nursing note on November 22, 2019, stating that the "resident was observed with a 2 cm x 1 cm non-blanching purple area to right outer calf during care. New order received for repositioning for comfort and offloading.

Review of Resident R6's care plan dated November 22, 2019, revealed pillows to be used to help with offloading and pressure relief.

Review of wound team notes dated January 13, 2020, Stage 3 (previously unstageable) pressure area of the right outer calf now measuring 1.7 x 1.7 x 0.1 cm. Cleanse site, apply skin prep around the wound, apply nickel thickness Santyl ointment to wound base every day and as needed, cover with foam dressing, off-load pressure on area.

Observation of treatment to right calf on February 11, 2020, at approximately 1:30 p.m. revealed that a pillow or any other device, was not in use for off-loading.

The above information was conveyed to the Nursing Home Administrator and Director of Nursing in an interview with on February 11, 2020 at approximately 2:30 p.m.


28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.10(d) Resident Care Policies

28 Pa. Code 211.12(d)(3)(5) Nursing Services




 Plan of Correction - To be completed: 03/09/2020

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 #5 had heel boots replaced during survey. Resident #6 had pillow placed during survey.
2. An audit will be completed of current residents who have pressure injuries to ensure they have care planned preventative interventions as of 2/12/20 in place and to determine if any worsened in last 30 days.
3. Director of Staff Development or designee will provide re-education to facility licensed nursing staff on facility policy and procedure for pressure injury prevention, tracking, reporting and documentation.
4. A Quality Assurance and Performance Improvement plan will be developed. Director of Nursing or designee will complete random residents with pressure injuries weekly for 4 weeks and then monthly for 2 months to verify they have weekly monitoring and prevention interventions in place as per resident care plan. Audit findings will be reported to the monthly QAA for review and recommendations.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:


Based on observations and review of facility policy, it was determined that the facility failed to maintain proper infection control practices during wound treatments, for two of two residents reviewed (Resident R5 and R6).

Findings include:

Review of the facility policy labeled "Dressing Technique" dated revision June 19, 2015, revealed the procedure for changing a dressing is as follows: (1) Wash your hands in the resident's room; (2) prepare a clean field away from the treatment cart; (3) cleanse the surface, place a barrier between the surface and the dressing items; ...(7) place the plastic (garbage) bag away from the clean surface.

Observation of Resident R5's wound treatment on February 11, 2020, at approximately 1:00 p.m., revealed that licensed nurse Employee E5 prepared what was to be a clean field by placing a towel over residents' papers and next to items on the over the bed table. The surface of the table was not cleaned off and disinfected.

Observation of Resident R6's wound treatment on February 11, 2020, at approximately 1:30 p.m. revealed that licensed nurse Employee E4 placed a trash bag on the resident's bed to dispose of the supplies used during the resident's wound treatment. Further observation revealed that a pillow from the residents' bed was used to prop the leg while the treatment was being performed. This did not prepare a clean field for the dressing change.

The above was discussed with the Director of Nursing on February 11, 2020 at approximately 2:00 p.m.

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



 Plan of Correction - To be completed: 03/09/2020

1. Resident #5 and 6 have no signs or symptoms of wound infection as per registered nurse assessment completed on 2/12/20 and monitoring completed by Wound practioner.
2. An audit will be completed of current residents who have pressure injuries to determine if any signs or symptoms of wound infection in the last 14 days.
3. Director of Staff Development or designee will provide re-education to facility licensed nursing staff on the facility dressing change technique policy and proper infection control practices.
4. A Quality Assurance and Performance Improvement plan will be developed. Director of Nursing or designee will complete random dressing change audits with licensed nursing staff weekly for 4 weeks and then monthly for 2 months to verify they are following policy and infection control practices as related to dressing changes. Audit findings will be reported to the monthly QAA for review and recommendations.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on clinical record review, observation, and review of documentation provided by the facility, it was determined that the facility failed to ensure adequate supervision was provided to prevent accidents for one of six residents reviewed (Resident R4).

Findings include:

Review of Resident R4's clinical record revealed diagnoses including quadriplegia (paralysis/weakness to both sides of the body), and anxiety.

Review of the November 24, 2019, Quarterly Minimum Data Set (an assessment tool for resident care) revealed that Resident R4 requires extensive assist of two people for personal hygiene and dressing needs. Resident R4's care plan also states that all care is to be given by two staff.

Review of the nurse aide trainee policy reveals that nurse aide trainees are to rely on the appointed nurse aide on the floor for information on the residents and their care. Employee E5 received new hire orientation that reviewed plan of care and its importance in October, 2019.

Review of a fall investigation report revealed that on January 27, 2020, "while Employee E5 (a nurse aide trainee) was providing incontinent care without a second caregiver, the resident rolled out of the bed and unto the floor." The resident stated that she hit her head and shoulder and was sent to the hospital emergency room with negative results of diagnostic tests. Statements from the fall investigation report revealed that Employee E5 knew the resident was a two person assist but no one would help her.

Interview with the Director of Nursing and Nursing Home Administrator on February 11, 2020 at approximately 3:15 p.m., confirmed that Resident R4 did not receive adequate supervision to prevent accidents.

28 Pa. Code 201.18(a)(b)(3) Management

28 Pa. Code 211.5(f) Clinical Records

28 Pa. Code 211.10(a)(c)(d) Resident Care Policies

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services






 Plan of Correction - To be completed: 03/09/2020

1. Resident #4 had no injuries at time of fall but went to ER on 1/27/2020 for evaluation as per family request and returned on 1/28/2020. Nursing Assistant Trainee was placed on administrative leave and resigned on 1/27/2020.
2. An audit will be completed of residents who are in need of 2 assist for bed mobility, to determine if any injuries occurred in last 30 days as a result of care plan not being followed for bed mobility/incontinence care.
3. Director of Staff Development or designee will provide re-education to facility nursing staff that care plans for residents who are identified to be 2 assist for bed mobility/incontinence care, must be followed.
4. A Quality Assurance and Performance Improvement plan will be developed. Director of Nursing or designee will audit random residents that are in need of 2 assist for bed mobility/incontinence care weekly for 4 weeks and then monthly for 2 months to ensure 2 assist with bed mobility/incontinence care was provided. Audit findings will be reported to the monthly QAA for review and recommendations.


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