Nursing Investigation Results -

Pennsylvania Department of Health
LUTHERAN HOME AT HOLLIDAYSBURG, THE
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
LUTHERAN HOME AT HOLLIDAYSBURG, THE
Inspection Results For:

There are  77 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.
LUTHERAN HOME AT HOLLIDAYSBURG, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a complaint survey completed on April 25, 2019, it was determined that The Lutheran Home at Hollidaysburg 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:


483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:


Based on review of residents' clinical records and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents were free from significant medication errors for four of five residents reviewed (Residents 1, 2, 3, 4).

Findings include:

A quarterly Minimum Data Set (MDS) assessment for Resident 1, dated March 19, 2019, revealed that the resident was cognitively impaired and had diagnoses that included Parkinson's disease (degenerative disorder that affects the motor system). Physician's orders, dated March 12, 2019, included orders for the resident to receive 25-100 milligrams (mg) of carbidopa-levodopa (combination medication to treat Parkinson's disease) three times a day at 7:00 a.m., 1:00 p.m. and 5:00 p.m.

Resident 1's Medication Administration Records (MAR's) for April 2019 revealed that staff did not administer carbidopa-levodopa to the resident at the times that were ordered by the physician. On April 1, staff administered the 7:00 a.m. dose at 9:54 a.m.; On April 7, staff administered the 7:00 a.m. dose at 11:04 a.m., and the 1:00 p.m. dose at 12:21 p.m., which was one hour and 17 minutes between doses. On April 20 staff administered the 7:00 a.m. dose at 10:06 a.m., the 1:00 p.m. dose at 12:17 p.m., and the 5:00 p.m. dose at 4:07 p.m.

Interview with the Director of Nursing on April 25, 2019, at 4:42 p.m. confirmed that the medication was not administered to Resident 1 in accordance with the physician's order and it should have been.


A quarterly MDS assessment for Resident 2, dated January 9, 2019, indicated that the resident was cognitively impaired and had diagnoses that included cardiac arrhythmia (irregular heart rhythm). Physician's orders, dated March 29, 2019, included an order for the resident to receive 25 milligrams (mg) of metoprolol (treats heart conditions) two times daily and to hold the medication if his systolic blood pressure (the top number of a blood pressure reading) was less than 130 millimeters of mercury (mmHg). Physician's orders dated April 6, 2019, included an order to change metoprolol to 25 mg once daily and to hold the medication if the systolic blood pressure was less than 130 mmHg.

Resident 2's MAR's for March and April 2019 revealed that there was no documented evidence that the nursing staff obtained and documented a blood pressure reading prior to administering metoprolol to the resident at 8:00 a.m. on March 30 and 31, 2019, and April 1-5, 2019; at 4:00 p.m. on April 2 and 3, 2019; and at 12:00 p.m. on April 6-8, 10, 12-15, 17, 19, 20 and 23, 2019.

Interview with the Director of Nursing on April 25, 2019, at 4:42 p.m. confirmed that there was no documented evidence that nurses obtained and documented a blood pressure reading prior to administering metoprolol to Resident 2 on the above dates and times.


A quarterly MDS assessment for Resident 4, dated January 18, 2019, revealed that the resident was cognitively impaired and had diagnoses that included diabetes (disease that interferes with blood sugar control). Physician's orders, dated January 27, 2019, included orders for the resident's blood sugar level to be checked daily at 7:30 a.m. and for the resident to receive 500 mg of Metformin (treats diabetes) two times per day with breakfast and supper.

Observations of Resident 4 on April 25, 2019, at 8:20 a.m. revealed that he was eating breakfast and the meal included two waffles, cereal, juice and milk. Observations during medication administration on April 25, 2019, at 9:20 a.m. revealed that Licensed Practical Nurse 1 obtained the resident's blood sugar level, which was 242 milligrams per deciliter (mg/dL), and administered Metformin to the resident.

Interview with Licensed Practical Nurse 1 on April 25, 2019, at 9:25 a.m. revealed that she did not think it mattered what time she checked Resident 4's blood sugar level because he was not receiving insulin (injected medication that lowers blood sugar levels) and that he usually took his medications after breakfast, including Metformin.


Undated manufacturer's instructions for Cymbalta (a combination pain and antidepressant medication) indicated that the capsule should be swallowed whole and that it should not be opened, crushed or chewed. Manufacturer's instructions for Tylenol Arthritis (pain medication) indicated that the medication should not be crushed.

An admission MDS assessment for Resident 3, dated January 7, 2019, indicated that the resident was alert and oriented and had diagnoses that included arthritis and bladder cancer. Physician's orders, dated December 31, 2018, included orders for the resident to receive 30 mg of Cymbalta daily, 1300 mg of Tylenol Arthritis extended release two times a day, 400 mg of cranberry daily, and 250 mg of ginger root daily.

Observations during medication administration on April 25, 2019, at 8:40 a.m. revealed that Licensed Practical Nurse 1 crushed Tylenol Arthritis for Resident 3 and added it to pudding. She then opened the Cymbalta capsule, the cranberry capsule, and the ginger capsule, poured them over the pudding, mixed them into the pudding, and administered them to the resident.

Interview with Licensed Practical Nurse 1 on April 25, 2019, at 9:40 a.m. revealed that she always crushed Tylenol and she did not pay attention to the "do not crush" label on the medication. She further stated that she was not sure if she should open the Cymbalta, cranberry or ginger, but it made it easier for the resident to swallow so she just opened them.

Interview with the Director of Nursing on April 25, 2019, at 4:42 p.m. confirmed that the medications mentioned above were not administered in accordance with physician's orders and/or manufacturer's instruction and they should have been.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 3/14/19.


 Plan of Correction - To be completed: 05/08/2019

Facility is unable to correct late med administration for Resident 1 on April 1, 2019 as it is in the past. Parameters that include blood pressure readings were built into the Medication Administration Record for Resident 2's metoprolol that require the blood pressure to be entered on Medication Administration Record prior to administering the medication. Facility is unable to correct late med administration and blood sugar reading for Resident 4 on April 25, 2019 as it is in the past. Facility is unable to correct crushing of medication for Resident 3 on April 25, 2019 as it is in the past.

Root Cause suspected to be the need for re-education.
Re-education will be provided on prevention of medication errors to licensed nursing staff to protect residents in similar situations.
The facility will implement measures and alter systems to ensure that the problem does not recur. Specifically, education will be provided to licensed nursing staff in regard to medications that can be crushed, the importance of timely medication administration, and adhering to physician ordered parameters of medication administration. Also, parameters that include blood pressure readings were built into the Medication Administration Record for residents that require the blood pressure to be obtained prior to administering a medication and this reading will be required to be entered on Medication Administration Record prior to administering the medication, or the electronic health record will not allow the medication to be signed off as given.
The Director of Nursing or designee will monitor the Medication Administration Record for accuracy of timeliness of medication administration and that ordered parameters were followed for three residents per day for 2 weeks and then three residents per week for 6 weeks. The Director of Nursing or designee will complete a med pass audit on 3 nurses per week for 2 weeks and then one nurse per week for 6 weeks to monitor that crushing of medications is appropriate.



Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port