Pennsylvania Department of Health
MEADOW VIEW REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MEADOW VIEW REHABILITATION & HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a revisit survey completed on February 7, 2024, it was determined that Meadow View Rehabilitation & Healthcare Center failed to correct the federal deficiencies cited during the survey of December 14, 2024, and continued to be out of 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.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected 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 a review of clinical records, select facility policies and incident/accident reports and staff interview, it was determined that the facility failed to consistently implement planned fall prevention approaches, including assistance with activities of daily living for a resident at risk for falls with known unsafe behaviors and fall risk factors related to toileting needs, to prevent a fall with serious injury, a fractured arm, for one resident out of 13 sampled (Resident 1)

Findings include:

A review of the current facility policy for "Fall Risk Assessment" dated as reviewed June 20, 2023, revealed that the purpose of this procedure is to provide guidelines for "a resident risk factor and establish resident-centered falls prevention plan based on relevant assessment information including cognition and continence status."

A review of the facility policy for "Safety and Supervision of Residents" dated as reviewed June 20, 2023, revealed that the purpose of this procedure is to provide guidelines for resident safety and supervision and assistance to prevent accidents facility wide, "monitoring the effectiveness of interventions will include: ensuring the interventions are implemented correctly and consistently, evaluating the effectiveness, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions".

A review of facility policy for "Urinary Continence and Incontinence - Assessment and Management" date as reviewed June 20, 2023, revealed that the purpose of this procedure is to provide guidelines for staff and practitioners to appropriately screen and manage individuals with urinary incontinence. Indicating if an individual remains incontinent staff will initiate a toileting plan, and the care should be individualized at night to maintain comfort. Staff will document the results of toileting in the resident's medial record. Residents who have cognitive impairments staff will use a "check and change" strategy that involves checking the resident's continence status at regular intervals and using incontinence devices or garments to maintain dignity and comfort and protect the skin.

A review of clinical records revealed that Resident 1 was admitted to the facility on January 16, 2024, with diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life) and overactive bladder (a bladder control problem which leads to a sudden urge to urinate).

An Admission Minimum Data Set assessment (MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated January 20, 2024, revealed that the resident was cognitively impaired with a BIMs score of 5 (The BIMS test is used to get a quick snapshot of how well you are functioning cognitively. It is a required screening tool used in nursing homes to assess cognition), required moderate to extensive staff assistance with activities of daily living, including an assist of one staff person for transfers (from bed, chair, wheelchair, standing position), toileting, and performance of personal hygiene and was frequently incontinent of urine.

A review of the resident's plan of care, initially dated January 16, 2024, revealed that the resident was at risk for falls related to behaviors: dementia, bladder incontinence, decreased strength and endurance and generalized weakness, history of self-transfers. Care planned interventions were to ambulate the resident with an assist of one, bed mobility with an assist of two, implement preventative fall interventions/devices, and to have a clip alarm on while in and out of bed. On January 25, 2024, the clip alarm was changed to a sensor pad alarm in the bed and chair, when in and out of bed on January 25, 2024.

The resident's care plan, initially dated January 16, 2024, also identified that the resident had episodes of bladder and bowel incontinence related to dementia. The planned interventions were that staff would assist the resident with toileting needs, check, and change the resident every two hours (for incontinence), and as needed, implement a toileting schedule as indicated, offer bed pan or commode as needed, toilet before and after meals, toilet prior to bedtime and upon awakening.

A review of nursing progress notes dated January 18, 2024, at 11:25 AM, revealed that the resident's family member was "very worried that her mother would not be able to use the call bell; assurance was provided that staff would consistently help with all ADLs."

A nursing progress note titled "fall occurrence note" dated January 22, 2024, at 6:56 AM revealed that staff observed the resident on the floor of the resident's room, laying on her left side. The resident's bed alarm was in the garbage can and she was wearing non-skid socks. Staff assisted the resident back to bed. Nursing noted that the resident was without injury and the physician was notified. The resident was unaware of what happened due to being confused only oriented to person and place.

The facility did not revise the resident's fall prevention plan and approaches after this fall.

A review of a facility incident report dated January 25, 2024, at 7:29 AM revealed that a staff member found the resident was found sitting upright on the floor in her room. The resident complained of left arm pain and the bed was soaking wet. The resident's bed alarm was not sounding but did work when re-tested (by staff). The last time the resident was toileted was the evening shift prior (3 PM to 11 PM on January 24, 2024). Staff asked the resident at 4:30 AM on January 25, 2024, (about toileting) and she refused, and staff was unsure of saturation level of bed or brief at this time. Resident states she was trying to go to the bathroom and is confused at baseline, she was unaware where she was and how she ended up on the floor. Resident had turned off alarm and thrown in garbage previously (fall on January 22, 2024). The resident was assessed and unable to raise her left arm over her shoulder and was screaming in pain. All other extremities were within normal limits. The resident was placed on oxygen therapy at two liters per minute and x-rays were ordered for her left arm.

The findings of X-ray (diagnostic imaging studies) for the resident's left humerus (arm) performed at the facility revealed a "an acute humeral neck fracture."

On January 25, 2024, at 4:55 PM the resident was transferred to the emergency department for an orthopedic consult related to an acute humeral neck fracture.
(Bone of the upper arm that connects the shoulder to the elbow).

A review of an employee witness statement dated January 25, 2024, at 7:10 AM revealed, that Employee 1, a nurse aide, stated that the last time she saw the resident was at 4:30 AM (on January 25, 2024) and she was sleeping. The staff member woke her up to (attempt) toilet her and she (the resident) said she was fine. She stated the last time the resident was toileted was on second shift (evening shift on January 24, 2024) she refused (toileting) for my shift, and she had a bed alarm on at this time.

A review of the Documentation Survey Report for January 2024 (record of tasks nursing staff provided for the resident) revealed a task for scheduled toileting of the resident. A review of the scheduling toileting for January 25, 2024, revealed that staff offered toileting to the resident at 2:01 AM and the resident was continent at that time. There is no documented evidence that the resident was "offered to toilet at 4:30 AM and refused" on January 25, 2024, as noted in the incident report and Employee 1's statement. According to the documentation survey report the resident was toileted and continent at 2:01 AM on January 25, 2024, which differed from Employee 1's statement and the incident report.

A review of the Documentation Survey Report for January 2024 revealed that the facility staff failed to document that the resident was being checked and changed for incontinence and every 2 hours as outlined in the resident's plan of care.

There was also no documented evidence that the facility checked the placement and functioning of the resident's clip alarm since the resident had a known history of removing her alarm, when she fell 3 days earlier on the morning of January 22, 2024, and the alarm was not sounding at the time of both falls (January 22, 2024, and January 25, 2024).

After the resident's fall on January 25, 2024, the resident's care plan was updated to include a scheduled toileting program the addition of 6:00 AM, sensor alarm bed/chair alarm and motion and new physician orders to check placement of chair and bed alarms.

The facility failed to demonstrate timely and consistent implementation of measures planned to prevent falls, including timely assistance with toileting needs, including checking and changing for incontinence and functioning safety alarms, which was confirmed during interview at the time of the survey ending February 7, 2024, the Director of Nursing (DON) and the Nursing Home Administrator (NHA).

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

28 Pa. Code 211.5 (f) Medical records

Plan of Correction - To be completed: 02/14/2024

1. Resident BT no longer resides in the facility.
2. Residents residing in the facility that have been identified as a fall risk with alarms have the potential to be affected by this alleged deficient practice. The DON/designee checked all residents with alarms for proper placement and functioning. Alarms identified as not functioning were immediately replaced. DON/designee completed Fall Risk Evaluation for residents residing in the facility, care plans reviewed and revise to ensure interventions are appropriate. DON/designee reviewed current residents to ensure scheduled toileting plans continue to meet the needs of the resident, toileting plans revised as needed.
3. DON/designee re-educated nursing staff on 1/25/23 on the types of alarms, reviewing functioning to include battery placement, attachment for clip and sensor alarms and replacing if not functioning. DON/Designee initiated orders for checking placement and functioning of alarms on the treatment record to be signed off by licensed nursing staff and in the tasks for the certified nursing assistants. DON/designee re-educated on 2/13/2024 nursing staff on completion of 3 day voiding diary on admission and initiating scheduled toileting plan based on the results of the voiding diary, and completing a bowel and bladder assessment quarterly. Education was re-enforced on interventions of alarm use and bowel and bladder programs 2/22/2024 with aids and licensed staff as previously educated.
4. DON/designee will complete an audit daily for two weeks alternating shifts to ensure alarms are in place and functioning, then twice a week for 2 weeks, then monthly for 2 months. Results of these audits will be reviewed by the QAPI for further recommendations.
DON/designee will randomly audit 5 resident a week for 4 weeks, then monthly for 2 months to ensure toileting plan is appropriate for the residents identified needs. Results of these audits will be reviewed by the QAPI committee for further recommendations.

483.75(c)(d)(e)(g)(2)(i)(ii) REQUIREMENT QAPI/QAA Improvement Activities:

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.

§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.70(e) and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.70(e). Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.

Observations:

Based on review of the facility's plan of correction for the deficiencies cited during the survey of December 14, 2023, and the findings of the survey ending February 7, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement plans to correct quality deficiencies related to fall prevention and significant medication errors and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies.

Findings include:

The facility's deficiencies and plan of correction for the survey ending December 14, 2023, revealed the facility developed a plan of correction that included quality assurance monitoring systems to ensure that solutions were sustained. This plan was to be functional by December 28, 2023. The results of the current survey ending February 7, 2024, identified repeat quality deficiencies related to fall prevention and significant medication errors.

In response to the deficiency cited related to resident falls during the survey of December 14, 2023, the facility's plan of correction revealed that the plan included the DON (director of nursing) / designee will audit residents falls during the clinical meeting to verify if interventions were in place including necessary staff supervision to prevent further falls. The audits will be completed weekly for four weeks then monthly for two months thereafter. Results of the audits will be reviewed at Quality Assurance Committee and changes will be made as necessary.

However, at the time of the revisit survey ending February 7, 2024, review of clinical records revealed Resident 1 fell in the facility on the morning of January 22, 2024 and again on the morning of January 25, 2024, with the second fall resulting in a fractured arm. sustaining There was no documented evidence the resident's clip alarm was checked for placement and functioning prior to the falls and the alarm was not sounding at the time of either fall. The resident removed the alarm at the time of the fall on January 22, 2024, and staff failed to timely toilet and/or check or change the resident for incontinence prior to the fall on January 25, 2024.

In response to the deficiency cited related to significant medication errors during the survey of December 14, 2023, the facility's plan of correction revealed that the plan included the DON / designee will re-educate the licensed nursing staff on the Medication Administration policy including preventing medication errors. Further the DON / designee will conduct random medication competencies for 2 licensed nurses per week to verify they remain competent in medication administration. The competencies will be completed weekly for four weeks then monthly for two months thereafter. Results of the audits will be reviewed at Quality Assurance Committee and changes will be made as necessary.

However, at the time of the revisit survey ending February 7, 2024, a review of clinical records revealed that Resident 2 had received Resident 3's Humalog insulin. Resident 2 received 25 units of Humalog insulin instead of the physician ordered 25 units of Levemir insulin. Employee 2 failed to follow facility policy despite being educated on the Medication Administration policy and the facility performing competencies in response to the prior deficiency cited on December 14, 2023, related to medication errors. .

The facility's QAPI committee failed to identify that the facility had failed to implement their plan of correction, in a manner consistent with the regulatory guidelines for the deficiencies cited, to ensure that solutions to the problem were sustained.

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 201.18(e)(1) Management.

Plan of Correction - To be completed: 02/14/2024

1. The facility will continue to monitor QAPI by the stated audits, results and interventions required for ongoing compliance for fall prevention and proper administration of medications.
2. All residents have the potential to be affected by the identified deficient practice. The NHA/DON/Designee will continue to routinely monitor the POC for compliance and address any needed intervention.
3. NHA/Designee will educate the Department Managers in problem identification and initiation of a planned intervention for resident safety and compliance.
4. NHA will monitor the monthly QAPI for inclusion of effective interventions for identified concerns.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff:

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.

§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e).

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

Observations:

Based on a review of clinical records, select facility policy and incident reports and staff interview, it was determined that the facility failed to provide nursing staff with the necessary skills and competencies to accurately and safely transcribe physician verbal telephone orders for one resident out of 13 sampled (Residents 2).

Findings include:

A review of facility policy entitled "Verbal Orders" last reviewed June 2023, revealed that the individual receiving the verbal orders must write it on the physician's order sheet as v.o. (verbal order) or t.o. (telephone order). The individual receiving the order will read back the order to the practitioner to ensure the information is clearly understood and correctly transcribed, record the practitioners last name and credentials, and record the date and time of the order. The practitioner will review and countersign the verbal order during his next visit.

According to the 28 Pa. Code 211.3 (a) Verbal and telephone orders shall be given to a registered nurse, physician or other individual authorized by appropriate statutes and the State Boards in the Bureau of Professional and Occupational Affairs and shall immediately be recorded on the resident ' s clinical record by the person receiving the order. The
entry shall be signed and dated by the person receiving the order.

A review of the clinical record revealed that Resident 2 was admitted to the facility on March 30, 2020, with diagnosis to include type 2 diabetes and hypertension.

A review of an incident report dated January 8, 2024, at 8:04 AM Employee 2, LPN, erroneously administered Humalog 100 u/ml (short acting insulin help to quickly reduce blood sugar levels during mealtimes) 25 units to Resident 2 instead of administering Levemir 100 u/ml (long acting insulin that maintains a steady insulin level throughout the day) 25 units. The Humalog insulin administered to Resident 2 was prescribed to Resident 3.

A review of an eMar (electronic-Medication Administration Record) order administration note dated January 8, 2024, at 8:04 AM revealed Levemir 100 u/ml insulin and Novolog 100 u/ml insulin were held per MD orders.

A review of a nursing note written by Employee 3, RN (registered nurse) dated January 8, 2024, at 8:05 AM revealed that this nurse spoke with the physician regarding glucose monitoring. A new order was noted to monitor glucose levels every 30 minutes x 2, then every hour x 3, then every two hours and as needed for signs and symptoms of hypoglycemia. Employee 3 did not document that the physician gave an order to hold the resident's routine scheduled insulin as noted on the eMar. There was also no information noted as to when the every two hours blood sugars were to end for monitoring Resident 2.

A nursing note written Employee 2, LPN, dated January 8, 2024, at 2:03 PM revealed that the employee stated the physician was called after the medication error occurred with Resident 2. The employee noted that the physicians ordered the following: monitor the resident throughout the day, watch for signs and symptoms of hypoglycemia, take blood sugar now, then in 30 minutes, then every hour x 3, then two hours. Repeat for evening shift.

A review of the physician's orders revealed no orders entered for the resident's insulin to be held or orders entered for the blood glucose monitoring as noted by Employee 2.

An interview with the Nursing Home Administrator on February 7, 2024, at approximately 1:00 revealed she spoke with Employee 3, RN and the employee stated that she became busy with the events going on related to the medication error and did not transcribe the orders the physician had verbally given to the nursing staff in the resident's clinical record.

During an interview February 7, 2024, at approximately 2:30 PM, The Nursing Home Administrator and Director of Nursing confirmed that Employee 3 failed to demonstrate competency obtaining and transcribing physician verbal orders for Resident 2.

28 Pa. Code 211.3 9 (a) Verbal and telephone orders

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

28 Pa. Code 211.9 (a)(1)(b)(d)(k) Pharmacy services

Plan of Correction - To be completed: 02/14/2024

1. The physician order was obtained for the Completion of Accuchecks to assess resident PM's blood sugars. The facility cannot retro actively correct the incomplete transcription of the order.
2. Residents residing in the facility have the potential to be affected by this alleged deficient practice. A 2 week look back of medication orders has been completed. All identified orders have been reviewed for accurate and safe transcription. Any concern has been addressed and verified.
3. DON/designee will educate licensed nursing staff on transcribing verbal telephone orders accurately and completely upon obtaining the order from the physician.
4. The DON/designee will review physician verbal orders of medication orders 5 times weekly for 4 weeks then randomly for 2 months in clinical meeting daily to ensure order has been transcribed correctly. Results of the order review will be reviewed by the QAPI committee for further recommendations.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on review of resident clinical records, select facility policy, and facility incident reports, and staff interview it was revealed that the facility failed to assure that one of 13 residents reviewed was free of a significant medication error (Resident 2).

Findings include:

A review of a current facility pharmacy policy, entitled "Administering Medications" last reviewed by the facility June 2023 revealed medications are to be administered in a safe, timely manner as prescribed. Further it was indicated the individual administering the medication checks the label three times to verify the right resident, right medication, right dose, right time, and right method of administration before giving the medication.

A review of the clinical record revealed that Resident 2 was admitted to the facility on March 30, 2020, with diagnosis to include type 2 diabetes and hypertension.

A review of a facility incident report dated January 8, 2024, at 8:04 AM revealed that Employee 2 (LPN) erroneously administered Humalog 100 u/ml (short acting insulin help to quickly reduce blood sugar levels during mealtimes) 25 units to Resident 2 instead of administering Levemir 100 u/ml (long acting insulin that maintains a steady insulin level throughout the day) 25 units. The Humalog administered to Resident 2 was prescribed for Resident 3.

A witness statement from Employee 2, LPN, revealed that the nurse indicated that during morning medication pass another employee came up to her for an update on a resident. After the conversation the Employee 2 stated that she did not refocus and pulled the wrong insulin pen and administered it to Resident 2 and a medication error had occurred.

A review of a nursing note dated January 8, 2024, at 2:03 revealed that the facility performed blood glucose monitoring of Resident 2 at 7:30 AM, 8:00 AM, 9:00 AM, 10:00 AM, 12:00 PM, and 2:00 PM.

A review of the resident's blood glucose, after the medication error, January 10, 2024 were as follows:

7:30 AM - 80 mg/dl
8:00 AM - 112
9:00 AM - 140
10:00 AM - 100
12:00 PM - 114
2:00 PM - 106

An interview with the Nursing Home Administrator and Director of Nursing on February 7, 2024 at approximately 2:30 PM confirmed that Employee 2 administered the incorrect insulin medication to Resident 2, failing to ensure the resident was free from significant medication errors.

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

28 Pa. Code 211.9 (a)(1)(d) Pharmacy Services.

Plan of Correction - To be completed: 02/14/2024

1. Resident PM had no adverse effects related to insulin administration.
2. Residents residing within the facility with insulin orders have the potential to be affected by this alleged deficient practice. DON/designee reviewed blood sugars for current residents residing in the facility for blood sugars out of their normal range. No discrepancies were identified. After self-reporting, the nurse was immediately removed from medication cart, educated on insulin administration and insulin administration competency completed prior to continuation of medication administration. Nurse continued to have medication administration competencies weekly for 4 weeks.
3. DON/designee immediately re- educated licensed nurses on the 5 rights of medication and comparing the medication label to the medication administration order before each administration and Insulin administration. Nursing staff completed posttest on insulin administration. DON/designee-initiated Insulin administration competencies on licensed nursing staff on 1/8/24. Education was re-enforced on 2/22/2024.
4. DON designee will randomly complete medication administration competencies on 2 licensed nurses weekly x 4 weeks and then monthly for 2 months. Results of these competencies will be reviewed by the QAPI committee for review and further recommendations.

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