Nursing Investigation Results -

Pennsylvania Department of Health
GARDENS AT BLUE RIDGE, THE
Patient Care Inspection Results

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GARDENS AT BLUE RIDGE, THE
Inspection Results For:

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GARDENS AT BLUE RIDGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on the findings of an abbreviated survey, in response to four complaints and four incidents, completed on May 3, 2019, at Gardens at Blue Ridge; the facility was found to be not in compliance with the 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 as they relate to the Health portion of the survey process.












 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on clinical record review and staff interview it was determined that the facility failed to follow physician orders for one of eight residents reviewed (Resident 7).

Findings include:

Review of Resident 7's clinical record on April 30, 2019, at approximately 11:15 AM revealed diagnoses including hypertension (elevated/high blood pressure) and coronary artery disease (CAD - disease of the arteries that feed blood to the heart).

Review of Resident 7's physician orders revealed an order for metoprolol 12.5 (medication used to treat high blood pressure) 12.5 mg by mouth every 12 hours and to hold the medication for a systolic blood pressure (blood pressure at the time the heart beats) less than 110 mmHg (millimeters of mercury - measure of pressure exerted) or heart rate of less than 60 beats per minute.

Review of Resident 7's medication administration record (MAR - documention tool utilized to record when a medication is provided) revealed that Resident 7 did not have heart rate monitoring in place for the administration of the metoprolol medication as ordered by the physician.

During a staff interview on May 1, 2019, at approximately 1:00 PM, Director of Nursing confirmed that there was no heart rate monitoring with the administration of metoprolol and that it was the facility's expectation that staff were assessing and recording Resident 7's heart rate which the administration.

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

28 Pa. Code 211.12(d)(3) Nursing services.



 Plan of Correction - To be completed: 05/28/2019

Preparation, submission and implementation of this plan of correction does not constitute an admission of agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continuously improve the quality of care and to comply with all state and federal regulatory requirements.

1. Resident # 7 was not negatively affected by this alleged deficiency by receiving medication.
2. Other residents who receive Metoprolol are at risk for this alleged deficient practice. Supplemental documentation was added. Other residents reviewed for supplemental documentation as indicated.
3. Education was provided to licensed staff to add supplemental documentation when placing orders.
4. Audits of residents with parameters will done 5 x a week for 2weeks then 3x a week for 2 weeks and then monthly x 3 months. Audits will be reviewed at QAPI.

483.45(d)(1)-(6) REQUIREMENT Drug Regimen is Free from Unnecessary Drugs: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.
483.45(d) Unnecessary Drugs-General.
Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-

483.45(d)(1) In excessive dose (including duplicate drug therapy); or

483.45(d)(2) For excessive duration; or

483.45(d)(3) Without adequate monitoring; or

483.45(d)(4) Without adequate indications for its use; or

483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or

483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.
Observations:


Based on clinical record review, facility policy review, and staff interview it was determined that the facility failed to ensure received adequate monitoring with the use of psychotropic medications for one of eight residents reviewed (Resident 4).

Findings include:

Review of Resident 4's clinical record on April 30, 2019 at approximately 12:00 PM revealed diagnoses including psychosis (mental health disorder characterized by decreased contact with reality) and hypertension (elevated/high blood pressure).

Review of Resident 4's physician orders revealed an order for Remeron (antidepressant medication used to treat symptoms of depression) 30 mg by mouth at bedtime dated March 26, 2019; Seroquel (antipsychotic medication used to treat symptoms of psychosis) 50 mg by mouth in the evening, dated March 26, 2019; and escitalopram oxalate (selective serotonin reuptake inhibitor: medication used to treat depression and anxiety) 10 mg by mouth once a day, dated March 26, 2019.

Review of Resident 4's clinical record revealed that Resident 4 was care planned for the use of psychotropic medication use. The psychotropic medication care plan included the intervention of "Monitor for side effects and report to physician: Anti-depressant - Sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photo sensitivity and excess weight gain. [sic] Monitor for side effects and report to physician: Antipsychotic medication - sedation, drowsiness, dry mouth, constipation, blurred vision, [extrapymidal symptoms - involuntary movement of the face, tongue or extremities which is a common side effect of antipsychotic medication], weight gain, edema [swelling], postural hypotension [decrease of blood pressure upon standing], sweating, loss of appetite, urinary retention." The care plan and interventions were initiated on July 6, 2016.

Review of Resident 4's medication and treatment administration records (documentation tool utilized to document medication and treatment administration) revealed that Resident 4 had antidepressant and antipsychotic medication side effect monitoring in place until March 25, 2019. At which time it was stopped during transfer to an emergency room. Upon return to the facility on March 27, 2019, side effect monitoring was never restarted.

During a staff interview on May 1, 2019, at approximately 2:00 PM the Director of Nursing revealed that there should have been side effect monitoring in place for Resident 4.

28 Pa code 211.12(d)(1)(3)(5) Nursing services




 Plan of Correction - To be completed: 05/28/2019

1. Resident # 4 was not negatively affected by this alleged deficient practice by not having behavior monitoring documentation.
2. Other residents who require behavior monitoring are at risk for this alleged deficient practice. Behavior monitoring documentation was added. Other residents reviewed for proper documentation.
3. Education provided to licensed staff to add behavior documentation when entering orders.
4. Audit of behavior documentation will be done 5 x a week for 2 weeks, then 3 x a week for 2 weeks, then monthly x 3 months. Audits will be reviewed at QAPI.



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