Nursing Investigation Results -

Pennsylvania Department of Health
NAAMANS CREEK COUNTRY MANOR
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
NAAMANS CREEK COUNTRY MANOR
Inspection Results For:

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NAAMANS CREEK COUNTRY MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an Abbreviated survey completed on March 20, 2019, in response to a complaint and a reportable event, it was determined that Naamans Creek Country Manor 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.



 Plan of Correction:


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


Based on a review of clinical record and staff interview, it was determined that the facility failed to ensure that residents were free of significant medication errors which resulted in actual harm to Resident R1 experiencing a hypoglycemic episode, requiring two doses of Glucagon injection, one dose of Dextrose intravenously and transfer to the hospital via emergency services for one of four residents reviewed. (Resident R1)

Findings include:

Review of Resident R1's diagnoses list revealed a diagnosis of, but not limited to Type 2 Diabetes Mellitus (failure of the body body to produce insulin) without complications.

Review of February 2019 physician's orders and Medication Administration Records dated February 23, 2019, revealed an order for the insulin medication Humulin R U-500 inject 25 units subcutaneously with breakfast for blood sugar 150 and higher. Humulin R U-500 inject 25 units subcutaneously with lunch and dinner.

A review of nursing notes dated February 25, 2019, at 6:25 p.m. revealed "Patient ordered Humulin U-500 25 units with meals. Patient given incorrect dose of insulin. BS (blood sugar) at 4:30 p.m. was 77. New orders to do accuchecks q (every)1 hr for 6 hrs (hours), given one dose of Glucagon, house supplements and orange juice with sugar. Observe for hypoglycemia and alert MD (physician) with any changes."

Review of nursing note dated February 26, 2019, at 5:12 a.m. noted, "Resident request to use the bathroom at 0200 (2:00 a.m.) while in the bathroom (10 min) resident began perspiring, tensing up and speech became unclear/blood sugar was taken BS decrease to 47 resident was transferred from toilet to bed with maximal assist; at this time MD was called via charge nurse, while assigned nurse made several attempts to bring sugar to normal range. BS 40 resident was given Glucagon with negative results/ MD states send pt to Emergency Room (ER) while awaiting for Emergency Medical Transport (EMT) resident received second Glucagon injection BS when obtain BS 41/ resident continues with non responsive behavior nurse remained with resident to keep resident alert/EMT arrived assessed resident placed IV with Dextrose due to BS continuing to decrease/once IV was placed and medication received resident alert with clear speech and able to make needs known/resident take to [hospital] for observation/management; POA (Power of Attorney) made aware."

A review of "Statement via phone conversation" by the Director of Nursing (DON) with licensed nursing staff, Employee E2 revealed "I read the order, it was for insulin U-500 25 units, I did not see anything in the MAR (Medication Administration Record) to tell me about it being a high dose or that I had to use another syringe." DON proceeded to ask Employee E2 during interview, "when you read her name did you not see the red warning signs right above where pharmacy placed her name sticker?" Licensed nursing staff Employee E2 responded that she in error did not see or read the warning labels on box and bottle to administer with U-500 syringe that was available. She never knew there were different syringes for the U-500 insulin. She has only ever used a U-100 (syringe) for everything.

Regular insulin U-500 is 5 times more potent than the Regular insulin U-100. The use of the U-100 syringe with the insulin Humulin R-500 resulted in more insulin medication being delivered.

Observation of the Humulin R U-500 box on March 15, 2019, at approximately 1:30 p.m. confirmed that a warning label was placed on the medication's box indicating "Warning- Highly Concentrated IMPORTANT: Use only with a U-500 syringe."

A review of the "Medication Safety Alert Sheet Focus on U-500 Insulin" provided by the pharmacy stated that "U-500 insulin is only available as regular insulin in a concentration of 500 units/ml (milliliters) Due to the potential confusion in the volume of insulin ordered, directions for injection should include the insulin volume to be administered in milliliters. A TB (tuberculin) syringe is recommended for administration. It should be noted this highly concentrated solution of insulin has a prolonged duration of therapy and patients should be continually monitored for hypoglycemia. Recommendations for safe prescribing, dispensing and administration include: Two nurses should check the dose and volume when drawing and administering this medication."

Review of Resident R1's February 2019 Medication Administration Record revealed no documented evidence that two nurses checked the admistration of the insulin medication Humulin R U- 500 to Resident R1 as recommended by the pharmacy.

A review of the facility investigation into the medication error involving Resident R1 dated February 25, 2019, concluded that the incorrect syringe was used during the administration of the insulin medication Humulin R U-500 to Resident R1.


The nurse did not follow the pharmacy warning box label or the warning in red on the bottle to use a U-500 syringe and the nurse did not follow drug warning on three occasions therefore did not follow 5 rights of drug information (right patient, right time and frequency of administration, right dose, right route and right drug)."

The facility failed to ensure that the correct syringe was utilized in the administration of insulin medication to Resident R1 which resulted in actual harm to Resident R1 experiencing a hypoglycemic episodes, requiring two doses of Glucagon injection, 1 dose of Dextrose intravenously and transfer to the hospital via emergency services.


28 Pa. Code 211.5(f) Clinical records
Previously cited 08/24/18, 09/15/17

28 Pa. Code 211.9(a)(1) Pharmacy services
Previously cited 08/24/18, 09/15/17

28 Pa Code 211.10(c) Resident care policies
Previously cited 08/24/18, 09/15/17

28 Pa Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 08/24/18, 09/15/17




















 Plan of Correction - To be completed: 05/07/2019

Resident R1 returned to the facility on U-500 quick pen. Resident is receiving insulin as ordered and is free of insulin medication error.

Current residents with physician orders for insulin will be reviewed to ensure residents are receiving correct insulin dosage and are free of significant med error.

Center Nurse Executive/Designee has re-educated licensed nursing staff on proper insulin administration including U-500 insulin.

Center Nurse Executive/Designee will conduct random weekly observations of insulin administration to ensure residents are receiving insulin as ordered.

Results of audit will be reviewed at the monthly QI meeting.
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, facility documentation and staff interview, it was determined that the facility failed to provide the appropriate education to licensed staff to ensure the proper administration of an insulin medication for one of two residents reviewed. (Resident R1)

Findings include;

A review of Resident R1's admission record dated February 16, 2019, revealed a diagnosis of Type 2 Diabetes Mellitus (failure of body to produce insulin) without complications.

A review of Resident R1's physician orders dated February 23, 2019, revealed an order for the insulin medication Humulin R U-500 inject 25 units subcutaneously with breakfast for blood sugar 150 and higher. Humulin R U-500 inject 25 units subcutaneously with lunch and dinner.

Review of nursing notes dated February 25, 2019, at 6:25 p.m. revealed "Patient ordered Humulin U-500 25 units with meals. Patient given incorrect dose of insulin. BS (blood sugar) at 4:30 p.m. was 77. New orders to do accuchecks q (every)1 hr for 6 hrs (hours), given one dose of Glucagon, house supplements and orange juice with sugar. Observe for hypoglycemia and alert MD (physician) with any changes."

A review of facility investigation dated February 25, 2019, confirmed a medication error occurred involving the administration of Humulin R U-500- 25 units 3 doses to Resident R1. The incorrect syringe was utilized in the administration of the insulin medication. The investigation concluded, "The nurse did not follow the pharmacy warning box label or the warning in red on the bottle to use a U-500 syringe. Nurse did not follow drug warning on three occasions therefore did not follow 5 rights of drug information." Further review of the facility's investigation stated, "Agency will re-educate nurse regarding following the 5 rights of drug administration (right patient, right time and frequency, right dose, right route, right drug) and correct administration U-500 insulin."

A review of facility documentation of event reporting dated February 27, 2019, revealed that a medication error had occurred on February 25, 2019, stating, "Resident R1 was administered insulin R U-500 in an insulin U-100 syringe times three doses. After last dose it was brought to the nurses attention by another nurse that only U-500 syringes should be used for that insulin. ... Investigation concluded that licensed nurse responsible for medication error followed the correct dose as per MD orders but drew up the insulin in the wrong insulin syringe causing the resident to receive a larger dose due to the concentration of U-500 insulin."

A review of the "Medication Safety Alert Sheet Focus on U-500 Insulin" provided by the pharmacy stated that "U-500 insulin is only available as regular insulin in a concentration of 500 units/ml (milliliters) Due to the potential confusion in the volume of insulin ordered, directions for injection should include the insulin volume to be administered in milliliters. A TB (tuberculin) syringe is recommended for administration. It should be noted this highly concentrated solution of insulin has a prolonged duration of therapy and patients should be continually monitored for hypoglycemia. As Humulin R U-500 is dispensed and administered more frequently, the risk for medication errors will also increase and may be associated with grave adverse events. Recommendations for safe prescribing, dispensing and administration include: Two nurses should check the dose and volume when drawing and administering this medication."

A review of an interview conducted by the facility with licensed agency staff, Employee E2, revealed that Employee E2 reported that she never knew there were different syringes for the U-500 insulin. She has only ever used a U-100 (syringe) for everything. She in error did not see or read the warning labels on box and bottle to administer with U-500 syringe that was available. Licensed nursing staff, Employee E2 indicated that the Nurse Practitioner Educator (NPE) has added to the MAR (Medication Administration Record) for patients needing U-500 insulin that a U-500 syringe must be used. Had this been in place, the error would not have occurred."

An interview on March 15, 2019, at 11:00 a.m. with the Director of Nursing, licensed Employee E1, confirmed that education was not provided to licensed staff on Humulin R U-500 insulin management prior to its use by licensed employees. The Director of Nursing stated that the "Medication Safety Alert Sheet" provided by the pharmacy was part of the MAR for Resident R1 who had orders for Humulin R U-500, indicating that it was placed in the MAR and the licensed employee should have seen such information.

Refer to F760.

28 Pa. Code 211.9(a)(1) Pharmacy services
Previously cited 08/24/18, 09/15/17

28 Pa Code 211.10(c) Resident care policies
Previously cited 08/24/18, 09/15/17

28 Pa Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 08/24/18, 09/15/17


































 Plan of Correction - To be completed: 05/07/2019

Resident R1 returned to the facility on U-500 quick pen. Resident is receiving insulin as ordered.

Licensed Nurses will be reviewed to ensure current nurses have received education for administration of the U-500 insulin. No other residents are on U-500 insulin.

Center Nurse Executive/designee has re-educated licensed nursing staff on proper administration of U-500 insulin.

Center Nurse Executive/designee will complete random weekly audits to ensure licensed nurses have been educated on proper administration of the U-500 insulin.

Results of audits will be reviewed at the monthly QI meeting.
483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 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 observation, and clinical record review, it was determined that the facility failed to ensure proper infection control practice during the application of a skin protectant cream for one of two residents observed (Resident R2).

Findings include:

Review of Resident R2's March 2019 physcian's orders revealed a order for the skin protectant cream Nutrashield with Olivamine Remedy 1% apply to bilateral buttocks, sacrum every shift and as needed.

Observation conducted on March 15, 2019, at 2:45 p.m. of Resident R2 revealed that the resident was placed in bed to have treatment to bilateral buttocks applied after incontinence care was completed. Licensed nursing staff, Employee E4 obtained gloves and was holding the skin protectant barrier cream Nutrashield Olivamine remedy 1% on the left hand and with the right hand proceeded to touch the bed controls to raise Resident R2 up in bed. After the resident was raised up in bed at the proper level, Licensed nursing staff, Employee E4 proceeded to apply the barrier cream with her right hand to the resident's buttocks without changing gloves and washing hands after touching the bed controller.

The facility failed to ensure proper infection control during the application of a skin barrier cream to Resident R2.

28 Pa Code 211.12(c)(d)(1)(5) Nursing services
Previously cited 08/24/18, 09/15/17





 Plan of Correction - To be completed: 05/07/2019

Resident R2 skin protectant cream/Nutrashield is being applied using proper infection control practices.

Current Licensed Nursing Staff will be observed during the application of skin protectant cream/Nutrashield to ensure it is applied following infection control practices.

Center Nurse Executive/Designee will re-educate Licensed nursing staff on following infection control practices during the application of skin protectant cream/Nutrashield.

Center Nurse Executive/Designee will perform random weekly observations of Licensed nursing staff during the application of skin protectant cream/Nutrashield to ensure infection control practices are followed.

Results of audits will be reviewed at the monthly QI meeting.

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