Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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REFORMED PRESBYTERIAN HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Findings of an abbreviated, complaint survey completed on February 7, 2019, at Reformed Presbyterian Home identified deficient practice, unrelated to the reported complaint allegations, under the requirements of 42 CFR part 483, Subpart B Requirements for Long Term Care Facilities and 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:

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on review of facility policy, observation and staff interview, it was determined that the facility failed to properly store medications in one of ten resident rooms (Room 321).

The facility policy "Storage of Medications" dated 7/31/18, indicated that medications and biologicals are to be stored safely, securely and properly.

During an observation of the lunch meal on 2/7/19, at 12:53 p. m. in Room 321, there was a medication cup that contained four pills sitting on the overbed table in front of a resident and she was drinking a liquid medication from another medication cup. Upon inquiry, she stated that she was taking her medications now that she is done eating her lunch.

During an interview on 2/7/19, at 12:55 p. m. Licensed Practical Nurse Employee E1 confirmed that she left medications with a resident and returned to the nurse's station.

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

 Plan of Correction - To be completed: 03/20/2019

1. Nurse involved was re-educated / counseled on day of observation (2/7/19). Documentation of counseling on file with NHA.

2. All nurses will be re-educated by the ADON and/or DON to medication storage policy and resident self-administration of medication policy. Signature sheets documenting education and understanding on file with NHA.

3. Compliance rounds will be conducted a minimum of 5 times a week which will look for medications left at the bedside. Compliance audits will be on file with NHA. Audits will continue until 100% compliance X 3 consecutive months.

4. Medication Pass audits to be completed monthly by consultant pharmacy. Results to be reported to QAPI committee.

5. Audit results will be reported to QAPI committee and results tracked.

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