Nursing Investigation Results -

Pennsylvania Department of Health
CLIVEDEN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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CLIVEDEN NURSING AND REHABILITATION CENTER
Inspection Results For:

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CLIVEDEN NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on an Abbreviated Survey in response to two complaints completed on January 24, 2019, it was determined that Cliveden Nursing and Rehabilitation Center 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:


483.25 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 review of a resident's clinical record and an interview with facility staff, it was determined that the facility failed to follow physician orders to administer a medication as instructed for one of four records reviewed (Resident R1).

Findings include:

Review of Resident R1 clinical record revealed an admission date of April 30, 2018, with diagnoses that included Cerebral Infarction (stroke), altered mental status, and Multiple Myeloma (cancer of plasma cells that make antibodies to fight infection) not achieving remission.

Review of Resident R1's physician orders revealed a medication Revlimid (a chemotherapy drug) to be given one 10 mg capsule for 14 days, each month, then stopped for 14 days, that started on May 15, 2018.

Review of Resident R1's progress note dated December 3, 2018, indicated the resident missed multiple doses of her Revlimid medication for the month of November.

An interview with the Director of Nursing (DON) on January 24, 2019 at 1:00 p.m., revealed every month, Resident R1's son would bring the Revlimid medication (14 pills) from home and give it to the facility for his mother. At the end of the 14 days he would take the finished bottle of medication from the facility. When exchanging the bottles of medication in November the son noticed only 8 pills in the bottle. DON investigated the issue and found that an agency nurse was signing out the pills without giving them to the resident.

The facility failed to follow physician orders for one resident receiving chemotherapy medication.

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





 Plan of Correction - To be completed: 02/17/2019

Preparation submission and implementation of this plan of correction does not constitute an admission or agreement with the facts and conclusions. 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.


* R1 continues to receive Revlimid medication as ordered

* There are no other residents receiving Revlimid

* R1 attending physician and oncologist were contacted and the attending ordered labs and to resume medication regimen

* A process was developed to monitor resident R1 Revlimid to include a count that involves the nurses to sign out the medication showing the quantity and the remainder until the doses are completed.

* The DON/designee will audit resident R1's MAR and count sheet q month to ensure the Revlimid is administered as ordered.

* ADON/designee will randomly audit the MARs weekly x 4 and then monthlyx3 to ensure residents are receiving their medications as ordered.

* The Educator will in-service the licensed staff on following the physicians order

* Results of audits will be discussed during QAPI committee meeting monthly


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