Nursing Investigation Results -

Pennsylvania Department of Health
OAKMONT CENTER FOR NURSING & REHABILITATION
Patient Care Inspection Results

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OAKMONT CENTER FOR NURSING & REHABILITATION
Inspection Results For:

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OAKMONT CENTER FOR NURSING & REHABILITATION - 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 March 27, 2019, it was determined that Oakmont Center for Nursing and Rehabilitation 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 for the Health portion of the survey process.







 Plan of Correction:


483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in 483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:
Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide pharmaceutical services to assure accurate dispensing and receiving of medications for one of seven residents (Resident R1).

Findings include:

The facility policy entitled "Medication and Treatment Orders" dated 9/27/18, indicated that the QAPI Committee will conduct a root cause analysis of medication administration errors to determine the source of errors, implement process improvement steps and compare results over time to determine that system improvements are effective in reducing errors.

Review of the Minimum Data Set dated 1/30/19, indicated that Resident R1 had diagnoses that included multiple sclerosis (degenerative neuromuscular disease), depression and hemiplegia (weakness on one side of the body).

Review of a physicians order dated 12/5/18, indicated that Resident R1 was ordered Tecfidera (medication for multiple sclerosis) 240 mg. capsule by mouth to be given at 9:00 a.m. and 9:00 p.m. In addition, the physician order indicated that the Tecfidera was to be reordered from the specialty pharmacy every 25 days to ensure the medication was received.

Review of Resident R1's Medication Administration Record (MAR) for the month of January 2019, indicated that the Tecfidera had been reordered from the specialty pharmacy on 1/25/19.

Review of the MAR for the month of February 2019, indicated that Resident R1 was not administered the Tecfidera on 2/3/19, at 9:00 p.m., 2/4/19, at 9:00 a.m. and 2/4/19, at 9:00 p.m. because the medication was not available from the pharmacy.

During an interview on 3/18/19, at 1:55 p.m., the Director of Nursing confirmed that the Tecfidera was not administered to Resident R1 as ordered on 2/3/19, and 2/4/19, as listed above because the specialty pharmacy failed to supply the medication.

During an interview on 3/27/19, at 11:20 a.m., Pharmacy Technician Employee E1 confirmed that the specialty pharmacy failed to supply the Tecfidera for Resident R1 after receiving the reorder on 1/26/19.


28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited 12/21/18.

28 Pa. Code 211.9(f)(k) Pharmacy services.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 12/21/18.




 Plan of Correction - To be completed: 05/01/2019

Disclaimer: Preparation, Submission and Implementation of this POC does not constitute an admission of, or agreement with, the facts and conclusions set forth on the complaint survey report. Our POC is prepared and executed as a means to continuously improve the quality of care and to comply with applicable state and federal regulatory requirements.
Plan of Correction for Requirement of 42 CFR Part 483, Subpart B, Requirements for Long Term Facilities and the 28 PA Code: The facility does employ and obtain the services of a licensed pharmacist, Susan Allen, through who will be consulted immediately on emergency situations like this in the future.
Plan of Correction: Corrective action for the resident found to be affected will be : Orders have/had been put in place for re-ordering the medication seven days early; the local pharmacy cannot refill due to insurance restrictions.
We will identify other residents having the potential to be affected by the same deficient practice by doing audits on all non-facility pharmacies upon admission.
As a measure to put into place to ensure the deficient practice does not re-occur, we will audit the whole house for outside pharmacy usage weekly x 4, then twice a month for 2 months, then monthly. The DON, ADON or delegated nurse will then audit for any outside pharmacy usage with monthly cart checks. The pharmacy was also educated on the situation.



483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
483.45(f)(2) Residents are free of any significant medication errors.
Observations:
Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to make certain that residents were free from significant medication errors for one of seven residents (Resident R1).

Findings include:

The facility policy entitled "Adverse Consequences and Medication Errors" dated 9/27/18, indicated that a medication error is defined as preparation or administration of drugs or biologicals that is not in accordance with the physician order, manufacturer specifications or accepted professional standards. Examples include omission errors - a drug is ordered but not administered.

The "Adverse Consequences and Medication Errors" policy also indicated that the Attending physician is notified promptly of any significant errors or adverse consequences and that the following information is documented in an incident report and in the resident's clinical record: factual description of the error, name of physician and time notified, subsequent physician orders, residents condition for 24 to 72 hours or as directed.


Review of the Minimum Data Set dated 1/30/19, indicated that Resident R1 had diagnoses that included multiple sclerosis (degenerative neuromuscular disease), depression and hemiplegia (weakness on one side of the body).

Review of a physicians order dated 12/5/18, indicated that Resident R1 was ordered Tecfidera (medication for multiple sclerosis) 240 mg. capsule by mouth to be given at 9:00 a.m. and 9:00 p.m.

Review of the MAR for the month of February 2019, indicated that Resident R1 was not administered the Tecfidera on 2/3/19, at 9:00 p.m., 2/4/19, at 9:00 a.m. and 2/4/19, at 9:00 p.m. because the medication was not available from the pharmacy.

Review of the Physician Note dated 2/5/19, indicated that "had difficulty obtaining one of Resident R1's multiple sclerosis medications for a few days from the pharmacy, symptoms began to return but abated after medication restarted".

Review of the Progress Notes for the period of 2/3/19 until 2/5/19, did not include the notification of the physican, or any assessment of Resident R1's condition.

During an interview on 3/18/19, at 1:55 p.m., the Director of Nursing confirmed that the Tecfidera was not administered as ordered on 2/3/19, and 2/4/19, as listed above and the medication omission was a significant medication error.

During an interview on 3/27/19, at 1:30 p.m., the Director of Nursing confirmed that the staff failed to complete incident reports for Resident R1's significant medication omission errors on 2/3/19, and 2/4/19, and failed to document information regarding physician notification and resident change of condition assessment for adverse consequences.


28 Pa. Code: 201.14(a) Responsibility of licensee.
Previously cited 12/21/18.

28 Pa. Code 211.9(f)(k) Pharmacy services.

28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 12/21/18.



 Plan of Correction - To be completed: 05/01/2019

Plan of Correction for Resident found to be affected by deficient practice: In order to immediately remedy the situation, staff were educated and signed off on the importance of following proper protocol when a medication is missed: utilization of FirstDose, as well as encouraging the pharmacy to send the medication stat. The on call pharmacist will also be utilized as necessary. The resident, health care provider, and family must be immediately notified if the medication is not available and any side effects/ill effects from not receiving the medication must be documented and reported to the health care practitioner immediately. We will continue to order the outside pharmacy medications seven days prior and review medications not given daily.
To avoid this from happening to other residents, we will continue to review medications not given daily as well as do a whole house audit for outside pharmacy usage as part of our daily clinical meeting. As stated in the tag earlier, a whole house audit for outside pharmacy use will be done weekly x 4, then twice a month x 2, then monthly.
Nursing staff will also be educated to place orders for outside pharmacy usage in a separate binder.

211.12(i) LICENSURE Nursing services.:State only Deficiency.
(i) A minimum number of general nursing care hours shall be provided for each 24-hour period. The total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.7 hours of direct resident care for each resident.
Observations:
Based on review of nursing time schedules and staff interviews, it was determined that the facility administrative staff failed to provide the minimum number of general nursing hours to each resident in a 24 hour period on one of 21 days (3/10/19).

Findings include:

Review of nursing time schedules for the period 2/22/19, through 3/14/19, revealed that the facility failed to maintain 2.7 hours of general nursing care to each resident in a 24 hour period on the following dates:

3/10/19 - 2.56 hours

During an interview on 3/25/19 at 2:05 p.m., the Director of Nursing confirmed that the facility failed to meet the nursing hour requirements on 3/10/19.


 Plan of Correction - To be completed: 05/01/2019

Plan of Correction: One day did fall below 2.56. PPD is projected each day by the staffing coordinator and DON. To prevent this from happening again, ALL available staff will be contacted to see if they can come in. The DON and ADON were in that day.
To prevent this from happening in the future, all supervisors will be educated on how to adjust the PPD to meet state requirements, including adjustment for call offs and no shows. NHA and DON will over see this.


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