Nursing Investigation Results -

Pennsylvania Department of Health
SARAH A. TODD MEMORIAL HOME
Patient Care Inspection Results

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SARAH A. TODD MEMORIAL HOME
Inspection Results For:

There are  53 surveys for this facility. Please select a date to view the survey results.

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SARAH A. TODD MEMORIAL HOME - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid, State Licensure and Civil Rights survey and an abbreviated survey in response to an incident, completed on May 23, 2019, it was determined that Sarah A Todd Memorial Home 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:


483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
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.
Observations:


Based on surveyor observation, facility policy review, and staff interview, it was determined that the facility failed to 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 1970 and other drugs subject to abuse, for one of two medication carts observed (Hall 3 medication cart).

Findings Include:

Review of facility policy titled, "Controlled Medication Storage," with a policy review date of November 2017, revealed "the access system used to lock controlled medications and other medications subject to abuse cannot be the same access system used to obtain the non-scheduled medications."

Observation of Hall 3 medication cart on May 21, 2019, at 11:59 AM revealed 355 50mg tablets of Ultram (Pain medication) and 28 tablets of Ultram ER (extended release pain medication) stored in the medication cart, not separately locked in a permanently affixed compartment.

Review of Drug Enforcement Administration fact sheet on Ultram, dated October 2018, revealed "Dependence and abuse, including drug-seeking behavior and taking illicit actions to obtain the drug are not limited those patients with prior history of opioid dependence. The risk in patients with substance abuse has been observed to be higher. Tramadol hydrochloride is associated with craving and tolerance development."

Review of Food and Drug Administration fact sheet on Ultram, revised March 2008, on page 18 revealed: "ULTRAM can be abused and may be subject to criminal diversion."

During an Interview with the Nursing Home Administrator on May 23, 2019, at 10:30 AM revealed that she would expect the medications to be stored in compliance with facility policy and federal regulation and that they are now locked as such.




















 Plan of Correction - To be completed: 06/21/2019

1. All Ultram is currently locked separately from non-scheduled medications.
2. All controlled drugs will continue to be kept separately in a locked container apart from non-scheduled medications.
3. All licensed nursing staff will be educated on ensuring that controlled medications are locked separately from non-scheduled medications by 6/21/2019.
4. Audits will be done weekly for each medication cart for all residents taking Ultram to ensure that they are locked appropriately for one quarter. The number of audits will vary related to the number of residents taking Ultram. Random audits will then be done monthly for another quarter to ensure compliance.
5. Corrective action will be completed by 6/21/2019.
483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:


Based on facility policy review, facility documentation review, and staff interview, it was determined that the facility failed to ensure that staff reported an allegation of physical abuse in a timely manner for one of 25 resident records reviewed.

Findings Include:

Review of facility policy titled "Resident Abuse, Neglect, Exploitation of Residents, and Misappropriation of Resident Property," with a revision date of December 6, 2018, revealed "6. Reporting Abuse: a. Staff members of all departments must report alleged abuse, neglect, and exploitation of residents and misappropriation of resident belongings incidents to their supervisor immediately."

Review of facility documentation revealed that on January 21, 2019, at 9:50 PM Nurse Aide (NA) 1 reported to Registered Nurse (RN) 1 that on January 20, 2019, on the 3-11 shift, Resident 41 was combative in the bathroom and NA 2 came into the bathroom to assist NA 1. NA 1 reported that NA 2 held Resident 41's arms and made a statement "that I can give it to you too."

Review of NA 1's witness statement, dated January 21, 2019, revealed that NA 2 was holding Resident 41's arms tightly so the resident couldn't slap NA 1 or NA 2. NA 1 alleges that she told NA 2 to stop holding Resident 41's hands like that because it can cause bruises and that NA 2 stated "I don't care." NA 1 also alleges that NA 2 stated "I can give to you too."

Review of facility investigation, including witness statements from NA 2, other staff members, and Resident 41, failed to corroborate NA 1's allegations. The facility unsubstantiated the abuse allegation.

NA 1 failed to immediately report the allegation of abuse.

During staff interview on May 22, 2019, at 2:11 PM the Nursing Home Administrator and Director of Nursing both stated that NA 1 should have reported the alleged abuse immediately.

28 Pa Code: 201.18(b)(1)(e)(1) Management.















 Plan of Correction - To be completed: 06/21/2019

1. Resident 41 was not harmed by this deficient practice. The employee involved was educated on the importance of reporting suspected abuse immediately.
2. All staff is educated at orientation and twice a year at fall and spring in-services regarding abuse policies/procedures and reporting suspected abuse immediately.
3. All staff will again be educated on abuse policies and procedures and reporting guidelines by 6/21/2019.
4. When suspected abuse is reported, the timeline of events will be monitored to ensure that reporting is timely. Four audits will be done weekly via staff questionnaire for one quarter with random staff members to ensure that they are aware of reporting requirements.
5. Corrective action will be completed by 6/21/2019.
483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils: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.
483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.
Observations:


Based on surveyor observation, clinical record review, as well as staff interview, it was determined that the facility failed to provide special eating equipment for residents who need them for one of 25 residents observed (Resident 66).

Findings include:

Review of Resident 66's clinical record revealed diagnoses that included Alzheimer's disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and delusional disorder (disorder in which a person holds fixed false beliefs and is unable to tell what is real from what is imagined).

Review of Resident 66's care profile (instructions for care) revealed resident uses a lipped divided plate for meals.

Surveyor observation on May 20, 2019, at 12:04 PM revealed resident eating lunch from a standard plate.

During an interview with NA 3 (Nurse Aide) on May 20, 2019, at 12:07 PM she revealed that she thought Resident 66 normally got a special plate at each meal.

At that time, Dietary Aide (DA) 1 re-plated a meal for Resident on a blue, lipped, non-divided plate.

Review of Resident 66's meal ticket for the observed lunch meal revealed resident was to receive a divided plate.

During an interview with the Nursing Home Administrator on May 23, 2019, at 10:32 AM she revealed the expectation that Resident 66 should have gotten the appropriate adaptive plate.

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



 Plan of Correction - To be completed: 06/21/2019

1. Resident 66's meal ticket was changed so adaptive equipment was listed after every meal item so it is more visible to staff. Dining assistant involved will be educated on the importance of providing the resident with proper adaptive equipment on meal ticket by 6/6/2019.
2. All dining staff will be educated on importance of providing all residents with the proper adaptive equipment as listed on their meal tickets by 6/21/2019.
3. All meal tickets were modified so adaptive equipment is printed at the top of the ticket and after each food item.
4. Audits in dining rooms and on test trays will be done weekly for one quarter to ensure all residents are receiving appropriate adaptive equipment. After that, random audits will be done monthly for another quarter to ensure compliance.
5. Corrective action will be completed by 6/21/2019.
211.3(c) LICENSURE Oral and telephone orders.:State only Deficiency.
(c) A physician's telephone and oral orders for medication shall be dated and countersigned by the prescribing practitioner within 48 hours. Oral orders for Schedule II drugs are permitted only in a bona fide emergency.
Observations:


Based on clinical record review and staff interview, it was determined that the facility failed to ensure that verbal/ telephone orders for medications were countersigned within 48 hours by the ordering practitioner for one of 25 residents reviewed (Resident 49).

Findings include:

Review of facility policy, "Physician's Orders," revealed, "All verbal orders for medications must be counter-signed by the ordering practitioner within forty-eight (48) hours of the receipt of the telephone order."

Review of Resident 49's clinical record revealed that a verbal/telephone order for Buspar (anti-anxiety medication) twice per day was received on February 11, 2019. Further review of the order revealed that the prescribing practitioner did not countersign the order until February 19, 2019.
Further review of Resident 49's clinical record revealed that a verbal/telephone order to increase Zyprexa (antipsychotic medication used to treat certain mental/mood disorders) was received on March 11, 2019. Further review of the order revealed that the prescribing practitioner did not countersign the order until March 25, 2019.

Finally, review of Resident 49's clinical record revealed that a verbal/telephone order to discontinue Melatonin (medication used for treatment of trouble sleeping due to sleep cycle disorders) was received on April 8, 2019. Further review of the order revealed that the prescribing practitioner did not countersign the order until April 15, 2019.
During an interview with the Nursing Home Administrator on May 23, 2019, at 10:30 AM, she revealed the expectation that the verbal orders should have been countersigned within 48 hours.







 Plan of Correction - To be completed: 06/03/2019

1. Resident 49 was not harmed by this deficient practice. Physicians were educated on the importance of signing all verbal/telephone orders within 48 hours of giving them.
2. Both facility physicians were educated on the importance of signing all verbal/telephone orders within 48 hours for all residents in the facility.
3. Registered nurses will be educated on the importance of ensuring that the attending physicians signed all verbal/telephone orders within 48 hours of receiving them.
4. 5 audits will be done weekly to ensure that all verbal/telephone orders are signed within 48 hours for one quarter. After that random audits will be completed monthly for another quarter to ensure compliance.
5. Corrective actions will be completed by 6/21/2019.

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