Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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GARDENS AT BLUE RIDGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on November 30, 2021 in response to a complaint, it was determined that Gardens at Blue Ridge, The 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:

483.25(k) REQUIREMENT Pain Management: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(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Based on closed record review and interviews the facility failed to provide pain medication according to physician's order for 1 of 6 residents reviewed for pain management, (Resident 1).

Findings included:

A review of the closed clinical record revealed Resident 1 was admitted to the facility from the hospital on August 17, 2021. Resident 1 had clinical diagnoses that included failure to thrive (FTT-a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments) and protein calorie malnutrition (state of inadequate intake of food).

A review of the discharge summary from the hospital revealed that resident 1 was admitted after experiencing a fall at home. The admission history at the hospital revealed the resident wasn't eating or drinking fluids for three weeks prior to the fall and was diagnosed with sepsis (a life-threatening complication of an infection), hypernatremia (a high concentration of sodium in the blood), and hypokalemia (blood level low in potassium). Prior to transfer to the facility, Resident 1 was placed on comfort care, antibiotics were discontinued, and morphine sulfate (a drug used to treat moderate to severe pain) was started for pain management.

The resident was transferred to the facility on August 17, 2021, and admitted to the facility at approximately 5:50 PM, with a DNR (Do Not Resuscitate) status, prescription for morphine, comfort measures, and a plan to admit to hospice service due to FTT and severe malnutrition.

Based on the progress notes dated August 17, 2021, at 10:29 PM the morphine sulfate orders were already reviewed and approved by the physician and faxed to the pharmacy.

Resident 1's progress notes stated he "appeared agitated" on admission to the facility. The family was present and informed the staff that resident 1 may be having pain. A progress note dated August 18, 2021, at 5:38 AM states "up all night hollering and staff trying to make resident comfortable by turning from side to side and keeping him off his buttock. Tylenol given with very little relief, morphine to arrive today for pain ...".

A review of the clinical record revealed that staff failed to notify the supervisor, physician, or pharmacy until August 18, 2021, at 10:07 AM that the dosage of morphine ordered for resident 1 was not available in the facility emergency stock.

The medication administration record for resident 1 revealed he didn't receive his first dose of morphine for pain control until August 18, 2021, at 11:30 AM, almost twenty hours after his admission to the facility. Resident 1's pain score was 10 out of 10 after the first dose of morphine was administered. Two additional doses of morphine 15 minutes apart were administered and on August 18, 2021 at 12:30 PM staff documented, "resident sleeping at this time no moaning or groaning noted, resting well. No need for more morphine every 15 minutes."

During an interview with the Nursing Home Administrator on November 29, 2021, there was agreement that staff should have notified the supervisor and physician to obtain the correct dosage of morphine when the resident was admitted to the facility.

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

 Plan of Correction - To be completed: 12/14/2021

1) Resident #1, is no longer on the facility.
2)House wide audit will be completed to identify resident has morphine ordered and is available in a timely manner to administer to the resident.
3)DON/designee will educate staff on contacting the Physician and or pharmacy to ensure we have the morphine available to administer as ordered by the Physician.
4)Random audits (10%) will be completed of residents receiving PRN morphine to ensure administered per MD. These audits will be conducted 3 times weekly for one month and 2 times weekly for two months or until substantial compliance has been achieved.
Audits will be reported to QAPI monthly for review and further recommendations as needed.
5)Date of compliance December 14, 2021.

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