Nursing Investigation Results -

Pennsylvania Department of Health
BRANDYWINE HALL
Patient Care Inspection Results

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BRANDYWINE HALL
Inspection Results For:

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BRANDYWINE HALL - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on January 29, 2020, in response to three complaints at Brandywine Hall, it was determined that Brandywine Hall 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 for the health portion of the survey process.



 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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.
483.25 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 clinical record review, facility policy review, and interview, it was determined that the facility failed to ensure that medication ordered by the physician was administered timely for three of four residents reviewed (Resident R1, Resident CL1, and Resident CL2).

Findings include:

Review of facility policy titled, "Medication Administration: General" subsection "Practice Standards" revealed number five which indicated, "doses will be administered within one hour of the prescribed time unless otherwise indicated by prescriber."

Review of Resident R1's clinical record revealed diagnoses including but not limited to following: peripheral vascular disease (poor circulation of the extremities); toxic encephalopathy (neurologic disorder caused by exposure to neurotoxic organic with symptoms, including altered mental status, memory loss, and visual problems); hemiplegia and hemiparesis (weakness or partial loss of movement); and acute kidney failure (kidneys suddenly become unable to filter waste products from your blood).

Review of Resident R1's physician orders revealed an order for Gabapentin 300 mg (milligram) with administration instructions of one capsule by mouth three times a day for nerve pain. Further review of physician orders revealed an order for Tylenol (Acetaminophen) 325 mg with administration instructions of "Give 2 tablet by mouth three times a day for pain".

Review of Resident R1's January 2020 Medication Administration Audit Report revealed that on January 1, 2020, Gabapentin and Tylenol were scheduled to be given at 9:00 a.m. but Gabapentin was administered at 13:12 (1:12 p.m.) and Tylenol was administered at 13:14 (1:14 p.m.) Continued review revealed Gabapentin and Tylenol were scheduled to be administered at 13:00 (1:00 p.m.) but Gabapentin was administered at 15:16 (3:16 p.m).

Review of the January 2020 Medication Audit Report further revealed that from January 2, 2020 through January 28, 2020, the medications were administered late an additional 17 times for Gabapentin and an additional 11 times for Tylenol (Acetaminophen) for Resident R1.

Review of Resident CL1's clinical record revealed diagnoses including but not limited to following: cancer metastasized to bone (cancer spread into bone); anxiety (intense, excessive and persistent worry and fear about everyday situation); and pulmonary embolism (blood vessel in the lung(s) gets blocked by a blood clot, characterized by pain and/or shortness of breath).

Review of Resident CL1's physician orders revealed an order for Zofran 8 mg; Give 1 tablet by mouth three times a day for Nausea and Reglan 5 mg; Give 1 tablet by mouth every 8 hours for nausea/vomiting 0800 and 1600 doses given with Zofran before meals.

Review of Resident CL1's January 2020 Medication Audit Report revealed that Zofran 8 mg was to be administered on January 1 at 21:30/9:30 p.m., but was not administered until 12:52 a.m. on January 2, 2020.

Review of Resident CL1's January 2020 Medication Audit Report revealed that on January 6, 2020 Reglan 5mg was administered at 10:16 a.m. when medication instruction indicated 8:00 a.m. Further review revealed that Reglan was to be administered at 12:00 a.m. on January 4, 2020, but was not administered until 1:23 a.m., and on January 7, 2020, was not administered until 2:22 a.m.

Review of Resident CL1's physician orders revealed an order for Methadone HCI (opioid which can be used for pain management) 10 mg; Give 6 tablet by mouth every 6 hours for chronic pain secondary to CA (cancer) with mets (metastasis) to equal 60 mg.

Review of Resident CL1's January 2020 Medication Audit Report revealed that on January 1, 2020, Methadone HCI was administered at 6:10 a.m. and then at 13:00/1:00 p.m; which is more than 6 hours as indicated on physician order. Further review revealed that on January 2, 2020, Methadone HCI was administered at 5:53 a.m. and then administered at 13:28/1:28 p.m; which is more than 6 hours. Continued review of audit report revealed that on January 4, 2020, Methadone was administered at 1:23 a.m. then administered at 6:32 a.m.; which is less than 6 hours as indicated by physician's order. Further review of audit report revealed that Methadone was administered on January 5, 2020 at 23:45/11:45 p.m. and administered again at 6:56 a.m. on January 6, 2020; which is over 7 hours after previous dose.

Review of Resident CL1's physician orders revealed an order for Eliquis 5mg; Give 1 tablet by mouth every 12 hours for pulmonary embolism.

Review of Resident CL1's January 2020 Medication Audit Report revealed that on January 1, 2020, Eliquis was administered at 9:38 a.m. and then administered again at 12:52 a.m. on January 2, 2020, which is over 15 hours from previous dose. Further review revealed the next dose on January 2, 2020, was given at 8:16 a.m.; which is less than 12 hours after previous dose administered. The next dose was administered at 22:13/10:13 p.m.; which is almost 14 hours after previous dose of Eliquis.

Further review of Resident CL1's January 2020 Medication Audit Report revealed that on January 3, 2020, Eliquis was administered at 10:12 a.m and then administered again at 1:26 a.m on January 4, 2020. Eliquis was administered again on January 4, 2020, at 8:07 a.m.; which is approximately 7 hours from previous administration. Continued review of the audit report revealed that subsequent Eliquis administration was recorded as 22:37/10:37 p.m.; which is 14 hours from previous administration.

Additional review of Resident CL1's Medication Audit Report revealed that on January 5, 2020, Eliquis was administered at 8:03 a.m. and the next administration was recorded at 22:25/10:25 p.m.; which is 14 hours after previous administration.

Review of Resident CL2's clinical record revealed diagnoses including but not limited to the following: atrial fibrillation (irregular and rapid heart beat); hypertension (HTN) (elevated/high blood pressure); heart failure; and coronary artery disease (narrowing of the blood vessels which supply the heart with blood and oxygen).

Review of Resident CL2's clinical record revealed a physician's order for Hydralazine HCI (vasodilator - used to prevent strokes, heart attacks, and kidney problems) 10 mg with administration instructions of "Give 1 tablet by mouth every 8 hours for HTN".

Review of Resident CL2's Medication Audit Report for January 2020, revealed that on January 1, 2020, Hydralazine HCI was given at 6:57 a.m. then administered again at 17:54/5:54 p.m.; which is greater than 8 hours from previous medication administration. The medication was then administered at 21:26/9:26 p.m.; which is less than 8 hours from previous administration.

Review of Resident CL2's Medication Audit Report for January 2020, revealed that on January 2, 2020, Hydralazine HCI was given at 6:23 a.m. and then administered at 17:41/5:41 p.m., which is greater than 8 hours from previous medication administration. The medication was then administered at 21:16/9:16 p.m.; which is less than 8 hours from previous administration.

Review of Resident CL2's Medication Audit Report for January 2020, revealed that on January 3, 2020, Hydralazine HCI was given at 6:05 a.m. and then administered at 15:20/3:20 p.m.; which is greater than 8 hours from previous medication administration. The medication was then administered at 21:44/9:44 p.m.; which is less than 8 hours from previous administration.

Review of Resident CL2's Medication Audit Report for January 2020, revealed that on January 4, 2020 , Hydralazine HCI was given at 5:50 a.m. and then administered at 15:54/3:54 p.m.; which is greater than 8 hours from previous medication administration. The medication was then administered at 22:24/10:24 p.m.; which is less than 8 hours from previous administration.

Review of Resident CL2's Medication Audit Report for January 2020, revealed that on January 5, 2020, Hydralazine HCI was administered at 15:06/3:06 p.m. then administered on January 6 at 12:07 a.m.; which is greater than 8 hours from previous administration. Continued review of the medication audit report revealed that the next administration of Hydralazine HCI was at 6:19 a.m.; which is less than 8 hours as directed by physcian orders.

Interview occurred on January 28, 2020, at approximately 3:29 p.m. with the Nursing Home Administrator and Director of Nursing when the above information was presented.

28 Pa Code 211.12(c) Nursing Services

28 Pa Code 211.12(d)(1)(5) Nursing Services







 Plan of Correction - To be completed: 03/16/2020

Resident R1 is receiving medications as per physician order timely.
Resident CL1 and CL2 are discharged.

All current residents are receiving medications as per physician order timely.

NPE/designee wiil re-educate licensed nursing staff on following physician orders for timely medication administration, and professional nurses are completing medication administration competencies.

UM/designee will complete 3 random weekly audits per unit to ensure medication administration is completed timely.

UM/designee will report findings to the Director of Nursing and will be reviewed at QAPI monthly for 3 months.


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