Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to two complaint's completed on March 31, 2022, it was determined that Monroeville Rehabilitation and Wellness 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 related to 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.
Based on facility policy, clinical record reviews and staff interview, it was determined that the facility failed to provide medications per a physician order for one of seven Residents (Resident R1)

Findings include:

A review of policy "Medication Administation", indicated medications are administered, as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so to comply with Federal Laws governing Medical Administration and in order to ensure the safe, accurate and timely administration of medications.

During a clinical record review and subsequent review of the Medication Administration Record (MAR) documentation indicated that Resident R1 did not receive a dose's of Revlimid (medication used to treat multiple Myeloma) on 2/4-2/21/22, 2/23/22, 3/3/22, 3/5-3/11/22, 3/14-3/15/22, 3/17/22, 3/19-3/21/22 and 3/23/22 and to see nurses notes.

Review of Resident R1's progress note dated 2/4-2/21/22, 2/23/22, 3/3/22, 3/5-3/11/22, 3/14-3/15/22, 3/17/22, 3/19-3/21/22 and 3/23/22 for the corresponding dates indicated the medication was not given, not available.

During an inteview on 3/31/22 at 12:30 p.m. the Nursing Home Administrator stated that the Resident was receiving a grant for the medication, it was very expensive. The grant had since run out, he was no longer taking it.

During an interview on 3/31/22 at 12:45 p.m with Registered Nurse E1, it was confirmed the Oncologist was aware Resident R1 was no longer taking medication and that medication was an active order Resident R1.

During an interview on on 3/31/22, at 1:00 p.m. the Nursing Home Administrator confirmed that the medication was not available for these resident's as indicated.

28 Pa. Code: 201.14(a)Responsibility of licensee.

28 Pa. Code: 211.9(a)(1)(f)(2)(4)(g)(h)(k)Pharmacy services.

 Plan of Correction - To be completed: 04/26/2022

The Facility will provide medications per a physician order to residents. Resident R1 missed doses of Revlimid was reviewed with the physician and the order was discontinued.
The Director of Nursing or Designee will complete an audit of residents receiving specialty medications to ensure they are available and administered as per physician order,
The Director of Nursing or Designee will re-educate licensed nurses, including new hires and agency nurses, on the facility policy and procedure for medication administration and administering medications per physician orders.
The Director of Nursing or Designee will complete an audit of residents on specialty drugs 3 times a week for four weeks then monthly for 3 months to ensure medications are administered per physician orders.
The results of these audits will be forwarded to the Quality Assurance and Performance Improvement Committee for review and frequency of audits.

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