Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

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ROSE CITY NURSING AND REHAB AT LANCASTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey completed on February 25, 2020, in response to two complaints at Rose City Nursing and Rehab at Lancaster, it was determined that Rose City Nursing and Rehab at Lancaster 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:

483.45(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.

Based upon review of facility policy and procedure, clinical record review, staff interview, and review of documentation provided by the facility to the State Agency, it was determined that the facility failed to ensure residents were free from significant medication errors for one of three residents reviewed (Resident R1).

Findings include:

Review of facility policy and procedure titled "Administering Oral Medications" , revised July 2019, revealed "check the label on the medication and confirm the medication name and dose with the MAR (Medication Administration Record); check the medication dose; confirm the identity of the resident and explain the procedure to the resident."

Review of Resident R1's diagnosis list revealed diagnoses including hypertension (high blood pressure), Parkinson's disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), seizure disorder (neurological disorder that causes brief episodes of spasms, unresponsiveness), anxiety disorder (feelings of persistent anxiety) and depression (major loss of interest in pleasurable activities, characterized by change in sleep patterns, appetite and/or daily routine).

Review of Resident R1's October, 2019, Medication Administration Record (MAR) revealed that on October 12, 2019, at 6:00 a.m., Resident R1 received Amlodipine (medication used to treat high blood pressure) 2.5 mg, Paxil (anti-depressant medication) 30 mg, Seroquel (anti-psychotic medication) 25 mg, Carvedilol (medication used to treat high blood pressure) 3.125 mg and Zantac (medication used to treat reflux) 150 mg.

Review of Resident R1's clinical progress notes dated October 12, 2019, revealed "RN supervisor made aware of incident in which resident had received [resident's] roommate's scheduled medications as follows: Gabapentin [anticonvulsant medication also used to treat nerve pain] 600 mg, Baclofen [muscle relaxant] 10 mg, Delzicol [non-steroidal anti-inflammatory medication] 800 mg, Fenofibrate [medication used to lower cholesterol] 145 mg, Effexor [anti-depressant medication also used to treat nerve pain] 150 mg, Geodon [anti-psychotic medication used to treat schizophrenia] 20 mg, Carbidopa-Levodopa [medication used to teat Parkinson's Disease] 50-200 mg, Propranolol ER [medication used to treat high blood pressure] 160 mg, Protonix [medication used to treat reflux disease] 40 mg and Ativan [anti-anxiety medication] 0.5 mg. Resident identified as stable at this time, listed medications administered - called [resident's physician], reviewed resident's medications, medications taken in error, resident's diagnoses and allergies. New orders: VS [vital signs] monitoring, report any changes in status to physician, obtain EKG [electrocardiogram - heart status evaluation] STAT [immediately] or no later than 1 day, hold all resident's psychotropic medications including any antidepressants, anxiolytics, antipsychotics, hypnotics, or mood stabilizers r/t [related to] risk of synergistic polypharmacy [multiple medications] complications. Monitor over the next 24 hours."

Review of Resident R1's clinical record revealed Resident R1 received the above mentioned medications at approximately 8:00 a.m. on October 12, 2019 after receiving regularly scheduled physician ordered medications at 6:00 a.m.

Review of documentation provided to the State Agency by the facility revealed that the medication error had occurred, Resident R1's EKG was normal and there was no negative outcome to the medication error.

Interview with the Nursing Home Administrator on February 25, 2020, at approximately 2:45 p.m. confirmed that the above medication error had occurred and Resident R1 received resident's roommate's medications on October 12, 2019, at approximately 8:00 a.m.

Interview with the Director of Nursing on February 26, 2020 at approximately 10:30 a.m. revealed that the agency employee was immediately removed from the facility and is not permitted to return.

 Plan of Correction - To be completed: 03/10/2020

1. Facility unable to retroactively correct medication error however R1 has not had any further significant medication errors.
2. The facility will complete 14 day lookback review of current residents to ensure they are free from significant medication errors
3. Licensed nursing staff will be educated on Policy and Procedure for Administering Oral Medications.
4.DON/Designee will conduct daily observation of 1 Licensed Nurse Medication Administration for 3 weeks to ensure Policy and Procedure for Administering Oral Medications is being followed, then observation will be conducted of Licensed Nurse Medication Administration 3 times a week for 1 month. Results of audits will be reviewed in facility QAPI meeting for further action planning

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