Nursing Investigation Results -

Pennsylvania Department of Health
PLATINUM RIDGE CENTER FOR REHABILITATION AND HEALING
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations

Click here for definitions Click here for definitions Click here for definitions Click here for definitions
Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
PLATINUM RIDGE CENTER FOR REHABILITATION AND HEALING
Inspection Results For:

There are  102 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
PLATINUM RIDGE CENTER FOR REHABILITATION AND HEALING - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to three complaints, completed on January 16, 2020, it was determined that Platinum Ridge Center for Rehabilitation and Healing, was not in compliance with the 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 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 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.
Observations:
Based on review of facility policy and clinical records and staff interviews it was determined that the facility failed to make certain controlled substances were accounted for accurately for nine of 12 residents (Resident CR1, R2, R3, R4, R5, R6, R7, R8, and R9).

Findings include:

The facility policy "Documentation of Medication Administration" last reviewed 9/5/19, indicated a nurse shall document all medications administered to each resident on the resident's medication administration record (MAR).

Review of the clinical record indicated Resident CR1 was admitted to the facility 12/30/19, with a diagnosis of gangrene (death of body tissues due to blood loss).

Review of the January 2020, MAR indicated Resident CR1 received Tramadol 50mg (an opioid pain medication used to treat moderate to severe pain) 1/1/20, two doses 1/3/20, 1/4/20, three doses 1/5/20, 1/7/20, and two doses 1/8/20.

Review of Resident CR1's Controlled Drug Administration Record for prescription numbers 1096750 indicated that a dose of Tramadol was signed out without corresponding documentation of administration to the resident on 1/4/20.

Review of the clinical record indicated Resident R2 was admitted to the facility 11/21/19, with a diagnosis of stage four pressure ulcer (full thickness skin loss with extensive destruction and tissue damage).

Review of the January 2020, MAR, indicated Resident R2 received Oxycodone/Acetaminophen 5/325mg (a narcotic combination medicine used to relieve moderate to severe pain) on: 1/2/20, two doses 1/4/20, 1/5/20, 1/6/20, two doses 1/8/20, two doses 1/9/20, 1/10/20, 1/12/20, 1/14/20, and two doses 1/15/20.

Review of Resident R2's Controlled Drug Administration Record for prescription number 1086675 indicated that additional doses of Oxycodone/Acetaminophen were signed out, without corresponding documentation of administration to the resident: two doses 1/3/20, 1/7/20, 1/9/20, 1/13/20, and 1/15/20 . Additionally, one pill was noted as missing on 1/10/20.

Review of the clinical record indicated Resident R3 was admitted to the facility 9/27/19, with a diagnosis of gastrointestinal hemorrhage (significant blood loss in the digestive tract).

Review of the January 2020, MAR, indicated Resident R3 received Oxycodone/Acetaminophen 5/325 mg on: two doses 1/12/20, 1/13/20, 1/14/20, two doses 1/15/20.

Review of Resident R3's Controlled Drug Administration Record for prescription number 1104189 indicated that additional doses of Oxycodone/Acetaminophen were signed out without corresponding documentation of administration to the resident: two doses 1/13/20, and 1/14/20.

Review of the clinical record indicated Resident R4 was admitted to the facility 12/11/19, with a diagnosis of osteoarthritis (degeneration of joint cartilage and the underlying bone).

Review of the December 2019, and January 2020, MAR, indicated Resident R4 received Oxycodone Immediate Release 5mg (a narcotic medicine used to relieve moderate to severe pain) on: 12/18/19, 12/21/19, 12/26/19, 12/31/19, and 1/3/20.

Review of Resident R4's Controlled Drug Administration Record for prescription number 1068135 indicated that additional doses of Oxycodone were signed out without corresponding documentation of administration to the resident: two doses 12/19/19, 12/20/19, 12/23/19, 12/24/19, 12/27/19, 12/28/19, 12/29/19, 12/30/19, 1/3/20, 1/6/20, 1/7/20, 1/8/20, two doses 1/9/20, 1/13/20, and 1/15/20.

Review of the clinical record indicated Resident R5 was admitted to the facility 11/27/19, with a diagnosis of displaced intertrochanteric fracture of right femur (hip fracture above the thigh bone).

Review of the December 2019, and January 2020, MAR, indicated Resident R5 received Hydrocodone/Acetaminophen 5/325mg (a narcotic combination medicine used to relieve moderate to severe pain) on: 12/26/19, 12/31/19, 1/1/20, 1/4/20, 1/5/20, 1/9/20, two doses 1/10/20, and 1/15/20.

Review of Resident R5's Controlled Drug Administration Record for prescription number 1050046 indicated that additional doses of Hydrocodone/Acetaminophen were signed out without corresponding documentation of administration to the resident: 12/26/19, and 1/9/20.

Review of the clinical record indicated Resident R6 was readmitted to the facility 12/24/19, with a diagnosis of dislocation of the left sternoclavicular joint (after effects of shoulder dislocation).

Review of the December 2019, and January 2020, MAR, indicated Resident R6 received Hydrocodone/Acetaminophen 5/325mg on: 12/27/19, 12/28/19, 12/29/19, and 12/30/19.

Review of Resident R6's Controlled Drug Administration Record for prescription number 1085547 indicated that additional doses of Hydrocodone/Acetaminophen were signed out without corresponding documentation of administration to the resident: 12/28/19, 12/31/19, and 1/2/20.

Review of Resident R6's Physician's Order dated 12/25/19, indicated that the order is discontinued on 12/31/19.

Review of the clinical record indicated Resident R7 was admitted to the facility 1/9/20, with a diagnosis of heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of the January 2020, MAR indicated Resident R7 received Tramadol 50mg on: 1/14/20, 1/15/20, and 1/16/20.

Review of Resident R7's Controlled Drug Administration Record for prescription numbers 1112846 indicated that two additional doses of Tramadol were signed out without corresponding documentation of administration to the resident on 1/15/20.

Review of the clinical record indicated Resident R8 was readmitted to the facility 11/24/19, with a diagnosis of malignant neoplasm of the bladder (bladder cancer).

Review of the November and December 2019, and January 2020, MAR indicated Resident R8 received Lorazepam 1mg (a medication is used to treat anxiety) on: 12/1/19, 12/8/19, and 1/7/20.

Review of Resident R8's Controlled Drug Administration Record for prescription numbers 4126294 indicated that a dose of Lorazepam was signed out without corresponding documentation of administration to the resident on 12/15/19.

Review of the clinical record indicated Resident R9 was readmitted to the facility 11/18/19, with a diagnosis of hepatic failure (a condition in which the liver is unable to perform its normal functions).

Review of the January 2020, MAR, indicated Resident R9 received Oxycodone Immediate Release 5mg on: 1/1/20, 1/2/20, 1/3/20, two doses 1/4/20, two doses 1/5/20, 1/7/20, 1/8/20, two doses 1/9/20, two doses 1/10/20, 1/11/20, 1/12/20, two doses 1/14/20, and 1/15/20.

Review of Resident R9's Controlled Drug Administration Record for prescription number 1086556 indicated that additional doses of Oxycodone were signed out without corresponding documentation of administration to the resident: 1/13/20, 1/14/20, and 1/15/20.

During an interview on 1/16/20, at 3:40 p.m. the Nursing Home Administrator confirmed that the facility failed to make certain controlled substances were accounted for accurately for nine residents (Resident CR1, R2, R3, R4, R5, R6, R7, R8, and R9).

28 Pa. Code: 211.9(a)(1)(j) Pharmacy services.
Previously cited 5/31/18, 7/19/19.

28 Pa. Code: 211.12(d)(1)(5) Nursing services.
Previously cited 2/23/18, 5/31/18, 7/19/19.



 Plan of Correction - To be completed: 02/21/2020

F0755 The facility will ensure controlled substances are appropriately dispensed, recorded and accurately reconciled for all residents. All residents who receive controlled substances have the potential to be affected by the deficient practice. Resident R2, R3, R4, R5, R6, R7, R8, R9 assessed for pain and their pain regimen reviewed by the Director of Nursing or designee for possible follow up. All current resident Controlled Substances logs and Medication Administration Record will be audited by the Director of Nursing or designee for accurately documented and reconciled controlled medication administration records. Resident's discharged in past 7 days will have record reviewed by the Director of Nursing or designee to ensure proper disposition or disposal of medications according to facility policy. The relevant policy and procedures were reviewed by Administration and warranted no changes. Root cause analysis performed and determined additional staff education is required. All facility licensed nurses will be educated by the Director of Nursing and Assistant Director of Nursing on the facility policy and procedure related to medication administration, proper accounting and disposition for controlled substances, and proper reporting of missing medications. The Director of Nursing or designee shall randomly audit at least five resident controlled substance logs and medication administration records weekly for four weeks and at least five resident controlled substance logs and medication administration records monthly for three months. Results of the audits will be reported to the facility Quality Assurance Performance Improvement committee until substantial compliance is achieved and the QAPI committee provides their recommendations for possible follow up. The Director of Nursing shall ensure compliance.

Back to County Map


  
Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance



Copyright 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement

Visit the PA Power Port