Pennsylvania Department of Health
GETTYSBURG CENTER
Patient Care Inspection Results

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GETTYSBURG CENTER
Inspection Results For:

There are  137 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.
GETTYSBURG CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on March 21, 2024, it was determined that The Gettysburg Center 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.


 Plan of Correction:


483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to notify the resident/resident representative of a resident's transfer in writing to include the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman; and failed to notify a representative of the Office of the State Long-Term Care Ombudsman for three of three resident records reviewed for hospitalization (Residents 21, 84, and 297).

Findings include:

Review of Resident 21's clinical record on March 20, 2024, at 9:13 AM, revealed diagnoses that included type two diabetes mellitus (the body does not make enough insulin or cannot use it as well as it should) and atrial fibrillation (quivering or irregular heartbeat in the upper chamber of the heart).

Further review of Resident 21's clinical record revealed that on October 1 and 5, 2023; November 5, 2023; and January 14, 2024, Resident 21 was transferred out of the facility to the hospital and subsequently was admitted to the hospital.

During an interview on March 20, 2024, at 1:05 PM, with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the surveyor requested a copy of the Resident Representative transfer notices and Ombudsman notifications for the aforementioned hospital transfers.

During an additional interview on March 21, 2024, at 11:43 AM, with the NHA, it was revealed that the facility had not been notifying the Ombudsman due to not having an Admissions Director. The NHA also revealed that the facility had not been aware that transfer notices needed to be sent, and they had not been done.

Review of Resident 84's clinical record on March 19, 2024, at 10:20 AM, revealed diagnoses that included dementia (progressive, irreversible degenerative brain disease that results in decreased contact with reality and decreased ability to perform activities of daily living) and Parkinson's disease (disorder of the brain that causes unintentional and uncontrollable movements of the body, stiffness, and difficulty with balance and coordination).

Further review of Resident 84's clinical record revealed that on December 8, 2023, Resident 84 was transferred and admitted to the hospital. Resident 84 subsequently returned to the facility on December 11, 2023.

As of March 21, 2024, at 12:15 PM, the facility was unable to provide a hospital transfer form nor evidence that the State Ombudsmans office was notified of Resident 84's transfer to the hospital.

During an additional interview on March 21, 2024, at 11:43 AM, with the NHA, it was revealed that the facility had not been notifying the Ombudsman due to not having an Admissions Director. The NHA also revealed that the facility had not been aware transfer notices needed to be sent, and they had not been done.

Review of Resident 297's clinical record on March 20, 2024, at 9:19 AM, revealed diagnoses that included protein-calorie malnutrition (not enough protein and calories are consumed to meet the body's needs) and dementia.

Further review of Resident 297's clinical record revealed that on February 24, 2024, and on March 18, 2024, Resident 297 was transferred out of the facility to the hospital and subsequently was admitted to the hospital.

During an interview on March 20, 2024, at 1:05 PM, with the NHA and DON, the surveyor requested a copy of the Resident Representative transfer notices and Ombudsman notifications for the aforementioned hospital transfers.

During an additional interview on March 21, 2024, at 11:43 AM, with the NHA, it was revealed that the facility had not been notifying the Ombudsman due to not having an Admissions Director. The NHA also revealed that the facility had not been aware transfer notices needed to be sent, and they had not been done.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(3) Management.



 Plan of Correction - To be completed: 05/10/2024

1. Residents 21, 84, and 297 have had transfer forms filled out for the dates noted and the State Ombudsman has been notified of resident transfers.

2. A Comprehensive review of residents discharged in the last 2 weeks to be reviewed to ensure that transfer form and State Ombudsman notifications have been completed.

3. The facility will take the further steps to ensure the problem does not recur by In-servicing the IDT Team on F Tag 623.

4. Compliance will be monitored by the NHA/Designee through 4 audits weekly x 2 weeks to ensure residents who have been discharged have the transfer form and State Ombudsman notifications completed, with audit results being reported to the QAA committee to determine the need for further follow up/monitoring.



483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

483.10(i)(3) Clean bed and bath linens that are in good condition;

483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv);

483.10(i)(5) Adequate and comfortable lighting levels in all areas;

483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and

483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to ensure protection of residents' personal property while in the facility and upon discharge or after death for two of two discharged residents reviewed (Residents 95 and 96).

Findings include:

Review of facility policy, Center Operations Policies and Procedure, Personal Property: Patient's, revision date August 15, 2023, read, in part, personnel will identify and record the resident's belongings upon admission to a center. All items brought into the Center will be listed on the Inventory Of Personal Effects form and kept in the resident's clinical chart. Any additional items brought into the Center after admission must be added to this list. The resident representative will sign the Inventory Of Personal Effects for again at discharge to acknowledge receipt of personal property. In the event of the resident's discharge or death, return of any personal property remaining in the Center must be made within 30 days after the discharge or death.

Review of Resident 95's clinical record revealed diagnoses that included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and chronic kidney disease (CKD - kidneys don't function as they should).

Review of Resident 95's clinical record revealed the resident was admitted to the facility January 11, 2023, and was in the process of being transferred to the hospital on January 2, 2024, due to a change in condition and, subsequently passed away.

Further clinical record review revealed Resident 95's clinical record failed to contain an inventory of personal effects, or communication with the resident's representative regarding return of personal property remaining at the facility within 30 days after their death.

Review of Resident 96's clinical record revealed diagnoses that included dementia and history of falls.

Review of Resident 96's clinical record revealed she was admitted to the facility on December 22, 2023, and left against medical advice on December 25, 2023.

Additional review of Resident 96's clinical record revealed that it failed to contain an inventory of personal effects, or communication with the resident representative regarding return of personal property remaining at the facility within 30 days after discharge.

During an interview with the Nursing Home Administrator (NHA) on March 21, 2024, at 9:17 AM, it was revealed that the facility could not locate Resident 95's and 96's Inventory Of Personal Effects form. It was further explained that the nursing department initiates the Inventory Of Personal Effects form. It is located in the "hard" medical record, and could be updated by any staff member.

During an interview with the NHA on March 21, 2024, at 10:37 AM, it was revealed that Residents 95 and 96 should have had an inventory of personal effects initiated during admission and signed upon discharge.

28 Pa. code 201.18(b)(2) Management.




 Plan of Correction - To be completed: 05/10/2024

1. Resident 95 and Resident 96 have discharged from facility

2. A Comprehensive review of current residents in the facility to be completed by the Director of Nursing/Designee to ensure Inventory of Personal Effects Forms have been initiated.

3. The facility will take the further steps to ensure the problem does not recur by In-servicing Nursing staff on F Tag 584 and Center Practices Policies and Procedures, Personal Property, Patients.

4. Compliance will be monitored by the Director of Nursing/Designee through 4 audits weekly x 2 weeks to ensure Inventory of Personal Effects Forms are completed, with audit results being reported to the QAA committee to determine the need for further follow up/monitoring.


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for one of 23 residents reviewed (Resident 88).

Findings include:

Review of Resident 88's clinical record revealed diagnoses that included muscle weakness (weakness of muscle movements) and hemiplegia (a total or nearly complete paralysis on one side of the body).

Observation of Resident 88 on March 18, 2024, at 12:14 PM, revealed Resident 88 in her bed in her room, with a bed-side commode sitting in the corner of the room.

An interview with Resident 88 at that time revealed that the bed-side commode belonged to her.

Review of Resident 88's care plan on March 18, 2024, revealed an active care plan for, Resident requires assistance for ADL (activities of daily living) care related to: recent hospitalization, cardiovascular accident, with a date initiated of February 8, 2024. Review of the care plan failed to reveal any directions for Resident 88's use of a bed-side commode.

An interview with the Director of Nursing on March 20, 2024, at 12:20 PM, revealed that Resident 88's care plan should have been updated to include her use of the bed-side commode, and that it would be updated.

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



 Plan of Correction - To be completed: 05/10/2024

1. Resident 88's care plan has been updated to reflect the use of Bedside Commode.

2. A Comprehensive review of Care plans for current residents with bedside commodes will be completed by the Director of Nursing/Designee to ensure accuracy of the resident's comprehensive care plan.

3. The facility will take the further steps to ensure the problem does not recur by in-servicing the Nursing Management Team on F Tag 657, Care Plan Timing & Revision with focus on Bedside commodes.

4. Compliance will be monitored by the Director of Nursing/Designee using the care plan audit through a review of four care plans weekly x 2 weeks to ensure accuracy of the resident's comprehensive plan of care, with audit results being reported to the QAA committee to determine the need for additional follow up / monitoring.


483.25(l) REQUIREMENT Dialysis: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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to provide and document post-dialysis assessments for one of one resident reviewed for dialysis (Resident 150).

Findings include:

Review of facility policy, titled "NSG253 Dialysis: Hemodialysis (HD) - Communication and Documentation)", last revised June 15, 2022, revealed the policy stated, "[The facility] staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility."

Review of the "Practice Standards" section of the policy revealed it included, "1. Prior to a patient leaving the [Facility] for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record or the state required form and send with the patient to his/her HD facility visit ... 3. Upon return of the patient to the [Facility], a licensed nurse will: 3.1 Review the certified dialysis facility communications; 3.2 Evaluate/observe the patient; and 3.3 Complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form."

Review of the facility's "Hemodialysis Communication Record" form, revealed the section for post-hemodialysis stated facility staff were to document the condition of the access site; a resident's blood pressure, temperature and pulse; presence of bruit or thrill (sound that blood makes when flowing through a shunt); post-hemodialysis complications such as dizziness, nausea, vomiting, fatigue or hypotension (low blood pressure); and any new orders from the dialysis center. Finally, the form had an area for the licensed nurse to sign and date the post-dialysis assessment.

Review of Resident 150's clinical record on March 18, 2024, at approximately 11:30 AM, revealed diagnoses that included heart failure (decreased ability of the heart to effectively pump blood to the body) with stage 5 chronic kidney disease (severe decrease ability of the kidneys to filter toxins from the blood), which required hemodialysis (a process which removes toxins from the blood using a machine).

Review of Resident 150's physician orders revealed Resident 150 was sent to a dialysis center every Monday, Wednesday, and Friday for dialysis treatments.

Review of Resident 150's Hemodialysis Communication Record sheets dated March 8 and 18, 2024, revealed that facility staff did not complete the post-hemodialysis treatment section upon Resident 150's return to the facility. Review of both forms revealed that they had been reviewed and signed by a facility medical practioner.

During a staff interview on March 21, 2024, at approximately 10:45 AM, Nursing Home Administrator revealed it was the facility's expectation that staff complete the post-dialysis assessment when a resident returns to the facility from a dialysis treatment.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.




 Plan of Correction - To be completed: 05/10/2024

1. Resident 150's Hemodialysis Communication Form will be completed.

2. A comprehensive review of residents currently on Hemodialysis will be completed by the Director of Nursing/ Designee to ensure completion of the Hemodialysis Communication Form.

3. The facility will take the further steps to ensure the problem does not recur by in-servicing Licensed Nurses on F Tag 698, as well as Hemodialysis Communication and Documentation Policy.

4. Compliance will be monitored by the Director of Nursing/Designee through 4 audits weekly x 2 weeks to ensure the completion of the Hemodialysis Communication Form, with audit results being reported to the QAA committee to determine the need for further follow up/monitoring.



483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:

Based on observation, staff interviews, and facility policy review, it was determined that the facility failed to ensure medications were stored in a manner that met professional standards for one of three medication carts observed (North 1 Medication cart).

Findings include:

Review of facility policy, titled "5.3 Storage and Expiration Dating of Medications, Biologicals", last revised August 7, 2023, revealed subsection 9 of "Procedures", stated, "Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. Facility should ensure that no transfers between containers are performed by non-Pharmacy personnel."

Observation of the North 1 Medication cart on March 19, 2024, at approximately 9:30 AM, revealed that there was a medicine cup filled with small, round, red tablets stowed in the top drawer of the medicine cart. Observation of the medicine cup revealed "Senna S" (over-the-counter medication used to treat constipation) was written on the medicine cup with marker. The medicine cup was stored with multiple manufacturer-provided over-the-counter medicine containers.

During a staff interview at the time of the observations, Employee 1 (Licensed Practical Nurse) stated it was her opinion that staff had placed the medicine in the medicine cup with the other small over-the-counter medicine containers because the pharmacy sent a large bottle of the Senna-S medication. At the time of the interview, Employee 1 displayed the large bottle of Senna-S in a lower drawer.

During a staff interview on March 21, 2024, at approximately 10:45 AM, the Nursing Home Administrator confirmed that medications should be stored in the original containers received from pharmacy.

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





 Plan of Correction - To be completed: 05/10/2024

1. No residents were harmed from medications not stored in original containers.

2. A Comprehensive review of medication carts to be conducted to ensure all OTC medications are properly stored in their original containers.

3. The facility will take the further steps to ensure the problem does not recur by In-servicing Licensed Nurses on F Tag 761 in regards to Subsection 9: Facility should ensure the medications and biologicals are stored in the original containers in which they were originally received.

4. Compliance will be monitored by the Director of Nursing/Designee through 4 audits weekly x 2 weeks to ensure that OTC medications are stored in the original containers, with audit results being reported to the QAA committee to determine the need for further follow up/monitoring.


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards;

483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on clinical record review, observation, facility policy review, and staff interviews, it was determined that the facility failed to provide medications in a manner consistent with infection control practices for one of four residents observed for medication administration (Resident 3).

Findings include:

Review of facility policy, titled "6.0 General Dose Preparation and Medication Administration", last revised January 1, 2022, revealed the "Applicability", section stated, "This Policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with Applicable Law and the State Operations Manual when administering medications."

Review of Resident 3's clinical record on March 19, 2024, at approximately 10:00 AM, revealed diagnoses that included breast cancer and congestive heart failure (CHF - condition that results in decreased ability of the heart to pump blood efficiently throughout the body).

During medication administration observations conducted on March 19, 2024, at approximately 9:05 AM, Employee 1 (Licensed Practical Nurse) was observed preparing medications for administration to Resident 3.

During the preparation of the medication, Employee 1 was observed dispensing nine separate medications from multi-dose containers into her bare hand, then dropping the medication into a medicine cup. Employee 1 was also observed dispensing one medication from a "blister-pack" (card of medications that have individual pills/doses in small separate pockets) into her bare hand, then dropping the medication into the medicine cup.

At approximately 9:20 AM, Employee 1 administered the medications to Resident 3.

During a staff interview on March 20, 2024, at approximately 1:25 PM, the Director of Nursing revealed it was her expectation that staff only handle medications with gloved hands.

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



 Plan of Correction - To be completed: 05/10/2024

1. No residents were harmed as a result of Nurse 1 dispensing medications into bare hands.

2. Education immediately provided to Nurse 1 to ensure the problem does not recur.

3. The facility will take further steps to ensure the problem does not recur by In-servicing Licensed Nurses on F Tag 880 as well as General Dose Preparation and Medication Administration.

4. Compliance will be monitored by the Director of Nursing/Designee through 4 medication pass audits weekly x 2 weeks to ensure Medication Administration policies in regards to Infection Control are being followed with audits being reported to the QAA committee to determine the need for further follow up / monitoring.



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