Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Inspection Results For:

There are  92 surveys for this facility. Please select a date to view the survey results.

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on June 28, 2022, it was determined Hampton House Rehabilitation and Nursing 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:

483.45(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 on review of resident clinical records, select facility policy and information submitted by the facility and staff interviews it was revealed the facility failed to assure that one out of six residents sampled were free of significant medication errors. (Resident 3).

Findings include:

A review of the facility policy entitled Admission Medication Reconciliation Process dated April 1, 2022 indicated when a resident is admitted or readmitted from the hospital the hospital medication orders will be reconciled with the attending physician at the time of admission to the facility. The procedure indicates that for a new admission reconciliation the nurse will review medications listed on the hospital transfer form with the attending physician, covering physician or physician extender. Any changes are to be noted on the hospital transfer form if applicable and the facility is to retain a copy of the hospital transfer form with medications listed in the active medical record. The nurse is to review the diagnosis for each medication with the attending physician and is to indicate and note if a resident has a listed diagnosis without a medication ordered and it's to be discussed with the physician/physician extender. The nurse is also to notify if the resident is receiving a medication which requires laboratory monitoring or medications requiring a stop date or dose adjustment will be discussed with the physician/physician extender.

Clinical record review revealed that Resident 3 was admitted to the facility on May 20, 2022, with diagnoses to include but not limited to, epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), Bipolar disorder (a serious mental illness characterized by extreme mood swings, a mood disorder that causes radical emotional changes and mood swings, from manic, restless highs to depressive, listless lows. Most bipolar individuals experience alternating episodes of mania and depression) bladder cancer and dysphagia (difficulty swallowing).

Nursing documentation dated May 20, 2022 at 5:51 PM indicated the resident was admitted to the facility oriented to his room. The certified registered nurse practitioner (CRNP) was called and all orders that were sent from the hospital were verified and noted by the CRNP.

Information submitted by the facility dated May 21,2022 at 4:00 PM indicated that Resident 3 was vomiting and nursing noted upon review of medical records from the hospital that another resident's medication list from the hospital were in Resident 3's admission packet, which the resident's family handed to nurse upon Resident 3's admission to facility. This medication list was erroneously used to review Resident 3's medications with the CRNP. The CRNP was called made aware that other resident's name was on medication list. The CRNP gave new orders to send Resident 3 to the hospital for evaluation and treatment as Resident 3 had received medications, which were intended for another resident.

A review of medication administration record (MAR) revealed that Resident 3 erroneously received the received the following medications:

Lipitor 80 mg, May 20, 2022 at 5 PM
Keflex 500 mg May 20, 2022 at 6 PM and on May 21, 2022 at 6 AM and 12 PM
Aspart 100 u/ml May 20, 2022 5 units administered at 4 PM
Lisinopril 10 mg May 21, 2022 at 9 AM
Toprol 25 mg May 21, 2022 at 9 AM
Nicotine 21 mg patch resident refused patch on May 21, 2022
Tresiba Flex Touch Pen 20 units (for diabetes) May 21, 2022 9 AM

Nursing documentation dated May 21, 2022 at 3:40 PM indicated that Employee 2 reviewed the medication list received by the hospital and it was determined possible medication errors had occurred. The CRNP was made aware and recommended Resident 3's transfer to the hospital for evaluation and treatment. Resident 3 was sent to the hospital for evaluation and treatment at 4:00 PM on May 21, 2022.

Nursing documentation dated May 21, 2022 at 5:50 PM by Employee 3 indicated that Resident 3 was send to the hospital via stretcher per CRNP's request at 4:45 pm due to continuous vomiting that carried over from previous shift. Vitals were unable to be obtained due to non compliance and continuous moving while vomiting. Medication list was not sent (CRNP request) and medication was on hold per CRNP request from previous shift.

A review of Resident 3's hospital records dated May 21, 2022 indicated he was evaluated for receiving insulin and other medications and was not a diabetic. The hospital completed blood work and an EKG and the clinical impression was an accidental medication error. Resident 3 was discharged in stable condition.

Interview with the director of nursing (DON) on June 28, 2022, confirmed that the facility failed to follow their medication reconciliation policy by failing to ensure that the correct medications were ordered for Resident 3. Employee 1, RN, contacted the CRNP and provided another's resident's medication information to the CRNP and in response the CRNP ordered incorrect medications for Resident 3, resulting in a significant medication error. Resident 3 experienced vomiting and was evaluated at the ER for the medication error.

28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services

 Plan of Correction - To be completed: 07/15/2022

Resident 3 was sent to the hospital for evaluation/treatment at the time of the occurrence. He returned to the facility with clarified admission orders. Employee 1 was educated by Nursing Admin on medication reconciliation admission process. Acute care hospital was notified of their erroneous record disposition. Resident 3's family/MD were notified of incident. Resident 3 no longer resides at the facility.

Current facility residents that were admitted within the last 14 days will have a chart review completed by the Unit Mangers to determine that the hospital records received upon SNF admission were accurate.

Licensed staff were given a New Admission Order Verification education and competency by Staff Development Educator/designee. Nurses who do not meet competency requirements will be removed from admission process until reeducation with a satisfactory competency is complete. RPH will complete a new admission medication reconciliation for all new admissions. RPH to notify facility if clarification orders are needed if a discrepancy is noted.

DON/designee will conduct random audits of new admission orders against the discharged medication list from the acute care hospital as they occur with results to QAPI monthly for 3 months.

Facility will complete the corrective action by July 15, 2022

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