Nursing Investigation Results -

Pennsylvania Department of Health
INN AT FREEDOM VILLAGE, THE
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
INN AT FREEDOM VILLAGE, THE
Inspection Results For:

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INN AT FREEDOM VILLAGE, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare Recertification, State Licensure, and Civil Rights Compliance Survey completed on February 6, 2020, it was determined that Inn at Freedom Village 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 of the Health survey process.





 Plan of Correction:


483.20(g) REQUIREMENT Accuracy of Assessments: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.
483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.
Observations:


Based on observation, review of the facility's policy and procedure, clinical records review, and staff interview, it was determined that the facility failed to ensure that the physician's order was accurately reflected on the resident electronic medication administration record for one of 12 residents reviewed (Resident #191).

Findings include:

A review of the facility policy and procedure titled "General Dose Preparation and Medication Administration" with a revision date of January 1, 2013, indicated, "to confirm the medication administration record (MAR) reflects the most recent medication order".

An observation on February 4, 2020, at 12:05 p.m., revealed a medication bag hanging on an IV (IV- a therapy that delivers fluids directly into a vein) pole in Resident #191's room. The medication bag was labeled "Vancomycin (antibiotic) 1.25 grams (12.5 milliliters) in Sodium Chloride 9%, 250 milliliters, infuse Vancomycin 1.25 grams (250 milliliter) intravenously over 90 minutes **infuse entire contents of bag**.

Review of the physician's IV order sheet dated February 3, 2020, revealed an order of Vancomycin 1.25 grams 1.25 gram/200 milliliters, administer 250 milliliters total (1.25 grams) for 5 days.

An interview with licensed nurse Employee E3, on February 4, 2020, at 12:11 p.m., revealed that the Vancomycin medication bag observed by the surveyor was administered to Resident #191 on the morning of February 4, 2020.

A review of Resident #191's Electronic Medical Record (EMR) MAR revealed an order on February 4, 2020, for Vancomycin HCL Solution use one gram intravenously one time a day related to acute cholecystitis (inflammation of the gallbladder). Further review revealed that the MAR was signed on February 4, 2020, at 8:00 a.m., indicating that the medication was administered.

Review of the facility documentation dated February 4, 2020, revealed that the IV Vancomycin order was clarified with the physician. The physician ordered Vancomycin 1.25 grams daily for Resident #191, the order was faxed to the pharmacy and the pharmacy supplied 1.25 grams of Vancomycin. The admitting nurse did not update the previous order of Vancomycin one gram on the computer.

A review of Resident #191's MAR revealed that the Vancomycin one gram ordered and transcribed in the EMR was discontinued on February 4, 2020, at 2:27 p.m., and was updated to Vancomycin 1.25 grams.

An interview with the Director of Nursing (DON) on January 6, 2020, at 12:30 p.m., confirmed that the physician's order of Vancomycin 1.25 grams was incorrectly transcribed to the EMR MAR.


Accuracy of Assessments
CFR(s): 483.20(g)

28 Pa. Code 211.5(f) Clinical records

28 Pa. code 211.12(c) Nursing services

28 Pa. Code 211.12(d)(1)(5) Nursing services
Previously cited: 3/27/19










 Plan of Correction - To be completed: 04/01/2020

Preparation and execution of this plan of correction in no way constitutes an admission or agreement by The Inn at Freedom Village of the truth of the facts alleged in this statement of deficiency and plan of correction. In fact, this plan of correction is submitted exclusively to comply with state and federal law. The Inn at Freedom Village reserves the right to challenge in legal proceedings, all deficiencies, statements, findings, facts and conclusions that form the basis of the stated deficiency. This plan of correction serves as the allegation of compliance. This statement of deficiencies will be taken to The Inn at Freedom Village Quality Assurance/Assessment Committee on the next scheduled meeting date of The Inn at Freedom Village.
The EMR MAR for resident #191 was immediately updated on 2/4/2020 by The Assistant Director of Clinical Services to reflect the order of 1.25 grams daily of Vancomycin. The DCS/designee reviewed current residents with IV orders on 2/5/2020 to ensure accuracy and add no other residents identified. No current residents have the ability to be affected. On 2/25/2020 the DCS/designee will educate licensed nursing staff on the policy and procedure for General Dose Preparation and Medication Administration policy. The Director of Clinical Services or designee will audit IV orders weekly for 3 months to assure accurate transcription. The results of these audits will be monitored and reviewed for compliance to standard at the Quality Assurance and Performance Improvement Committee meeting for three months, and afterwards as necessary.

483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on observation, review of the facility's policy and procedure, clinical records review, and staff interview, it was determined that the facility failed to follow the physician's order regarding an antibiotic order, for one of 12 residents reviewed (Resident #191).

Findings include:

A review of the facility's policy and procedure titled "Administration of an Intermittent Infusion", with the last revision date of May 1, 2016, revealed that the medication bag should be completely empty, but fluid remains in the drip chamber ensuring the complete dose is delivered.

Clinical records review of Resident # 191 revealed that the resident was admitted to the facility on February 3, 2020, with list of diagnoses not limited to, calculus (stone) of gallbladder (an expandable pear-shaped organ located beneath the liver)with chronic cholecystitis (inflammation of the gallbladder) with obstruction, and infection following a procedure, organ and space surgical site.

An observation on February 4, 2020, at 12:05 p.m., revealed a medication bag that was hanging on a pole in Resident #191's room, attached to a medication pump machine with a label that revealed "Vancomycin (antibiotic) 1.25 grams (12.5 milliliters) in Sodium Chloride 9%, 250 milliliters, infuse Vancomycin 1.25 grams (250 milliliter) intravenously ( IV- a therapy that delivers fluids directly into a vein) over 90 minutes **infuse entire contents of bag**. Additional observation revealed a 50-milliliter solution was left in the Vancomycin bag.

Review of the physician order dated February 3, 2020, revealed an order of Vancomycin 1.25 grams, administer 250 milliliters total (1.25 grams) for 5 days.

Interview with licensed nurse Employee E3, on February 4, 2020, at 12:11 p.m., revealed that the Vancomycin medication bag observed by the surveyor was administered to Resident #191 on the morning of February 4, 2020. During the interview, Employee E3 confirmed that the Vancomycin bag had 50 milliliters solution left in the bag . Employee E3 further stated that the IV infusion machine had indicated that the medication infusion was already completed but upon seeing that there were solutions left in the bag, she/ he was supposed to call the supervisor, but that did not happen.

Review of Resident #191's February 2020 medication administration record (MAR) revealed that the Vancomycin was signed that it was administered on February 4, 2020, at 8:00 a.m.

An interview with the pharmacist on February 5, 2020, at 1:35 p.m., confirmed that the entire solution in the
Vancomycin bag should have been administered to the resident.

The facility failed to follow the physician's order to administer Vancomycin 1.25 grams to Resident #191.


28 Pa. Code 201.18(b)(1) Management

28 Pa. Code 211.5(f) Clinical records

28 Pa. Code 211.12(c) Nursing services

28 Pa. 211.12(d)(1)(5) Nursing services
Previously cited 3/27/19














 Plan of Correction - To be completed: 04/01/2020

The nurse administering the IV received re-education on 2/5/2020 by the Pharmacist. The DCS/designee reviewed current residents with IV orders on 2/5/2020 to ensure accuracy and add no other residents identified. The DCS/designee re-educated the licensed nurses on administration of an Intermittent Infusion on 2/5/2020. The Director of Clinical Services or designee will audit 2 IV administrations monthly for three months to assure compliance with standard. The results of these audits will be monitored and reviewed for compliance to standard at the Quality Assurance and Performance Improvement Committee meeting for three months, and afterwards as necessary.



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