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).
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
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.