Pennsylvania Department of Health
KENDAL AT LONGWOOD
Patient Care Inspection Results

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KENDAL AT LONGWOOD
Inspection Results For:

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KENDAL AT LONGWOOD - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated survey in response to a complaint completed on February 2, 2024, it was determined that Kendal at Longwood 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.


 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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.
483.25 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 clinical record review and staff interview it was determined the facility failed to notify the physician of missed medication doses for six of six residents reviewed. (Residents R1, R2, R3, R4, R5, and R6)

Findings Include:

Review of Resident R1's Medication Administration record (MAR) for September and October 2023 revealed Latanoprost .005% eye drops (medication for the treatment of high pressure in the eye) were not administered as ordered on September 27-30, 2023 and October 4, 2023.

Review of Resident R1's clinical record revealed the physician was not notified of the missed does of medication.

Review of Resident R2's MAR for September 2023 revealed Senna (stool softener) 8.6 milligrams was not administered on September 1-6 2023, September 8-10 2023, and September 12-19, 2023.

Review of Resident R2's clinical record revealed the physician was not notified of the missed does of medication.

Review of Resident R3's MAR for September 2023 revealed Lumigan .01% (medication for the treatment of high pressure in the eye) were not administered on September 26, 2023.

Review of Resident R3's clinical record revealed the physician was not notified of the missed does of medication.

Review of Resident R4's MAR for September 2023 revealed Aldactone 25mg (treats high blood pressure) was not administered on September 2, 2023.

Review of Resident R4's clinical record revealed the physician was not notified of the missed does of medication.

Review of Resident R5's MAR for September 2023 revealed clonazepam (anti-anxiety) was not administered for one dose the morning of September 18, 2023.

Review of Resident R5's clinical record revealed the physician was not notified of the missed does of medication.

Review of Resident R6's MAR for September 2023 and October 2023 revealed Pyridium 100mg (used to treat urinary tract infections) was not administered on October 11, 2023, Preservision Supplement (multivitamin) was not administered for two doses on September 26, 2023 and October 19, 2023, and Ocusoft Lid Scrub (eye cleanser) was not administered on September 26, 2023.

Review of Resident R6's clinical record revealed the physician was not notified of the missed does of medication.

Interview with the Nursing Home Administrator and the Director of Nursing on February 2, 2023 at 11:30 a.m. revealed these medications were not administered due to unavailability from the pharmacy and the physician was not notified per policy when the medications were unable to be administered as ordered.

This has been identified as a past non-compliance situation.

This was identified by the facility and a plan of correction was developed and put into place including audits of all residents for possible missed notifications to the physician, revisions to the policy and procedure regarding medication errors, education of nursing staff of the policy changes, and continuing audits to ensure compliance.

28 Pa. Code 211.12(5) Nursing Services

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


 Plan of Correction - To be completed: 03/22/2024

Past noncompliance: no plan of correction required.
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 clinical record review and staff interview it was determined the facility failed to provided pharmacy services by not obtaining needed medications for six of six residents reviewed. (Residents R1, R2, R3, R4, R5, and R6)

Findings Include:

Review of Resident R1's Medication Administration record (MAR) for September and October 2023 revealed Latanoprost .005% eye drops (medication for the treatment of high pressure in the eye) were not administered as ordered on September 27-30, 2023 and October 4, 2023.

Review of Resident R2's MAR for September 2023 revealed Senna (stool softener) 8.6 milligrams was not administered on September 1-6 2023, September 8-10 2023, and September 12-19, 2023.

Review of Resident R3's MAR for September 2023 revealed Lumigan .01% (medication for the treatment of high pressure in the eye) were not administered on September 26, 2023.

Review of Resident R4's MAR for September 2023 revealed Aldactone 25mg (treats high blood pressure) was not administered on September 2, 2023.

Review of Resident R5's MAR for September 2023 revealed clonazepam (anti-anxiety) was not administered for one dose the morning of September 18, 2023.

Review of Resident R6's MAR for September 2023 and October 2023 revealed Pyridium 100 mg (used to treat urinary tract infections) was not administered on October 11, 2023, Preservision Supplement (multivitamin) was not administered for two doses on September 26, 2023 and October 19, 2023, and Ocusoft Lid Scrub (eye cleanser) was not administered on September 26, 2023.

Interview with the Nursing Home Administrator and the Director of Nursing on February 2, 2023 at 11:30 a.m. revealed these medications were not administered due to unavailability from the pharmacy.

This has been identified as a past non-compliance situation.

This was identified by the facility and a plan of correction was developed and put into place including Audits of all residents for possible missed notifications to the physician, revisions to the policy and procedure regarding medication errors, education of nursing staff of the policy changes, and continuing audits to ensure compliance.

28 Pa. Code 211.9(a)(1) Pharmacy Sevices

28 Pa. Code 211.12(3)(5) Nursing Services

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

28 Pa. Code 201.18. Management


 Plan of Correction - To be completed: 03/22/2024

Past noncompliance: no plan of correction required.

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