Nursing Investigation Results -

Pennsylvania Department of Health
PROMEDICA SKILLED NURSING AND REHABILITATION (JERSEY SHORE)
Patient Care Inspection Results

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PROMEDICA SKILLED NURSING AND REHABILITATION (JERSEY SHORE)
Inspection Results For:

There are  75 surveys for this facility. Please select a date to view the survey results.

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PROMEDICA SKILLED NURSING AND REHABILITATION (JERSEY SHORE) - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey completed on May 19, 2022, it was determined that ProMedica Skilled Nursing And Rehabilitation - Jersey Shore 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(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills: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(g)(4)-(5) Enteral Nutrition
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.
Observations:

Based on review of select facility policies and procedures, clinical record review, observation, and staff interview, it was determined that the facility failed to provide appropriate treatment and services for one of two residents reviewed for enteral feeding (Resident 23).

Findings include:

Clinical record review for Resident 23 revealed the resident has had a PEG (percutaneous endoscopic gastrostomy, tube used to provide nutrition directly through the stomach) as a sole source of nutrition since his admission on January 6, 2022.

A review of Resident 23's physician orders dated January 6, 2022, were for the resident to receive Two Cal HN formula each evening at 8:00 PM to infuse at 80 ml (milliliters) per hour until 1000 ml are infused with a 325 ml water flush every three hours, and a 30 ml water flush before and after medication and feedings.

Observation of Resident 23 on May 16, 2022, at 10:50 AM revealed the resident was in bed sleeping. The feeding pump was on a pole next to the bed. No feeding or flush were hanging on the pole. The pump was off. A dried tan colored substance, which was the same color as the liquid in a bottle of Two Cal HN that sat on the resident's stand was observed on the feeding pump in several places, on a large area covering the power cord to the pump, and covering the solid base of the pole the pump was on.

An observation of Resident 23 on May 17, 2022, at 8:33 AM revealed the resident was in bed sleeping. A bag of water for flushing was hanging on the pole with a bottle of two Cal HN. The same dried tan colored substance was on the pump, power cord, and base of the pole. The feeding pump was observed on with the screen indicating the feeding was being infused at 80 ml/hour and an H20 (water flush) of 350 ml was to infuse every three hours.

In a concurrent interview with Employee 3, Licensed Practical Nurse, she indicated the enteral feeding order was for 325 ml water flush every three hours with the feeding and the pump was set incorrectly to 350 ml. Employee 1 confirmed the dried substance on the pump, cord, and pole.

The surveyor reviewed the above findings during an interview with the Nursing Home Administrator and the Director of Nursing on May 17, 2022, at 1:30 PM.

483.25 (g) Assisted nutrition and hydration
Previously cited 6/4/21

28 Pa. Code 211.10(d) Resident care policies

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


 Plan of Correction - To be completed: 07/06/2022

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.

F693

1) The tan substance on Resident #23's feeding pump, power cord and base has been cleaned. Resident #23 is receiving water flushes via enteral feeding as ordered.

2) New admissions and current residents with feeding tubes have the potential to be affected by the deficient practice. Current residents with feeding tubes will be reviewed to validate that water flushes are being administered as ordered and tube feeding equipment is clean.

3) To prevent the deficient practice from re-occurrence – licensed nurses will be educated by the DON (Director of Nursing)/designee on the administration of enteral nutrition and maintaining cleanliness of equipment utilizing the "Focus on F-tag 658" and the federal regulation on or before the date of compliance.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to ensure appropriate treatment and services for residents receiving enteral feedings. Audits will be completed by the DON/designee with trends reported through QA&A.

5) Date of compliance: July 6, 2022

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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 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 observation and staff interview, it was determined that the facility failed to ensure appropriate acquisition and dispensing of medications regarding expiration dates for two of three nursing unit medication rooms (2nd floor and 3rd floor, Resident 16).

Findings include:

Interview with the Administrator on May 19, 2022, at 9:25 AM confirmed that the facility does not have policies and/or procedures on the acquisition of over-the-counter stock medications or a process to monitor for expirations.

Observation of a medication administration pass on May 17, 2022, at 8:25 AM revealed Employee 1, licensed practical nurse, preparing to administer Vitamin B1 100 mg (milligrams) to Resident 16. Employee 1 noted that Vitamin B1 was not available in the medication cart, so she went to the over-the-counter stock medication room on the 2nd floor to obtain a bottle. Employee 1 returned to the medication cart with two bottles of Vitamin B1 indicating that the bottles expired in April 2022.

Observation of the 3rd floor medication room on May 17, 2022, at 10:14 AM revealed the following expired over the counter stock medications:

Four bottles of Zinc 50 mg, expired April 2022
One bottle of Vitamin B1 100 mg, expired April 2022
One bottle of opened Loratadtine (an allergy medication) 10 mg, expired April 2022

Interview with Employee 2, licensed practical nurse, on May 17, 2022, at 10:17 AM confirmed the above findings for the 3rd floor medication room.

28 Pa. Code 211.9 (k) Pharmacy services

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


 Plan of Correction - To be completed: 07/06/2022

1) The expired medications have been removed from the 2nd floor and 3rd floor medication rooms.

2) Observations of the remaining medication storage areas in the facility will be completed and any expired medications will be removed.

3) To prevent the deficient practice from re-occurrence– licensed nurses will be educated by the DON (Director of Nursing)/designee on appropriate acquisition and dispensing of medication utilizing the "Focus on F-tag 755" and the federal regulation on or before the date of compliance.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to ensure appropriate acquisition and dispensing of medications with regards to expiration dates. Audits will be completed by the DON/designee with trends reported through QA&A.

5) Date of compliance: July 6, 2022

483.45(f)(1) REQUIREMENT Free of Medication Error Rts 5 Prcnt or More: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(f) Medication Errors.
The facility must ensure that its-

§483.45(f)(1) Medication error rates are not 5 percent or greater;
Observations:

Based on observation, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 16 and 47).

Findings include:

The facility's medication error rate was 11.54 percent based on 26 medication opportunities with three medication errors.

The policy entitled "Medication and Treatment Guidelines," last reviewed on September 27, 2021, indicates that medications are administered in accordance with standards of practice and state specific and federal guidelines. Medications are administered in accordance with ensuring that the right medication is administered.

Review of the package insert and patient instructions for Advair Diskus (an inhaler to treat chronic lung disease) last revised August 2020, indicates that users should rinse their mouth out with water after breathing in the medication, spit out the water, and do not swallow it.

Observation of a medication administration pass on May 17, 2022, at 8:25 AM revealed Employee 1, licensed practical nurse, administering Advair Diskus one inhalation to Resident 16. After Resident 16 inhaled the Advair medication, Employee 1 handed him water to drink with no verbal instructions. Resident 16 took a sip of water and swallowed. Resident 16 did not rinse his mouth and spit out the water after using the Advair Diskus. Interview with Employee 1, at this time, revealed that she was not aware if Resident 16 should have rinsed his mouth out after the administration of the Advair.

Observation of a medication administration pass on May 17, 2022, at 9:15AM revealed Employee 2, licensed practical nurse, crushed Resident 47's Potassium Chloride 10 milliequivalent (MEq) tablet and mixed with applesauce. The medication label noted the medication is not to be chewed or crushed, may mix in water.

Interview with Director of Nursing and Nursing Home Administrator on May 18, 2022, at 2:00 PM confirmed these findings. The Nursing Home Administrator stated the facility no longer utilizes a do not crush list, the nurses would be alerted by the medication label.

Observation of a medication administration pass on May 17, 2022, at 9:15 AM revealed Employee 2 administered Resident 47 Docusate Sodium 100 milligrams (mg), two tablets. Interview with Employee 2 at this time confirmed the tablets were from the facility stock medication bottle. Employee 2 crushed Resident 47's Docusate Sodium and mixed it with applesauce. Review of Resident 47's current physician orders revealed an order for nursing staff to administer Resident 47 Docusate Sodium 100 mg soft gel (medication that dissolves between 20 and 30 minutes in the stomach).

Interview with Director of Nursing and Nursing Home Administrator on May 18, 2022, at 2:00 PM confirmed these findings.

The facility failed to ensure a medication error rate of less than five percent.

28 Pa. Code 211.10(a) Resident care policies

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


 Plan of Correction - To be completed: 07/06/2022

1) Resident #16 is being offered to rinse his mouth after the administration of his Advair inhaler. Resident #47's Potassium Chloride tablets were changed to Klor-Con Sprinkle Capsules and are being administered as ordered. Resident #47's Docusate Sodium soft gels were changed to Docusate Sodium tablets and are being administered as ordered.

2) Residents will receive Advair, Potassium Chloride and Docusate Sodium as ordered and in accordance with manufacturer's recommended guidelines.

3) To prevent the deficient practice from re-occurrence– licensed nurses will be educated by the DON (Director of Nursing)/designee on medication administration utilizing "Focus on F-tag 759" and the federal regulation on or before the date of compliance.

4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to ensure a medication error rate below five percent. Audits will be completed by the DON/designee with trends reported through QA&A.

5) Date of compliance: July 6, 2022


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