Pennsylvania Department of Health
LUTHERAN COMMUNITY AT TELFORD
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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LUTHERAN COMMUNITY AT TELFORD - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and a Civil Rights Compliance survey completed on June 13, 2024, it was determined that Lutheran Community at Telford 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 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 clinical record review and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 19 sampled residents. (Resident 19)

Findings include:

Clinical record review revealed that Resident 19 had diagnoses that included hypotension and Parkinson's disease. A physician's order dated May 5, 2023, directed staff to administer a medication (midodrine hydrochloride) three times a day for orthostatic hypotension (low blood pressure when standing, sitting, or lying down). Staff was not to administer the medication if the resident's systolic blood pressure (SBP) was 140 millimeters mercury (mm/Hg) or higher. Review of Resident 19's Medication Administration Record revealed that staff administered the medication when the resident's SBP was above 140 mm/Hg on four occasions in May 2024 and one occasion in June 2024.

In an interview on June 13, 2024, at 12:10 p.m., the Director of Nursing confirmed that the medications were administered outside of established parameters for Resident 19.

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

Plan of Correction - To be completed: 07/30/2024

Looking back at documentation in the nurses' notes on the four incidents in May medication was given incorrectly, there was no indication of any ill effects to this resident. Nurse practitioner aware.

When confirming an order where parameters are prescribed, those parameters will be entered into the supplemental documentation.

Audits will be done weekly for one month, monthly for three months and then randomly. Data will be reviewed at QAPI.

Nurses that administered medication without following established parameters were counseled.

All staff will be re-educated on following the established parameters of medications when ordered.

Monitored by Director of Nursing and Resident Care Coordinators.

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