Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Survey in response to a complaint completed on January 31, 2020, it was determined that Somerton Nursing and Rehabilitation Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.

 Plan of Correction:

483.12(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on resident and staff interviews, review of facility policies and facility documentation, it was determined that the facility failed to conduct a complete and thorough investigation of an incident of missing resident medications for one of five residents reviewed. (Resident R1).

Findings include:

Review of facility policy entitled, "Abuse Investigation and Reporting" dated July 2017 revealed, "All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by the facility management".

Interview with Resident R1 on January 31, 2020 at approximately 11:00 a.m. stated her cancer medication Revlimid (a drug used to treat multiple myeloma (bone marrow cancer), either in combination with another medicine or by itself after other forms of cancer therapy) was missing which arrived in the facility approximately two weeks ago. Resident R1 stated she gave the medications to the nursing supervisor, Employee E5, after it was delivered to her by the courier carrier.

Interview with licensed staff, Employee E4, on January 31, 2020 at approximately 12:00 p.m. stated, Resident R1 reported to staff approximatley two weeks ago that she gave the medications (Revlimid) to the nursing supervisor . Employee E4 stated the pharmacy informed her that the medication costs approximately $16,000 and the medication was currently on hold due to the unavailability of the medication from the manufacturer. Employee E4 also stated that she searched all medication carts in the facility and searched resident R1's room and could not locate the medications.

Review of physician orders for Resident R1 dated December 23, 2019 revealed an order to give Revlimid capsule 10 milligrams by mouth once daily to start on January 20, 2020 and to stop on February 10, 2020. The order status was documented as "on hold". Review of January 2020 Medication Administration Record for Resident R1 revealed that the resident did not receive the medication from January 20, 2020 to January 31, 2020.

Interview conducted over the telephone with Employee E5, nursing supervisor on January 31, 2020 at approximately 2:45 p.m. confirmed that she received the medication package from Resident R1 on January 11, 2020. Employee E5 stated she placed the package containing medications in admissions office and she forgot to put it in a locked medication cart.

Interview with the Director of Nursing, on January 31, 2020 at approximately 12:30 p.m. stated she was not aware of the missing medication (Revlimid) for Resident R1.

Interview with the Nursing Home Administrator on January 31, 2020 at approximately 1:30 p.m. confirmed that the facility did not conduct a complete and through investigation of missing medication for Resident R1.

The facility failed to conduct a complete and thorough investigation of an allegation of missing resident medications for one of five residents.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.10(c)(d) Resident care policies

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

 Plan of Correction - To be completed: 02/18/2020

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

Investigation was conducted, medication was delivered on 1/9/2020 was not located. Arrangements were made to have new medication sent, it was received on 2/5/2020, signed for by the unit manager and placed in cart. Physician was informed and the resident started the medication

House wide audit for specialty medications from outside pharmacies was conducted. One other resident was identified, and her medication was delivered and being given

DON/Designee conducted audit of resident's specialty medications. All packages from a specialty pharmacy will be given to DON/Designee. Will have the resident sign for package and it will be given to the unit manager or charge nurse to put in medication cart

DON/Designee will educate licensed nursing staff on the procedure for specialty medications. The staff will also be educated on the process for reporting and investigation of incidents

DON/Designee will conduct audits weekly x 4 weeks then monthly for two months.

Results will be reviewed at Quality Assurance Performance Improvement meeting.

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