Pennsylvania Department of Health
GARDENS AT GETTYSBURG, THE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

GARDENS AT GETTYSBURG, THE
Inspection Results For:

There are 139 surveys for this facility. Please select a date to view the survey results.

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GARDENS AT GETTYSBURG, THE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Findings of an abbreviated complaint survey completed on May 22, 2024, at The Gardens at Gettysburg identified that the facility 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 care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for one of 12 residents reviewed (Resident 2).

Findings Include:

Review of Resident 2's clinical record revealed diagnoses that included osteoporosis (condition where bone strength weakens and is susceptible to fracture) and osteoarthritis (joint degeneration resulting in pain).

Review of Resident 2's February and May 2024 MARs (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed orders for Miacalcin Nasal Solution (medication that contains calcitonin, a hormone that helps prevent bone loss in postmenopausal women) daily for osteoporosis.

Further review of the MARs revealed that Miacalcin was not adminstered on February 22-26, 2024, and on May 16, 2024.

Review of corresponding nursing progress notes revealed the following: on February 22, 2024 - "unavailable - pharmacy called - they will send in a new bottle"; on February 23, 2024 - "called [pharmacy] again - they had sent a supply earlier this month. they need DON [Director of Nursing] approval; on February 24 and 25, 2024 - "On order"; on February 26, 2024 - "medication unavailable- awaiting pharmacy delivery"; and on May 16, 2024 - "unavailable - ordered from pharmacy."

Further review of available clinical documentation failed to reveal that the physician was notified of the aforementioned missed doses of medication.

During an interview with the Nursing Home Administrator on May 22, 2024, at 1:45 PM , she revealed that she was not able to provide evidence that the physician was notified of the aforementioned missed medication doses.

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

Plan of Correction - To be completed: 06/17/2024

1. Resident 2 had no adverse impact due to not receiving doses of Miacalcin Nasal Spray and her Provider was made aware of the missed doses.
2. Current residents have had their MARs reviewed to ensure medications are available and the physician is notified in the event a medication is not available.
3. Facility Staff will be re-educated by the Nursing Home Administer/Designee to understand the Requirement of ensuring that residents receive medications in accordance with professional standards of practice.
4. MARs will be randomly audited for 10 residents a week for four weeks, then 10 residents a month for one month to ensure medications are available as ordered and physician is notified in the event a medication is not available. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvements meeting.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for one of 12 residents reviewed (Resident 1).

Findings Include:

Review of Resident 1's clinical record revealed diagnoses that included peripheral vascular disease (circulation disorder that affects blood vessels outside of the heart and brain, often those that supply the arms and legs) and congestive heart failure (weakness of the heart that leads to buildup of fluid in the lungs and surrounding body tissues).

Review of wound consultant wound assessment report, dated May 16, 2024, revealed that Resident 1 was evaluated on that date for a new stage II pressure injury (an open wound that affects both the top and bottom layers of the skin) to her left medial distal foot (refers to the inner edge of the foot, extending from the heel to the big toe).

Further review of the wound assessment report revealed daily treatment recommendations that included: cleanse the area with wound cleanser, apply calcium alginate to the wound (provides a moist cover to prevent the wound from drying out, allowing the wound to heal more quickly), and secure with bordered gauze (has an adhesive border of non-woven cloth tape and a non-adherent absorptive gauze pad).

Review of Resident 1's active physician orders revealed an order to cleanse the open area to left medial distal foot with wound cleanser, apply silver alginate to the wound base, and cover with bordered gauze dressing daily. This order was effective May 21, 2024.

Further review of Resident 1's clinical record failed to reveal any orders for treatment of the wound between May 16, 2024 and May 21, 2024.

During an interview with the Nursing Home Administrator on May 22, 2024, at 1:45 PM, she stated she would have expected treatment orders to be into place immediately following discovery of Resident 1's new skin concern.

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

Plan of Correction - To be completed: 06/17/2024

1. Resident 1 had no adverse impact from the delay in starting wound treatment.
2. Current residents with pressure injuries will have their wound consultations for the last 7 days reviewed to ensure treatment recommendations are entered timely and are completed as ordered.
3. Facility Staff will be re-educated by the Nursing Home Administer/Designee to understand the requirement of ensuring that residents treatment orders are entered timely and are documented after the treatment is provided.
4. Wound consultation reports will be audited to ensure new treatment orders have been entered timely for all residents with pressure injuries each week for four weeks then monthly for one month. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvements meeting.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§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 that the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 12 residents reviewed (Resident 2).

Findings Include:

Review of Resident 2's clinical record revealed diagnoses that included osteoporosis (condition where bone strength weakens and is susceptible to fracture) and osteoarthritis (joint degeneration resulting in pain).

Review of Resident 2's February and May 2024 MARs (Medication Administration Records - forms used to document physician orders as well as when and how medications are administered to a resident) revealed an order for Miacalcin Nasal Solution (medication that contains calcitonin, a hormone that helps prevent bone loss in postmenopausal women) daily for osteoporosis effective February 17, 2023.

Further review of the MARs revealed that nursing staff documented that Miacalcin was not adminstered on February 22-26, 2024, and on May 16, 2024.

Review of corresponding nursing progress notes revealed the following: on February 22, 2024 - "unavailable - pharmacy called - they will send in a new bottle"; on February 23, 2024 - "called [pharmacy] again - they had sent a supply earlier this month. they need DON [Director of Nursing] approval; on February 24 and 25, 2024 - "On order"; on February 26, 2024 - "medication unavailable- awaiting pharmacy delivery"; and on May 16, 2024 - "unavailable - ordered from pharmacy."

During an interview with the Nursing Home Administrator (NHA) on May 22, 2024, at 1:45 PM she revealed that the Miacalcin was not administered to Resident 2 because the staff could not locate the medication, and when a replacement was requested from the pharmacy, the pharmacy had to request approval from the facility to fill it since it was a non-covered medication. The process took a couple of days. The NHA also revealed that she did not have any additional information regarding the missed dose on May 16, 2024.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 06/17/2024

1. Resident 2 had no adverse impact due to not receiving medication the pharmacy did not have available.
2. MAR's will be audited for medication marked unavailable in last 7 days to ensure medication has been obtained and that MD has been notified of missed medications.
3. Facility Staff will be re-educated by the Nursing Home Administer/Designee to understand the requirement of ensuring that residents receive medications ordered by the physician from the pharmacy and notification is timely for medications that are unavailable.
4. MARs will be randomly audited for 10 residents a week for four weeks than 10 residents a month for one month to ensure all medication was available as ordered and physician is notified if a medication is not available. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvements meeting.

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