Pennsylvania Department of Health
UPMC NORTHWEST TRANSITIONAL CARE UNIT
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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UPMC NORTHWEST TRANSITIONAL CARE UNIT - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare Recertification, State Licensure, and Civil Rights Compliance Survey completed on September 6, 2024, it was determined that UPMC Northwest Transitional Care Unit 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.

Plan of Correction:

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to provide oxygen according to physician's orders for one of one residents reviewed for respiratory services (Resident R1).

Findings include:

Review of facility policy dated 8/2024, entitled "Oxygen Administration" indicated that "Verify physician order for desired oxygen saturation and oxygen flow rate." "And do not change the oxygen flow rate on fixed flow orders or titrate outside ordered parameters without contacting the physician and obtaining appropriate orders."

Resident R1's clinical record revealed an admission date of 8/16/24, with diagnoses that included chronic obstructive pulmonary disease (condition when your lungs do not have adequate air flow), and hypertension (high blood pressure).

Review of Resident R1's clinical record revealed a physician's order dated 8/16/24, for Oxygen via Nasal Cannula (a thin tube with two prongs that fit into the resident's nostrils to deliver oxygen) 3 lpm (liters per minute) at all times.

Observation on 9/4/24, at 10:30 a.m. revealed Resident R1 laying in his/her bed with supplemental oxygen in place and the liter flow rate set at 2 lpm. Observation on 9/4/24, at 12:25 p.m. revealed Resident R1 laying in his/her bed with supplemental oxygen in place and liter flow rate set at 2 lpm. Observation on 9/5/24, at 8:50 a.m. revealed Resident R1 laying in his/her bed with supplemental oxygen in place and the liter flow rate set at 2 lpm.

During an interview on 9/5/24, at 12:50 p.m. Registered Nurse Employee E2 confirmed that Resident R1's supplemental oxygen was on and set at 2 lpm and the provision of their respiratory services was not consistent with the physician's order dated 8/16/24, for oxygen at 3 lpm.

28 Pa. Code 211.10(c) Resident care policies

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

Plan of Correction - To be completed: 10/11/2024

For Resident R1, a new order to titrate the oxygen based on the pulse oximeter reading was obtained along with a new nasal cannula order for 2 liters per minute order.

Orders for all new residents on oxygen will be audited to assure the oxygen liter per minute flow the resident is receiving matches with the physician order as well as a titrating order if present.

The Registered nurses/Licensed Practical nurses will be educated on the policy Oxygen Administration to assure that residents are receiving the correct liters per minute oxygen flow per the physician order.

The Director of Nursing/designee will audit all resident physician orders for those residents on oxygen to assure the oxygen flow rate the resident is receiving matches the physician order. This will be audited weekly for 3 months.

This will be reported out at the quarterly Quality Assurance Process Improvement meeting.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of facility policy, observation, and staff interviews, it was determined that the facility failed to store controlled schedule II-V medications (medications that may be abused or cause addiction that are closely monitored due to high risk of diversion) in a separately locked, permanently affixed compartment in the medication refrigerator.

Findings include:

A facility policy entitled, "Management of Controlled Drugs" dated 8/2024, revealed, "Storage and maintenance of Controlled drugs: Store and maintain controlled drugs properly according to federal, state, or local regulations."

Observation on 9/4/24, at 1:05 p.m. of the medication room refrigerator revealed several vials of controlled scheduled II-V medications in a separately locked container that was attached to a removable shelf, therefore it was not permanently affixed to the refrigerator, this was witnessed and confirmed by the Licensed Practical Nurse Employee E1.

Interview with the Director of Nursing on 9/4/24, at approximately 1:30 p.m. confirmed that the controlled scheduled II-V medications should be stored in a separately locked permanently affixed compartment, and not attached to a removable shelf.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

Plan of Correction - To be completed: 10/11/2024

The shelf for the box for the schedule II-V medications in the locked refrigerator in the medication room was secured in the refrigerator so it could not be remove. After secured, it was tested and could not be removed.

This is the only refrigerator for medications in the medication room

The Registered nurses/Licensed Practical nurses will be educated as to why the shelf with the box for the schedule II-V medications needs to be secure and not removable at all times.

The Director of Nursing/designee will audit weekly for 3 months that the shelf for the schedule II-V medications in the medication room refrigerator is unable to be removed. If an issue, will contact maintenance.

This will be reported out at the quarterly Quality Assurance Process Improvement meeting.

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