Nursing Investigation Results -

Pennsylvania Department of Health
ANN'S CHOICE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

ANN'S CHOICE
Inspection Results For:
There are 37 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


ANN'S CHOICE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, and State Licensure Survey completed on January 28, 2020, it was determined that Ann's Choice, was not in compliance with the 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:

483.25(k) REQUIREMENT Pain Management:

This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on review of facility policy, clinical record review and staff interviews, it was determined that the facility failed to ensure the timeliness of medication administration for pain management for Resident R1 which resulted in actual harm to Resident R1 experiencing uncontrolled pain for one of 24 residents reviewed (Resident R1).

Findings include:

Review of policy, "Medication Administration, Receipt, Storage & Disposal," created April 2005, and revised January 2020, revealed under Unavailable Medications when the licensed nurse... determine that an ordered medication is unavailable, the following steps are initiated: if medication has not been ordered, fax request immediately, call pharmacy and let them know which medication is needed, if medication has been ordered from pharmacy, check delivery manifest(s) to validate receipt, if manifest medication has been delivered, licensed nurse are to locate medication, if manifest reflects medication has not been delivered, call the pharmacy to check on delivery date and time. If medication is not located and or has not been delivered, licensed nurse is to check on availability of medication from the Omnicell machine (automated medication dispensing system) in skilled nursing. Notify clinical manager/wellness manager or nursing supervisor (where available) immediately, Document in the resident's electronic medical record if medication has not been delivered and medication has either been pulled form the Omnicell machine or not administered and provider was notified.

Review of Resident R1's nursing notes dated January 17, 2020, at 1:15 a.m. revealed that the resident arrived to the facility at 7:15 p.m. (on January 16, 2020) with the diagnoses of acute and chronic burst lumbar fracture (vertebrates located on the lower back), low back pain and anxiety. The resident was alert to people, place and time and able to make needs known. The resident "c/o (complaint) low back pain...unable to ambulate to bathroom due to pain. Orders were verified with [the physician]."

Review of physician's orders dated January 16, 2020, for Resident R1 revealed an order for Tylenol Extra strength (pain medication) 500 milligrams (mg) one tablet three times per day and Tramadol (narcotic pain medication) 50 mg one tablet as needed every twelve hours starting January 16, 2020.

Review of nursing notes dated January 17, 2020, at 6:22 p.m. revealed "ADON (Assistant Director of Nursing) notified at approximately 3:05 p.m. that resident had not received any medications, including pain medications. Went to assess resident and found her to be visibly upset and reporting to be in 'such pain' and also reported not receiving medications including her 'heart medicine.' Immediately reassured resident and went to speak to the charge nurse and instructed her to call MD (physician) and administer medications, specifically pain medications. ADON then went to Clinical Manager to report the situation and instruct the Clinical Manager to go out and assist the Charge Nurse."

Review of nursing notes dated January 17, 2020, at 11:50 p.m. revealed "3:30 p.m. resident visibly upset about her medications, spoke with [physician] and order received to administer most of a.m. medications and Tramadol (pain medication) provided to resident, she express relief that she received her medications. Staff sat and talked with her, allowed to vent her frustrations, assured her that all her medications are in the building and all will be provided."

Review of Resident R1's January 2020, Medication Administration Record revealed Resident R1 received her first dose of Tramadol on January 17, 2020, at 4:29 p.m. (21 hours after admission) A follow up with Resident R1 at 6:29 p.m. confirmed that pain medication was effective. Further review of Resident R1's Medication Administration Record confirmed that Resident R1 was not administered pain medications during the evening shift (3:00 p.m.-11:00 p.m. shift) on January 16, 2020, and the 11:00 p.m.-7:00 a.m. shift (January 16, 2020, to January 17, 2020) for a total of 2 shifts following admission to the facility.

Review of the documentation submitted to the State agency dated January 17, 2020, revealed that the Activities Manager approached the Assistant Director of Nursing at approximinatley 3:00 p.m. on January 17, 2020, to report that the resident reported not receiving any of her medications since admission. The Activities Manager reported speaking with the Clinical Manager at approximately 2:30 p.m. The activities manager waited an addition 30 minutes with the resident who was tearful and expressed being in pain before going to the Assistant Director of Nursing for further assistance.

Further review of the clinical record revealed no documented evidence that licensed nursing staff assessed the resident for pain during the rest of the evening shift on January 16, 2020, after admission or during the 11-7 shift (January 16, 2020 into January 17, 2020).

Review of the Omnicell (automated medication delivery system) Inventory list revealed that Tramadol HCL 50 milligrams was in stock with an expired date of December 31, 2019.

Interview conducted on January 28, 2020, at 12:28 p.m. with Employee 20 confirmed that the Resident R1 was transferred to the facility from the hospital on January 16, 2020, at approximately 7:15 p.m. "Pick-up from hospital was 6:30 p.m. I received report from hospital and was told resident was medicated with Tramadol prior to discharge. I completed an initial assessment and [Resident R1] confirmed that she had no pain and was comfortable. I verified orders with doctor. Two medications were narcotics and required a physician's prescription. Doctor reported she was calling pharmacy which she did. The Supervisor Employee E21, arrived at 8:00 p.m. to complete order entry. At 11:00 p.m. Supervisor reported that she was still working on order entry. The deadline for pharmacy is midnight. Order entry was not completed until 12:18 (a.m.). Therefore, no medications were delivered in the morning."

Interview conducted on January 27, 2020, at 11:00 a.m. with Activities Director, Employee E22, confirmed that she met with Resident R1 on January 17, 2020, at approximately 2:30 p.m. and Resident R1 was tearful and reported that she had not received any medications since her arrival the previous evening.

Findings were reviewed and confirmed with Nursing Home Administrator and Director of Nursing on January 28, 2020, at approximately 2:00 p.m. regarding Resident R1 not receiving pain medications timely. During interview the Nursing Home Adminsitrator and Director of Nursing indicated that an investigation was completed and two licensed nurses were terminated.

The facility failed to ensure that Resident R1 received pain medication timely to ensure proper pain management, resulting in actual harm to Resident R1 not been administered pain medication for a period of 3 shifts since admission to the facility, experiencing pain and becoming tearful.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.10(c) Resident Care policies

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

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 12/6/19, 1/12/18

Plan of Correction - To be completed: 03/16/2020

What corrective action will be accomplished for those residents found to have been affected by the deficient practice:
Notified physician of missed medications on 1/17/20
Medication authorization obtained from Pharmacy on 1/17/20 to administer pain medication
Reviewed medication regimen to determine what other medications were not administered. Notified provider on 1/17/20 and orders obtained. Reviewed with provider as to what medication to hold
R1 was further assessed for pain as well as other signs and symptoms related to missed medications on 1/17/20.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Records of Residents admitted since 1/16/20 will be reviewed by the Director of Nursing or designee to ascertain delivery and administration of medications.
Audit of all medication cabinets was performed on 1/22/20 to ensure all ordered medications were available for delivery. Medications requiring refill were ordered from the pharmacy.
A review of all Medications due for administration since 1/16/2020- 1/22/20 will be conducted by the Director of Nursing or designee to identify other potential missed doses. Providers will be notified of any missed medications and further orders carried out.

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What measures will be put in place or what systemic changes you will make to ensure the deficient practice does not recur:
Education will be provided to licensed nurses by the Director of Nursing or designee to review processes for medication ordering, reconciliation, Pixis/ omnicell access, controlled substance authorization and provider notification of unavailable meds.
Medication and delivery reconciliation process will be standardized and educated to all nurses.

How the corrective actions will be monitored to ensure the deficient practice will not recur. Ie, what quality assurance program will be put in place:

Director of Nursing or designee will conduct an audit of new admissions and delivery of medications 100% x 2 weeks
Director of Nursing or designee will conduct an audit of new admissions and delivery of medications at 50% x 2 weeks
Director of Nursing or designee will then conduct a random audit of new admissions and delivery of medications x 2 weeks.
Director of Nursing or designee will conduct a random audit of 10 MARS will be completed weekly x 1 month, then 10 monthly x 2 months, to identify medications not administered per order.
Findings will be reviewed at the monthly Quality Assurance meeting for three months.

483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:

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.

§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Observations:

Based on review of clinical records and facility policies, and interviews with staff, it was determined that the facility failed to ensure that the resident's wishes for advance directives (one's wishes on life-sustaining medical or surgical treatment), were reflected accurately in the clinical record for one of 24 resident records reviewed (Resident R13).

Findings include:

A review of the facility policy and procedure on advance directive dated April, 2019, indicated that, "Advance Care Planning Documents are the documents in the residents record that relate to health care wishes such as code status discussion sheets, physician orders, and advance directive documents. It also stated that, the resident's advance care planning documents and treatment choices will be reviewed at each service to ensure accuracy of documentation and consistency with the resident's wishes."

Review of the clinical record for Resident R13 revealed that the resident was admitted with diagnoses including Heart Failure (excessive body/lung fluid caused by a weakened heart muscle), Chronic Kidney Disease (the gradual loss of kidney function), Cognitive Communication Deficit (these deficits result in difficulty with thinking and using language).

Review of Pennsylvania Orders for Life-Sustaining Treatment (POLST, which specifies the types of medical treatment that a person wishes to receive towards the end of life), dated March 3, 2019, for Resident R13 indicated " DNR" (Do Not Resuscitate), and 'Comfort Measures Only'. (DNR order instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the person's heart stops beating).

Review of Resident R13's January 2020 physician's orders indicated the code status as 'Resuscitation' ("Code Status" means the type of emergent treatment a person would or would not receive if his or her heart or breathing were to stop). Review of the clinical records indicated that the wishes, preferences and instructions for future health care, and end of life optionswere not accurately maintained for R13.

Interview with the Director of Nursing, on January 27, 2019, approximately at 2:04 p.m., confirmed that the physician's orders for Resident R13 did not accurately reflect the wishes of the resident for emergency care measures.

The facility failed to ensure accurate documentation was maintained regarding the resident's wishes for advance directives.

28 Pa Code 201.14(a) Responsibility of licensee

28 Pa Code 201.29(a) Resident rights

28 Pa Code 211.5(f) Clinical records

28 Pa Code 211.12(d)(1) Nursing services
Previously cited

28 Pa Code 211.12(d)(3) Nursing services
Previously cited 12/6/18

28 Pa Code 211.12(d)(5) Nursing services
Previously cited

Plan of Correction - To be completed: 03/06/2020

What corrective action will be accomplished for those residents found to have been affected by the deficient practice:
The advanced directive of R13 were removed from EMAR
Advance directive/POLST orders are now maintained in the resident chart

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Initial audits will be conducted by SW or designee to review current resident records to ensure advance directive orders are reflected on code discussion order sheets and/or POLST forms and care plan.
Resident PCPs will be contacted by nursing to address any advanced directive order discrepancies.

What measures will be put in place or what systemic changes you will make to ensure the deficient practice does not recur:
Staff Development Coordinator or designee will provide education to current interdisciplinary team on advance directive policy and procedure.

How the corrective actions will be monitored to ensure the deficient practice will not recur. Ie, what quality assurance program will be put in place:
Social Worker or designee will conduct weekly random audits of physician advance directive orders and resident care plans for 4 charts per week x 30 days and then monthly random audits of 25% of the resident x 60 days.
Audit outcomes will be reviewed by the interdisciplinary team at the monthly Quality Assurance Meeting for compliance for three months.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Observations:

Based on staff interviews and clinical record review, it was determined that the facility failed to send notice of facility initiated emergency transfers to the Office of the State Long Term Care Ombudsman for two of 24 clinical records reviewed. (Residents R8, R44)

Findings includes:

Resident R8 was admitted to to facility on July 22, 2019 with the diagnoses included, but not limited to, osteoporosis (decreased bone density and softening of the bone), cerebral vascular accident (CVA-stroke) and anxiety disorder.

Review of the clinical record revealed that Resident R8 was hospitalized from September 3, 2019 to September 10, 2019 and treated for congested heart failure (excessive body/lung fluid caused by a weakened heart muscle). There was no documented evidence that the Office of the State Long Term Ombudsman was notified of transfer.

Resident R44 was admitted to the facility on September 27, 2019 with the diagnoses include hypertension
(elevated blood pressure), cerebellar ataxia (progressive loss of coordination and difficulties with
balance and gait) and right hip fracture. Review of the clinical record revealed that resident R44 was hospitalized three times: October 3 to October 21, 2019 for surgical repair of right hip fracture; October 28 to November 4, 2019 for anemia (reduction of red blood cells) and December 2 to December 4, 2019 for elevated temperature.
There was no documented evidence that the Office of the State Long Term Ombudsman was notified
of the facility initiated transfers to the hospital.

Interview of the Administrator, Employee E1 on January 28, 2020 at 12:12 p.m. confirmed that the facility
did not notify the State Ombudsman Office of facility initiated emergency transfers to the hospital.

The facility failed to send notifications of facility initiated emergency transfers to the Office of the
State Long Term Care Ombudsman.

28 Pa. Code 201.18 (b)(3) Management

Plan of Correction - To be completed: 03/16/2020

What corrective action will be accomplished for those residents found to have been affected by the deficient practice:
As the transfers of two residents (Residents R8, R44) occurred in the past, those notifications cannot be amended. Going forward, the facility will send notifications of facility-initiated emergency transfers to the Office of the State Long Term Care Ombudsman, as required.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
What measures will be put in place or what systemic changes you will make to ensure the deficient practice does not recur:
The Admission Department, who are responsible for notification of the State Ombudsman Office of facility-initiated emergency transfers to the hospital were educated on required notification procedures. The decision tree titled, "Involuntary Discharge and Transfer Notices: When and what to send to the PA Long Term Care Ombudsman State Office" was utilized for this education.

How the corrective actions will be monitored to ensure the deficient practice will not recur. ie, what quality assurance program will be put in place:
The Administrator, or designee, will audit the Ombudsman notification log monthly for accuracy for three months. Results of the audit will be reported monthly to the facility Quality Assurance committee for three months.

483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Observations:

Based on staff interviews and clinical record review, it was determined that the facility did not complete a comprehensive care plan for one of 24 residents reviewed (Resident R14).

Findings include:

Review of the facility policy and procedure on care plans with origination date September 2019, indicated that each resident will have an individualized care plan developed. It also stated that the care plan will include measurable objectives, preferences, goals, and will address the resident's medical, nursing, mental and psychosocial needs.

A review of the clinical record revealed that, Resident R14 had admitting diagnoses including Unspecified Dementia without Behavioral Disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and Mixed Receptive-Expressive Language Disorder (a communication disorder in which both the receptive and expressive areas of communication may be affected in any degree, from mild to severe).

On January 28, 2020, approximately at 10:17 a.m., review of Pennsylvania Orders for Life-Sustaining Treatment (POLST), dated July 26, 2019, for Resident R 14 indicated, " DNR" (Do Not Resuscitate), and 'Comfort Measures Only'.

Review of the care plan for Resident R14 on January 28, 2020, approximately at 10:26 a.m., revealed that 'Comfort Measures Only' was not identified as a diagnosed problem in the comprehensive care plan, and there were no interventions and outcomes(goals) care planned for this care area.

On January 28, 2020, approximately at 11:29 a.m. the Director of Nursing conducted an independent verification of the care plan and confirmed that the findings stated above for Resident R14 were accurate.

The facility failed to develop a comprehensive care plan in reference to Resident R14 end of life wishes.

28 Pa Code 211.11(c) (d) Resident care plan

28 Pa Code 211.11(d) Resident care plan

28 Pa Code 211.12 (d)(1) Nursing service
Previously cited 12/6/18

28 Pa Code 211.12 (d)(3) (5) Nursing service
Previously cited 12/6/18

28 Pa Code 211.12 (d)(5) Nursing service
Previously cited 12/6/18

Plan of Correction - To be completed: 03/16/2020

What corrective action will be accomplished for those residents found to have been affected by the deficient practice:
Measurable goals and interventions have been added to R14's holistic care plan in relation to end of life.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Initial audits will be conducted by SW or designee to review current residents holistic care plans have measurable goals and interventions. Care plans will be updated as necessary.

What measures will be put in place or what systemic changes you will make to ensure the deficient practice does not recur:
Staff Development Coordinator or designee will provide education to current interdisciplinary team to ensure that each resident has a comprehensive care plan to reflects residents individuals needs as it relates to end of life services.
Weekly random audits of 25% of the current resident x 30 days and then monthly random audits of 25% x 60 days by SW or designee of resident end of life wishes

How the corrective actions will be monitored to ensure the deficient practice will not recur. Ie, what quality assurance program will be put in place:
Audit outcomes will be reviewed by the interdisciplinary team at the centers monthly Quality Assurance Meeting for compliance for three months.

483.25 REQUIREMENT Quality of Care:

§ 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 review of clinical records, review of facility documentation, and interviews with staff, it was determined that the facility failed to ensure medications were administered as ordered by the physician for one of 24 residents reviewed. (Resident R1)

Findings include:

Review of the clinical record for Resident R1 revealed that the resident was admitted to the facility with diagnoses including osteoporosis with current pathological fracture (decreased bone density and softening of the bone); chronic atrial fibrillation (irregular heart beat ); gastro-esophageal reflux disease (chronic digestive disease where the liquid content of the stomach refluxes into the esophagus); major depressive disorder; cardiac arrhythmia (irregular heartbeat); anemia (reduction of red blood cells) and anxiety.

Further review of the clinical record of Resident R1 revealed Resident R1 was admitted to the facility from the hospital on January 16, 2020 at approximately 7:45p.m. Review of physician's orders dated January 16, 2020 revealed the following medications were ordered:
Cyanocobalamin (Vitamin B12) 1000 mcg. tablet oral once per day; Aspirin Low Dose (for diagnosis of hypertension) 81 milligram (mg) tablet, delayed release once per day; Ferrous Sulfate (supplement) 325 mg. one tablet every day; Lorazepam (anti anxiety medication) 0.5 mg. tablet oral two times per day; Miralax (for the treatment of constipation) 17 gram oral powder packet every day; Muro 128 5% eye ointment to both eyes every day; Protonix (for the treatment of esophageal reflux) 40 mg. tablet delayed release every day; Sertraline (anti- depressant medication) 100 mg. tablet every day; Vitamin D3 50 mcg (2000 units) one capsule every day; Colace (for the treatment of constipation) 100 mg. one capsule every day; Effexor(anti-depressant medication) 75 mg XR one capsule every day; Gabapentin (ant-epileptic medication) 100 mg. one capsule two times daily; Pepcid (medication for the treatment of esophageal reflux) 20 mg. one tablet every day; Propafenone (for the treatment of atrial fibrillation) 150 mg. one tablet two times per day; Quetiapine (anti-depressant medication) 25 mg. one tablet every day; Senna (for the treatment of constipation) 8.6 mg. one tablet every day; Alendronate (for the treatment of Vitamin D deficiency) 70 mg. one tablet every week

Review of Resident R1's January 2020 Medication Administration Record (MAR) revealed Resident R1 was not administered the following medications as ordered by the physician on January 16, 2020 at 8:00p.m.: Lorazepam .5mg; Muro 128 5% ointment to both eyes; Colace 100 mg; Gabapentin 100 mg; Propafenone 150 mg; Quetiapine 25 mg; Senna 8.6mg.

Further review of January 2020 MAR revealed that the following medications were not administered as ordered by the physician on January 17, 2020 at 8:00 a.m. Lorazepam .5mg; Protonix 440 mg; Propafenone 150 mg; Alendronate 70 mg; Muro 128 2%, Icy Hot Advanced Relief Adhesive Patch 7.5% and Gabapentine 100mg.

Review of Resident R1's nursing note dated January 17, 2020 at 6:20 p.m. "ADON (Assistant Director of Nursing) notified at approximately 3:05 P.M. that resident (Resident R1) had not received any medications, including pain medication. Went to assess resident and found her to be visibly upset and reporting to be 'in such pain' and also reported not receiving medications including her heart medicine.' Immediately reassured resident and went to speak to the charge nurse and instructed her to call MD (physician) and administer medications. ADON then went to Clinical Manager to report the situation and instruct the Clinical Manager to go out and assist the Charge Nurse. Resident's responsible party was notified...Physician was notified. ADON assured that Charge Nurse and Clinical Manager followed through...Area Agency on Aging was notified. NHA and DON aware of situation."

Interview on January 28, 2020 at 11:00 a.m. with Director of Nursing, Employee E2 confirmed that Resident R1 did not receive medication as prescribed by the physician. The Director of Nursing further stated during interview that as a result an investigation was completed and two licensed nurses were terminated.

The facility failed to ensure that Resident R1 received medications as ordered by the physician following admission to the facility.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 211.10(c) Resident Care policies

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

28 Pa. Code 211.12(d)(5) Nursing Services
Previously cited 12/6/19, 1/12/18

Plan of Correction - To be completed: 03/16/2020

What corrective action will be accomplished for those residents found to have been affected by the deficient practice:
Notified physician of missed medications on 1/17/20
Medication authorization obtained from Pharmacy on 1/17/20 to administer pain medication
Reviewed medication regimen to determine what other medications were not administered. Notified provider on 1/17/20 and orders obtained. Reviewed with provider as to what medication to hold
R1 was further assessed for pain as well as other signs and symptoms related to missed medications on 1/17/20.

How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken:
Records of Residents admitted since 1/16/20 will be reviewed by the Director of Nursing or designee to ascertain delivery and administration of medications.
Audit of all medication cabinets was performed on 1/22/20 to ensure all ordered medications were available for delivery. Medications requiring refill were ordered from the pharmacy.
A review of all Medications due for administration since 1/16/2020- 1/22/20 will be conducted by the Director of Nursing or designee to identify other potential missed doses. Providers will be notified of any missed medications and further orders carried out.

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What measures will be put in place or what systemic changes you will make to ensure the deficient practice does not recur:
Education will be provided to licensed nurses to review processes for medication ordering, reconciliation, Pixis/ omnicell access, controlled substance authorization and provider notification of unavailable meds.
Medication and delivery reconciliation process will be standardized and educated to all nurses.

How the corrective actions will be monitored to ensure the deficient practice will not recur. Ie, what quality assurance program will be put in place:
Director of Nursing or designee will conduct an audit of new admissions and delivery of medications 100% x 2 weeks
Director of Nursing or designee will conduct an audit of new admissions and delivery of medications at 50% x 2 weeks
Director of Nursing or designee will then conduct a random audit of new admissions and delivery of medications x 2 weeks.
Director of Nursing or designee will conduct a random audit of 10 MARS will be completed weekly x 1 month, then 10 monthly x 2 months, to identify medications not administered per order.
Findings will be reviewed at the monthly Quality Assurance meeting for three months.

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