Nursing Investigation Results -

Pennsylvania Department of Health
SHENANDOAH MANOR NSG CTR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SHENANDOAH MANOR NSG CTR
Inspection Results For:
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SHENANDOAH MANOR NSG CTR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an abbreviated complaint survey completed on May 31, 2022, it was determined that Shenandoah Manor Nursing Center 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:

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

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.

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:

Based on review of resident clinical records, select facility policy and reports and interview with facility staff it was revealed that the facility failed to assure that two out of five residents sampled were free of significant medication errors resulting in one resident requiring hospitalization in intensive care for treatment of severe hypoglycemia due to the serious medication error (Residents CR1 and Resident 64).

Findings include:

A review of a facility policy for administering medications, dated as reviewed April 2022, revealed that, medications are administered in a safe and timely manor and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The individual administering medications verifies the resident's identity before giving the resident his/her medications. The individual administering the medication checks the label three times to verify the right resident, the right medication, right dosage, the right time and the right method (route) of administration before giving the medication.

Clinical record review revealed that Resident CR1 was admitted to the facility on May 11, 2022, with diagnoses to include, congestive heart failure ( a chronic progressive condition that affects the pumping power of the heart muscle), Chronic kidney failure, stage 3 (the kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of the blood), and nephrotic syndrome with diffuse membranous glomerulonephritis ( the immune system attacks the glomeruli in membranous nephropathy, it causes changes to the filters that lead you to lose large amount of protein into the urine. If this continues at high levels, it can eventually lead to kidney failure).

A review of a 5-day Minimum Data Set assessment (MDS - a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status utilized in nursing homes) dated May 15, 2022, revealed that Resident CR1 was cognitively intact and required staff assistance for activities of daily living.

A review of a facility medication administration error report dated May 20, 2022, at 12 PM, revealed that on May 17, 2022, at 1 PM, Resident CR1 received Resident 62's (his roommate) medications.

The report indicated that Resident CR1 erroneously received:
-Jardiance tablet 25 mg, an antihyperglycemic, used to control blood sugar in diabetics
-Metformin HCL tablet 1000 mg, an Insulin Response Enhancers, used to control blood sugar in diabetics
-Glimepiride tablet 4 mg, Antihyperglycemic - Sulfonylurea Derivatives, used to control blood sugar in diabetics
- Baclofen tablet 30 mg, a muscle relaxant medication
-Tecfidera DR (delayed release) 240 mg capsule, a Multiple Sclerosis Agent
-Zoloft 175 mg, an antidepressant medication
-Zinc 220 mg, a dietary supplement
-multi vitamin
-Vitamin C 1000 mg
-Aspirin 81 mg
-Vitamin B-12, 1000 mcg
-Allegra 180 mg, an allergy medication
-Tylenol 650 mg, a non narcotic pain medication

A review of prescribing information from the JARDIANCE(empagliflozin tablets), for oral use revealed that limitations of use were noted as Not recommended for use to improve glycemic control in adults with type 2 diabetes mellitus with an eGFR (A glomerular filtration rate (GFR) is a blood test that checks how well your kidneys are working. Your kidneys have tiny filters called glomeruli. These filters help remove waste and excess fluid from the blood. A GFR test estimates how much blood passes through these filters each minute) of less than 30 ml/min/1.73 m2

A review of the results of Resident CR1's recent lab studies dated May 18, 2022 revealed an estimated glomerular rate of 26 ml/min with the normal noted as greater than 60 ml/min. The lab report noted that the resident's result was "low."

The laboratory report also revealed that Resident CR1's glucose level was 12 mg/dl (normal value 70-120 mg/dl) and the lab value was flagged as "critical low."

According to the lab report the resident's blood sample was drawn at the facility on May 18, 2022, at 7:49 AM; received at the lab on May 18, 2022 at 5:28 PM and reported to the facility on May 19, 2022 at 12 AM. The medication error report revealed that the error occurred on May 17, 2022 at 1 PM.

A review of a hand written employee witness statement with no date or time indicated, revealed that Employee 2 (PTA-physical therapy assistant) stated, "While treating Resident CR1 (at the bedside) Resident CR1 made me aware that he had not received his medicine yet that day. (the date and time was noted as 1 PM on May 17, 2022). I discussed with nursing that Employee 1 (LPN), who was his nurse for the day. Employee 1 (LPN) stated that the resident was correct, he had not receive his medicine today and she would be in to give them (meds) to him. Minutes later, Employee 1 (LPN) returned and Resident CR1 began to take his medicine. Almost immediately, following taking one half of the meds given to him he stated that he usually takes 8 to 10 pills. I counted how many pills were left in the cup, there were 10 (remaining). He then asked that I take a picture of the remainder of the pills in the cup and send the picture to his sister from his phone. Resident CR1 was very confused as to why he would be taking so many extra pills, and was uncomfortable with it. After talking to his sister on his cell phone, the sister then called nursing. Employee 1 (LPN) returned to the resident's room to explain the mix up, stating that "sometimes when pharmacy cannot get the regular doseage, they have to substitute, increasing the amount of pills. Resident CR1 agreed and took the rest of the pills in the cup, and our therapy session continued as planned."

The report concluded that Employee 1 (LPN) failed to follow the facility's medication policy and failed to check to ensure that Resident CR1 was given the correct medications. Employee 1 (LPN) was suspended at that time.

Nursing documentation dated May 18, 2022 4:10 PM revealed "Called to evaluate resident Resident in bed. Jerking movement of arms noted. head turned to the left blank stare noted non verbal unable to follow directions. Grunts with tactile stimulation. Physician made aware and order received and noted to transport to emergency room for eval. Sister made aware. 911 called awaiting arrival."

Nursing documentation dated May 18, 2022 at 4:45PM "Called to resident's room to assess. Resident was nonverbal but responsive. Eyes opened but staring. Upper and lower body appeared to be in contracture. 911 arrived (emergency medical transport) and resident transported to hospital via ambulance litter accompanied by EMS crew."

A review of hospital emergency room documentation dated May 18, 2022, at 5:33 PM revealed "complaints of low glucose level at nursing facility. The patient has no history of diabetes and was found with a glucose of 30mg/dl after seizure like episode and unresponsive state. EMS checked blood sugar to be 30 mg/dl. Given an amp of D50 (intravenous fluid with sugar in it it increase the residents blood glucose level.) The patient is back to baseline status. The sister called and denied any history of diabetes. The patients blood glucose went from 30 mg/dl to 150 mg/dl after an amp of D50. Blood glucose has now come down to 64 mg/dl. I have ordered an amp of D50 at this time."

Resident CR1 was then transferred to another hospital and admitted to the intensive care unit for further care. A review of hospital documentation revealed that Resident CR1 was transferred from the emergency room and admitted to another acute care hospital on May 19, 2022, at 12:41 AM. He was admitted to the intensive care unit. The admitting diagnosis was severe acute symptomatic hypoglycemia.

Hospital documentation revealed that his hospital course included "presented to the hospital with severe hypoglycemia, after seizure like activity. After treatment in the ED, he continued to have hypoglycemia he was transferred to the ICU for continued medical management. Upon further investigation, it was found he was given his roommate's diabetic medications in error at the skilled facility."

He was discharged from the hospital on May 24, 2022, and admitted to another skilled nursing facility.

A review of a facility grievance form dated May 23, 2022 (no time indicated) filed by Resident CR1's sister, revealed that "resident received wrong medications due to increased amount of pills in the cup that her brother received."

A review of a statement written by the Director of Nursing (DON) at the time of the grievance revealed "Resident CR1 was sent out to the hospital on May 18, 2022, at 4:45 PM after being found with an altered mental status and decreased level of consciousness. Resident CR1 was evaluated in the emergency room and found to have a glucose of 30. Resident had labs at 7:46 AM on May 18, 2022, and when blood work results came back, the resident had already left the facility. The blood sugar was 12. The resident was admitted to the ICU with hypoglycemia and receiving treatment for unstable blood sugars. On May 19, 2022 at approximately 10 AM, Employee 1 (LPN) came to the DON asking " Did I do something to him (Resident CR1) with the meds?" I asked what she was referring to and she (Employee 1 LPN) stated " Employee 3 (LPN) told me (DON) that the residents sister called and said Resident CR1 didn't feel good since he took his meds." Unknowing the entire situation, I responded, "he had several other medical and was still being worked up by the hospital". Employee 1 (LPN) was appreciative at that time and left my office."

The DON then noted on May 20, 2022, "I received a message from Employee 4, LPN, stating, " Resident CR1's sister is concerned with the meds he received from Employee 1 (LPN) on May 17, 2022, at 1 PM and the way she (Employee 1 LPN) talked to her on the phone. I (DON) reached out to Resident CR1's sister regarding concerns that were brought to my attention. There were 16 pills in the cup. She reported that he had never been on this many pills. She said her brother texted her and took a picture of all the pills and sent to her as she is a registered nurse.. She reports that she doesn't know what the "pink" pill was. Resident CR1's sister asked Employee 1 (LPN) to please go in and evaluate the pills and discuss with the resident. Employee 1 (LPN) went to the resident's room and told the resident the same explanation and did not evaluate the pills and discuss with the resident. The resident then took the pills. The sister sent the pictures of the pills to the DON. Six of the remaining pills remaining in the cup were able to be identified. These medications were not on Resident CR1's medication list, but identified as his roommate, Resident 62's meds."

During an interview May 31, 2022 at approximately 12 PM, the DON confirmed that Employee 1 had administered the incorrect medications to Resident CR1 resulting in the resident's hospitalization in intensive care for treatment of severely low blood sugar. It was also confirmed that Employee 1 failed to identify or report the medication error until she was questioned by the DON on May 20, 2022, following the grievance lodged by Resident CR1's sister.

Clinical record review revealed that Resident 64 was admitted to the facility on September 25, 2021, with diagnosis to include diabetes.

A physician order dated January 1, 2022, was noted for Novolin 70/30 ( a combination of short acting and long acting insulin) suspension 100 units/ml, inject 10 units subcutaneously, one time a day for diabetes, before breakfast.

A review of the resident's May 2022 medication administration record (MAR) indicated that the resident's insulin was to be administered at 8 AM. However, documentation indicated that the resident did not receive the prescribed and scheduled insulin until 10:30 AM on May 17, 2022, two and half hours after the resident's breakfast. Facility documentation revealed that Resident 64's breakfast meal was delivered to his room at approximately 8 AM on May 17, 2022.

During an interview on May 31, 2022, at approximately 12 PM, the Director of Nursing confirmed that Resident 64's insulin was not administered timely and was a significant medication error because of the potential for negative outcome to the resident related to blood sugar management.

Refer F770

28 Pa Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services

28 Pa Code 211.9(a)(1)(k) Pharmacy services

Plan of Correction - To be completed: 07/05/2022

Resident CR1 is no longer a resident at the facility. Upon employee 1's return from suspension, the facilities Corporate Educator and Pharmacy Consultant have provided re-education on the facilities Medication Administration policy including checking the label three times to verify the right resident, right medication, right dosage, right time, and right method. Additionally, supervised medication passes are being conducted, with ongoing random audits, for employee 1.

Current resident's medications are being administered as prescribed and nurses are checking the label three times to verify the right resident, right medication, right dosage, right time, and right method.

Appropriate nursing staff have been re-educated on proper medication administration with the Corporate Educator. Appropriate nursing staff will demonstrate a mock medication pass to ensure full competency of medication administration per policy.

DON/Designee will audit mediation administration to ensure compliance.

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 a review of clinical records and select facility policy and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards by failed to administer medications timely as scheduled and/or prescribed for two residents out of six sampled (Resident 62 and 78).

Findings include:

A review of a facility policy for administering medications, dated as reviewed by the facility April 2022, revealed that, medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Clinical record review revealed that Resident 78 was admitted to the facility on July 15, 2017 with diagnoses to include dementia and hypertension.

The resident had a physician orders dated December 28, 2021, Lopressor Tablet 50 MG (Metoprolol Tartrate - an antihypertensive medication), Give 50 mg by mouth two times a day for hypertension, give with food. The resident's May 2022 medication administration record (MAR) indicted that the medication was to be given at 8 AM and 4 PM.

Pharmacy documentation indicated that on May 17, 2022, Employee 1, LPN, administered Lopressor 50 mg to Resident 78 at 10:02 AM. Facility documentation indicated that the breakfast meal was delivered to the resident at approximately 8 AM that morning.

Employee 1 failed to administer the resident's medication with food as prescribed, and as scheduled at 8 AM.

A review of the clinical record revealed that Resident 62 was admitted to the facility on May 6, 2016 with diagnosis to include diabetes and depression.

Resident 62 had a physician order dated August 5, 2021, Metformin HCL ( a diabetic medication ) 1000 mg by mouth once a day for diabetes, give with breakfast. The resident's May 2022 MAR indicted that the medication was scheduled to be given at 8 AM.

Pharmacy documentation indicated that on May 17, 2022, Employee 1 administered metformin 1000 mg to Resident 62's at 10:36 AM.

Resident 62 also had a physician order dated December 28, 2021, for Glimepiride ( a diabetic medication ) 4 mg by mouth once a day for diabetes, give with breakfast. According to the resident's May 2022 MAR indicated that the medication was scheduled for administration at 8 AM.

Pharmacy documentation indicated that on May 17, 2022, Employee 1 administered Glimepiride 4 mg to Resident 62 at 10:36 AM by Employee 1 (LPN).

Facility documentation indicated that the breakfast meal was delivered to the resident at approximately 8 AM.

Employee 1 failed to administer the resident's diabetic medications with food as prescribed and scheduled at 8 AM.

The resident had a physician order dated April 15, 2022, Zoloft, 175 mg ( an antidepressant medication) by mouth once a day for depression. The May 2022 medication administration record (MAR) indicted that the medication is to be given at 9 AM.

Pharmacy documentation indicated that on May 17, 2022, Employee 1 administered Zoloft 175 mg to the resident at 10:36 AM.

During an interview May 31, 2022 at approximately 12 PM, the Director of Nursing confirmed that Employee 1 failed to administer medications timely and as ordered for Resident 78 and 62.

28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing Services

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

Plan of Correction - To be completed: 07/05/2022

Resident 62 and 78 medications are given as prescribed and within one hour of the prescribed times. Upon employee 1's return from suspension, the facilities Corporate Educator and Pharmacy consultant have provided re-education on the facilities Medication Administration policy. Additionally, supervised med passes are being conducted, with random audits ongoing, for employee 1.

Current resident's medications are given as prescribed and within one hour of the prescribed times.

Appropriate nursing staff have been re-educated on the importance of giving mediation as prescribed and within one hour of the prescribed times. The facilities Medication Administration policy will be reviewed with appropriate nursing staff. Appropriate nursing staff will demonstrate a mock medication pass to ensure full competency of medication administration per policy.

DON/Designee will audit medication administration, and PCC reports, to ensure compliance.

483.50(a)(1)(i) REQUIREMENT Laboratory Services:

§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to provide timely laboratory services to meet the needs of one of 6 sampled residents (Resident CR1).

Findings include:

Clinical record review revealed that Resident CR1 was admitted to the facility on May 11, 2022, with diagnoses to include, congestive heart failure (a chronic progressive condition that affects the pumping power of the heart muscle), Chronic kidney failure, stage 3 (the kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of the blood), and nephrotic syndrome with diffuse membranous glomerulonephritis (the immune system attacks the glomeruli in membranous nephropathy, it causes changes to the filters that lead you to lose large amount of protein into the urine. If this continues at high levels, it can eventually lead to kidney failure).

A physician order was noted May 17, 2022, for CMP (comprehensive metabolic panel, or chemical screen (CMP is a panel of 14 blood tests that serves as an initial broad medical screening tool ), Pre Albumin ( Find out if you are getting enough nutrients, especially protein, in your diet) and TSH ( A Thyroid Stimulating Hormone test measures the amount of the hormone in the blood) to be completed on May 18, 2022.

The lab documentation indicated that the blood was drawn at the facility on May 18, 2022, at 7:49 AM, the sample received at the lab on May 18, 2022, at 5:28 PM and the results reported to the facility on May 19, 2022, at 12 AM. A review of the results of laboratory studies revealed that Resident CR1's glucose level was noted to be 12 mg/dl (normal value, 70-120 mg/dl. This lab value was flagged as "critical low."

The sample of blood was drawn at 7:49 AM on May 18, 2022, but not received by the lab until 5:28 PM on May 18, 2022, and the results, which were critcally low, were not received by the facility until May 19, 2022, at 12 AM

Prior to the facility receiving the lab results on May 19, 2022, at 12 AM, the resident had been transferred to the emergency room May 18, 2022 at 4:50 PM for a change in condition. Hospital documentation dated May 18, 2022 revealed that Resident CR1's blood sugar was checked by the emergency medical technicians en route to the hospital and was noted to be 30 mg/dl (a critical low reading).

During an interview May 31, 2022 at approximately 12 PM, the Director of Nursing confirmed that the resident's laboratory studies were not completed promptly and the results were not received timely.

28 Pa Code 211.12 (c)(d)(3)(5) Nursing Services

28 Pa. Code 201.21 (b) Use of outside resources

Refer F760

Plan of Correction - To be completed: 07/05/2022

Resident CR1 is no longer a resident at the facility.

Current resident's laboratory studies are being completed promptly and results are being received timely.

The laboratory consultant has been notified and the laboratory and has made adjustments to decrease the time from collection to delivery to the testing laboratory. In addition, the laboratory has implemented a more direct drop off process to prioritize the specimens.

DON/Designee will monitor turn-around times to ensure compliance.

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