Pennsylvania Department of Health
CONTINUING CARE AT MARIS GROVE
Patient Care Inspection Results

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CONTINUING CARE AT MARIS GROVE
Inspection Results For:

There are  48 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.
CONTINUING CARE AT MARIS GROVE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey completed on Febuary 1, 2024, it was determined that Maris Grove was not in compliance with the following requirements of 42 CFR 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as it relates to the Health portion of the survey process.


 Plan of Correction:


483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.
483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.
Observations:


Based on a review of established guidelines for cardiopulmonary resuscitation (CPR), the facility's policies, residents' clinical records, and staff interviews, it was determined that the facility failed to ensure that CPR was provided in accordance with established facility policy and procedure for Resident 207, creating a situation for one of six residents were placed in an Immediate Jeopardy situation related to failure to perform cardiopulmonary resuscitation.

Findings include:

Review of guidelines from the American Heart Association (AHA), dated 2020, revealed, the AHA urged all potential rescuers to initiate CPR unless a valid Do Not Resuscitate (DNR) order was in place; if there were obvious clinical signs of irreversible death present, including rigor mortis (stiffness of the limbs and body that develops 2 to 4 hours after death and may take up to 12 hours to fully develop), dependent lividity (reddish-blue discoloration of the skin resulting from the gravitational pooling of blood in the lower lying parts of the body in the position of death), decapitation (separation of the head from the body), transection (division by cutting across the body), or decomposition (decay); or if initiating CPR could cause injury or peril to the rescuer.

Review of the facility's policy titled "Cardiopulmonary Resuscitation" (CPR), dated May 2022, stated that "in the case of an unwitnessed arrest of a resident who is a FULL CODE, determination of the appropriateness of CPR initiation should be undertaken by the nurse after a resident assessment, validation of Code Status and interventions appropriate to the findings initiated."

Further review of the facility policy revealed, "the licensed nurse will assess the resident upon discovery of the unresponsiveness. Assessment of death in which CPR would be a futile and inappropriate intervention requires that ALL SEVEN of the following signs be present and that the arrest be unwitnessed:
i. Resident is unresponsive.
ii. Resident has no respiration.
iii. Resident has no pulse.
iv. Resident's pupils are fixed and dilated.
v. Resident's skin is cold relative to the resident's baseline skin temperature.
vi. Resident has generalized cyanosis.
vii. There is presence of venous pooling of blood in dependent body parts causing purple discoloration of the skin which does blanch with pressure (liver mortis)".

Review of Resident 207's clinical record revealed Resident 207 was admitted to the facility on August 14, 2023, with diagnoses including but not limited to Hemiplegia (one-sided paralysis or weakness), Spinal Stenosis (spinal column narrows and compresses the spinal cord) and Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves).

Review of Resident 207's clinical record revealed, a Pennsylvania Orders for Life-Sustaining Treatment (POLST) dated August 15, 2023, indicating Resident 207's intention to have FULL treatment which includes attempt resuscitation, CPR. The POLST was signed by the physician on August 15, 2023.

Review of Resident 207's clinical record revealed a nursing note by Registered Nurse, Employee E4, dated January 22, 2024, at 6:35 a.m. indicating that "upon entering [resident] room, it was clear the resident was expired, [resident] was sitting up in bed 45 degrees with [resident] head turned to the right, there was some brown colored emesis on [resident] right shoulder, [resident] skin was warm but extremely pale." Employee E4 noted employee observed no respiration and there was no pulse. "The resident's pupils were fixed and dilated. The nurse was not able to open [resident] mouth because her jaw was rigid, the rest of her body was flaccid. The resident was pronounced at 6:39 a.m."

Further review of the nursing note revealed that Employee E4 did not initiate CPR, "because she had it in her mind that [resident] was a Code B (on POLST document - DNR - Do Not Resuscitate)." Employee E4 indicates that in hindsight she should have confirmed the code status on the chart, initiated CPR and called emergency services per protocol.

Review of facility documentation including written statement from non-licensed Employee E5, dated January 23, 2023, at 6:54 a.m. revealed when Employee E5 "got too [resident]'s room, [resident], was quiet. Before turning on the light, Employee E5 asked resident if [resident] needed continence care. Resident did not respond. Employee E5 turned on the light and found resident laying with [his/her] head to the side of [his/her] pillow with dark emesis coming out of [his/her] mouth. Employee E5 called out to resident several times but [he/she] did not reply. Employee E5 then ran to get the nurse, Employee E4.

Additional review of facility documentation revealed Nurse Aide, Employee E5 documented the last time Employee E5 saw Resident 207 was at approximately 2:50 a.m., when employee provided continence care.

Review of facility documentation including written statement by Registered Nurse (RN), Employee E4, dated January 22, 2024, at 5:10 p.m., indicated that "he/she was in the hallway starting his/her final rounds when the non-licensed, Employee E5, came running toward him/her in alarm, proclaiming he/she thinks resident is dead. Employee E4 noted he/she followed Employee E5 into the resident's room. Upon entering [resident]'s room, it was clear the resident was expired, [resident] was sitting up in bed 45 degrees with [his/her] head turned to the right, there was some brown colored emesis on [his/her] right shoulder, skin was warm but extremely pale. Employee E4 stated [he/she] observed no respiration and there was no pulse. The resident's pupils were fixed and dilated. The nurse was not able to open resident's mouth because [his/her] jaw was rigid, the rest of the body was flaccid."

Additional review of documentation including statement by licensed, Employee E4 documented that he/she did not initiate CPR "because she had it in her mind that Resident was a Code B, (on POLST document - DNR - Do Not Resuscitate)." Employee E4 further indicated, "in hindsight he/she should have confirmed the code status on the chart, initiated CPR and called emergency services per protocol." Employee E4 notes [he/she] notified the physician that resident had expired at 6:35 a.m., and then contacted resident's family.

Further review of licensed, Employee E4 witness statement indicated, it wasn't until the Nurse Supervisor Employee 6, came into the room and asked if he/she did CPR, since the resident was a code A, (Cardiopulmonary Resuscitation CPR: person has no pulse and is not breathing), did he/she realize the error.

Interview conducted with the Nursing Home Administrator and the Director of Nursing on January 29, 2024, at 10:00 a.m. revealed the administration was aware staff did not perform Cardiopulmonary Resuscitation to Resident 207 in accordance with resident's identified interventions as indicated on POLST, and CPR should have been provided in accordance with the facility's policy.

On January 29, 2024, at 3:05 p.m., Immediate Jeopardy was identified and the Nursing Home Administrator and Director of Nursing were informed that the health and safety of residents were in Immediate Jeopardy due to the RN failing to provide CPR in accordance with a resident's POLST and the facility's policy.

The facility submitted an action plan on January 29, 2024, at 5:38 p.m. that included the following actions: a full house audit of all resident's charts was performed to ensure accurate code status were in place and in accordance with resident's wishes. Education provided to nursing staff, with successful return demonstration via questionnaire to ensure staff comprehend training and retain information. All staff upon hire will receive advance directive and code status training with successful return demonstration via questionnaire prior to resident contact. Director of Nursing will conduct mock resuscitation drills every shift x1 week for 4 weeks and monthly x3. Trends will be identified and shared with QAPI committee for further review.

The Immediate Jeopardy was lifted on January 30, 2024, at 2:32 p.m. when it was confirmed that the facility provided nursing staff with education regarding providing CPR in accordance with residents' advanced directives, and the facility's policy, and completed a Code Blue drill to ensure that licensed nurses were prepared to respond to situations that required CPR. Any remaining staff were scheduled to receive the education prior to the start of their next shift.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

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

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






 Plan of Correction - To be completed: 02/20/2024

Resident # 207 is no longer in the facility
The DON or designee conducted an audit of all current residents to identify those with a full code status. 5 residents have been identified and have the potential to be affected.
The SDC or designee has in serviced the nursing staff on the facility policy for Advanced Directives and code status.
A full house audit of all resident's charts was performed to ensure accurate code status in place and accordance with resident's wished. This was completed on 01/22/24. In-house education provided to nursing staff with successful demonstration via questionnaire to ensure staff comprehend and retain training information. 100% of in-house education provided to nursing staff was completed 1/31/24.
Additional state-mandated training was completed on 2/15/24 and 2/16/24 by CHR Consulting Services with return demonstration via questionnaire. All staff, upon hire, will receive education on advanced directives and code status training with successful return demonstration via questionnaire prior to resident contact.
The DON or designee, will conduct mock resuscitation drills every shift weekly for four weeks and monthly for three months. The DON or designee will complete a code evaluation for each drill. Results of the audits will be reported to the QAPI committee monthly for review. Additional audits and education may be determined based on audit findings.

483.70 REQUIREMENT Administration:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
483.70 Administration.
A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
Observations:

Based on a review of their job descriptions it was determined that the Continuing Care Administrator (CCA), and the Director of Nursing (DON) did not effectively manage the facility to ensure that CardioPulmonary Resuscitation was provided in accordance with the facility policy and procedures to residents that are a full code.

Findings include:

Review of the job description for the Continuing Care Administrator (CCA) revealed the essential function is responsible for ensuring compliance with all federal, state, local and facility regulations, and policies. Oversees and audits nursing services to ensure high quality nursing delivery systems.

Review of the job description for the Director of Nursing (DON) revealed the responsibility of the job position is to coordinate and implement the comprehensive delivery of nursing services to all Continuing Care residents (skilled nursing, long term care, assisted living and memory care) according to Erickson's Person-Centered Approach care model and standards, professionally recognized nursing practices and local, state, and federal regulations.

The findings in this report identified that the facility failed to ensure that CPR (CardioPulmonary Resuscitation) was provided in accordance with the facility policy and procedures to residents that are a full code (life sustaining interventions). The CCA and DON failed to fulfill their essential job duties that the federal and state guidelines and regulations were followed.

Refer to F678

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

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

28 Pa. Code 207.2(a) Administrator's Responsibility

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

28 Pa. Code 211.12(d)(2)(3) Nursing Services


 Plan of Correction - To be completed: 03/07/2024

Immediate communication via webex between organization's regional team and community administration conducted on 1/22/24 to review policies and plan for education of nursing staff.
Resident # 207 is no longer in the facility.
The DON or designee conducted an audit of all current residents to identify those with a full code status. 5 residents have been identified and have the potential to be affected.
The SDC or designee has in serviced the nursing staff on the facility policy for Advanced Directives and code status.
A full house audit of all resident's charts was performed to ensure accurate code status in place and accordance with resident's wished. This was completed on 01/22/24. In-house education provided to nursing staff with successful demonstration via questionnaire to ensure staff comprehend and retain training information. 100% of in-house education provided to nursing staff was completed 1/31/24.
Additional state-mandated training was completed on 2/15/24 and 2/16/24 by CHR Consulting Services with return demonstration via questionnaire. All staff, upon hire, will receive education on advanced directives and code status training with successful return demonstration via questionnaire prior to resident contact.
The DON or designee, will conduct mock resuscitation drills every shift weekly for four weeks and monthly for three months. The DON or designee will complete a code evaluation for each drill. Results of the audits will be reported to the QAPI committee monthly for review. Additional audits and education may be determined based on audit findings.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:


Based on observations and staff interviews it was determined that the facility failed to ensure the dignity of residents in one of the three units observed (Cardinal 2).

Findings include:

Observations conducted during the environmental tour of the rooms on the Cardinal 2 unit was conducted on January 29, 2024.

Observation conducted in Resident 39's room on January 29, 2024, at 10:00 a.m., revealed a white paper with a typewritten note "After each meal, make sure [resident's name] mouth is clean. Check for any residue on the tongue let her/him take multiple sips of water, and if possible, brush their teeth following breakfast and dinner. Thank you, [staff name]" The note was posted on the wall of the room near the door visible from the hallway outside the room.

Observation conducted in Resident 11's room on January 29, 2024, at 12:17 p.m., revealed a white paper with a typewritten note "Toileting Needs: Dear caregivers [resident's name] frequently has bowel movement after meals, please take [resident's name] to the toilet after each meal to give her/him the opportunity to have bowel movement. From Therapy. Additional observation revealed two other notes one for feeding instructions and the other for ambulation and transfer instruction from rehab staff. All notes were posted on the wall of the room near the door visible from the hallway outside the room.

Observation conducted in Resident 24's room on January 29, 2024, at 12:23 p.m., revealed a white paper with a typewritten note "Attentions Caregivers: Resident is able to walk to/from the bathroom with wheeled walker with contact guard of caregiver with cueing for safe rolling walker management and left knee extension. She/He does not need the bedpan." The note was from rehab staff and was visible from the hallway outside the room.

Observation on February 1, 2024, at 11:30 a.m., in the presence of licensed Employee E3 revealed that the above notes were still present in the rooms of Residents 39, 11, and 24. Employee E3 confirmed that the notes indicating the resident's confidential personal and clinical information should have not been posted in an area visible in public areas.

28 Pa. Code 201.29(j) Resident Rights

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



 Plan of Correction - To be completed: 03/07/2024

Resident #39-The signage referenced has been removed from the resident's room and care plan updated with appropriate interventions.
Resident # 11- the signage referenced has been removed from the resident's room and care plan updated with appropriate interventions.
Resident # 24- the signage referenced has been removed from the resident's room and care plan updated with appropriate interventions.
The Clinical Manager or designee conducted a 100 percent audit of all resident's rooms to validate that no signage is present in the resident's rooms with personal care information visible from the hallway outside the room. Any discrepancies will be corrected promptly.
The Staff Development Coordinator (SDC) or designee in-serviced the direct care staff on the facility policy for Residents Rights to include that no signage will be present in resident's rooms with personal care information visible from the hallway outside the room.
The Director of Rehab in-serviced all therapy staff on the facility policy for Residents Rights to include that no signage will be present in residents rooms with personal care information visible from the hallway outside the room.
The Clinical Manager (CM) , or designee, will conduct audits of resident's rooms to validate no signage is present in residents rooms with personal care information visible from the hallway outside the room weekly for four weeks and monthly for two months. Results of the audits will be reported to the QAPI committee monthly for review. Additional audits and education may be determined based on audit findings

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary: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.
483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of 483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:


Based on clinical record review and staff interview it was determined the facility failed to complete a discharge summary for one of three residents reviewed. (Resident 50)

Findings Include:

Review of resident's records revealed a progress note dated October 31, 2023, at 2:36 am, noting the resident discharged to Riddle Hospital at approximately 1:30 am. Resident noted to have shortness of breath, pulse ox was 56% on room air. Resident was put on O2 @ 5liters via nasal cannula. Pulse ox was up 82%. Resident was lethargic, sweaty and could not respond much when name was called. Blood sugar was 256, vital signs were unstable. Nursing supervisor called on-call doctor and resident was sent out via EMS. POA was made aware before resident was sent out to hospital.

Further review of resident's record revealed a progress note dated October 31, 2023, at 7:03 am, noting resident was being admitted to Riddle Hospital with a diagnosis of pneumonia. It was further noted that Resident 50 never returned to the facility. Resident 50 expired in the hospital on November 2, 2023.

Review of Resident 50's entire clinical record revealed there was no discharge summary completed for Resident 50.

Interview with the Director of Nursing on February 1, 2024, at 2:28 p.m. confirmed there was no documentation of medication disposition or documentation that personal belongings were returned to the family upon the discharge of Resident 50.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(2)(3) Management

28 Pa. Code 211.12(c)(d)(3) Nursing services


 Plan of Correction - To be completed: 03/07/2024

Resident #50 late entry documentation entered into the medical record pertaining to disposition of resident's belongings and medications following discharge from facility.
The Medical Records Coordinator or designee will conduct a 100 percent audit of all resident discharges in the last 30 days to validate a discharge summary has been completed to include disposition of resident's belongings and medications following discharge from facility. Any discrepancies will be corrected.
The Staff Development Coordinator (SDC) or designee in-serviced the licensed nursing staff on the facility policy for discharge.
Residents who have discharged will be reviewed in the daily clinical meeting to validate a discharge summary has been completed to include disposition of resident's belongings and medications following discharge from facility. Any discrepancies will be corrected.
The Director of Nursing (DON) or designee, will conduct audits to validate a discharge summary has been completed to include disposition of resident's belongings and medications following discharge from facility weekly for four weeks and monthly for two months. Results of the audits will be reported to the QAPI committee monthly for review. Additional audits and education may be determined based on audit findings.

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 records review and staff interview, it was determined that the facility failed to ensure the physician's order regarding blood sugar was followed for one of the 17 residents reviewed (Resident 19).

Findings include:

A review of Resident 19's diagnosis revealed malignant neoplasm of the connective and soft tissue of the pelvis, and Hypoglycemia (low blood sugar level).

A review of the physician order dated December 19, 2023, revealed an order to check Resident 19's blood sugar every four hours when awake. Call a physician if blood sugar is less than 60 or greater than 350.

A review of the January 2024, Treatment Record revealed that from January 1, 2024, until January 31. 2024, Resident 19 had a blood sugar below 60 on the following days: January 3, 2024, at 12:00 a.m., 38 mg/dl; January 7, 2024, at 12:00 p.m., 44 mg/dl; January 9, 2024, at 8:00 a.m., 38mg/dl; January 10, 2024, at 4:00 p.m., 44 mg/dl; January 14, 2024, at 8:00 a.m., 38 mg/dl; January 15, 2024, at 8:00 a.m., 55 mg/dl; January 15, 2024, at 12 noon, 48 mg/dl; January 16, 2024, at 8:00 a.m., 36 mg/dl; January 20, 2024, at 8:00 a.m., 36 mg/dl; January 21, 2024, at 12:00 a.m., 44 mg/dl; January 24, 2024, at 8:00 a.m., 56 mg/dl; January 24, 2024, at 4:00 p.m., 35 mg/dl; January 26, 2024, at 4:00 p.m., 36 mg/dl; and January 26, 2024, at 8:00 p.m., 39 mg/dl.

The clinical records review failed to reveal that the physician was notified of Resident 19's blood sugar result of below 60 mg/dl on the dates/time mentioned above.

An interview with the Director of Nursing on February 2, 2024, at 11:30 a.m., confirmed that the physician was not notified of Resident 19's below 60 mg/dl blood sugar on the dates/time mentioned above.

The facility failed to ensure the physician's order to be notified when Resident 19's blood sugar level was below 60 mg/dl ( 14 times) was followed.



28 Pa. Code 211.5(f) Clinical records

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



 Plan of Correction - To be completed: 03/07/2024

Resident #19- The medical provider reviewed the resident's record and documented in progress notes acknowledgement of blood sugar results.
The Clinical Manager or designee conducted a 100 percent audit of all resident's with a physician order for blood sugars to validate that the physician orders were followed. Any discrepancies will be corrected promptly.
The CM or designee will review all residents with blood sugars daily during morning clinical meeting to validate physician orders were followed.
The Staff Development Coordinator (SDC) or designee in-serviced the licensed nursing staff on the facility policy for Physician Orders to include following physician orders for blood sugars.
The Director of Nursing (DON) or designee, will conduct audits of resident's with a physician order for blood sugars to validate that physician orders were followed weekly for four weeks and monthly for two months. Results of the audits will be reported to the QAPI committee monthly for review. Additional audits and education may be determined based on audit findings.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
483.45 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 pharmacy services provided medications timely for one of the 17 residents reviewed. (Resident 19).

Findings include:

Review of Resident 19's clinical records revealed the resident with a diagnosis of Hypoglycemia (low blood sugar).

Review of Resident 19's physician orders dated January 17, 2023, revealed an order for True plus Glucose 4 gram chewable four tablets every four hours for low blood sugar.

Review of Resident 19's January 2024, Medication Administration Record (MAR) revealed Resident19's glucose tablet was not administered on the following day/time: January 18, 2024, at 2:00 a.m.; January 20, 2024, at 2:00 p.m.; January 27, 2024, at 6:00 a.m., and January 27, 2024, at 10:00 a.m.

REview of Resident 19's clinical records and administration notes revealed that Resident 19's glucose tablet was not administered to the resident on the above-mentioned dates/time due to awaiting pharmacy delivery of the medication.

Interview with the Director of Nursing conducted on February 1, 2024, at 11:00 a.m., confirmed that Resident 19's glucose tablet was not administered due to the unavailability of the medication in the facility, awaiting pharmacy delivery.

The facility failed to ensure pharmacy services provided the glucose tablet for Resident 19 which was ordered for the resident 'hypoglycemia.

28 Pa. Code 211.5(f) Clinical records

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



 Plan of Correction - To be completed: 03/07/2024

Resident #19- Medication is present in facility for administration per MD orders.
The Clinical Manager or designee conducted a 100 percent audit of all resident's physician orders to validate that all medications are present in the facility for administration. Any discrepancies will be corrected promptly.
The CM or designee will review all residents with new medication orders or refills due daily during morning clinical meeting to validate that all medications are present in the facility for administration. Any discrepancies will be corrected promptly.
The Staff Development Coordinator (SDC) or designee in-serviced the licensed nursing staff on the facility policy for Medication Administration, Receipt, and Storage to include timely receipt of medications.
The DON or designee, will conduct a random audit of residents with new medication orders or refills due to validate that all medications are present in the facility for administration and have been received timely weekly for four weeks and monthly for two months. Results of the audits will be reported to the QAPI committee monthly for review. Additional audits and education may be determined based on audit findings.


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