Pennsylvania Department of Health
GREEN RIDGE CARE CENTER
Patient Care Inspection Results

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GREEN RIDGE CARE CENTER
Inspection Results For:

There are  98 surveys for this facility. Please select a date to view the survey results.

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GREEN RIDGE CARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Abbreviated Complaint, and Civil Rights Compliance survey completed on February 2, 2024, it was determined that Green Ridge Care Center was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.45(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 clinical records and select facility policy and incident reports, and staff interviews it was revealed that the facility failed to assure that one of 18 residents reviewed was free of a significant medication error (Resident 81), which compromised the resident's clinical condition and required corrective treatment to reverse the effects of the error.

Findings include:

A review of the facility's current pharmacy policy and procedures last reviewed January 2024, revealed that facility staff should only prepare medications for one resident at a time. Staff should verify each time a medication is administered that it is the correct medication at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident.

A review of the clinical record revealed that Resident 81 was admitted to the facility on December 21, 2023, with diagnosis to include rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein in the blood) and acute kidney failure.

A review of an admission MDS assessment dated December 27, 2023, (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) revealed that the resident was moderately cognitively impaired.

A facility incident report dated January 10, 2024, at 8 AM , revealed that Employee 1 (LPN) erroneously administered the following medications to Resident 81, which were prescribed for Resident 10:

Cymbalta 30mg two tablets (antidepressant medication)
Iron 325 mg one tablet (mineral supplement)
Metoprolol Succinate ER 25 mg half tablet hold for systolic blood pressure is less then 100 or heart rate less than 60 (blood pressure medication)
Procardia XL 30 mg one tablet (blood pressure medication)
Senna-S 8.6 mg one tablet (stool softener)
Ativan 0.5mg one tablet (anti-anxiety medication that can cause drowsiness, dizziness, loss of coordination, headache, nausea, blurred vision)
Buspirone HCL 7.5 mg one tablet hold if lethargic (anti-anxiety medication)
Memantine HCL 5mg one tablet (dementia medication)
Oxycodone HCL 5 mg one tablet (opioid narcotic pain medication that can cause confusion, shallow breathing, and slowed heart rate)
Seroquel 75 mg one tablet (anti-psychotic medication which can cause drowsiness, dizziness, and lightheadedness)

These medications were not prescribed for Resident 81 during the resident's stay, to date, at the facility.

A review of a nursing note dated January 10, 2024, at 9:07 AM revealed that Resident 81 was lethargic, sleepy, and only arousable with tactile stimuli (physical touch e.g., sternal rub The resident's blood pressure was 65/36 mm/Hg (a blood pressure of 65/36 is considered a dangerously low blood pressure that can reduce the blood flow to the brain and other organs in the body). The Certified Registered Nurse Practitioner was notified at that time and new orders were obtained.

A review of the resident's blood pressures after the medication error on January 10, 2024 were as follows:

9:05 AM - 65/36 mm/Hg
9:22 AM - 70/42 mm/Hg
9:45 AM - 80/46 mm/Hg
9:55 AM - 84/60 mm/Hg
10:00 AM - 80/64 mm/Hg
10:10 AM - 92/40 mm/Hg

A review of the Resident 81's January 2024 Medication Administration Report (MAR) revealed that on January 10, 2024, the resident required, and was administered Narcan 0.4 mg/ML (an emergency medication used to treat an opioid overdose) intravenously (through the veins) one time for sedation and Sodium Chloride 0.9% 100 ml intravenously every hour for 2 hours then 60 ml every hour.

The facility's investigation report indicated at 8:00 AM on January 10, 2024 Employee 1 entered Resident 81's room to obtain vital signs then exited the room to obtain the resident's medications. While Employee 1 was preparing the resident's medications, other staff entered the room to get Resident 81 out of bed to take her to the dining room. Once Employee 1 had prepared all the medications, she decided not to administer the medications to Resident 81 until the staff were finished getting the resident up out of bed.

Employee 1 placed Resident 81's medications off to the side of the med cart to later administration. Employee 1 prepared Resident 10's medications. Once Resident 10's medications were prepared, Employee 1 placed the cup of medications intended for Resident 10 to the side. At approximately 8:10 AM staff brought Resident 81 out of her room. Employee 1 stopped the resident in the hall and grabbed Resident 10's medications and administered Resident 10's medications to Resident 81.

Employee 1 realized the error and notified Employee 2, RN (registered nurse) Supervisor. Instead of awaiting further instruction or notifying the physician, Employee 1 then administered Resident 81's prescribed Lasix 40 mg tablet and Potassium 2 0 meq tablet to Resident 81 without identifying if any of these medications may interact with the other medications Employee 1 had erroneously administered to the resident. At approximately 8:30 AM Employee 2 went to the dining room to assess Resident 81 but was met in the hallway by staff, returning Resident 81 to the unit due to a sudden change in condition.

A review of a witness statement from Employee 1 dated the following day, January 11, 2024, revealed that this nurse stated that other staff came into Resident 81's room to provide care to the resident while she was preparing the resident's medications. The employee stated she labeled the medication cup with the resident's pre poured medications and began preparing Resident 10's medications. Employee 1 indicated that staff brought the resident out of her room to go to the dining room. Employee 1 stated that she stopped the resident grabbed the wrong medication cup, that was poured for Resident 10 and administered the wrong medications to Resident 81. Employee 1 indicated that when the nursing supervisor went to assess the resident, he was met in the hall with by staff returning the resident to her room. Employee 1 stated that Resident 81 at that time was extremely lethargic (sluggish, extremely fatigued, lack of energy).

An interview with the Nursing Home Administrator and Director of Nursing on February 2, 2024 at approximately 2:00 PM confirmed that Employee 1 administered the incorrect medications to Resident 81 on January 10, 2024, failing to ensure the resident was free from significant medication errors.




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






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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Step 1

On 1/10/2024, Employee 1 (LPN) gave Resident 81 the wrong medications. The medications received were Resident 81's roommate's medications. Employee 1 realized that the medication error occurred and immediately notified the supervisor. The supervisor meets staff bringing Resident 81 out of the dining room due to a sudden change in condition. Resident was assessed by RN supervisor and the MD was notified and new orders received to:

· Administer Narcan 0.4mg per md order along with NSS bolus until BP came up and then 60cc/hr.
· Neuro checks and vital signs q 1 hour. IV fluids were completed at 1610. Resident back to baseline.
· MD ordered CBC and BMP for am (1/11/2024)
· Vitals changed to q 4 hours x 24 hours then q 8 hours x 24 hours.
· Employee 1 was disciplined and a medication competency completed with LPN prior to administering of medication independently.
· Family was notified and a reportable event was submitted to the Department of Health.

Step

To identify other residents that have the potential to be affected, on 1/11/2024 and 1/12/2024 the DON/Designee completed head to toe assessments on all incapable residents (BIMS <12) to ensure no change in conditions were noted related to medication errors. There were no negative findings.

To identify other residents that have the potential to be affected, on 1/11/2024 the DON/designee completed resident interviews on with those resident capable (BIMS 12>) to ensure no other resident received incorrect medication(s). There were no negative findings.

Step 3

To prevent this from reoccurring, the DON/designee educated nursing staff on medication administration policy, refraining from pre-pouring medications, administering all meds at time of removal from med cart and documenting administration immediately after administration. Education was done both in person and verbally via the telephone on 1/11/2024. (nursing did sign upon return to the community)

In addition to the education, between 1/10/2024 and 1/12/2024 the DON/designee completed medication skills observations on all licensed nursing. Ad hoc education was provided as needed.

Step 4

To monitor and maintain ongoing compliance, the DON/designee will complete 5 head to toe assessments on incapable residents weekly x4 then monthly x2 to monitor for medication error adverse effects. Negative findings will be addressed as needed.

To monitor and maintain ongoing compliance, The DON/designee will complete 5 interviews with interview-able residents weekly x 4 then monthly x 2 to ensure they receive the right medication. Negative findings will be addressed as needed.

To monitor and maintain ongoing compliance, the DON/designee will conduct 5 medication skill observations with licensed nursing weekly x 4 then monthly x 2 to monitor if medications have been pre-poured, administered at time of removal from medication cart and documented immediately after administration. Ad hoc education will be provided as needed.

The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

Step 5

Alleged date of compliance 03/07/2024.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure the presence of physician documentation of the clinical rationale for the continued use of multiple psychoactive medications, including antipsychotic and duplicate drug therapy for anxiety disorder, prescribed for one resident out of five sampled residents (Resident 73).

Findings include:

A review of Resident 73's clinical record revealed that he was admitted to the facility on November 9, 2023, with diagnoses that included anxiety, dementia with behavioral disturbance, Lewy body dementia [is a progressive dementia that results from protein deposits in nerve cells of brain and affects movement, thinking skills, mood, memory, and behavior], osteoarthritis [is a progressive dementia that results from protein deposits in nerve cells of brain and affects movement, thinking skills, mood, memory, and behavior], and repeated falls.

A review of the resident's clinical record physician's orders revealed the following orders:

November 9, 2023, Pimavanserin Tartrate Oral Capsule 34 MG [Nuplazid is in the drug class of antipsychotics that is used to treat the symptoms of a certain mental/mood disorder (psychosis) that might occur with Parkinson's disease.] Give 1 capsule by mouth one time a day related to unspecified dementia with behavioral disturbance.

November 11, 2023, Sertraline HCL (antidepressant used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, social anxiety disorder) Oral Tablet 25 MG Give 1 tablet by mouth one time a day related to unspecified anxiety disorder.

December 12, 2023, Buspirone HCL (anti-anxiety medicine) Oral Tablet 5 MG Give 1 tablet by mouth three times a day related to anxiety disorder.

December 13, 2023, Seroquel Oral (antipsychotic used to treat certain mental/mood disorders (such as schizophrenia, bipolar disorder, sudden episodes of mania or depression associated with bipolar disorder) Tablet 25 MG Give 1 tablet by mouth at bedtime related to neurocognitive disorder with Lewy bodies.

December 16, 2023, Ativan (an antianxiety medication used to treat anxiety) Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth one time a day related to unspecified anxiety disorder and December 30, 2023, Ativan Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed (PRN) for increased anxiety/agitation related to unspecified anxiety disorder.

A review of the facility's consultant pharmacist's consultation report dated January 3, 2024, identified that Resident 73 had experienced multiple falls that occurred on 11/22/2023, 11/23/2023, and 12/20/2023. A comprehensive review of the medical record was conducted and identified that the following medications may contribute to falls: Two (2) antipsychotics: Nuplazid 34 mg daily and Seroquel 25 mg twice per day for Lewy Body dementia. Ativan 0.5 mg once daily and every eight (8) PRN for anxiety (PRN dose not administered prior to any fall). Sertraline 25 mg daily for anxiety, and Buspar 5 mg three times per day for anxiety.

The pharmacist requested that the attending physician evaluate these medications as possibly causing or contributing to falls, deducing/discontinuing as appropriate and that if the therapy was to continue it would be recommended that the prescriber document an assessment of risk versus benefits, indicating that the medication is not believed to be contributing to falls in Resident 73; b) the facility interdisciplinary team ensures ongoing effectiveness and potential adverse consequences.

A review of the attending physician's progress notes dated January 6, 2024, noted that Resident 73 was receiving Sertraline (Zoloft) and buspirone (Buspar) and Seroquel for the resident's mood.

There was no documented evidence that attending physician documented the individualized clinical rationale for continuing the other psychoactive drugs, including duplicate drug therapy prescribed for anxiety disorder.

A review of the physician's response dated January 16, 2024, revealed that a physician extender, a certified registered nurse practitioner, and the resident's attending physician) addressed the pharmacist's recommendations and decreased the resident's dose of the antipsychotic drug Seroquel dose to 25 mg at bedtime and increased the resident's antidepressant Zoloft to 50 mg oral daily.

Through survey ending February 2, 2024, there was no documented evidence provided that the resident's attending physician documented the individualized clinical rationale for continuing the other psychoactive drugs, including duplicate drug therapy prescribed for anxiety disorder and that the physcian had thoroughly evaluated the combination of these medications and their potential side effects that may be negatively affecting the resident.

Interview with the Director of Nursing (DON) on February 2, 2024, at 10:24 AM, confirmed that Resident 73's attending physician failed to document an evaluation of potential adverse consequences, including an assessment of the resident's condition and documented the clinical necessity of each psychoactive drug, including antipsychotics and duplicate drug therapy for anxiety disorder, in maintaining or improving the resident's function and abilities.



28 Pa. Code 211.9 (k) Pharmacy services.

28 Pa. Code 211.2 (d)(3) Medical Director.

28 Pa. Code 211.5(f) Medical records.






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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Step 1

Resident 73's physician provided a progress note addressing the following: rationale and risk vs benefit of each psychotropic medication, justification for continued antipsychotic med use and duplicate drug therapy.

Step 2

To identify other residents that have potential to be affected, the DON/designee will complete an audit for current residents who are on mutltiple psychoactive medications, including antipsychotic and duplicate drug therapy for anxiety disorder to verify presence of physician documentation of clinical rationale for continued use.

Step 3

To prevent this from reoccurring, the DON/designee will notify each physician on unnessary psychotroic use and documentation to support clinical rationale for conintued use of multiple psychoactive medications.

Step 4

To monitor and maintain compliance, the DON/designee will audit monthly pharmacy recommendations to verify that the physician addressed recommendations related to multiple psychoactive medications (including duplicate therapy) and documented the clinical rationale for continued used. The audits will be completed monthly times 3 months. The results of the audits will be forwarded to QAPI committee for further review and recommendations

Step 5

Alleged date of compliance 03/07/2024

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:

Based on a review of clinical records, and staff interview, it was determined that the facility failed to act upon identified declines in bowel and bladder function and implement individualized approaches to restore normal bowel and bladder function to the extent possible for one out of 18 sampled residents (Resident 36).

Findings include:

A review of the clinical record revealed that Resident 36 was admitted to the facility on May 4, 2022, with diagnoses, which included cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) and muscle weakness.

A review of Resident 36's quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated August 3, 2023, revealed that the resident was occasionally incontinent of bladder and always continent of bowel.

A review of Resident 55's quarterly Minimum Data Set assessment dated October 30, 2023, revealed that the resident was now frequently incontinent of bladder and occasionally incontinent of bowel.

There was no documented evidence at the time of the survey ending February 2, 2024, that the facility had acted upon the decline in the resident's bowel and bladder continence and developed and implemented an individualized plan to decrease episodes of incontinency and restore normal function to the extent practicable for this resident.

Interview with the Nursing Home Administrator on February 2, 2024, at approximately 2:00 PM confirmed that the facility failed to address the resident's increase in incontinency with an individualized plan to improve the resident's function and prevent further decline.



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



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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.


Step 1

Resident # 36 was reassessed post a noted MDS decline of bowel and bladder status and placed on an appropriate toileting plan based on the 72-hour tracking completion. The plan of care was updated to reflect changes.

Step 2

To identify other residents that have potential to be affected, the DON/designee completed a review for current residents to determine if there was a noted decline from their most current MDS and their prior MDS. Residents identified with declines will be reassessed to ensure appropriate toileting plans are in place post the 72-hour tracking completion with care plans updated as needed.

Step 3

To prevent this from reoccurring, the DON/designee will educate the RNAC/designee on reporting declines identified for the current MDS related to bowel and bladder function to the DON/designee.

Step 4

To monitor and maintain compliance, the RNAC will audit and report in clinical morning meeting any noted declines in bowel and bladder function for the residents current MDS . The DON / designee will reassess those residents identified to ensure that an appropriate toileting program is in place post the completion of a 72-hour tracker. Care plan updates to be completed as needed. The audits will be completed 5 days per week times 4 weeks and then monthly times 2. The results of the audits will be forwarded to QAPI committee for further review and recommendations.

Step 5

Alleged date of compliance 03/07/2024

§ 211.1(a) LICENSURE Reportable diseases.:State only Deficiency.
(a) When a resident develops a reportable disease, the administrator shall report the information to the appropriate health agencies and appropriate Division of Nursing Care Facilities field office. Reportable diseases, infections and conditions are listed in § 27.21a (relating to reporting of cases by health care practitioners and health care facilities).

Observations:

Based on a review of facility documentation and staff interview, it was determined that the facility failed to timely report confirmed cases of Respiratory Syncytial Virus (RSV) to the State Licensing Agency, Department of Health, Division of Nursing Care Facilities as required.

Findings include:

Review of facility documentation during the survey ending February 2, 2024, revealed that the facility had an outbreak of RSV, that began on January 22, 2024, with Resident 36.

Four other residents test positive for RSV during the months of January 2024 through the survey ending February 2, 2024.

The facility failed to report these confirmed cases of RSV to the State Licensing Agency, Department of Health, Division of Nursing Care Facilities.

Interview with the Nursing Home Administrator on February 2, 2024 at approximately 2:00 PM confirmed that the facility failed to report confirmed cases of RSV as required to the State Licensing Agency.


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

Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

Step 1

All RSV cases reported to ERS on 2/2/24.

Step 2

To identify other residents that have potential to be affected, the DON/designee audited the last 3 months of the ICP's infection log to ensure all necessary reported infections were reported to ERS.

Step 3

To prevent this from reoccurring, the NHA educated DON and ICP on timely reporting of reportable infections to ERS To prevent this from reoccurring, the DON educated the nursing supervisors to notify DON of any new infections requiring reporting.

Step 4

To monitor and maintain compliance, the NHA will audit infection log weekly x 4 weeks then x 2 months to ensure all infections reported timely to ERS. The results of the audits will be forwarded to QAPI committee for further review and recommendation

Step 5

Alleged date of compliance 03/07/2024.




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