Pennsylvania Department of Health
TUCKER HOUSE NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TUCKER HOUSE NURSING AND REHABILITATION CENTER
Inspection Results For:

There are 154 surveys for this facility. Please select a date to view the survey results.

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TUCKER HOUSE NURSING AND REHABILITATION CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to two complaints, completed on March 15, 2024, it was determined that Tucker House Nursing and Rehabilitation 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 Pennsylvainia Long Term Care Licensure Regulations related to the health portion of the survey process.

Plan of Correction:

483.25(l) REQUIREMENT Dialysis:

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(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on clinical record review, policy and procedure review and interviews with staff, it was determined that the facility failed to assure an ongoing collaboration with the dialysis facility for the provision medications as ordered by the physician before and after hemodialysis treatment for one of one residents on renal dialysis. (Resident R1)

Findings include:

A review of the facility policy titled Administering Medications dated April 1, 2022 revealed that the licensed nurse was responsible for administering and documenting in the clinical record the administration of medications and treatments according to the orders, in required time frames, as set forth by the physician.

A review of the policy titled Dialysis dated April 1, 2022 revealed that it was the facility's responsibility to ensure that the dialysis services were managed so that each resident attain or maintain their highest practicable physical, mental and psychosocial well-being. The policy indicated that it was the responsibility of the facility to ensure that the resident's needs related to dialysis treatment was met. The policy also indicated that it was the facility's responsibility to ensure effective communication and collaboration of the resident's care plan inorder to implemented the dialysis care among the nursing home and dialysis staff.

Review of the facility's dialysis contract revealed that the facility contracted with an outside dialysis center to provide hemodialysis care and services, within professional standards of practice for the residents. According to the contract, the center and the facility were to provide ongoing communication and collaboration with the dialysis facility regarding the residents' care and services.

Review of Resident R1's March 2023 physican's orders revealed an order for hemodialysis (a machine that filters wastes, salts and fluids from the blood when a persons' kidneys are not working normally) care weekly on Monday, Wednesday and Friday, by the physician.

Clinical record review revealed that Resident R1 was scheduled to leave the facility weekly at 5:00 a.m., on Monday, Wednesday and Friday and return to the facility at 12:00 noon each Monday, Wednesday and Friday after completing hemodialysis care.

Clinical record review revealed that the physician had ordered medications to be administered to Resident R1 before his departure for the dialysis center. The nursing staff were responsible for giving Resident R1the medication Lispro (insulin) 10 units subcutaneously before meals for diabetes mellitus. The resident was scheduled morning doses on March 1, 2024, March 4, 2024, March 6, 2024, March 11, 2024. Review of the medication administration record revealed no evidence that the medication was administered according to the physican's orders.

Clinical record review revealed that the physician had ordered medications to be administered to Resident R1 upon return from the dialysis center. The physician had ordered that Lispro (insulin) 10 units be administered subcutaneously at noon, upon return from the dialysis center. On March 1, 2024, March 6, 2024, March 8, 2024 and March 11, 2024 upon return from dialysis at noon the insulin, Lispro as ordered by the physician was not given to Resident R1.

Clinical record review revealed that physician had ordered that Phos lo (calcium acetate phosphate binder) oral capsule 667 mg be administered three times a day at 8:00 a.m., 12:00 p.m., and 5:00 p.m., daily to Resident R1 for hyperkalemia. On March 1, 2024, March 4, 2024, March 6, 2024 March 8, 2024 and March 11, 2024 Resident R1 did not receive the medication Phos lo as ordered by the physician for administration at 8:00 a.m. Clinical record review revealed that Resident R1 was not administered the medication phos lo, as ordered by the physician at 12:00 p.m., on March 1, March 8, 2024 and March 11, 2024.

Clinical record review revealed that Resident R1 was ordered apixaban a 5mg tablet one tablet every 12 hours for atrial fibrillation to be administered at 9: 00 a.m., and 9:00 p.m., daily. On March 1, 2024, March 4, 2024 March 8, 2024 and March 11, 2024 this resident did not receive the 9:00 a.m., doses as ordered by the physician.

Clinical record review revealed that Resident R1 was ordered medication isosorbide mononitrate ER 60 mg one tablet one time a day for hypertension. On March 1, 2024, March 4, 2024, March 6, 2024 and March 11, 2024 Resident R1 did not receive the medication, isosorbide mononitrate ER as ordered by the physician.

Interview with the director of nursing, Employee E2, at 2:00 p.m., on March 15, 2024 confirmed that Resident R1 who had a diagnosis of end stage kidney disease and was ordered hemodialysis treatments outside of the facility three days during the week was not receiving medications as ordered by the physician for the month of March, 2024.

28 PA. Code 201.18(b)(1)(3) Management

28 PA. Code 211.10(a)(b)(d) Resident care policies

28 PA. Code 211.12(d)(1)(2)(3)(5) Nursing services

28 PA. Code 211.5(f)(x)(ix)(viii)(vii) Medical records

28 PA. Code 201.21(c) Use of outside resources

Plan of Correction - To be completed: 04/01/2024

R1 was discharged to the hospital on 3/12/24.

Current residents that receive outside dialysis services will be reviewed to ensure medication administration is scheduled to accommodate dialysis time and the medications are being administered as ordered.

Licensed staff were re-educated on the medication administration policy and the dialysis policy.

DON or designee will audit 2 dialysis residents per week x 2 months to ensure medications are being administered as ordered and administration times accommodate dialysis chair time. Results will be reviewed during facility's monthly QAPI meeting.

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