Nursing Investigation Results -

Pennsylvania Department of Health
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
Inspection Results For:

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Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a Complaint completed on March 5, 2020, it was determined that Premier Armstrong Rehabilitation and 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:

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Based on a review of facility policies and documents and staff interviews it was determined that the the facility failed to conduct a through investigation into the misappropriation of resident property for one of three resident (Resident R2).

Findings include:

A review of facility "Abuse" policy dated 7/1/19, revealed the facility prohibits the misappropriation of resident property by anyone including staff, family and friends. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident misappropriation of property. The Administrator and Director of Nursing are responsible for investigation and reporting.

A review of the Admission Record indicated that Resident R2 was admitted to the facility on 1/17/2020, with diagnoses that included diabetes, high blood pressure, muscle weakness, right and left shoulder pain, absence of left leg below the knee, and absence of right leg above the knee.

A review of admission physician orders dated 1/17/2020, revealed Resident R2 was ordered Hydrocodone - Acetaminophen tablet (Norco - a narcotic medication to relieve pain) 7.5 - 325 milligrams (mg) to be administered one tablet by mouth every six hours as needed (PRN) for pain.

A review of the facility "Daily Narcotic Record" dated 1/30/2020, indicated Resident R2 had 19 Norco tablets on hand. The facility is missing the "Daily Narcotic Record" for 1/31/2020.

A review of the January 2020, Medication Administration Record indicated Resident R2 was administered one dose of Norco from the time period of 1/30/2020, until 2/1/2020.

A review of "Daily Narcotic Record" dated 2/1/2020, indicated Resident R2 had zero (0) Norco tablets on hand.

During an interview on 3/4/2020, at 12:35 p.m. the Director of Nursing (DON) confirmed that the 1/31/2020, "Daily Narcotic Record" was missing and Resident R2 was missing approximately 15 - 17 Norco tablets. The DON also confirmed that the facility failed to investigate to determine the accurate number of missing tablets, their location and the identity of an alleged perpetrator.

28 Pa Code: 201.14(c)(d)(e) Responsibility of licensee.

28 Pa. Code: 201.18 (b)(1)(2)(e)(1) Management.

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

Resident R2 no longer resides at the facility.

All other narcotics from the cart were reconciled and accounted for with none missing. Statements were received, beginning on 2-1-20 from all those having access to the Med Cart.

All licensed staff will be inserviced by DON/ADON on the Narcotic reconciliation procedure to insure that any discrepancies are reported during or at the end of the immediate shift. If discrepancy is noted during count/reconciliation licensed staff involved will not leave and will notify the RN supervisor/DON/ADON as necessary. All nursing staff will also be inserviced on the abuse and neglect policy which also includes misappropriation of belongings by the DON/ADON.

Audit will be done by DON/ADON comparing the Narcotic Tally sheet vs the individual Narcotic sheet vs the actual card of Narcotics weekly x4 for 4 out of 7 med carts and then monthly x2 for all 7 carts with a report to QA Committee monthly x3. Any discrepancies noted will be addressed immediately. NHA will monitor incidents/grievances for areas of abuse with report to the appropriate agency as necessary ongoing with a report to QA monthly x3.
51.3 (f) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(f) If a health care facility is
aware of a situation or the occurrence
of an event at the facility which
could seriously compromise quality
assurance or patient safety, the
facility shall immediately notify the
Department in writing.
The notification shall include
sufficient detail and information to
alert the Department as to the reason
for its occurrence and the steps which
the health care facility shall take to
rectify the situation.
Based on a review of facility policies, facility documentation and staff interviews, it was determined that the facility failed to notify the State Survey Agency (SSA) of a reportable incident for one of three residents (Resident R2).

Findings include:

A review of facility "Abuse" policy dated 7/1/19, indicated that the facility is to initiate the investigation of the substantiated or alleged incident to the appropriate authority immediately.

Review of facility documents on 3/4/2020, revealed 15 - 17 tablets of Resident R2's Norco (a narcotic pain reliever) were discovered missing on 2/1/2020.

During an interview on 3/4/2020, at 12:35 p.m., Director of Nursing confirmed that the alleged incident regarding the misappropriation of Resident R2's property was not reported to the SSA as required.

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

An ERS report and appropriate PB-22's were completed and submitted. AAA and state police were notified.

DON was inserviced on what constitutes a reportable event and procedure for misappropriation of resident belongings.

NHA will monitor all incidents/grievances to assure all those needing reported are done so appropriately and timely with a report to the QA Committee monthly x3 and if no issues are found will review monthly at QA

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