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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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PENNYPACK 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 November 18, 2024, it was determined that Pennypack Nursing and Rehabilitation 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 as they relate to the Health portion of the survey.

Plan of Correction:

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

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.

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

Observations:

Based on review of clinical record, review of facility policy, and interview with facility staff, it was determined that the facility failed to ensure that residents were free of significant medication errors for one of five newly admitted resident reviewed (Resident R1).

Findings Include:

Review of facility policy titled "Medication and Treatment Orders" and dated July 2016, revealed the following; "15. Upon admission, the admitting nurse will review the transfer record of the newly admitted patient. The admitting nurse will then notify the attending physician or on-call physician to review admission medications on the transfer record. After medications are reviewed with the physician, the admitting nurse or designee will input the approved medications from the transfer record into the PCC Emar system. The admitting nurse will need to review the transfer record against the Emar record after all medications have been transcribed to ensure all medications are transcribed correctly."

Review of the clinical record for Resident R1 revealed that the patient was admitted to the facility on October 20, 2024, for skilled nursing care following discharge from an acute care hospital. The admitting diagnoses included cerebral edema (swelling of the brain), pulmonary embolism (a blockage in the lungs caused by a blood clot), diabetes (inability of the body to produce enough insulin or to use it effectively), seizure disorder (abnormal electrical activity in the brain), cushing's syndrome (caused by prolonged exposure to group of medications known as glucocorticoids).

Review of the hospital discharge summary revealed that the list of prescribed medications included Depakote 500 milligrams 1,000 two tablets by mouth every 12 hours. The last time the medication was administered was on October 20, 2024 at 8:51 a.m.

Review of Resident R1's nursing note dated October 20, 2024 at 3:30 p.m. revealed "New order received to continue medication as per hospital discharged summary papers."

Review of Resident R1's October 2024 Medication Administration Record revealed that the medication Depakote 500 milligrams was not transcribed into the resident's orders and Medication Administration Record per physician instructions.

An interview was conducted with Interim Director of Nursing, Employee E4 on November 7, 2024, at 11:00 a,m. Employee E4 confirmed that the the transcription error.

28 Pa. Code 211.9 (a)(1) Pharmacy Services

28 Pa. Code 211.9 (d) Pharmacy Services

Plan of Correction - To be completed: 11/25/2024

1.Resident R1 no longer resides in the facility.

2. New admission/Readmission orders are reviewed to ensure accurate order transcription.

3. Licensed nursing staff have been educated on the policy and procedure of medication transcription on admission to ensure accurate transcription.

4. Audits of the admission orders will be completed by DON/Designee twice weekly for 4 weeks to ensure new admission orders are properly transcribed

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