Initial Comments:
A focused fundamental survey was conducted December 12-13, 2023, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was five and the sample consisted of three individuals.
Plan of Correction:
483.460(k)(8) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that drug administration errors and adverse drug reactions are reported immediately to a physician.
Observations:
Based on review of facility provided documentation, record review, and interview, it was determined that the facility failed to ensure that all medication errors were immediately reported to the physician. This applied to one of three medication errors reviewed. Findings included:
Review of facility provided documentation for a medication error investigation was completed on December 12, 2023. This review revealed that a medication error occurred for Individual #4 on September 28, 2023, when Individual #4 did not receive an as needed medication for constipation after not having have a bowel movement for three days prior. On September 28, 2023, nursing advised residential staff to administer Individual #4's as needed medication for constipation if Individual #4 did not have a bowel movement by the time the evening medications were administered. On September 29, 2023, in the morning, nursing discovered that the medication was not administered as ordered the previous night. Further review of Individual #4's record and facility provided documentation failed to reveal that the physician was notified of this medication error immediately upon its discovery.
Interview with the health services supervisor on December 12, 2023, at 1:30 PM, confirmed that the physician was not notified of Individual #4's medication error that occurred on September 28, 2023
Plan of Correction:TAG 0376 – DRUG ADMINISTRATION
Allegheny Valley School (AVS), 109 Windy Ghoul Dr, makes its best efforts to operate in full compliance with both Federal and State law. Nothing included in this Plan of Correction is an admission otherwise. AVS, 109 Windy Ghoul Dr, has submitted this Plan of Correction to comply with its regulatory obligation and does not waive any objections to the merits or form of any allegations contained herein. Please note that AVS, 109 Windy Ghoul Dr, may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
For the effected individual, his physician was notified of the med error on 12/13/23 and no new orders were provided. The nurse involved in the medication administration error involving individual #4 was addressed via the standard retraining process on 12/14/23. The additional nurses will receive retraining by 1/15/24 on the AVS Protocols "Facility Medications Errors" with specific emphasis placed on immediately notifying the Physician.
The Health Supervisor (HSS) will audit the affected individual and all other remaining medication errors for individuals in Allegheny/Beaver County ICF group homes for immediate Physician notification. This will be completed by 12/22/23. On 12/19/23, the Medication Error Review Form was updated to include immediate Physician Notification.
To monitor the effectiveness of the Facility medication Errors training, the Health Services Supervisor, Assistant Health Services Supervisor, or designee will review all telephone orders for Medication Errors for timely Physician's notification for the nurse involved in the error and the Medication Error Review Form.
For ongoing monitoring of facility medication errors, the Health Services Supervisor, Assistant Health Services Supervisor, or designee will review all telephone orders for Medication Errors of timely Physician's notification and the Medication Error Review Form. Any concerns will be relayed to the Administrator for follow up.
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