Initial Comments:
A focused fundamental survey was conducted June 24, 25, and 26, to determine compliance with the Requirements of the 42 CFR Part 483, Subpart I, Requirements for Intermediate Care Facilities. The census during the survey was 12 and the sample consisted of three individuals. Two deficiencies were identified as a result of the survey.
Plan of Correction:
483.430(e)(2) STANDARD
STAFF TRAINING PROGRAM
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For employees who work with clients, training must focus on skills and competencies directed toward clients' health needs.
Observations:
Based on documentation review and staff interview, it was determined that the facility failed to ensure staff demonstrated skills and competencies towards client health needs. This was noted for one out of eight investigations reviewed.
Findings included:
A. Facility incident reports and investigations from the past year were reviewed on June 24-25, 2024. This review revealed the following:
B. Review of an investigation report for Individual #5 revealed that on August 4, 2023, while on a home visit with family, this individual was taken to the doctor for evaluation of pressure areas on her bilateral feet. The after-visit summary from this appointment revealed a diagnosis of cellulitis of toe left foot, pressure injury of toe on left foot, stage two, and pressure injury of toe of right foot, stage two.
C. Review of witness statements within the investigation packet revealed that on August 2, 2023, two separate staff noted areas of redness and/or swelling on Individual #5's feet. The facility determined that the target staff failed to report these reddened and swollen areas to facility nursing staff.
D. The Program Director was interviewed on June 26, 2024, at 9:00 AM. The FD confirmed the above-mentioned findings.
Plan of Correction:In regards to Item B, an internal investigation determined that staff failed to report redness and swelling in Individual #5's feet to facility nursing which resulted in the diagnosis of cellulitis of toe left foot, pressure injury of toe on left foot, stage two, and pressure injury of toe of right foot, stage two. On September 12, 2023, all staff were retrained on reporting concerns to facility nursing as well as education on pressure ulcers, risk factors, and prevention. All staff will be trained again at the July 2024 team meeting on skin integrity, pressure injuries, and reporting concerns timely to facility nursing. In addition to retraining, the facility assignment sheet was updated on 7/2/2024 to include a space for staff to document concerns reported to nursing on their shift. Nursing staff and house staff will be responsible for checking the documentation to ensure all concerns are addressed in a timely manner. This intervention will benefit Individual #5 as well as other individuals living in the facility by ensuring the staff have the ability to identify signs of pressure injuries and understand the importance of notifying facility nursing of medical concerns. Effectiveness will be evident by no further incidents regarding pressure injuries or failing to report medical concerns to facility nursing. The QIDP and ICF Supervisor will have overall responsibility for assuring the effectiveness of this intervention.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
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The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on staff interview and incident report revie, it was determined the facility failed to ensure four individual's medications were administered without error. (Individual #1, #2, #3 and #4).
Findings included:
A. Individual #1
1. On October 2, 2024, the wrong dose of Coumadin was administered on September 30, 2023 and October 1, 2023.
B. Individual #2
1. On July 18, 2023, on the p.m. shift nurse reported that Individual #2 had been receiving the wrong medication (eye drop) and the wrong persons medication. Timelol Maleate which was another individual ' s eye drop was administered instead of Dorzolamide-Timolol for 35 doses.
C. Individual #3
1. On March 18, 2024, the individual received the wrong dose of the seizure medication Midazoram.
D. Individual #4
1. On April 23, 2024 , the individual received the eye drops in the wrong eye.
2. On May 2, 2024, Noon eye drops were omitted.
D. Individuals #1, #2, and #3 had no ill effects from the medication errors. Individual # 4 experienced slight eye irritation.
E. The above-referenced errors resulted in a total of 40 medication administration errors from September 30, 2023 to May 2, 2024.
F. The Program Director was interviewed on June 26, 2024, at 9:00 a.m. During the interview, it was confirmed that staff failed to administer drugs in compliance with physician's orders.
Plan of Correction:In regard to Item A1 Individual #1 was prescribed 2.5mg of Coumadin daily. On September 30, 2023 and October 1, 2023, Individual #1 received the wrong dose of Coumadin when Coumadin 2.5mg half tablets were found in their medication cartridge. The Health Service Supervisor contacted the Coumadin Clinic and PCP immediately upon discovery. The nurse committing this error was retrained on 10/4/23 on medication pass procedures and checking the medication cassettes to ensure all medications in the cassette and the MAR match before administering any medications. Staff was trained to check the above actions for every med pass. The ICF has also transitioned to Tarrytown Pharmacy and no longer uses the medication cartridge. All medications now come in blister packs and when there is a change in dosage, the pharmacy will send out new blister packs with the updated order.
In regard to Item B1, it was discovered on July 18, 2023, that Individual #2 had been receiving the wrong medication (eye drop) and the wrong persons' medication. Timelol Maleate which was another individual's eye drop was administered instead of Dorzolamide-Timolol for 35 doses. Nursing staff was retained on 7/20/23 regarding the proper procedures for administering medications, making sure that the medication matches the MAR and that the correct name is on the label before administering any medications. Staff were trained to check the above actions for every med pass.
In regard to Item C1, on March 18, 2024, Individual #4 received the wrong dose of the seizure medication Midazolam. The nurse was retrained on 3/20/24 on making sure that the Medication label and the MAR match before administering any medications. The staff was retrained on checking the medication order and reaching out to a supervisor or prescribing physician with any dosage questions. Staff were trained to check the above actions for every med pass. The effectiveness of the interventions will be evidenced by no further incidents of individuals not receiving medications as prescribed. The ICF/ID Health Service Supervisor will have overall responsibility for the monitoring and effectiveness of these interventions.
In regard to Items D1 and D2, On April 23, 2024 , Individual #4 received eye drops in the wrong eye and on May 2, 2024, Individual #4 12pm eyedrops were omitted. The nurse committing the error was retrained on the proper medication administration procedures on 4/23/24 by the Health Service Supervisor. The nurse was retrained to always read the label on the medication and ensure it matches the MAR and that proper administration of the medication occurs. On 5/5/24, all nursing staff were retrained on the proper procedure to ensure that medication is given as prescribed and to make alternative arrangements with CRF Nursing or the Health Service Supervisor if they are going to be unavailable to administer a medication at the prescribed time.
Additional retraining on the above cited incidents will occur at the July 2024 Health Services' meeting with all health services and nursing staff.
These interventions will benefit all individuals in the facility by assuring that all medications are administered according to the physician's orders. The effectiveness of the interventions will be evidenced by no further incidents of individuals not receiving medications as prescribed. The ICF/ID Health Service Supervisor will have overall responsibility for the monitoring and effectiveness of these interventions
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