Pennsylvania Department of Health
WILLOW TERRACE
Patient Care Inspection Results

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WILLOW TERRACE
Inspection Results For:

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WILLOW TERRACE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on an Abbreviated Survey in response to a complaint, completed on February 14, 2024, it was determined that Willow Terrace 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 Pennsylvania Long Term Care Licensure Regulations, related to the health portion of the survey process.



 Plan of Correction:


483.25 REQUIREMENT Quality of Care: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 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:


Based on clinical record review, observation of medication administration and staff interview, it was determined that the faciltiy failed to ensure that medications were administered timely for one of nine residents reviewed. (Resident R1)

Findings include:


Review of Resident R1's clinical record revealed that the resident had the diagnosis of aphasia (a disorder that results from damage to portions of the brain that are responsible for language). Continued review of the resident's clinical record revealed an order dated January 5, 2024 "May crush medications unless contraindicated."

Review of Resident R1's January 2024 physician's orders revealed an order obtained January 8, 2024 for Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals), give 1 tablet by mouth one time a day for nutritional needs, wound healing, crush and serve with applesauce/fluids; Aspirin 81 milligrams oral tablet chewable (Aspirin), give 1 tablet by mouth one time a day for Cerebral Vascular Accident (order date 1/5/2024); Amlodipine Besylate oral tablet 5 mg, 1 tablet by mouth one time a day for hypertension (high blood pressure (Order date 1/16/24); Metoprolol Tartrate Oral Tablet 25 milligrams 0.5 tablet by mouth every 12 hours for hypertension (Ordered 1/5/24); MiraLax Oral Powder 17 GM/SCOOP, 1 scoop by mouth one time a day for constipation, mix in 4-6 oz of fluids. (ordered 2/12/24); Multivitamin-Minerals Oral Tablet (Multiple Vitamins w/ Minerals), give 1 tablet by mouth one time a day for nutritional needs, wound healing crush and serve with applesauce/fluids.


Observation of the medication administration with Licensed nurse, Employee E3, on February 14, 2024 at 11:26 a.m. revealed that Resident R1 was administered the above morning medications scheduled for 9:00 a.m. 1 hour and 30 minutes later at 11:26 a.m. instead of at the scheduled time of 9:00 a.m. through 10:00 a.m.

28 Pa. Code 211.12(d)(1) Nursing services






 Plan of Correction - To be completed: 03/18/2024

This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

R1's physician was notified of the morning medications that were administered late. No new orders were received.

The DON/designee conducted a medication administration audit for the week of 2/18/24 to 2/24/24 on the 3rd floor to ensure medications were given out timely.

Licensed staff were educated on medication administration and timeliness of Medications being administered by the DON/designee.

The DON/designee will conduct random medication pass observations of licensed staff to ensure timeliness of medication administration. Observations will be done weekly x 4 weeks and monthly x 2 months. Results of these observations will be submitted to the quality assurance committee to determine if further action is needed.

35 P. S. § 448.809b LICENSURE Photo Id Reg:State only Deficiency.
Law amended July 11, 2022 Act 79 2022 HB 2604

(1) The photo identification tag shall include a recent
photograph of the employee, the employee's first name, the
employee's title and the name of [the health care facility or
employment agency.] any of the following:
(i) The health care facility.
(ii) The health system.
(iii) The employment agency.
(iv) The fictitious name of an entity under
subparagraph (i), (ii) or (iii) which is registered with
the Department of State under 54 Pa.C.S. Ch. 3 (relating
to fictitious names) or a successor statute.

(2) The title of the employee shall be as large as possible
in block type and shall occupy a one-half inch tall strip as
close as practicable to the bottom edge of the badge.


(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title "Physician."
(ii) A Doctor of Osteopathy shall have the title
"Physician."
(iii) A Registered Nurse shall have the title
"Registered Nurse."
(iv) A Licensed Practical Nurse shall have the title
"Licensed Practical Nurse."
(v) All other titles shall be determined by the
department. Abbreviated titles may be used when the title
indicates licensure or certification by a Commonwealth
agency.

(4)A notation, marker or indicator included on an identification badge that differentiates employees with the same first name is considered acceptable in lieu of displaying an employee's last name.


Observations:


Based on observation and staff interview, it was determined that the faciltiy failed to ensure that staff displayed photo identification tags on their uniforms for two of 10 employees observed. (Employee E10 and Employee E11)

Findings include:

Observations on February 14, 2024 at 1:24 p.m. revealed that nurse aide, Employee E10 was not wearing her photo identification tag. Interview with Employee E10 at the time of the observation confirmed that she was not wearing her photo identification tag.

Observations on February 14, 2024 at 12:35 p.m. p.m. revealed that Licensed nurse, Employee E11 was not wearing her photo identification tag. Interview with Employee E11 at the time of the observation confirmed that she was not wearing her photo identification tag.



 Plan of Correction - To be completed: 03/18/2024

This Provider submits the following plan of correction is good faith and to comply with Federal regulations. This plan is not admission of wrongdoing nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies.

The NHA/designee did an initial observation of random staff to ensure staff were wearing photo identification tags.

Staff were educated by the NHA/designee on the policy for wearing photo identification tags on their uniforms.

The NHA/designee will conduct Random observation audits of staff to ensure photo identification is displayed on their uniform.

Observations will be done weekly x 4 weeks and monthly x 2 months. Results of these observations will be submitted to the quality assurance committee to determine if further action is needed.



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