Pennsylvania Department of Health
ADVANCED CARE CENTER OF BUTLER
Patient Care Inspection Results

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ADVANCED CARE CENTER OF BUTLER
Inspection Results For:

There are  6 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
ADVANCED CARE CENTER OF BUTLER - 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 January 16. 2024, it was determined that Advanced Care Center of Butler 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.


 Plan of Correction:


483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
Observations:

Based on a review of facility activity calendars, and resident and staff interviews it was determined that the facility failed to provide and schedule Activities Department led activities during the evenings and on weekends for four of four months (10/23, 11/23, 12/23, and 1/24).

Findings include:

A review of the facility's activity calendars for the time period 10/23, through 1/24, revealed that the facility scheduled activities as follows:
October 2023:
* No scheduled activity after 3:00 pm on 10/1/23, 10/15/23, and 10/29/23
* No scheduled activity after 1:00 pm on 10/14/23, and 10/28/23
* No Activity Department led activities on 10/7/23, 10/8/23, 10/21/23, and 10/22/23
* No Activity Department led activities after 3:30 pm on Monday, Tuesday and Fridays.
* No Activity Department led activities after 5:00 pm on Wednesday and Thursday

November 2023
* No scheduled activity after 3:00 pm on 11/12/23, and 11/26/23
* No scheduled activity after 1:00 pm on 11/11/23, and 11/18/23,
* No Activity Department led activities on 11/5/23, 11/19/23, and 11/25/23,
* No Activity Department led activities after 3:30 pm on Monday, Tuesday, Thursday and Fridays.
* No Activity Department led activities after 5:00 pm on Wednesday and Thursday (11/9/23)

December 2023
* No scheduled activity after 3:00 pm on 12/3/23, 12/17/23, and 12/31/23
* No scheduled activity after 1:00 pm on 12/2/23, 12/9/23, 12/16/23, 12/23/23, and 12/30/23
* No Activity Department led activities on 12/10/23, 12/24/23, 12/25/23, and 12/26/23
* No Activity Department led activities after 3:30 pm on Monday, Tuesday, Thursday and Fridays.
* No Activity Department led activities after 5:00 pm on Wednesday and Thursday (12/14/23 and 12/28/23)

January 2024 ( reviewed on 1/8/24) activities are scheduled activities
* No scheduled activity after 3:00 pm on 1/14/24 and 1/28/24
* No scheduled activity after 1:00 pm on 1/6/24, 1/13/24,
* No Activity Department led activities on 1/7/24, and 1/21/24
* No Activity Department led activities after 5:00 pm on Monday, Tuesday, Wednesday, Thursday and Friday

During an interview on 1/8/24, at 10:20 a.m. Activities Director Employee E1 confirmed that the facility failed to provide and schedule Activity Department led activities on various days of the month as well as into the evening hours. It was further confirmed that when an Activities Aide is scheduled on Saturdays it is for four hours from 11:00 am until 3:00 p.m. and Sundays for 1:00 p.m. until 5:00 p.m. Nurse aides distribute newspapers and pass activity sheets when no activity staff is on duty.

During an interview on 1/8/24 at 11:00 a.m. Resident R2 stated that the activities available on the weekend were dismal.

During an interview on 1/8/24 at 2:30 p.m. the Nursing Home Administrator confirmed that the based on the Activity calendars the facility failed to provide activities led by the Activities Department in the evenings and on various weekend days.

Pa Code: 211.10(d) Resident Care Policies


 Plan of Correction - To be completed: 03/08/2024

The current activities schedule will be reviewed by the QAPI committee to determine scheduling needs that will meet supportive activities for the residents.
The Nursing Home Administrator or designee will interview all residents on current census to survey resident likes and needs.
The Nursing Home Administrator will attend the resident council meetings at the approval of the resident council in orders for activities issues to be addressed.
A change in policy and scheduling will occur to cover evenings and weekends. The NHA or designee will audit the activity schedule and the running of activities weekly x 4 weeks and then monthly until compliance is reached.
Results of the audits will be presented at the quarterly QAPI committee meeting.
483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records: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.
§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Observations:

Based on a review of the facility's policies, documents, resident medical records, and contract pharmacist and staff interviews it was determined that the facility failed to make certain that pharmacy services provided met pharmacy standards of practice for one of four residents (Resident R1).

Findings include:

A review of facility "Provider Pharmacy Requirement" reviewed and approved for 2023 and 2024 indicated that the contracted pharmacy would perform initial medication assessments, maintain medication profiles including medications dispensed and information such as age, diagnosis, weight and condition of the resident. The Pharmacy reviews the profile before dispensing any medication, screen new medication for appropriate indication or diagnosis and assists the prescriber in providing therapeutic alternatives.

A review of Resident R1's Admission Record indicated that the resident was admitted to the facility on 11/21/23, with the diagnosis of heart failure, lack of coordination and muscle weakness.

A review of the facility's Authorization for Formulary Substitution form dated 11/27/23, indicated that the pharmacy notified the facility that Resident R1 was prescribed Farxiga for the treatment of diagnosis of congestive heart failure (CHF). The form indicated that Farxiga is a non formulary medication and the preferred medication was Glimiperide.

During an interview on 1/8/24, at 12:40 pm Contract Pharmacist Employee E2 confirmed that the medication Farxiga contains multiple properties and that although prescribed for the treatment of diabetes is often prescribed for the treatment of congestive heart failure. Glimiperide is also a medication prescribed for the treatment of diabetes but does not contain the properties to be prescribed for the treatment of CHF. She confirmed that the recommendation from the pharmacy to substitute glimiperide for farxiga was inappropriate,

During an interview on 1/8/24, at 1:50 pm Contracted Pharmacist Employee E2 indicated that after a review of Resident R1's medical records that Resident R1 was a payor source of Medicare Part A and the Pharmacy's computer system with automatically generate a Authorization for Formulary Substitution Form for medication that are on the non formulary listing. He confirmed that the form is first generated recommending a substitution that has the approval of the Pharmacy's Clinical Pharmacist Committee. This recommendation is based on the primary use for the medication and is not reviewed by a pharmacist prior to being sent to the facility for consideration and approval. For the medication farxiga the primary use is for the treatment of diabetes. The preferred substitution is glimiperide which also has the primary use of the treatment of diabetes. He further confirmed that the system failed to consider the prescribed use of the medication for Resident R1 was for the treatment of CHF and that Resident R1 had no evidence of a diagnosis of diabetes. He confirmed that the recommendation for this substitution was inappropriate.

During an interview on 1/8/24, at 2:10 pm Certified Registered Nurse Practioner (CRNP) Employee E4 confirmed that she approved the substitution of farxiga to glimiperide for Resident R1 due to her understanding that the pharmacy had a pharmacist review recommendations prior to making the recommendation. She confirmed that she failed to question the proper use of the medication glimiperide due to the understanding that medications have multiple prescribed uses for treatment of various diagnosis. Her determination was that the pharmacy generated the recommendation making it appropriate for the use in the treatment of CHF. She states that she was unaware that the form was automatically generated and that the pharmacy failed to have a pharmacist screen the medications for proper and appropriate use based on resident information.

During an interview on 1/16/24 at 1:15 pm the Nursing Home Administrator confirmed that the facility failed to make certain that the pharmacy screened recommendations for medication substitutions for appropriateness based on the resident's diagnosis prior to being submitted to the facility for approval which resulted in Resident R1 being prescribed an inappropriate medication.

PA Code: 211.9(a)(1)(k) Pharmacy Services.


 Plan of Correction - To be completed: 03/08/2024

The pharmacy consultant will do an audit for all current residents who had formulary change and will be reviewed by the pharmacist for corrections if necessary.
Revisions to the Pharmacy policy and procedure will include the DON or designee to review all formulary medication change requests daily before the medication order change before the medication order change is obtained.
The ADON will review daily and the DON will audit the formulary changes weekly x 4 weeks and then monthly until compliance is reached.
Results of the audits will be presented at the quarterly QAPI committee meeting.
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 a review of facility policies, documents, resident medical records and contracted pharmacist and staff interviews it was determined that the facility administered an inappropriate alternative medication for one of four residents resulting in the resident being transferred to the hospital for further evaluation. (Resident R1)

Findings include:

A review of facility " Medication administration" policy reviewed and approved for 2023 and 2024 indicated that medications are administered as prescribed in accordance with good nursing principles and practices. The Right medication and the right dose are monitored during administration.

A review of Resident R1's Admission Record indicated that the resident was admitted to the facility on 11/21/23, with the diagnosis of heart failure, lack of coordination and muscle weakness.

A review of the facility's Authorization for Formulary Substitution form dated 11/27/23, indicated that the pharmacy notified the facility that Resident R1 was prescribed Farxiga for the treatment of diagnosis of congestive heart failure (CHF). The form indicated that Farxiga is a non formulary medication and the preferred medication was Glimiperide.
The medication substitution was approved by Certified Registered Nurse Practioner (CRNP) Employee E 4 on 11/27/23.

A review of facility medication administration history records indicated that Resident R1 was administered the preferred substitution medication glimiperide on 11/28/23, and 11/29/23.

During an interview on 1/8/23, at 1:30 pm Registered Nurse (RN) employee E5 confirmed that when she administered the medication on 11/29/23, to Resident R1 she asked the resident if she took the medication at home. Because the medication being used for the treatment of diabetes and the resident had no evidence of a diagnosis of diabetes. When the resident stated that she not certain of her medications and that her family prepared them for her the RN administered the medication as prescribed.

During an interview on 18/23, at 3:00 pm RN Employee E6 confirmed that she administered the preferred medication to Resident R1 on 11/28/23 and failed to ask the resident questions regarding the lack of a diagnosis for diabetes. RN Employee E6 stated that medications are used for multiple diagnosis and she was in the understanding that the pharmacy had made the recommendation for the substitution and it was approved by CRNP Employee E4.

During a review of Resident R1's Progress notes dated 11/30/23, at 4:43 am it is indicated that the resident was found blood around her mouth, agonal breathing (breathing when a person is not getting enough oxygen and gasping for air) and unable to speak. Left arm was hanging off the bed. Resident had decreased strength in the left extremities. Paramedics notified. Resident transferred to the hospital. A progress note dated 11/30/23, at 6:50 am indicated that the facility was notified by a family member that the resident's blood sugar level had dropped into the 30's (in general a range of 70 to 140 is acceptable) and was receiving IV fluids. A progress note dated 11/30/23, at 12:50 pm indicated that the facility was notified by the hospital that the resident was admitted with diagnosis of hypoglycemia. (low blood sugar)

During an interview on 1/8/24, at 1:50 pm Contracted Pharmacist Employee E2 indicated that after a review of Resident R1's medical records that Resident R1 was a payor source of Medicare Part A and the Pharmacy's computer system with automatically generate a Authorization for Formulary Substitution Form for medication that are on the non formulary listing. He confirmed that the form is first generated recommending a substitution that has the approval of the Pharmacy's Clinical Pharmacist Committee. This recommendation is based on the primary use for the medication and is not reviewed by a pharmacist prior to being sent to the facility for consideration and approval. For the medication farxiga the primary use is for the treatment of diabetes. The preferred substitution is glimiperide which also has the primary use of the treatment of diabetes. He further confirmed that the system failed to consider the prescribed use of the medication for Resident R1 was for the treatment of CHF and that Resident R1 had no evidence of a diagnosis of diabetes. He confirmed that the recommendation for this substitution was inappropriate.

During an interview on 1/8/24, at 2:10 pm Certified Registered Nurse Practioner (CRNP) Employee E4 confirmed that she approved the substitution of farxiga to glimiperide for Resident R1 due to her understanding that the pharmacy had a pharmacist review recommendations prior to making the recommendation. She confirmed that she failed to question the proper use of the medication glimiperide due to the understanding that medications have multiple prescribed uses for treatment of various diagnosis. Her determination was that the pharmacy generated the recommendation making it appropriate for the use in the treatment of CHF. She states that she was unaware that the form was automatically generated and that the pharmacy failed to have a pharmacist screen the medications for proper and appropriate use based on resident information.

During an interview on 1/16/24 at 1:15 pm the Nursing Home Administrator confirmed that the facility failed to make certain that the medication substitutions were appropriate for the Resident R1's medical condition and diagnosis which resulted in a medication error in which Resident R1 was prescribed and administered an inappropriate medication.

PA Code: 211.12(d)(1)(2)(5) Nursing Services


 Plan of Correction - To be completed: 03/08/2024

Resident 1 did not return to the facility after hospitalization.
The pharmacy consultant will do a full house review of medications and assist the DON or designee in identifying any issues of inappropriate medication use.
The DON or designee will provide Safe Medication Administration education to the RNs and LPNs to include the new process of the formulary change faxes.
The DON or designee will perform medication and diagnosis audits weekly x 4 weeks on admission, with new medication orders and then monthly until compliance is reached.
Results of audits will be presented at the quarterly QAPI committee meeting.
51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on a review of residents medical records, facility documentation filed with the State Agency and staff interviews it was determined that the facility failed to report to the state agency a resident's transfer to the hospital for an evaluation of the resident's change in condition of unknown origin for one of four residents as required. (Resident R1)

Findings include:

A review of Resident R1's progress notes dated 11/30/23 at 4:43 am it was revealed that the resident was found at 4:30 am with blood around her mouth, agonal breathing (breathing when a person is not getting enough oxygen and gasping for air) and unable to speak. Left arm was hanging off the bed. Resident had decreased strength in the left extremities. Paramedics notified. Resident transferred to the hospital.

During a review of the facility's documents filed with the State agency it was revealed that there was no evidence that the facility notified the State agency of Resident R1's transfer to the hospital for evaluation of change in condition.

During an interview of 1/16/24, at 1:40 pm the Director of Nursing confirmed that the facility failed to notify the State agency of Resident R1's transfer to hospital for evaluation of a change in condition.


 Plan of Correction - To be completed: 03/08/2024

Resident R1 was sent out due to a change in condition and based on physician order. Resident R1 did not return from the hospital.
The DON or designee will review the regulatory requirements for reporting incidents.
The DON and designee will review the regulatory requirements for reporting incidents. The DON or designee will report any regulatory requirements as necessary and specified.
The DON or designee will review for any reportable during morning meeting and report as required by regulation.
NHA and DON will audit reportable incidents weekly to assure incidents that are required to be reported have been reported and accepted by the state agency.
The NHA and DON audits will be completed weekly x 4 weeks and then monthly until compliance is reached.
Results of the audits will be presented at the quarterly QAPI committee meeting.

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