Initial Comments:
A focused fundamental survey was conducted October 17-18, 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 four and the sample consisted of two 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 medication errors were immediately reported to the physician. This applied to one of one medication error reviewed. Findings included:
Review of facility provided documentation for a medication error was completed on October 18, 2023. This review revealed that a medication error occurred for Individual #1 on June 6, 2023, when a medication dose that was ordered to be on hold, was administered. Record review of Individual #1 was completed on October 18, 2023. This review revealed a physician's order on May 30, 2023, that read, "hold centrum on 6/6/23 one time only - then resume normal scheduled dosing." Further review of the facility provided documentation of this medication error revealed the nurse contacted the physician regarding this error on June 8, 2023.
Interview with the health services supervisor on October 18, 2023, at 12:05 PM, confirmed that following Individual #1's medication error on June 6, 2023, the nurse did not immediately report it to the physician and that the documentation showed the physician was contacted on June 8, 2023.
Plan of Correction:Allegheny Valley School (AVS), 345 Wiltshire 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, 345 Wiltshire 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, 345 Wiltshire Dr, may contest the merits and/or form of any deficiency or finding alleged below and take reasonable steps to appeal them.
The nurse involved in the medication administration error involving individual #1 will be addressed via the standard retraining process by 11/7/23. The nurse will receive additional retraining by 11/7/23 on the AVS Protocols "Facility Medications Errors" with specific emphasis placed on immediately notifying the Physician.
On 10/23/23, the Health Supervisor (HSS), audited the affected individual and all other remaining medication errors for individuals in Allegheny/Beaver County ICF group homes for immediate Physician notification. On 10/18/23, the Physician reviewed the Dexa Scan for individual #1 to determine if the Dexa Scan needed to be repeated. By 11/21/23 all nurses in the Allegheny/ Beaver County SFR medical department will be re-trained by the Health Services Supervisor or Assistant Health Services Supervisor on the "Facility Medications Errors" Protocol and Standards.
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.
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. Any concerns will be relayed to the Administrator for follow up.
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