Initial Comments:
A focused fundamental survey was conducted November 15-16, 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)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observations, review of physician's orders, and interviews, it was determined that the facility failed to ensure that all medications were administered without error. This applied to two (#3 and #4) of two individuals observed during the morning medication pass. Findings included:
Observations of part the morning medication pass were completed on November 16, 2023, from 5:39 AM to 6:48 AM. Beginning at 5:39 AM, staff was observed to prepare the medications for Individual #3. These medications included polyethylene glycol powder and according to the label on the bottle, the staff was to mix 17 grams in 8 ounces (oz) of fluid or food of choice. At 5:51 AM, all the medications for Individual #3 were ready to be administered and the staff was observed to add thickened water to a disposable cup containing the 17 grams of polyethylene glycol powder. The staff stated that the water was thickened to honey consistency and was observed to mix the water and powder. At this time, the staff was questioned by the surveyor as to how large the cup was and the staff responded that she did not know. The staff was further questioned if it was an 8 oz cup and the staff again responded that she did not know. At 5:51 AM, the staff was observed to administer the polyethylene glycol powder to Individual #3 as it was prepared and then administered the other medications. Beginning at 6:13 AM, staff was observed to prepare the medications for Individual # 4. These medications included polyethylene glycol powder and according to the label on the bottle, the staff was to mix 17 grams in 8 oz of fluid or food of choice. At 6:30 AM, all the medications for Individual #4 were ready to be administered and the staff was observed to add water to a personal plastic cup of Individual #4, which contained the 17 grams of polyethylene glycol powder and two other liquid medications. The staff added water to the personal plastic cup and the liquid level was observed to be slightly over half the cup capacity. The staff was then observed to mix the water and powder, and other liquid medications. At this time, the staff was questioned by the surveyor as to how large the cup was and the staff responded that she did not know. The staff was further questioned if it was an 8 oz cup and the staff again responded that she did not know. At 6:40 AM, the staff was observed to administer the polyethylene glycol powder to Individual #4 as it was prepared in the personal plastic cup with other medications. Individual #4 used a straw to drink the mix independently while the staff ensured it was completely administered.
At 7:33 AM, the staff was asked by the surveyor to clarify the amount of water used during the medication pass by using a measuring cup and the cups used during the medication pass. It was determined that the amount of fluid given to Individual #3 in the small disposable cup was 2 oz. The fluid level was measured in the personal cup of Individual #4 and it was determined the amount of fluid that was given to Individual #4 was approximately 6 oz. At 7:34 AM, the staff confirmed that she had not administered the full 8 oz of fluid to either Individual #3 or #4 as it was prescribed with the medication of polyethylene glycol powder.
Review of current physician's orders for Individual #3, dated September 5, 2023, revealed an order for polyethylene glycol powder "mix 17 grams in 8 oz of fluid or food of choice and take orally daily for constipation." Review of current physician's orders for Individual #4, dated September 5, 2023, revealed an order for polyethylene glycol powder "1 capful (17 gm) in 8 oz of fluid or food of choice and take by mouth twice daily."
Interview with the health services supervisor (HSS) on November 16, 2023, at 8:50 AM, confirmed that the staff did not administer the polyethylene glycol powder in accordance with the physician's order for both individuals. The HSS further confirmed that the staff should have measured the fluids to ensure the order was followed, this resulted in the errors.
Plan of Correction:Allegheny Valley School Ohioview SFR makes its best effort to operate in full compliance with both Federal and State regulations. Nothing included in the Plan of Correction is an admission otherwise.
AVS Ohioview SFR has submitted this Plan of Correction in order to comply with its regulatory obligation and does not waive any objections contained herein. Please note that AVS Ohioview SFR may contest the merits and/or form of any deficiency or finding alleged below and take responsible steps to appeal them.
The staff person involved in the medication administration errors on 11/16/23 involving Individual #3 and individual #4 was addressed via the standard disciplinary process on 11/17/23. This staff person received retraining on 11/17/23 for the Administration of Medication Protocol including the "Five Rights of Medication Administration". Specific emphasis was placed on "Right Technique", ensuring that all medication is given according to physician order, with specific emphasis placed on thorough and complete medication administration and ensuring that all medications that are ordered are administered accordingly. This training also outlined that for medications with special instructions, such as "mix with 8 ounces of fluid or food of choice", a measuring cup is to be used to ensure that the appropriate amount of liquid is offered.
To monitor the effectiveness of this training, two additional observations will be conducted by a Certified Practicum Observer for the staff person who committed the error in the next 30-day period. These observations will be completed by 12/16/23. Results will be relayed to the Administrator and the Health Services Supervisor. The Administrator will retain copies of these extra observations.
In order to protect all other potentially affected individuals, all med trained staff working at Ohioview received training regarding the Five Rights of Medication Administration on 11/16/23. Specific emphasis was placed on "Right Technique", ensuring that all medication is given according to physician order, with specific emphasis placed on thorough and complete medication administration and ensuring that all medications that are ordered are administered accordingly. This training also outlined that for medications with special instructions, such as "mix with 8 ounces of fluid or food of choice", a measuring cup is to be used to ensure that the appropriate amount of liquid is offered. The signed staff training sheet will be retained by the Administrator.
Ongoing monitoring via Practicum Observer protocol will occur every six months thereafter for all med trained staff. Any concerns will be relayed to the Health Services Supervisor or her designee, and the Administrator for appropriate follow-up.
To ensure that the Administration of Medication Protocol for complete medication pass without errors is followed, training will be completed for all Allegheny and Beaver County ICF homes regarding Medication Administration Protocol. This training was completed at the House Managers meeting on 11/21/23 and included specific emphasis on ensuring that all medications ordered by physician are administered without error, all special instructions are followed as ordered, and measuring cups are to be used for any liquid vehicle if a specific amount is ordered. The House Managers will be responsible for training their subordinate staff. Completed training sheets will be sent to Administrator by 12/15/23 and maintained by Administrator.
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