Initial Comments:
A focused fundamental survey was conducted January 24-25, 2024, 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 core 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 observation, review of physician's orders, and interview, it was determined that the facility failed to ensure that all medications were administered without error. This applied to one (#2) of two individuals observed during the afternoon medication pass. Findings included:
Observations of the afternoon medication pass were completed on January 24, 2024, from 3:31 PM to 3:47 PM. The house manager (HM) was observed to administer Individual #2's afternoon medications at 3:47 PM, which included the following medications:
- carbamazepam tab 200mg; take two tablets by mouth three times daily
- gavilax pow; mix 17 grams (gm) in eight ounces of liquid or food of choice and take by mouth twice daily.
A review of physican's orders, dated December 28, 2023, to reconcile the medication pass was completed on January 25, 2024. This review revealed that Individual #2 had an order to receive "Polyeth Gly Pow 3350 mix 17gm in 8 ounces of liquid or food of choice and take by mouth twice daily", "Sub For: Miralax, Gavilax" at 7:00 AM and 8:00 PM.
An interview was conducted with the assistant director of nursing (ADON) on January 25, 2024, at 9:40 AM. The ADON confirmed that Individual #2's current physician's orders state that Individual #2 is to receive their gavilax medication at 7:00 AM and 8:00 PM. The ADON stated that Individual #2's gavilax medication was transcribed incorrectly from the order into the medication administration record and further confirmed that the gavilax medication had been administered in error.
Plan of Correction:Allegheny Valley School Patterson 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 Patterson 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 Patterson SFR may contest the merits and/or form of any deficiency or finding alleged below and take responsible steps to appeal them.
For affected Individual #2, a physician's order was obtained for Gavilax powder on 1/25/24 to ensure that the physician's orders matched the medication administration record moving forward so that there were no additional errors with administration.
On 1/25/24, the Nurse Case Manager for the Patterson ICF home performed audits on all current cycle MARs and 90-day physician's orders for all individuals residing in the home. Results of these audits were forwarded to the Health Services Supervisor. No other issues were noted at this time.
Upon notification of the wrong time medication error, an investigation was immediately initiated for Neglect due to medication management for Individual #2. The nursing staff involved in the error received retraining on Physician's Pre-Printed 90-day orders and Medication Administration Record Protocols. All training was completed by 1/29/24, and training signature sheets were sent to the Administrator and will be maintained by the Administrator.
Additionally, all current cycle MARs were audited with the current 90-day reorders for all Individuals in the Allegheny and Beaver County ICF homes. These audits were performed by the Nursing staff and were completed on 1/31/24. Any errors discovered during this audit process were immediately reported to and addressed by the Health Services Supervisor. Completed audit sheets were sent to the Health Services Supervisor and copies were sent to the Administrator.
For other potentially affected individuals, training will be completed for all Allegheny and Beaver County nursing staff regarding additional monthly audit process for cycle MARs and physician's orders. This hands-on training will be completed by the Health Services Supervisor to ensure that the nursing staff are trained in effective ways of completing monthly audits on Physician's pre-printed 90-day orders and Medication Administration Records. This training will be completed by 2/21/24. Signature sheets will be maintained by the Health Services Supervisor and copies will be sent to the Administrator.
In order to monitor the effectiveness of this training, monthly audit sheets for all individuals residing in the Allegheny/Beaver ICF homes will be sent to the Health Services Supervisor for four months, from February 2024 through May 2024. Any issues discovered during the monthly audit process will be immediately reported to the Health Services Supervisor. Completed audit sheets will be maintained by the Health Services Supervisor and copies will be sent to the Administrator.
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