INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 13-14, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, The Highland House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
Based on observation of medication administration, staff and client interviews and a review of the policy and procedures, the facility failed to maintain client confidentiality as required by facility policy.
The facility's policy manual states that "the names and addresses as well as all other information and records pertaining to clients are not to be disclosed except with the explicit written permission of the individual(s) involved."
Client medication administration is conducted in a support staff office. This office was observed to be very busy with both staff and clients entering and exiting the office frequently. The door was observed to be open and closed frequently. Both staff and clients were interviewed and it was reported that the door does not always remain closed when clients are taking their medication, making the conversations between client and staff able to be heard by others waiting in line for their medications.
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Plan of Correction
Procedures for observing self-administration of meds will be updated to reflect the use of a sound shield in the hallway and self-administration will occur only after door is closed and locked to prevent unwanted access by other individuals. Re-training for all staff affected will be completed by the director or designee by 11/15/23. Ongoing monitoring will be completed by random inspection by the director or a designee during the med times established for the residents. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in four of four client records.
Client #1 was admitted on May 4, 2023 and was active at the time of the onsite investigation. The client was prescribed a medication and the prescription stated that one capsule was to be taken four times daily. The medication administration records showed that the medication was not given on July 8 and July 26, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed.
Client #1 was prescribed a medication and the prescription stated that one capsule was to be taken twice daily. The medication administration records showed that the medication was not given on July 15, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed.
Client #1 was prescribed a medication and the prescription stated that one tablet was to be taken daily. The medication administration records showed that the medication was not given on August 15-17, 2023. The documented reason for not being taken was " out of medication, med ordered. "
Client #1 was prescribed a medication and the prescription stated that one capsule was to be taken twice daily. The medication administration records showed that the medication was not given on August 3-5, 2023. The documented reason for not being taken was " med not here, out of med. "
Client #1 was prescribed a medication and the prescription stated that one tablet was to be taken once daily. The medication administration records showed that the medication was not given on August 17, 2023. The documented reason for not being taken was " med is ordered. "
Client #1 was prescribed a medication and the prescription stated that one capsule to be taken daily. The medication administration records showed that the medication was not given on September 5, 2023. The documented reason for not being taken was " awaiting refill from pharmacy. "
Client #1 was prescribed a medication and the prescription stated that one tablet was to be taken at bedtime. The medication administration records showed that the medication was not given on September 20, 2023. The documented reason for not being taken was " out of medication. "
Client #2 was admitted on March 31, 2023 and was active at the time of the investigation. Client #2 was prescribed a medication and the prescription stated that one film was to be taken twice daily. The medication administration records showed that the medication was not given on July 9, 2023. The documented reason for not being taken was " missed appointment - out of medication. " This medication was not given from July 9-22, 2023.
Client #2 was prescribed a medication and the prescription stated that one tablet was to be taken three times per day. The medication administration records showed that the medication was not being given on August 5, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on that date. This medication was also not given on August 13-16, 2023. The documented reason for not being taken was " waiting for prescription. "
Client #3 was admitted on February 15, 2023 and was active at the time of the investigation. Client #3 was prescribed a medication and the prescription stated that one tablet was to be taken twice daily. The medication administration records showed that the medication was not given on July 9-14, 2023. The documented reason for not being taken was " meds not delivered, waiting on rx. "
Client #4 was admitted on May 26, 2023 and was active at the time of the investigation. Client #4 was prescribed a medication and the prescription stated that one film was to be taken twice daily. The medication administration records showed that the medication was not given on July 7, 9 and 10, 2023. The documented reason for not being taken was " meds were not delivered. "
Client #4 was prescribed a medication and the prescription stated that one tablet was to be taken three times per day. The medication administration records showed that the medication was not given in the afternoon on July 8, 2023. There was no additional documentation included indicating a reason why the medication was not given as prescribed on that date.
Client #4 was prescribed a medication and the prescription stated that one capsule was to be taken three times daily. The medication administration records showed that the medication was not given July 21-26, 2023. The documented reason for not being taken was " waiting on prescription. "
Client #4 was prescribed a medication and the prescription stated that one capsule was to be taken three times a day. The medication administration records showed that the medication was not given on August 12, 2023. The documented reason for not being taken was " out of medication. "
Client #4 was prescribed a medication and the prescription stated that one tablet was to be taken at bedtime. The medication administration records showed that the medication was not given on August 26-31, 2023. The documented reason for not being taken was " waiting on prescription. "
Client #4 was prescribed a medication and the prescription stated that one tablet was to be taken at daily. The medication administration records showed that the medication was not given on September 6-7 and 10-14, 2023. The documented reason for not being taken was " out of med. "
Client #4 was prescribed a medication and the prescription stated that one tablet was to be taken at bedtime. The medication administration records showed that the medication was not given on September 1-13, 2023. The documented reason for not being taken was " waiting for prescription. "
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Plan of Correction
All staff will be re-trained by 11/15/23 by the director or designee on the proper procedures to observe self-administration and document those observations on the electronic MAR. This training will include the proper way to document when a resident refuses a med, when they are off-campus, or when a refill is unavailable due to the resident not completing a doctors appointment. Ongoing monitoring will be completed by random inspection of the electronic MAR by the director or designee, and remedial training will be completed as needed. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records and administrative documentation as well as staff and client interviews, the facility failed to notify the Department within 3 business dates of a serious injury due to a medication error or unusual circumstance.
Client #1 was admitted on May 26, 2023 and was active at the time of the investigation. On September 11, 2023, the client mistakenly took three times the prescribed amount of a once a day medication as it was " swapped " in the bottle for a three times a day medication. This caused the client to experience " super mania " where they were unable to sleep and saying " strange things " that didn ' t make sense. There is no documentation that an unusual incident report was filed with DDAP.
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Plan of Correction
Unusual incident reports will be completed and submitted via the electronic unusual incident reporting portal within 3 days by the lead clinician or director. Correspondence (email or text) between these individuals will serve as an accountability tool and will note when the incident was reported. |