Observations
Based on a review of staff time sheets, the nursing schedule and the client census, the facility failed to have one primary care staff person available for every seven clients.
On May 15, 2023, the client census was 24. There were two primary care staff on duty from 5pm-9pm and three primary care staff on duty from 9pm-12am.
On May 16, 2023, the client census was 21. There were two primary care staff on duty from 8pm-11pm.
On May 17, 2023, the client census was 22. There were three primary care staff on duty from 12am-7am, two primary care staff from 4pm-9pm and three primary care staff from 9pm-12am.
On May 18, 2023, the client census was 17. There were two primary care staff on duty from 7pm-9pm.
On May 19, 2023, the client census was 21. There were two primary care staff on duty from 6pm-9pm.
On May 20, 2023, the client census was 23. There were one to three primary care staff on duty for that 24 hour time period.
On May 21, 2023, the client census was 22. There were four primary care staff on duty from 2:30pm-4pm. There were one to three primary care staff on duty during the other 22.5 hours of May 21st.
On May 22, 2023, the client census was 21. There were two primary care staff on duty from 5pm-9pm.
On May 23, 2023, the client census was 17. There were two primary care staff on duty from 6pm-9pm.
On May 24, 2023, the client census was 19. There were two primary care staff on duty from 11pm-12am.
On May 25, 2023, the client census was 21. There were two primary care staff on duty from 12am -7am and from 4pm-11pm.
On May 26, 2023, the client census was 24. There were three primary care staff on duty from 12 am-7am, two primary care staff on duty from 4pm-11pm and three primary care staff on duty from 11pm-12am.
On May 27, 2023, the client census was 26. There were three primary care staff on duty from 12 am-7am, two primary care staff on duty from 7am-11pm and three primary care staff on duty from 11pm-12am.
On May 28, 2023, the client census was 24. There were three primary care staff on duty from 12 am-7am, two primary care staff on duty from 7am-11pm and three primary care staff on duty from 11pm-12am.
On May 29, 2023, the client census was 22. There were three primary care staff on duty from 12 am-7am, two primary care staff from 3pm-9pm and three primary care staff on duty from 9pm-12am.
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Plan of Correction
In response to the inadequate staffing ratios in the Duncansville withdrawal management unit the following will occur. LPN's and RN's will be prioritized as assigned nursing staff to the withdrawal management unit to maintain a ratio of 1 nurse to 7 withdrawal management clients. Additionally, there are two designated clinical staff who are assigned specifically to the withdrawal management unit Monday through Friday 8:00 AM to 4:00 PM to assist with maintaining appropriate ratios. A strategic plan has been developed to increase detox clinical support during off hours and weekend days which will be implemented to assist with appropriate staffing ratios in withdrawal management. Clinical positions have already been posted so recruiting and hiring can occur. A daily census review will be completed by Nurse Manager or Nurse Supervisor to ensure that the appropriate amount of LPN's and RN's are scheduled when designated clinical staff are not present to ensure the appropriate ratios are maintained. |
Observations
Based on a review of client medication records, the facility failed to follow their written policy and procedures regarding medications used by clients in two out of five client records reviewed.
The Medication Use, Medication Control, and Diversion Prevention policy states medications are routinely obtained from a contracted pharmacy and these medications are delivered or picked up in a timely manner. Clients may self-administer medications under the supervision of staff members who have been trained to monitor self-administration. The policy also states that the Medication Administration Record for each client shall include if a medication was or was not administered along with which staff person was monitoring the administration process.
Client # 1 was admitted on 12/21/22 and discharged on 3/22/23. This client's medication administration record indicated that one or more medications was not available for self-administration for the following dates in 2023: January 4th, 5th, 6th, 8th, 9th and 20th; March 16th and 17th. In addition to the medication not being available for self-administration, documentation was missing from the record on if multiple medications were administered on March 18, 2023.
Client # 5 was admitted on 2/17/23 and discharged on 3/9/23. This client's medication administration record indicated that a medication was not available for self-administration on February 19, 2023.
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Plan of Correction
Nurse Manager will complete a re-training with the entire medical department who facilitate medication line to include reviewing the expectation that all medication times will contain staff signatures with corresponding indicators from the key outlining why a medication was or was not provided. This training will occur by 8/31/2023 and all nursing staff will sign off on the training acknowledging understanding of these expectations. This will be monitored during monthly chart audits completed by the Nurse Manager and submitted for review by ED/AED/DON. In regards to timely arrival of medications; Duncansville has two pharmacy drop offs daily for medications ordered. In the event that a medication is not available by the usual contracted pharmacy the facility will then utilize the alternative contracted pharmacy. If this medication is still not available, the facility will contact the Medical Director for an alternative medication to be prescribed and will be noted in the electronic medical record. In addition, the facility will increase communication with the admission team to ensure accurate information is provided pertaining to admitting clients and will educate on medication ordering policies/procedures as well as encourage clients to bring current supply of medications to better prevent missed doses. |