INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 02, 2017 by staff from the Division of Accountability and Program Improvement. Based on the findings of the investigation, Gaudenzia Common Ground 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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709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Facility staff interviews were conducted in conjuncture with a client file review on February 2, 2017. Based on this review, the facility failed to file a written usual incident report with the Department within 3 business days following an unusual incident involving a physical assault by staff or a client.
On October 23, 2015, a client physically assaulted a staff member at the facility. There was no documentation available to verify that this incident had been reported to DDAP.
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Plan of Correction
The Facility Director will conduct a training with all staff on proper completion of usual and unusual incident reporting occurring within the facility. Staff will be educated on the types of unusual incidents and filing of a timely incident report to DDAP withing 3 days of the incident occurring. The Program Director will be responsible for collecting the reports and directly overseeing the incident reports are faxed to DDAP within 3 business days. This plan will be implemented by 6/1/17 |
709.63(a)(4) LICENSURE Medication records
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(4) Medication records.
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Observations
A review of client records was conducted on February 2, 2017. Based on this review, the facility failed to insure a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to medication records.
A review of the "Medication Administration Sheet" revealed medication documentation issues. On October 21, 2015, the client was prescribed 200 mg of Tegretal to be administered twice daily at 07:30 and 17:30. On this same date, October 21, 2015, the client was prescribed 15 mg of Buspar to be administered three times daily at 07:30 at 12:30 and at 17:30. On October 22, 2015, it appears the client was administered one dose of Tegretal at 07:30 and did not receive his second dose at 17:30. On this same date, October 22, 2015, the client was administered his 07:30 dose of Buspar but he did not receive his 12:30 dose nor his 17:30 dose. There was not documentation available to explain why these doses were not administered per physician orders.
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Plan of Correction
The RN supervisor will be responsible for overseeing medication administration for each client. The RN supervisor will be responsible for reporting to the Program Director any discrepancies or changes occurring in the administration of medication to clients during daily morning meeting. The RN supervisor is responsible for the daily auditing of client MAR's. The RN supervisor will record findings of medication errors and be responsible for recording the information on an incident report. The RN supervisor will be responsible for identifying reasons for missed doses and address with the client and dispensing nurse directly afterwards to investigate findings.The Program Director and RN supervisor will be responsible for training medical staff and educating them on how to properly document missed doses and making sure a plan of action is initiated to eliminate potential concerns. This plan will be implemented by 6/15/2017 |