Pennsylvania Department of Health
MILLCREEK MANOR
Patient Care Inspection Results

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MILLCREEK MANOR
Inspection Results For:

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MILLCREEK MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on February 2, 2024, it was determined that Millcreek Manor was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:

Based on review of facility policies and clinical records, and staff interviews, it was determined that the facility failed to follow physician's orders for two of three residents reviewed (Residents R4 and R7).

Findings include:

Review of a facility policy entitled "Person Centered Medication Administration" dated 1/10/24, revealed that all nurses are to follow physician orders as written.

Review of the facility hypoglycemic (low blood sugar) protocol entitled "Standing Diabetic Orders" dated 11/15/23, revealed that if blood sugar (BS) is less than 70 [milligrams/deciliter (mg/dL)] and resident is symptomatic and able to swallow, squeeze one entire tube [of oral glucose (form of sugar)] into mouth.

Review of Resident R4's clinical record revealed an admission date of 6/29/22, with diagnoses that included diabetes, high blood pressure, and depression.

Resident R4's clinical record revealed a physician's order dated 7/18/23, for Insulin Lispro sliding scale before meals at 7:30 a.m., 11:30 a.m., and 4:30 p.m.. Physician's orders further indicated that if BS results are 0 - 69 mg/dL follow hypoglycemic protocol and if BS results are 401 mg/dL and higher to administer 12 units of insulin and to call the physician.

Resident R4's Medication Administration Record (MAR) revealed Resident R4's BS at 4:30 p.m. on 1/4/24, was 69 mg/dL. Further review of Resident R4's clinical record lacked evidence of Glucose Gel being administered in accordance with physician's order for a BS 0 - 69 mg/dL.

Resident R4's MAR revealed Resident R4's BS at 7:30 a.m. on 1/3/24, was 489 mg/dL, on 1/4/24, BS was 443 mg/dL, and on 1/5/24, BS was 476 mg/dL and BS at 4:30 p.m. on 1/10/24, was 416 mg/dL. Further review of Resident R4's clinical record lacked evidence of physician notification in accordance with physician orders.


Resident R7 was admitted to the facility on 5/19/21, with diagnoses that included diabetes, pancreatectomy (removal of the pancreas), and Hodgkin lymphoma (cancer of the immune system).

Resident R7's clinical record revealed a physician's order dated 4/5/23, and again on 1/11/24, for Free Style Libre (a small sensor is placed in the back of your arm so the device can continuously monitor your blood sugars) every 3 hours and if results are above 400 mg/dL to notify physician.

Resident R7's MAR revealed the following BS results for January 2024 at 12:00 a.m.:
1/02/24 438 mg/dL
1/03/24 415 mg/dL
1/12/24 405 mg/dL
1/13/24 475 mg/dL
1/17/24 455 mg/dL
1/18/24 415 mg/dL
1/19/24 403 mg/dL
1/22/24 460 mg/dL
1/27/24 498 mg/dL
1/31/24 553 mg/dL

Resident R7's MAR revealed the following BS results for January 2024 at 3:00 a.m.:
1/13/24 425 mg/dL
1/17/24 422 mg/dL
1/20/24 425 mg/dL

Resident R7's MAR revealed the following BS results for January 2024 at 6:00 a.m.:
1/13/24 417 mg/dL
1/29/24 566 mg/dL
1/31/24 420 mg/dL

Resident R7's MAR revealed the following BS results for January 2024 at 9:00 a.m.:
1/13/24 478 mg/dL
1/18/24 524 mg/dL
1/19/24 407 mg/dL
1/27/24 489 mg/dL

Resident R7's MAR revealed the following BS results for January 2024 at 12:00 p.m.:
1/01/24 444 mg/dL
1/03/24 416 mg/dL
1/17/24 569 mg/dL
1/30/24 537 mg/dL

Resident R7's MAR revealed the following BS results for January 2024 at 3:00 p.m.:
1/17/24 422 mg/dL
1/18/24 552 mg/dL
1/19/24 403 mg/dL
1/24/24 413 mg/dL
1/27/24 428 mg/dL
1/30/24 479 mg/dL

Resident R7's MAR revealed the following BS results for January 2024 at 6:00 p.m.:
1/11/24 583 mg/dL
1/12/24 428 mg/dL
1/17/24 555 mg/dL
1/19/24 403 mg/dL
1/21/24 416 mg/dL
1/24/24 442 mg/dL
1/27/24 474 mg/dL
1/30/24 598 mg/dL

Resident R7's MAR revealed the following BS results for January 2024 at 9:00 p.m.:
1/02/24 492 mg/dL
1/12/24 518 mg/dL
1/19/24 457 mg/dL
1/22/24 465 mg/dL
1/23/24 432 mg/dL
1/24/24 408 mg/dL
1/26/24 498 mg/dL
1/27/24 420 mg/dL
1/31/24 469 mg/dL


Resident R7's clinical record lacked evidence of physician notification in accordance with physician orders for the above identified BS levels.

During an interview on 2/2/24, at approximately 12:23 p.m. the Nursing Home Administrator and Director of Nursing confirmed the physician ordered hypoglycemic protocol was not followed in accordance with physician orders for Resident R4.

During an interview on 2/2/24, at approximately 4:10 p.m. the Nursing Home Administrator and Director of Nursing confirmed the clinical record lacked evidence of physician notification in accordance with physician orders for Residents R4 and R7's BS above 400 mg/dL as identified above.

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1)(5) Nursing services





 Plan of Correction - To be completed: 03/04/2024

A review of documentation, going back for all residents who had blood glucose readings obtained will be audited for the last prior two months to determine if any other residents had similar situations. These situations will be addressed by the assistant director of nursing/designee. The Director of Nursing will monitor to ensure completion.

The physician and family will be notified of any instances where the physician order concerning blood glucose readings and the protocols to be followed were not followed. Families and resident will be notified as well.

R4, R7 and all other residents will have blood glucose readings obtained and protocols followed per physician order.

All nurses will be educated on following physician orders for obtaining blood glucose monitoring, following blood glucose protocols per physician order and notifying family and physicians.

Medication Administration Records and nurses notes will be monitored by Director of Nursing/designee 5 times a week times two weeks, weekly times two weeks and then monthly times two months to ensure blood glucose protocols and blood glucose physician orders are followed and family and physician are notified as needed. Correction action will be taken as needed. Nursing Home Administrator will monitor to ensure completion.

Results of the audit will be discussed in monthly quality assurance meetings.

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on review of facility policy and clinical records, and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for one of three residents reviewed (Resident R7).

Findings include:

Review of a facility policy entitled "Person Centered Medication Administration" dated 1/10/24, revealed that all nurses are to follow physician orders as written.

Resident R7's clinical record revealed an admission date of 5/19/21, with diagnoses that included diabetes, pancreatectomy (removal of the pancreas), and Hodgkin lymphoma (cancer of the immune system).

Resident R7's clinical record revealed physician's order dated 12/28/23, for "Novolog (type of insulin) 100 Units/ml (milliliter) inject 3 units subcutaneous (sq - injected into the tissue between the skin and muscle) in the morning (8:00 a.m.) for diabetes. Hold if BS (blood sugar) is below 270 [milligrams/deciliter (mg/dL)].

Resident R7's January 2024 Medication Administration Record (MAR) revealed that Resident R7 had a BS of 181 mg/dL on 1/5/24, 223 mg/dL on 1/6/24, and 144 mg/dL on 1/7/24, and staff failed to hold the Novolog 3 units as ordered for those occurrences.

Resident R7's clinical record revealed physician's order dated 12/27/23, for Novolog inject 3 units sq in the afternoon (12:00 p.m.) for diabetes. Hold if BS is below 270 mg/dL.

Resident R7's MAR revealed that Resident R7 had a BS of 236 mg/dL on 1/4/24, and staff failed to hold the Novolog 3 units as ordered.

Resident R7's clinical record revealed physician's order dated 12/27/23, and 1/12/24, for Novolog inject 3 units sq in the evening (5:00 p.m.) for diabetes. Hold if BS is below 270 mg/dL.

Resident R7's MAR revealed that Resident R7 had a BS of 226 mg/dL on 1/5/24, 150 mg/dL on 1/6/24, and 256 mg/dL on 1/15/24, and staff failed to hold the Novolog 3 units as ordered.

During an interview on 2/2/24, at approximately 12:23 p.m. the Nursing Home Administrator and Director of Nursing confirmed that Resident R7's insulin was not held in accordance with physician's orders and that Resident R7 was administered 3 units of Novolog when his/her BS was below 270 mg/dL on the above dates and times.

28 Pa. Code 211.12(d)(1)(5) Nursing services

28 Pa. Code 211.10(c) Resident care policies



 Plan of Correction - To be completed: 03/04/2024

All physician orders related to insulin administration in the last 30 days will be reviewed by the assistant director of nursing/designee to ensure that the physician orders pertaining to insulin administration were followed. Director of nursing will monitor to ensure completion.

Insulin orders for R7 and all other residents will be followed.

All nurses will be educated on how to properly follow a physician order that pertains to insulin administration.

The director of nursing/designee will audit the medication administration record to ensure compliance five days a week x two weeks; weekly x two weeks; then monthly x two months. Corrective action will be taken as needed.

Results of the audits will be discussed at the monthly quality assurance meeting.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(i) Medical records.
§483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:

Based on review of facility policy and clinical records and staff interview, it was determined that the facility failed to maintain accurate and complete documentation related to refusal of medications for one of three residents reviewed (Resident R4).

Findings include:

Review of facility policy entitled "Charting and Documentation" dated 1/10/24, revealed that the "residents medical record is a concise account of treatment, care, response to care, signs, symptoms, and progress of resident's condition" and it is a "written support of care and services provided" and serves as "communication among caregivers who are providing services."

Resident R4's clinical record revealed an admission date of 6/29/22, with diagnoses that included diabetes, high blood pressure, and depression.

Resident R4's clinical record revealed a physician's order dated 12/7/23, for Insulin Lispro 10 units subcutaneous (sq - injected into the tissue between the skin and muscle) daily at 11:30 a.m. Resident R4's Medication Administration Record (MAR) revealed Resident R4's 11:30 a.m. insulin was held on 1/1/24, 1/6/24, and 1/7/24, due to blood sugar results and on 1/10/24, indicating coverage was not needed.

Resident R4's clinical record revealed a physician's order dated 1/11/24, for Insulin Lispro 5 units sq daily at 11:30 a.m. Resident R4's MAR revealed Resident R4's 11:30 a.m. insulin was held on 1/20/24, indicating coverage was not needed.

Resident R4's clinical record revealed a physician's order dated 1/23/24, for Insulin Lispro 4 units sq daily at 11:30 a.m. Resident R4's MAR revealed Resident R4's 11:30 a.m. insulin was held on 1/29/24, due to blood sugar results.

Resident R4's clinical record revealed a physician's order dated 1/4/23, for Insulin Lispro 15 units sq daily at 4:30 p.m. Resident R4's MAR revealed Resident R4's 4:30 p.m. insulin was held on 1/9/24, and 1/19/24, indicating coverage was not needed, and on 1/13/24, indicating vital signs were outside parameter.

Resident R4's clinical record revealed a physician's order dated 1/22/24, for Insulin Lispro 13 units sq daily at 4:30 p.m. Resident R4's MAR revealed Resident R4's 4:30 p.m. insulin was held on 1/22/24, indicating coverage was not needed.

Resident R4's clinical record revealed a physician's order dated 1/4/24, for Lantus (type of insulin) 33 units sq daily at 4:30 p.m. Resident R4's MAR revealed Resident R4's 4:30 p.m. insulin was held on 1/13/24, indicating vital signs were outside parameter.

Resident R4's clinical record revealed a physician's order dated 12/28/23, for Lantus 33 units sq daily at 9:00 p.m. Resident R4's MAR revealed Resident R4's 9:00 p.m. insulin was held on 1/2/24, indicating coverage was not needed.

During an interview on 2/2/2024, at approximately 12:19 p.m. Nursing Home Administrator (NHA) and Director of Nursing (DON) stated that Resident R4 will often time refuse his/her insulin. NHA and DON also confirmed that Resident R4's physician's order lacked parameters for holding insulin and was for routine insulin administration and not based on a sliding scale requiring coverage. NHA and DON stated they believed all the dates and times indicated above were times Resident R4 refused his/her insulin and staff inaccurately documented that on the MAR.

28 Pa. Code 211.5(f)(ii)(iii) Medical records

28 Pa. Code 211.12(d)(1)(5) Nursing services




 Plan of Correction - To be completed: 03/04/2024

The Director of Nursing/Designee will review of all resident records on residents who received insulin in the last 30 days to ensure accurate and complete documentation related to refusal of insulin. Additionally, physician orders for insulin will be reviewed to ensure parameters are included as needed. Assistant Director of Nursing/designee will monitor the Director of Nursing to ensure completion.

Resident R4 and all other resident refusals of insulin will be documented.
All nurses will be educated on insulin refusal documentation.

The Assistant Director of Nursing/Designee will audit the medication administration record for insulin refusal five times a week times two weeks, weekly times two weeks and monthly times two months. Corrective action will take place as needed.

Results of the audit will be discussed at the monthly quality assurance meeting.


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