Pennsylvania Department of Health
GARDENS AT GETTYSBURG, THE
Patient Care Inspection Results

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GARDENS AT GETTYSBURG, THE
Inspection Results For:

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GARDENS AT GETTYSBURG, THE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated survey completed on February 12, 2024, it was determined that Gardens at Gettysburg, The was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards: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.
§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Observations:


Based on interview, record review, and the facility's licensed staff scope of practice, it was determined that the facility failed to follow professional standards of practice when providing medication administration for one (1) of three residents reviewed, Resident 1.

Findings include:

Review of the Pennsylvania Nursing Practice Act for Licensed Practical Nurses (LPN), Chapter 21.145. revealed Functions of the LPN. (a) The LPN is prepared to function as a member of the health-care team by exercising sound nursing judgement based on preparation, knowledge, experience in nursing and competency. The LPN participates in the planning, implementation and evaluation of nursing care using focused assessment in settings where nursing takes place. (1) An LPN shall communicate with a licensed professional nurse and patient's healthcare team members to seek guidance when the patient's care needs exceed the licensed practical nursing scope of practice.

A review of the facility policy titled, Medication Administration-General Guidelines last reviewed February 2024, states medications are administered in accordance with written orders of the attending physician.

Review of the clinical record for Resident 1 on February 9, 2024, at 1:00 PM, revealed diagnoses that included tibia and fibula fractures (both bones in lower right leg) due to a motor vehicle accident and chronic obstructive pulmonary disease (COPD- disease process that causes decreased ability of the lungs to perform).

A review of the facility event report revealed that on January 26, 2024, at 11:11 AM, Resident 1 was handed Resident 2's medications by Employee 1 (Licensed Practical Nurse). Resident 1 did take one of the pills from the cup and swallowed it, then stated to the nurse, "these don't look like my pills."

During an interview with the DON on February 9, 2024, the DON confirmed that Employee 1 retrieved the remaining pills from Resident 1 and reported the medication error immediately to the DON. The pill swallowed was identified as Resident 2's Tamsulosin (medication used to treat an overactive bladder). The DON also confirmed that the physician was notified, and the physician informed the staff to monitor Resident 1 for any side effects.

A review of the Medication Administration record for Resident 1 revealed she was never prescribed Tamsulosin during her stay at the facility from January 17, 2024, to February 5, 2024, when discharged to home.

During an interview with the Nursing Home Administrator (NHA) on February 12, 2024, the NHA confirmed that Employee 1 did not follow policy to prevent the medication error.

28 Pa. Code 211.10(c) Resident care policies.
28 Pa. Code(d)(1)(5) Nursing services.




 Plan of Correction - To be completed: 03/05/2024

1. Resident 1 had no adverse reactions from self-identified medication error. A medication error report was completed, the physician was notified and the resident was monitored for any negative outcomes.
2. Medication error reports for the last 30 days have been reviewed and no other residents have been identified as receiving incorrect medication.
3. Licensed Nurses will be re-educated by the Director of Nursing/Designee to understand the requirement of following the medication administration guidelines to prevent medication errors.
4. Random audits of medication passes will be done five times a week for four weeks then five times a month for two months to ensure nurses are following the medication administration guidelines to prevent medication errors. The results of the findings will be reported monthly at the facility Quality Assurance Performance Improvements meeting.


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