Pennsylvania Department of Health
SENA KEAN NURSING AND REHABILITATION CENTER
Patient Care Inspection Results

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SENA KEAN NURSING AND REHABILITATION CENTER
Inspection Results For:

There are  102 surveys for this facility. Please select a date to view the survey results.

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SENA KEAN NURSING AND REHABILITATION CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an Abbreviated Complaint Survey completed on January 31, 2024, it was determined that Sena Kean Nursing and Rehabilation Center 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 clinical records and staff interviews, it was determined that the facility failed to ensure that known medication allergies were verified prior to the administration of a medication for one of six residents reviewed (Resident R1).

Findings include:

Resident R1's clinical record revealed an admission date of 3/5/13, with diagnoses that included depression, schizophrenia (a disorder that affects the ability to think, feel and behave clearly), abnormal involuntary moments, convulsions/seizures and delusional disorders.

A nurse's note dated 1/15/24, at 10:00 a.m. documented a decline in Resident R1's condition and a physician's order to administer a one time dose of Haldol (an antipsychotic medication used to treat mental disorders including schizophrenia) 2.5 milligrams (mg).

The medication administration record revealed that the Haldol 2.5 mg IM (intramuscular injection) was administered at 11:30 a.m. on 1/15/24, as physician ordered.

Review of a nurse's note dated 1/15/24, at 12:25 p.m. identified the discovery that Haldol was listed under Resident R1's allergies.

A review of Resident R1's clinical record revealed that Haldol was listed as an allergy.

During interview on 1/30/24, at 1:50 p.m. Registered Nurse Employee E1 confirmed that Resident R1's allergy list was not checked prior to the administration of Haldol.


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




 Plan of Correction - To be completed: 02/26/2024

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
Resident R1 continues to reside at the facility with no negative outcomes.

Current residents with listed Haldol allergies have been reviewed and cross referenced against current medication orders.

Current Registered Nurse staff have been re-educated on the Medication Administration policy. With emphasis on reviewing new orders against resident documented allergies.

Facility DON or designee to audit new medication orders against resident documented allergies for contradiction daily for five (5) days, weekly for three (3) weeks, and monthly for two (2) months.

Results of audits will be reviewed with the Quality Assurance Performance Improvement (QAPI) Committee

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