Chapel Manor Nursing Home- Philadelphia (July 10th)
Based on review of nursing home policy, clinical record review, interviews with staff and observations, it was determined that the facility failed to complete interdisciplinary assessments to evaluate a resident’s ability to safely administer medications for one of 30 residents reviewed. Findings included the following: facility policy titled, Medication Self Administration, dated May 11, revealed residents may self administer medications if the resident is able demonstrate; knowledge of medications, medication schedule and a physician’s order permitting a resident to administer their own medications, including over the counter medications and vitamins. During initial tour of the facility on July 5, 2012, at 9:35 a.m., Resident R187, was observed to have two pill bottles of Vitamin C, a bottle of Tums and one pill in a medicine cup which was identified by Employee E5, as Vitamin B-12, 1000mcg. During the observation an interview with Employee E5 was conducted and confirmed that the staff was not aware that the resident was taking over the counter medications. The nurse further confirmed that the staff that administered the B-12, should have observed Resident R187 swallow the medication. Clinical record review, on July 5, 2012, revealed there was no physician’s order for the over the counter medications or permitting self administration by Resident R187. The facility failed to complete interdisciplinary assessment prior to self-administration of medication by a resident and failed to ensure Resident R187 ‘s compliance.
Based on interview with residents, observation, staff and review of clinical records and nursing home policy it was determined that the facility it was determined that the facility failed to follow physician’s orders. Findings included the following: Review of Resident R54’s minimum data set, dated June 5, 2012, revealed an undisclosed diagnosis. Further review of the assessment revealed that the resident required extensive assistance with transfers, ambulation and dressing. Review of physician’s orders, dated June 29, 2012, revealed that the resident was to be placed on a fluid restriction of no more than 1000 milliliters daily. This order indicated that of this 1000 ml of fluid, that dietary would provide the resident with 700 ml and nursing would provide 300 ml. A review of the Medication Administration Record of fluid, that dietary would provide the resident with 700 ml. and nursing would provide 300 ml. A review of the Medication Administration Record of fluid. Review of the facility’s policy, entitled Fluid Restriction, dated June 1, 1996 and reviewed yearly, stated that close monitoring will be provided to maintain adequate hydration. The policy continued that the staff were to maintain strict fluid intake and document’s compliance with restriction in the nurses’ notes. Observation of the resident’s and of the resident’s room July 5, 2012, at 2:00 p.m., with the resident in the bed, revealed on the overbed table, a 16 ounce cup, with the resident’s name and room number on the cup, filled with fluid. Interview with the resident at the time revealed that since the resident did not care for water, the cup was filled with juice.