Health inspection·February 12, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on staff interviews, record review, policy 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 of three residents reviewed (Resident 1). Residents Affected - Few 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, stated 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 Director of Nursing (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. Page 1 of 2 395247 395247 02/12/2024 Gardens at Gettysburg, The 741 Chambersburg Road Gettysburg, PA 17325

F 0658 During an interview with the Nursing Home Administrator (NHA) on February 12, 2024, the NHA confirmed that Employee 1 did not follow the facility policy to prevent the medication error. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.10(c) Resident care policies Residents Affected - Few 28 Pa. Code(d)(1)(5) Nursing services 395247 Page 2 of 2