Health inspection·April 25, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner for one of 12 residents reviewed (Resident R8). Findings include: Review of Resident R8's clinical record revealed that the resident was transferred to the hospital on September 7, 2023, due to fever. Further review of Resident R8's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to Resident R8 and their representative(s). Interview with the facility Administrator, Employee E1, on April 24, 2024, at 9:43 a.m. confirmed that Resident R8 and their representative were not notified in writing of the reasons for the transfer, and in a language and manner they understood. Further interview confirmed there was no system in place regarding written notice before discharge. 28 Pa. Code 201.14(a) Responsibility of license 28 Pa. Code 201.29(a) Resident rights Page 1 of 2 395718 395718 04/25/2024 Waverly Heights 1400 Waverly Road Gladwyne, PA 19035

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on review of the clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error related to the receiving wrong medication which was prescribed for another resident for one of 4 residents reviewed for medication administration (Resident R9). Residents Affected - Few Findings include: Review of FDA (Food and Drug Administration) guidelines for Morphine sulfate revealed that Morphine sulfate is an opioid agonist indicated for the relief of moderate to severe acute and chronic pain where an opioid analgesic is appropriate. (1) Morphine sulfate 100 mg per 5 mL (20 mg/mL) solution is indicated for the relief of moderate to severe acute and chronic pain in opioid-tolerant patients. WARNINGS AND PRECAUTIONS Risk of Medication Errors: Use caution when prescribing, dispensing, and administering to avoid dosing errors due to confusion between different concentrations and between mg and mL, which could result in accidental overdose and death. (5.1) Respiratory depression: Increased risk in elderly, debilitated patients, those suffering from conditions accompanied by hypoxia, hypercapnia, or upper airway obstruction. (5.2) Controlled substance: Morphine sulfate is a Schedule II controlled substance with an abuse liability similar to other opioids. (5.3) CNS effects: Additive CNS depressive effects when used in conjunction with alcohol, other opioids, or illicit drugs. Review of Physician orders for Resident R9 for April 2024 revealed no evidence that the resident had a physician order for morphine sulfate. Review of a facility investigation dated April 4, 2024, revealed that the charge nurse administered Morphine Sulfate (This medication is used to help relieve moderate to severe pain. Morphine belongs to a class of drugs known as opioid analgesics) 0.25 milligrams to Resident R1 by error. Nurse recognized error when she signed out the medication. Interview with Resident R9 on April 22, 2024, at 11:00 a.m. stated she received the wrong medication approximately 2 weeks ago. Resident stated she was sleeping and during her sleep she was awaken by a nurse by placing something like a liquid in her mouth. Resident stated she was asleep, and the nurse did not ask her anything to identify her. Interview with Director of Nursing on April 24, 2024, at 2:38 p.m. stated nurse did not follow appropriate practice of medication administration. Nurse did not identify the right resident/patient before she administered the medication which resulted in Resident R9 receiving wrong narcotic pain medication which could potentially cause serious side effects. 28 Pa. Code 211.10(c) Resident care policies 28 Pa. Code 211.12(d)(1) Nursing services 28 Pa. Code 211.12(d)(3) Nursing services 28 Pa. Code 211.12(d)(5) Nursing services 395718 Page 2 of 2