Health inspection·June 23, 2023

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 resident and staff interviews, state regulations, record review, scope of practice, and facility policy, it was determined that the facility failed to follow professional standards of practice when providing medication administration to 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 Administering Medications no date, states, Medications must be administered in accordance with the orders, including any required time-frame. The policy also states, If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident, or suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the Resident's Attending Physician or the facility's Medical director to discuss the concerns. A review of the clinical record for Resident 1 on June 22, 2023, at 5:00 PM, revealed diagnoses that included major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) . During an interview with Resident 1 on June 22, 2022, at approximately 4:15 PM, Resident 1 stated that she was not administered her Lasix (medication for edema) or the clonazepam (medication to treat her anxiety) on June 16, 2023, as ordered by the physician. Resident 1 also stated that she reminded the medication nurse at 3:30 PM that she hadn't received the clonazepam, but the nurse stated that it was too close to the next dose. Resident 1 stated that she requested the nurse to call the physician because he could approve administering the missed dose, but the nurse never administered the missed dose and Resident 1 stated the nurse would not call the physician. A review of Resident 1's Medication Administration Record (MAR) revealed orders for clonazepam 0.5 milligrams daily at 2:00 PM, and Lasix 20 milligrams daily at 1:00 PM. Page 1 of 2 395964 395964 06/23/2023 Shippensburg Rehabilitation and Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Further review of the MAR revealed that Resident 1 was not administered her clonazepam on June 16, 2023, at 2:00 PM. The MAR was coded that the Lasix was administered at 2:57 PM. The facility interviewed Employee 1 (Licensed Practical Nurse) who was administering medications on the afternoon of June 16, 2023. Employee 1 stated that she marked the Lasix in error and that it was not administered. Employee 1 also stated that she realized at the end of the day that she failed to click to the next page of the MAR, which detailed the order for clonazepam. Employee 1 stated that she informed the charge nurse and the charge nurse informed her to hold the medication as a nursing action. The Assistant Director of Nursing (ADON) stated Employee 1 worked until 5:00 PM on June 16, 2023. On June 22, 2023, the ADON provided email correspondence that revealed Employee 1 was re-educated on medication administration documentation, to administer all medications as ordered, and not to document a medication if not administered. On June 23, 2023, email correspondence from the Director of Nursing (DON) included a written statement by Employee 2 (Registered Nurse) who was the charge nurse on the afternoon of June 16, 2023. Employee 2 documented that Employee 1 informed her that the 2:00 PM clonazepam wasn't administered because she couldn't find Resident 1. Further review of Resident 1's care plan and clinical record failed to reveal that she has been evaluated to self-administer medications. During an interview with the ADON on June 22, 2022, at approximately 5:00 PM, she confirmed that Resident 1 should have received her Lasix and clonazepam as ordered. During correspondence with the DON on June 23, 2023, she stated that medications should be given as ordered by the physician depending on Resident availability. 28 Pa. Code 211.12(d)(1)(5)Nursing services 395964 Page 2 of 2