Quality Life Services: Medication Safety Failures - PA

The violations put residents at risk of dangerously low blood pressure that could lead to falls, fainting, or worse complications.

For one resident, staff administered Metoprolol 20 times between January and February when blood pressure readings fell below the threshold where doctors had ordered the medication to be held. On January 5, staff gave the blood pressure drug when the resident's reading was just 102/72 — well below the 120/70 threshold specified in physician orders.

The pattern continued through February. On February 6, staff administered Metoprolol when the resident's blood pressure measured 102/74. On February 20, they gave it again at 106/80.

"Resident 24's Metoprolol was administered on the above dates when it should have been held," the nursing home administrator confirmed to inspectors.

A second resident received three different blood pressure medications when readings fell below hold parameters. Staff gave Amlodipine on January 31 when blood pressure measured 98/60, despite orders to hold the drug for readings below 110 systolic. They administered it again February 5 at 102/54.

The same resident received Atenolol four times when blood pressure dropped below 110 systolic, including twice when readings were 98/60 and 102/54. Staff also gave Hydralazine seven times below the hold threshold, including once when blood pressure measured just 90/50.

For some medications, staff failed to check heart rates before administration despite physician orders requiring monitoring. The resident was supposed to receive Atenolol and Hydralazine only if heart rate stayed above 55 beats per minute, but records showed no documentation that staff checked pulse rates before giving the drugs.

The medication errors occurred alongside other care failures at the 787 Goucher Street facility.

Staff continued providing health shakes and fortified foods to a resident with weight loss for a month without physician orders. The resident had received the nutritional supplements before a December hospital stay, but when she returned December 30, no orders were written to continue them.

The dietitian told inspectors she realized the oversight January 30 and re-ordered the supplements. "Resident 14 continued to receive health shakes twice a day and fortified foods with all meals, despite not having a physician's order," she said.

The dietary manager confirmed the resident had been getting the unauthorized supplements since her December 30 readmission.

Inspectors also found failures in basic assessment documentation. Three residents' quarterly evaluations incorrectly reported they weren't receiving medications they actually took daily.

One resident received gabapentin twice daily and once at bedtime for rheumatoid arthritis from January 16 through February 19, but his February 3 assessment indicated he hadn't received anticonvulsant medication during the review period.

Another resident took 25 milligrams of Seroquel daily starting January 10, but her January 15 assessment showed no antipsychotic medication use.

A third resident received gabapentin three times daily for polyneuropathy from December 31 through January 3, but his January 3 assessment failed to document the anticonvulsant.

The administrator acknowledged all three assessments were coded incorrectly.

Care planning deficiencies affected infection control protocols. One resident with a surgically implanted gallbladder drain required Enhanced Barrier Precautions, with signs posted on his door and protective equipment available for staff. Physician orders from May prohibited showering due to the drain and required daily vigorous flushing.

Staff knew the protocols. A nursing aide confirmed the resident was on Enhanced Barrier Precautions and that staff must wear gowns when providing care.

But no care plan addressed the precaution requirements.

"Resident 6's care plan did not address his care needs related to EBP," the administrator confirmed.

The facility had previously struggled with weight monitoring. After October violations for failing to obtain required re-weights, administrators created a weight monitoring team and started auditing all residents.

But problems persisted. One resident dropped from 127.4 pounds December 13 to 117.8 pounds January 1 — a loss exceeding the five-pound threshold requiring immediate re-weighing. The dietitian requested a re-weight January 9, noting the significant loss.

No re-weight occurred.

On January 16, staff recorded the resident's weight as 136.2 pounds — an impossible 18.4-pound gain in 15 days. They didn't obtain a verification weight until January 21, when it measured 116.4 pounds.

The nursing director and administrator confirmed staff failed to follow the dietitian's re-weight recommendations and facility policy.

The inspection covered 26 residents at the facility, which provides long-term care and rehabilitation services in Johnstown. Federal inspectors cited violations affecting few to some residents, with minimal harm or potential for actual harm.

All violations occurred despite the facility's corrective actions from previous inspections, including the weight monitoring team and audit system implemented after October 2024 findings.

The medication administration failures represent the most serious safety concerns, as giving blood pressure drugs when readings are already low can cause dangerous drops in circulation, potentially leading to falls, loss of consciousness, or cardiovascular complications in elderly residents.

Quality Life Services did not immediately respond to requests for comment about the inspection findings.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Quality Life Services - Westmont from 2025-02-20 including all violations, facility responses, and corrective action plans.

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