River Front Rehabilitation And Healthcare Center
RIVER FRONT REHABILITATION AND HEALTHCARE CENTER in PENNSAUKEN, NJ — inspection on August 14, 2024.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyors did not observe any data collection forms in the facility QAPI binder associated with the data collection for the expired medication QAPI plan for February or April of 2024. At this point the surveyors requested from the facility DON and/or Licensed Nursing Home Administrator copies of data collection for the QAPI plan for expired medication cart medications that was revealed via consultant pharmacist reports.
On 08/13/2024 at 01:09 PM, during an interview with the facility DON and ADON, the DON told the surveyors that they do not have any data collected for the expired medication QAPI plan for February or April of 2024 and that they cannot provide the surveyor with any data from the 2/2024 QAPI Action Plan related to pharmacy reports that have expired meds as a major concern.
The DON further told the surveyor that the reason they did not have any audits is because the QAPI plan did not work, and they are coming up with a new one. On 08/13/2024 at 02:32 PM, the facility told the surveyor when asked where the facility obtained a rate of 77% compliance on the April 2024 QAPI plan the DON told the surveyor that It's possible that the data reported came from the monthly CP visit.
NJAC 8:39-33.1(c) 33.2(a)(b)(d)
315225
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 315225 B.
Wing 08/14/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109
The surveyor reviewed the unsampled resident's electronic health record and noted an order for pantoprazole 40 mg give 1 (one) tablet orally one time a day for GERD was ordered on 05/24/22 and was discontinued on 03/03/24.
The discontinued medication remained within the resident's active inventory of medications through 08/07/24, until surveyor inquiry.
2. On 08/07/2024 at 11:34 AM, the surveyor reviewed the Narcotic (a controlled substance used to dull the senses and relieve pain) Book in the presence of LPN #1 for the Pavilion Two Unit Short Hall Medication Cart.
The surveyor reviewed the Narcotic Count Record for August 2024 and noted that LPN #1, who was scheduled to work the 7 AM to 3 PM shift, had already signed his name in the space provided for the Offgoing Nurse Signature for the 3 PM to 11 PM shift.
When the surveyor asked why he signed the Narcotic Count Record prior to performing a narcotic count of all controlled medications within the medication cart with the Oncoming Nurse he stated, So I do not forget.
On 08/07/2024 at 11:56 AM, the surveyor interviewed RN/UM #1 of Pavilion Two who stated that the purpose of the narcotic count was for the incoming and outgoing nurses to document that they were in agreement that the count was correct.
The RN/UM #1 stated that it was not acceptable to sign out for the outgoing shift before the count was completed. LPN #1 was present at that time, and stated that he was mistaken.
On 08/08/2024 at 12:48 PM, the surveyor conducted a telephone interview with the Consultant Pharmacist (CP) who stated that the 7 AM to 3 PM nurse absolutely should not have signed out as the outgoing nurse on the 3 PM to 11 PM shift because they did not count with the incoming nurse.
The CP stated that the whole idea was to make sure that the narcotic count was okay.
The CP stated, It is not okay to pre-sign.
On 08/08/2024 at 1:33 PM, the surveyor interviewed the DON who stated that the process for the narcotic count was to sign to verify what you see at that point, because things change.
The DON stated that both the incoming and outgoing nurses should count what they have in the medication cart together and then sign afterward.
The DON further stated, We should never pre-sign for anything.
3. On 08/07/2024 at 12:13 PM, the surveyor observed the DON and RN/UM #1 as they performed a cycle count of back up controlled medications stored within the automated medication dispensing system.
The DON stated that the Registered Nurse Supervisor and the Infection Preventionist (IP) performed a cycle count daily.
315225
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 315225 B.
Wing 08/14/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
River Front Rehabilitation and Healthcare Center 5101 North Park Drive Pennsauken, NJ 08109