| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 retains an over the counter (OTC) medication list which states that they are permitted to take NyQuil, per manufacturer instructions, if experiencing cold symptoms. The OTC medication order was dated, 11/15/2022 and updated again on 11/21/2023 by their Primary Care Physician (PCP). The label on the prescribed NyQuil states to "ask a doctor or pharmacist before use if you are taking sedatives or tranquilizers". Individual #1 is currently prescribed Trazodone 100mg by mouth daily at bedtime. On 10/21/2024, Individual #1 was transported to the BTAMC Walk-In Clinic (urgent care) between approximately 8:30 -- 9am due to cold symptoms (coughing, runny nose, etc.). BTAMC's summary on 10/21/2024 visit provided contradictory information regarding the current medication, Trazodone. Information on the summary sheet stated to both continue taking Trazodone and discontinue taking Trazodone. BTAMC Walk-In Clinic's summary sheet also stated, "push fluids, rest. Use OTC meds as needed" Trazodone was administered at 8pm on 10/21/2024 and 10/22/2024, while NyQuil was simultaneously being administered on 10/21/2024 at 11:15am and 6:40pm, 10/22/2024 at 7:01am, 1:00pm, and 7:01pm. The Provider did not clarify the information listed on BTAMC's summary discharge for Individual #1, whether they should have continued the use of Trazodone while simultaneously administering NyQuil. Additionally, there is not documentation that BTAMC's Walk-In Clinic confirmed the use of NyQuil compared to other OTC medications while experiencing cold symptoms. The following events occurred after the administration of NyQuil. On 10/22/2024 at 3:00pm, Staff #5 reported that Individual #1 appeared sluggish and tired, began falling backwards while standing in the kitchen. Individual #1 was then assisted to the dining room table where they continued to lean while visibly falling asleep. On 10/23/2024 Staff #1 reported at approximately 2:15pm, Individual #1 appeared weak. Staff #3 arrived at the Individual's home when Individual #1 presented as disoriented. At that time, Staff #3 and Staff #2 obtained vitals on Individual. At that time, Individual #1 started to lean their head back and passed out for approximately 3 minutes. During this time, Individual was observed as pale, non-responsive, and blue lips. 911 was contacted and Individual transported to Penn Highlands emergency department. Subsequent testing at Penn Highlands was unremarkable and Individual #1 was advised to follow-up with PCP and discharged. On 10/24/2024 Individual was transported to Geisinger Emergency Departments due to reported confusion and feeling disoriented. Geisinger ER doctor did not recommend subjecting Individual #1 to same tests that were performed on 10/23/2024 and was discharged with instructions to follow-up with PCP or return to the ER immediately if they pass out again. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| As noted in the course of investigation with corresponding records, this was corrected the day after walk-in clinic visit through ongoing correspondence between program nurse and PCP regarding the OTC medication and request of alternative due to possible conflict. Supporting documentation was uploaded to departments shared drive. The medication was discontinued, and an alternate provided for ongoing use. |
01/02/2025
| Implemented |
| 6400.62(b) | Individual #1's current ISP dated 10/15/2054 and Individual #2's current ISP dated 10/22/2024 states that aerosolized chemicals are to be locked in the home. At the time of the home inspection (10/24/2024), Sprayway Glass Cleaner was located unlocked underneath the kitchen sink. | Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment. | The history of risk has been ingestion of liquid, non-aerosolized chemicals by individual #1 which is the language that should have been reflected in the ISP- not aerosolized. Actions by staff with securing other cleaning products were in line with actual needs, but not consistent with ISP because of this typographical error. The ISP for both individuals have been updated to correct the language to non-aerosolized chemicals. The ISP corrections have been submitted to SC (Attachment 1). Language has been updated in BSP as well (Attachment 2). This has been reviewed by staff (Attachment 2). |
01/02/2025
| Implemented |
| 6400.166(a)(11) | Individual #1's Medication Administration Record (MAR) from August -- October 2024 states that the diagnosis for Trazodone is sleep apnea. As of 11/25/2024, Individual #1 has not been diagnosed with sleep apnea. The diagnosis for Individual #1's Trazodone is insomnia disorder. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The MAR has been corrected to reflect current diagnosis from provider as attachment 6. It is unclear why the pharmacy initiated change, potentially as a result of prescriber conflict based on current health assessments or insurance purposes. At this time, individual #1 has completed his sleep study analysis and is diagnosed with sleep apnea. Treatment, unrelated to the trazodone, is in effect as a result. |
01/02/2025
| Implemented |
| 6400.168(a) | On 10/21/2024 Individual #1 was administered 2 doses of NyQuil (at 11:15am and 6:40pm) due to experiencing cold symptoms. Staff #6 reported on 10/22/2024 at 12:05am that Individual #1 was experiencing restlessness. On 10/22/2024 Individual #1 was administer 3 more doses of NyQuil (at 7:01am, 1:00pm, and 7:01pm). On 10/22/2024 at 12:30pm Staff #7 reported having to keep Individual #1 awake as they kept falling asleep while eating. On 10/22/2024 at 3:00pm Staff #5 reported that Individual #1 started falling backwards while standing in the kitchen, when Staff #5 caught them and went to the floor. Following this incident, Staff #5 reported that Individual #1 continued to visibly fall asleep while eating dinner. Individual #1 continued to be administered their 5th dose of Nyquil within a 32-hour period at 7:01pm on 10/22/2024. It was not until 10/22/2024 at 8pm that Nursing staff instructed home staff to hold the NyQuil due to the adverse reactions that Individual #1 was experiencing. The home did not immediately consult a health care practitioner or seek emergency medical treatment at the first sign of potential adverse reactions from the NyQuil. | If an individual has a suspected adverse reaction to a medication, the home shall immediately consult a health care practitioner or seek emergency medical treatment. | Individual had two ER visits subsequent to staff and nursing recognition of potential adverse reactions. While there were no substantiative findings from those early appointments, program nurse advocated for alternate medication to error on side of caution and medical record was updated to reflect strong sedative effect of this medication. Updated records regarding OTC and alternative were provided at time of inspection reflecting correction of immediate issue. These were uploaded to department¿s shared drive. This medication was replaced and is no longer used. |
01/02/2025
| Implemented |
| 6400.186 | Individual #1's ISP states that the refrigerator and freezer are to be locked in the home due to housemate (Individual #2). Individual #2's current ISP dated 10/22/2024 also states that the refrigerator and freezer have locking mechanisms installed due to an extensive history of consuming large quantities of uncooked meats. At the time of the home inspection (10/24/2024), the fridge was found to not be locked or have a locking mechanism installed. | The home shall implement the individual plan, including revisions. | The history of risk for Individual #2 has been the consumption of large quantities of meat stored in freezer that he is able to pilfer without notice to others. At the time of restrictive implementation, the storage unit used for these excess quantities was a refrigerator/freezer combination in basement of home. The plan was written with consideration of this equipment. At the time of move to new home, the appliance was not transferred. Instead, a chest freezer was located in the kitchen for convenience and accessibility. This was locked for the identified safety reason. Similar to citation 62b, actions by staff products were in line with actual needs, but not consistent with ISP because of this failure to update language when appliance was replaced. The ISP for both individuals have been updated to reflect the current appliance being used against the identified risk. The ISP corrections have been submitted to SC (Attachment 1). Language has been updated in BSP as well (Attachment 2). This has been reviewed by staff (Attachment 2). |
01/02/2025
| Implemented |