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F0658
D

Failure to Ensure Professional Standards in Medication Administration and Hospice Orders

Gettysburg, Pennsylvania Survey Completed on 06-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that care and services were provided in accordance with professional standards for two residents. For one resident with myasthenia gravis and muscle weakness, a nurse left medications (acetaminophen and ferrous sulfate) on the bedside table and exited the room to retrieve additional medication. The resident partially took the medications left at the bedside, despite not having a physician's order for self-administration of these medications. The resident's record only approved self-administration of saline nasal spray, and facility policy required an order and evaluation for self-administration of any medication. For another resident with Huntington disease who was admitted for respite hospice care, the clinical record did not contain a physician's order for hospice services, even though the care plan included interventions and contact details for hospice care. The facility's expectation, as stated by the NHA, was that physician orders for care and services should be entered, but this was not done at the time of review.

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