Pennswood Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Newtown, Pennsylvania.
- Location
- Route 413, Newtown, Pennsylvania 18940
- CMS Provider Number
- 395473
- Inspections on file
- 17
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pennswood Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of resistiveness to care was physically abused by a nurse aide, who punched the resident and twisted their wrist and hand during morning care. This resulted in a bruise and hematoma, with the abuse substantiated by both facility investigation and police. The incident was reported by another staff member and confirmed through documentation and interviews.
The facility did not maintain the fire resistance rating of smoke barrier partitions, as unsealed penetrations were observed in smoke barrier walls on the ground floor. These penetrations were found above smoke doors by room W7 and W1 around data wires, and by the DON's Office around two 3-inch pipes. This was confirmed in an exit interview with the Facility Administrator and Maintenance Supervisor.
The facility failed to maintain electrical wiring protection, affecting one of two floors. Observations revealed missing cover plates on junction boxes and an HVAC device, exposing inner wiring. These deficiencies were confirmed during an exit interview with the Facility Administrator and Maintenance Supervisor.
A resident on blood thinner medication fell and hit their head, but the facility failed to notify the physician in a timely manner, resulting in a delay of emergency medical care. Despite abnormal blood pressure readings and complaints of head pain, the physician was not informed until 10 hours later, leading to the resident's hospitalization and subsequent death due to a subdural hematoma.
A resident on Xarelto fell and hit their head, but the facility staff failed to notify the physician in a timely manner, leading to a delay in medical intervention. The resident exhibited elevated blood pressure and pain, yet was not reassessed promptly. Eventually, the resident was transferred to the hospital, where a subdural hematoma was diagnosed, and the resident passed away. The NHA and DON acknowledged the deficiencies, contributing to an Immediate Jeopardy situation.
Failure to Prevent Physical Abuse Resulting in Resident Harm
Penalty
Summary
A facility failed to protect a resident's right to be free from physical abuse, resulting in actual harm. The resident, who had severe cognitive impairment due to Alzheimer's disease and other conditions, was known to be resistive to care and sometimes combative. During morning care, the resident began kicking and punching staff. One nurse aide (E2) observed another nurse aide (E1) respond by punching the resident in the abdomen and aggressively twisting the resident's wrist and hand. This resulted in a bruise and hematoma to the resident's right hand and wrist, which was later documented by nursing and physician assessments. The facility's own investigation, as well as interviews and documentation, confirmed that the abuse occurred. The incident was reported by a staff member, and the abuse was substantiated by both the facility and the police. The resident did not recall the incident due to cognitive impairment, but physical findings were consistent with the reported abuse. The facility's failure to prevent this physical abuse constituted a violation of the resident's rights and resulted in actual physical harm.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain the fire resistance rating of smoke barrier partitions, which is a requirement for ensuring safety in the event of a fire. During observations conducted on December 9, 2024, it was noted that there were unsealed penetrations in the smoke barrier walls at several locations on the ground floor. Specifically, these penetrations were found above smoke doors by room W7 around data wires, above smoke doors by room W1 on the storage side around data wires, and above smoke doors by the Director of Nursing's Office around two 3-inch pipes. These observations were confirmed during an exit interview with the Facility Administrator and Maintenance Supervisor.
Plan Of Correction
The facility does and shall continue to ensure common fire walls are maintained free of unsealed penetrations. Pennswood Village Facilities will seal holes and penetrations using through penetration fire stop system C-AJ-8255 products in the following area. Repair shall be made 12/30/2024. The Maintenance Manager/Designee will continue to conduct inspections on a quarterly basis to identify any penetrations of common fire walls and seal them with the required sealant. Results of ongoing inspections will be reported to the Quality Assurance and Performance Improvement (QAPI) Team by the Maintenance Manager/Designee. Pennswood Village Maintenance Manager/Designee will oversee compliance.
Exposed Electrical Wiring in Facility
Penalty
Summary
The facility failed to maintain the protection of electrical wiring, which affected one of two floors. During an observation on December 9, 2024, at 10:10 a.m., it was noted that in the Housekeeping/Electrical Room on the ground floor, two junction boxes above the ceiling tiles were missing their cover plates, leaving the inner wiring exposed. Additionally, at 10:20 a.m. on the same day, it was observed that in the corridor by the elevator on the ground floor, an HVAC device was missing a cover plate, also exposing the inner wiring. These deficiencies were confirmed during an exit interview with the Facility Administrator and Maintenance Supervisor on December 9, 2024, at 12:15 p.m.
Plan Of Correction
The facility does and shall continue to ensure the protection of electrical wiring within the facility. Pennswood Village Facilities will place cover plates on the junction boxes in the Housekeeping/Electrical Room, and ensure that the HVAC device by the elevator has the missing cover is properly fastened to the unit. Repair shall be made by 12/30/2024. The Maintenance Manager/Designee will continue to conduct weekly rounds to identify and repair electrical wiring issues. The Maintenance Manager/Designee will see that all electrical work being done in the facility is done to completion. Pennswood Village Maintenance Manager/Designee will oversee compliance.
Failure to Timely Notify Physician After Resident Fall
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality for a resident who was on blood thinner medication and sustained a fall in the bathroom. The resident, who was on Xarelto, a medication that increases the risk of bleeding, fell and hit their head, but the facility did not notify the physician in a timely manner. Despite the resident's increased blood pressure and complaints of head pain, the physician was not informed until approximately 10 hours after the fall, leading to a delay in emergency medical care. The facility's policy required timely notification of the physician for significant changes in a resident's condition, including accidents with potential for physician intervention. However, the staff failed to follow this policy. The resident's neurological assessments showed abnormal blood pressure levels, but there was no documented evidence that the physician was notified of these changes or the resident's anticoagulant medication use until much later. The resident eventually developed symptoms such as headache, nausea, and vomiting, prompting a transfer to the hospital where a subdural hematoma was diagnosed. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition and medication. The nurse practitioner and registered nurses involved did not ensure timely reassessment or notification of the physician, contributing to the delay in care. The facility's failure to adhere to its own policies and procedures resulted in the resident not receiving necessary medical attention in a timely manner, ultimately leading to the resident's death in the hospital.
Plan Of Correction
Facility will immediately and accurately communicate with the physician/provider any pertinent change in condition of a resident. Notification of Changes in Resident's Status Policy has been reviewed and revised to include that the phone should be utilized or in person for all communication regarding significant change in status with physician/provider. Documentation to include physician/provider response. Education has been provided to all RNs and LPNs regarding the revised facility policy of Notifying Changes in Resident's Status. This education included assessing residents after change in condition, appropriate and complete notification of the physician/provider and method of notification. 85% of all RNs and LPNs have completed education by the end of the day 12/4/24. 100% of RNs and LPNs completed education by the end of the day 12/6/24. Every fall incident will be audited by interdisciplinary team to assure that appropriate and complete physician/provider notification has occurred. The audit will be reported on at Quality Assurance and Performance Improvement (QAPI) meeting by DON/Designee for a minimum of four quarters.
Removal Plan
- Facility will immediately and accurately communicate with the physician/provider any pertinent change in condition of a resident.
- Notification of Changes in Resident's Status Policy has been reviewed and revised to include that the phone should be utilized or in person for all communication regarding significant change in status with physician/provider. Documentation to include physician/provider response.
- Education has been implemented of all RNs (Register Nurse) and LPNs (Licensed Practical Nurse) regarding the revised facility policy of Notifying Changes in Resident's Status. This education includes assessing residents after change in condition, appropriate and complete notification of the physician/provider and method of notification. 85% of all RNs and LPNs will have completed education. 100% of RNs and LPNs will have completed education. If staff are not available, they will be educated prior to the start of their next shift in facility.
- Every fall incident will be audited by interdisciplinary team to assure that appropriate and complete physician/provider notification has occurred. The audit will be reported on at Quality Assurance and Performance Improvement (QAPI) for four quarters.
Failure to Timely Notify Physician After Resident Fall
Penalty
Summary
The Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility, resulting in a deficiency related to the care of Resident R17. The resident, who was on the anticoagulant medication Xarelto, fell in the bathroom and hit their head. Despite the elevated risk of bleeding due to the medication, the staff did not notify the physician in a timely manner. The incident report documented the fall at 2:05 a.m., but the physician was not notified until 3:40 p.m., and there was no evidence of a physician response. Following the fall, Resident R17 exhibited elevated blood pressure and complained of pain, yet the staff did not reassess the resident's condition in a timely manner. The resident's neurological assessments showed consistently high blood pressure, but there was no documentation of physician notification regarding these findings. The resident was eventually transferred to the hospital after developing symptoms such as headache, nausea, and vomiting, where a CT scan revealed a subdural hematoma. The resident passed away at the hospital due to the injury. Interviews with facility staff, including the night shift supervisor and the physician, revealed a lack of appropriate communication and follow-up procedures. The staff failed to notify the physician of the resident's anticoagulant use and high blood pressure, which could have influenced the medical response. The NHA and DON confirmed the deficiencies in staff actions and documentation, acknowledging the failure to meet federal and state guidelines, which contributed to an Immediate Jeopardy situation.
Plan Of Correction
The Nursing Home Administrator and Director of Nursing will fulfill essential duties and responsibilities of their position to ensure that the Federal and State guidelines and regulation are followed. Nursing Home Administrator and Director of Nursing reviewed and revised the Notification of Changes in Resident's Status Policy. The revision includes that the phone should be utilized or in person for all communication regarding significant change in status with physician/provider. Documentation to include physician/provider response. Education has been provided to all RNs and LPNs regarding the revised facility policy of Notifying Changes in Resident's Status. Nursing Home Administrator and Director of Nursing will continue to attend continuing education (CEU) approved by their state boards on a biennial basis. NHA will continue to complete 48 hours of continuing education every two years that are approved by the Board of Examiners of Nursing Home Administrators or National Association of Long-Term Care Administrator Boards (NAB). DON will continue to complete 30 hours of continuing education every two years that are approved by the State Board of Nursing. NHA/Designee and DON/Designee will conduct a root cause analysis on all reportable incidents submitted to Department of Health. Reportable incidents and their root cause analysis will be reported on at Quality Assurance and Performance Improvement (QAPI) meeting for a minimum of four quarters by NHA/Designee.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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