|§ 483.25 Quality of care |
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Based on review of clinical records and interview with facility staff, it was determined that the facility failed to demonstrate consistent monitoring and timely identification of a resident displaying a change in condition to assure that the resident received timely necessary treatment and prompt medical intervention at the level required for one (Resident CR1) out of eight residents reviewed.
A review of the clinical record of Resident CR1 revealed admission to the facility on March 1, 2019, with diagnoses including diabetes, controlled with an oral medication and insulin administered on a sliding scale.
The clinical record also revealed that the resident received scheduled apheresis treatments outside the facility (a procedure where blood is separated and one component is removed and then returned to the patient) for a diagnosis of polycythemia (bone marrow disease which produces increased red blood cells).
A review of the resident's physician's orders revealed the resident had an appointment scheduled for March 15, 2019, which the resident's family rescheduled for March 22, 2019.
A review of physician's progress notes dated March 18, 2019, revealed that the resident had a history of confusion, which had worsened since his admission to the facility. The physican noted that in discussion with the resident's family, the resident's confusion worsened when his hemoglobin went above 12 g/dl, but after apheresis would improve.
A review of the results of the resident's last laboratory studies, obtained on March 13, 2019, revealed the resident's hemoglobin was 13.6 g/dl (prior 12.5 g/dl 3/11/19 and 11.6 g/dl 3/6/19.)
A review of physical therapy progress notes for the week of March 9, 2019, through March 15, 2019, revealed the therapist documented that the resident had improved with ambulation up to 75 feet with the use of a rollator walker and minimal assistance.
According to review of physical therapy notes for the week of March 16, 2019 through March 22, 2019, the resident ambulated up to 50 to 75 feet, on March 18 and 19, 2019, with minimal assistance. On March 19, 2019, the therapist completed family training, according to documentation.
A review of physical therapy notes for March 20, 2019 through March 22, 2019, revealed that the resident was now requiring moderate to maximum assistance with for transfer and ambulation. The resident was only able to ambulated 0 to 10 feet. It was documented that the resident needed increased encouragement to participate due to increased lethargy. Therapy noted that the resident needed increased assistance for all functional abilities.
Review of the resident's physical therapy discharge summary dated March 25, 2019, revealed that the resident had been unable to stand during his therapy session on March 22, 2019, and unable to ambulate on March 21, 2019 and 22, 2019. Therapy documented that the resident demonstrated a functional decline since family training was provided on March 19, 2019, and medical decline March 20, 2019, until his hospital admission on March 22, 2019.
According to review of the resident's meal intake records for the month of March 2019, the resident's intakes were consistently 51% to 100%.
On March 19, 2019 the resident's meal intake for the dinner meal and on March 20, 2019 for breakfast was 26% to 50%.
The resident's meal intakes on March 20, 2019, for lunch and dinner, and on March 21, 2019 for breakfast, lunch and dinner were 0-25%.
On March 22, 2019, the resident refused both breakfast and lunch.
A review of nutritional progress notes dated March 22, 2019, at 1:36 p.m. revealed that the dietitian documented that the resident had notable changes in his appearance at meals with a significant weight loss of 16 pounds in the last month. She noted that the resident had a decline in meal intake and increased need for assistance with eating/meals.
A review of nursing progress notes revealed that the resident left the facility on March 22, 2019, at approximately 1:45 p.m. for an apheresis consultation/treatment. At 2:51 PM it was documented that the resident's family called the facility to notify them the resident was transferred to the hospital after an unresponsive episode at his appointment.
Telephone interview with the resident's responsible party on March 28, 2019, at 2:45 p.m., revealed that the resident had allegedly been left at his appointment unresponsive and unsupervised by facility staff. When the resident's family contacted the facility to notify them of the resident's transfer to the hospital, the facility had informed the resident's responsible that the resident had a decline during the past few days. The resident's responsible party stated they were unaware of any changes in the resident's condition since last seeing the resident on March 19, 2019. The resident's representative stated that when staff was asked about the actions taken by the facility to address these declines and physician notification, the facility was unable to state the interventions initiated.
According to a review of nursing progress notes from March 20, 2019, through March 22, 2019, there was no documented nursing identification of the resident's increased lethargy, inability to participate in therapy or significant decline in meal intakes.
Progress notes completed on March 20, 21, and 22, 2019 described the resident as participating in skilled therapies and tolerating them well.
Additionally nursing documented that "head to toe" assessments were completed on March 20 and March 22, 2019, that included assessment of vital signs. However, no vital signs were documented and available in the resident's clinical record on those dates.
When interviewed on April 12, 2019, at 2:45 p.m. the Director of Nursing Services was unable to provide documented evidence that the facility's nursing staff had timely identified and acted upon the resident's decline in condition prior to the resident's appointment outside the facility on March 22, 2019 which led to his hospitalization.
28 Pa. Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing Services.
Previously cited 6/29/18.
| ||Plan of Correction - To be completed: 05/08/2019|
This Plan of Correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
1. Resident CR1 discharged on 3/22/2019.
2. An initial audit of current residents demonstrating a significant change in condition by DON / designee to verify that there is consistent monitoring and timely identification of the resident's significant change in condition and to assure timely treatment and medical interventions.
3. Education to licensed nursing staff on proper identification of significant change in resident's condition and assuring timely treatment and medical interventions of resident's condition.
4. An audit, as scheduled, of current residents demonstrating a significant change in condition by DON / designee to verify that there is consistent monitoring and timely identification of residents displaying a significant change in condition to assure timely treatment and medical interventions. Results of the auditing and progress will be reported to the QAPI committee for further recommendations/revisions as needed.