§ 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.
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Observations:
Based on review of clinical records, and staff interviews, it was determined that the facility failed to ensure that physicians orders were followed for one of 10 residents reviewed (Resident 5).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 22, 2024, revealed that the resident was admitted on November 27, 2023; was cognitively intact; required substantial to maximum assistance for personal hygiene needs; and had diagnosis that included chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems).
A review of discharge instructions from the hospital, dated November 27, 2023, revealed that the resident was to follow up with orthopedics (medical specialty dealing with injures and diseases of the musculoskeletal system) in one to two weeks regarding right shoulder effusion (accumulation of fluid in the joint). There is no documented evidence in the clinical record that the resident had an orthopedic consult.
Interview with the Nursing Home Administrator and Director of Nursing on March 5, 2024, at 4:27 p.m. revealed that Resident 5 was a participant in Senior Life Program (a Medicare program that provides all-inclusive care for the elderly) at the time of her admission and that all consults had to be approved and scheduled through them. The Nursing Home Administrator and Director of Nursing believed that Senior Life's physician spoke with the resident and decided that an orthopedic follow up was not required, and therefore it was never completed. The Nursing Home Administrator confirmed that there was no documented evidence in Resident 5's clinical record to indicate that Senior Life determined the consult was not required.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
| | Plan of Correction - To be completed: 03/28/2024
1.Senior life communicated that while they did not have it documented, their office manager did recall a conversation that due to resident # 5's condition, the orthopedic appointment would not be scheduled unless her condition improved. Resident and responsible party decline orthopedic follow up on 2/26/24 in a discussion with their Primary Care Physician.
2.Director of nursing completed a 14 day look back to ensure senior life residents had appointments per physician orders for orthopedic appointments with no identified concerns.
3.Licensed nursing staff will be educated on ensuring physician orders are followed related to resident's orthopedic consultations, education will include but not limited to ensuring review of discharge instructions for new admissions and or re-admissions for orders for medical consults and appropriate follow up and scheduling if indicated. Director of nursing or designee will audit senior life resident's orders to ensure orthopedic consultations are followed per physician orders. Audits will be completed weekly times 4 weeks and monthly times 2 months.
4.Audit findings will be reviewed with Quality Assurance Performance Improvement Committee for additional recommendations as necessary
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