§ 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 facility policies, clinical record review and interviews with staff, it was determined that the facility failed to ensure that physician orders were followed related to toileting program, tubi-grips, gel cushion to wheelchair, for one resident of six residents reviewed. (Resident R1)
Findings include:
Review of facility policy, "Medication Order" undated, revealed, " it is the policy of Artman Lutheran to establish uniform guidelines in the receiving and recording of medication orders. To ensure safe and effective use of medications and that medication information on residents is captured, used and communicated".
Review of active physician order for Resident R1 revealed an order dated December 11, 2023 toileting schedule: Take resident to the bathroom/offer toileting resident at around 8:00 a.m., 11:00 a.m., 2:00 p.m., 5:00 pm, 8:00 p.m. check and change as need while asleep. Order dated May 1, 2023 " tubi-grips to bilateral lover extremities place on in am and remove at bedtime". On November 3, 2022, to "gel cushion to wheelchair check placement and integrity every shift".
A review of the Task Documentation for Toilet Use from May 1, 2024 -June 12, 2024, the following dates did not document 11:00 am toileting attempt:
May 1, 2,3, 4,6,7,8,9,10,11,12,13,14,15,16,17,18,19,21,22,23,24,25,26,27,28,29,30,31, 2024
June 2, 3,4,5,6,7, 8, 9, 10, 11, 12, 2024
On June 13, 2024, at 10:39 a.m. to 11:15 a.m. interview and observations were completed in the living room of Resident R1 participating in activities but was not taken to the complete a toilet program per the physician order at 11am. Further observations were completed during the same day from 12:22 p.m. to 2:05 p.m. with Resident R1 who as having lunch and then transitioned to the living room for activities. There was no implementation of toileting program at 2pm.
On June 13, 2024, at 12:37 p.m. observations made with Rehabilitation Director, Employee E13 that Resident R1 was sitting in her wheelchair eating lunch and had wheelchair foot rest heel loops/strips which would prevent the resident's heel to slide backwards was broken off on the right side. Resident R6 was sitting at the same dining table with Resident R1 and had a foot rest loop broken off as well on the left side. Employee E13 replaced it with new foo trest and reported that there was no need for the foo trest loops to be attached.
On June 13, 2024, at 1:05 p.m. observation was taken place that Resident R1 was sitting in the dining room with no tubi-grips per the physician order. License Nurse, Employee E5 confirmed the observation and reported " I must have forgot". Employee E5 went into Resident R1's room to locate tubi-grips and there was nonavailable. Employee E5 stated "I will have to order it".
28 Pa. Code 211.10(c) Resident care policies
28 Pa Code 211.12(d)(5) Nursing services
| | Plan of Correction - To be completed: 07/05/2024
It is the policy of Artman Lutheran Home that all physician orders are followed. After interviewing resident RI and staff a new toileting program was implemented to meet the resident's needs completed 6/19/2024. Care staff was in serviced on new program. A gel cushion was on resident's chair when Director of Nursing investigated. Tubi-grips were discontinued due to resident no longer requiring them. Supervisors will monitor all residents on a toileting program and monitor all residents' orders to ensure compliance. Audits will be completed weekly for 3 months,
(5 residents will be audited each week) and the Director of Nursing will review audits. Documentation of in servicing will be kept along with audits. All staff in servicing will be completed by July 5, 2024. Director of Nursing will implement a QAPI program for Physician orders.
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