|§483.50(a)(2) The facility must-|
(i) Provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws.
(ii) Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders.
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that laboratory testing was completed as ordered by the physician for one of eight residents reviewed (Resident 6).
A fax communication for Resident 6, dated November 21, 2019, revealed that the resident had an episode of nausea/vomiting/diarrhea early that a.m., telehealth (on call physician services) was paged and ordered a complete blood count (CBC - a test that measures the cells that make up your blood), comprehensive metabolic panel (CMP - a test that measures 14 different substances in your blood), 4 milligrams (mg) of Zofran (a medication to treat nausea) every six hours as needed, and one 4 mg dose of Immodium (a medication to treat diarrhea) and then 2 mg as needed every six hours. The fax indicated that laboratory results were attached. The physician's response included an order to repeat the CBC and obtain a urine culture and sensitivity (tests that identify bacteria in the urine and determine which antibiotics would be best for treatment) on November 23, 2019.
A nursing note for Resident 6, dated November 22, 2019, revealed that the resident was alert and oriented, voiced his needs, and was incontinent of bowel and bladder that shift. A nursing note for Resident 6, dated November 23, 2019, revealed that the resident was alert and oriented and incontinent of bowel and bladder.
There was no documented evidence that Resident 6's urine culture and sensitivity was obtained on November 23, 2019, as ordered by the physician.
Interviews with the Director of Nursing and Assistant Director of Nursing on December 19, 2019, at 11:45 a.m. confirmed that Resident 6's urine culture and sensitivity was not obtained on November 23, 2019, as ordered by the physician.
28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 9/19/19.
28 Pa. Code 211.12(d)(3) Nursing services.
Previously cited 9/19/19.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 10/28/19, 9/19/19.
| ||Plan of Correction - To be completed: 01/29/2020|
The submission of this plan of correction does not constitute admission or agreement on the part of the provider with the deficiencies or conclusions contained in the Statement of Deficiencies. This plan of correction is prepared and executed solely to respond to the allegation of non-compliance cited during the incident survey ended December 19, 2019.
1. Actions taken for the situation identified:
Resident R6 suffered no ill effects as a result of the failure to obtain the urine culture and sensitivity. On November 22, 2019, Resident R6 was ordered a 10-day course of antibiotics by mouth, as well as fluids through intravenous infusion, to treat an elevated white blood cell count that was noted through the laboratory blood testing the physician ordered at the onset of the nausea and vomiting. These interventions resolved the infection, as well as the nausea and vomiting.
2. How the facility will act to protect residents in similar situations:
Physician orders were reviewed to ensure that there were no other missed orders. No other residents were identified as having physician orders that were missed. A protocol for 24-hour chart checks will be implemented.
3. System changes and measures to be taken:
A 24-hour chart check protocol has been developed to ensure orders are carried out. The night shift staff will be responsible for reviewing orders on resident charts, including diagnostic tests, for clarification and follow through. Any identified discrepancies shall be reported for immediate follow up, including physician clarification of orders and notification of missed orders. The licensed nursing staff, including agency staff, will be re-educated on the protocol for reviewing orders through the 24-hour chart check.
4. Monitoring mechanisms to assure compliance:
The Assistant Director of Nursing/designee will perform weekly audits on 10% of physician orders to ensure orders have been carried out weekly for four (4) weeks, then monthly for two (2) months. Identified concerns will be addressed upon discovery. Audit results will be reviewed through monthly Quality Assurance Performance Improvement Committee meetings and further action plans and audits will continue until substantial compliance is achieved. From then on, monthly Quality Assurance Performance Improvement meetings will help to ensure quality standards are met through continual performance analyses and the implementation of systematic efforts to improve those processes that do not meet acceptable levels. This will include self-monitoring of identified deficient practices that shall be reviewed during the monthly Quality Assurance Performance Improvement Committee meetings, as well as the Quarterly Quality Assurance Meetings, until significant corrections are noted and ongoing, as necessary.
5. Date Corrective Action will be completed:
Substantial compliance is expected by 1/29/2020