Observations:
Based on review of the Pennsylvania Code Title 49. Professional and Vocational Standards, facility job descriptions, clinical records, facility documents, and staff interviews, it was determined that the facility failed to follow nursing standards of practice to ensure the physician was contacted regarding an incomplete order prior to medication administration for one of eight residents reviewed (Resident R1).
Findings include:
Review of Pennsylvania Code Title 49. Professional and Vocational Standards 21.11. General functions of the Registered Nurse (RN) (a)(4) stated, "Carries out nursing care actions which promote, maintain and restore the well-being of individuals and (b) The RN is fully responsible for all actions as a licensed nurse and is accountable to clients for the quality of care delivered and (d) The Board recognizes standards of practice and professional codes of behavior, as developed by appropriate nursing associations, as the criteria for assuring safe and effective practice."
Review of the facility's job description for RNs revealed "The purpose of the RN is to deliver care to residents utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation under the direction of the residents' attending physician. The RN will effectively interact with residents, family and other health team members while maintaining all standards of professional nursing."
Review of Resident R1's clinical record revealed an admission date of 4/8/25, with diagnoses that included osteomyelitis (an infection in the bone), weakness, and type II diabetes (condition where the body does not use insulin properly).
Resident R1's order summary revealed a physician's order for Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams (an antibiotic used to treat many different infections caused by bacteria), use 1 dose intravenously every 6 hours for 5 days. The physician's order lacked the amount the medication was to be reconstituted with and/or the rate the medication was to be administered.
Resident R1's clinical record progress notes dated 4/8/25, documented that Resident R1 received his/her Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams at 8:08 p.m. and 11:36 p.m. and that the medication was reconstituted per instructions and on 4/9/25, that the Piperacillin Sodium-Tazobactam Sodium Intravenous Solution Reconstituted 3.375 (3-0.375) grams was administered at the wrong rate and route.
Review of facility documents dated 4/10/25 and 4/15/25, revealed that the RN failed to ensure the physician was contacted regarding an incomplete medication order prior to administering the medication for the first and second doses.
During an interview on 4/30/25, at approximately 10:30 a.m. the Nursing Home Administrator confirmed that the RN failed to contact the physician regarding the incomplete medication order prior to the medication administrations that did not adhere to professional nursing standards.
28 Pa. Code 211.12(d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 05/30/2025
1. RN that failed to contact the physician regarding the incomplete medication order prior to medication administration no longer works at the facility.
2. An initial audit was completed on Intravenous orders to ensure the physician order was complete, ensure administration is per the physician order, correct route, and correct dose. If incomplete, staff will notify the physician for clarification.
3. Education will completed by the Director of Nursing, or designee, with all licensed nurses on Medication Administration, IV push Medications, Transcribing Physician Orders, Telephone Orders, and Verbal Orders, ensuring physician orders are complete and if not, they contact the physician for clarification.
4. Polaris Pharmacy will be completing IV training with all licensed nurses.
5. Medication Administration Competency audits will be completed with licensed nurses on all shifts by the Director of Nursing, or designee. These will be completed with five nurses per week for the next four weeks. Any concerns identified will be addressed via on the spot education, documented and signed as acknowledged by the nurse administering medications.
6. Audits will be completed by the Director of Nursing, or designee, on Intravenous orders to ensure physician order is complete, administration per the physician order, correct route, and correct dose daily for two weeks, then weekly for two weeks, then monthly for two months. If orders are found to be incomplete, the physician will be called at the time of the audit for clarification.
7. Review of audits will be completed at the facility Quality Assurance and Performance Improvement meeting for recommendations, follow up, and further actions.
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