|§483.10(e) Respect and Dignity. |
The resident has a right to be treated with respect and dignity, including:
§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
§483.12(a) The facility must-
§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free of chemical restraints that were not required to treat the resident's medical symptoms for one of three residents reviewed (Resident 3).
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated January 9, 2020, revealed that the resident was cognitively intact, could understand and be understood, received nutrition via a gastrostomy tube (tube surgically inserted through the abdomen into the stomach), and had diagnoses that included tongue, mouth and throat cancer with severe protein-calorie malnutrition. Physician's orders for Resident 3, dated January 3, 2020, included and order for the resident to receive 15 milligrams (mg) of Morphine Sulfate (a narcotic pain medication) through the gastrostomy tube every four hours as needed for severe pain.
Nursing notes for Resident 3, dated January 6, 10, 14, 15, 20 and 27, 2020, revealed that the resident was alert and oriented and either requested food, was found with food, and/or was getting water to drink from the tap. The notes indicated that the resident was told that he could not have anything by mouth.
During a facility audit of Resident 3's medications on February 14, 2020, at 7:00 a.m., it was determined that staff administered 15 mg of Morphine Sulfate during the night shift on January 31 and February 2, 3, 4, 5, 6, 7, 10, 11, 13 and 14, 2020, with documentation of "severe pain." An interview with Resident 3 by Registered Nurse 1 on February 14, 2020, revealed the resident indicated that he has never asked for Morphine because he did not know that he had an order for it, and he was never asked by a nurse if he needed anything for pain. Upon further investigation, it was determined that the same nurse, Registered Nurse 2, administered every dose of Morphine to Resident 3 on those dates.
An interview with Registered Nurse 2 by the Nursing Home Administrator, Director of Nursing, and Assistant Director of Nursing on February 14, 2020, at 7:00 a.m. revealed that Registered Nurse 2 gave Resident 3 the Morphine every night because he was up all night wandering and going through other residents' things, and she was aware that it was a chemical restraint.
28 Pa. Code 211.2(a) Physician services.
28 Pa. Code 211.8(b) Use of restraints.
28 Pa. Code 211.9(a)(1) Pharmacy services.
28 Pa. Code 211.12(a)(c)(d)(1)(5) Nursing services.
| ||Plan of Correction - To be completed: 03/05/2020|
- Resident # 3 is not chemically restrained.
- Based on nursing documentation and staff interviews, resident # 3 did not experience any adverse effects from receiving morphine, nor was he observed to be more lethargic or unable to perform his usual daily routines.
Registered Nurse (RN) #2 is no longer employed in the facility as of 2/17/2020.
- Residents with current orders for Morphine tablets had the potential to be affected by RN #2's deficient practice.
- Residents that exhibit wandering behaviors on the unit where RN #2 was working had the potential to be affected by this deficient practice.
DON/Designee completed an audit of residents with Morphine tablet orders and residents that exhibit wandering behaviors on the unit where RN #2 worked, which revealed no other residents were affected.
DON/Designee shall provide the nurses, new staff nurses and agency personnel an in-service regarding the proper administration of Morphine, that includes following the physician's order and indication for use, and how morphine administration that is not required to treat the resident's medical symptoms is considered a chemical restraint
- DON/Designee shall perform random audits of residents with current orders for morphine tablets and exhibit wandering behaviors daily x 5 days, weekly x 4 weeks then monthly x 2 months or until compliance is met, to ensure that morphine tablets are properly administered as per the physician's order and indication for use.
Results from audits shall be submitted to Quality Assurance Performance Improvement Committee for review and addressed as needed.