§ 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 upon review of clinical and hospital records, interviews with staff, and review of facility submitted documents and policies, it was determined the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, by failing to ensure physician orders were transcribed accurately on admission for two of three records reviewed (Closed Record Resident R1 and Resident R2).
Findings include:
Review of facility policy "Medication and Treatment orders", dated 1/2/25, indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Only authorized licensed practioners, or individuals authorized to take verbal orders from practioners, shall be allowed to write orders in the medical chart.
Review of clinical record indicated that Closed Record (CR) Resident R1 was admitted to facility 8/21/25, and discharged on 9/4/25, to a lower level of care.
Review of CR Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 8/27/25, indicated diagnoses of encephalopathy (group of conditions that cause brain dysfunction, leading to symptoms such as confusion, memory loss, and personality changes), chronic obstructive pulmonary disease (chronic lung disease that includes conditions such as chronic bronchitis and emphysema), and dementia (syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to do everyday activities).
Review of facility submitted document dated 10/28/25, indicated that upon admission, CR Resident R1's medication Hydroxyurea (used primarily to treat certain types of cancer and sickle cell anemia, working by slowing the growth of cancer cells and improving red blood cell flexibility) was transcribed incorrectly. The order was Hydroxyurea 1000mg PO daily, however it was transcribed as hydroxyurea 1000mg PO BID. This dosage continued till her discharge on 09/04/2025, and that dosage continued as part of her discharge instructions. On 10/06/2025, the daughter of the resident reported to the facility that the resident was in the hospital, she believed resulting from the error. Resident's provider was made aware.
Review of CR Resident R1's physician order dated 8/21/25, indicated to administer Hydroxyurea Oral Capsule 500 mg (milligrams) Give 2 capsules by mouth two times a day for Thrombocytosis.
Review of CR Resident R1's clinical record hospital referral summary dated 8/19/25, indicated Hydroxyurea 1000 mg oral (by mouth) daily listed on Medications [ordered list].
Further review of clinical record hospital medication list results dated 8/19/25, indicated Hydroxyurea 1000 mg oral (by mouth) daily. Also noted that this medication was restarted 8/15/2025, and is being continued daily; it is also an ongoing home medication.
During an interview on 11/18/25, at 10:28 a.m., the Nursing Home Administrator (NHA) confirmed that the facility failed to ensure CR Resident R1's physician orders on admission were transcribed accurately.
Review of clinical record indicated that Resident R2 was admitted to the facility 10/6/25.
Review of Resident R2's MDS dated 10/12/25, indicated diagnoses of fracture of olecranon (elbow), benign prostatic hyperplasia (enlarged prostate gland), and heart disease.
Review of Resident R2's active physician order dated 10/17/25, indicated to administer Omeprazole (medication used to treat conditions caused by excess stomach acid) Oral Capsule Delayed Release 20 mg Give 1 capsule by mouth two times a day for GERD (gastroesophageal reflux disease).
Review of Resident R2's admission physician order dated 10/6/25, and discontinued on 10/17/25, indicated to administer Omeprazole Oral Capsule Delayed Release 20 mg Give 1 capsule by mouth in the morning for GERD.
Review of Resident R2's clinical record physician progress note dated 10/17/25, indicated Resident R2 denies any heartburn or reflux and wasn't clear on why he was taking the Omeprazole BID prior to admission. Review of records indicated possible switch to Pantoprazole (medication that reduces stomach acid production) daily but orders resumed Omeprazole 20 mg BID (twice a day) upon hospital discharge - has been receiving Omeprazole 20 mg daily - resume at BID dosing.
Review of Resident R2's clinical record hospital discharge summary dated 10/6/25, indicated to administer Omeprazole (20 mg Delayed Release Capsule) 1 cap by mouth 2 times per day.
During an interview on 11/18/25, at 3:03 p.m., the NHA and Director of Nursing (DON) confirmed that the facility failed to ensure physician orders were transcribed accurately on admission for two of three records reviewed (Closed Record Resident R1 and Resident R2).
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 01/13/2026
Residents, R-1 and R-2, have discharged.
The DON or designee will audit admission orders of all new admissions and re-admissions to ensure accurate transcription for a period of three weeks, then monthly for 2 months.
Additionally, the DON and/or designee will conduct spot checks on residents receiving high-risk medications (ex. anticoagulants, insulin, psychotropics). Audits of five residents weekly for three weeks, and then monthly for 2 months will occur.
Also, the DON or designee will conduct random medication administration audits of five residents daily for 2 weeks, then five residents weekly for 1 month.
If a deficient practice is identified the DON will be informed.
Professional nursing staff will be re-educated on the Five Rights of Medication Administration (right patient, drug, dose, route, time).
At QAPI the audits will be reviewed and the need for additional monitoring determined.
Semi-annual competency audits of the professional nurses will ensure sustained compliance.
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