§ 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that admission orders were followed for one of five residents reviewed (Resident 2).
Findings include:
Resident 2's clinical record indicated that she was admitted to the facility on June 12, 2024, with diagnoses that included frequent falls and congestive heart failure. Admission orders for Resident 2, dated June 12, 2024, included orders for the resident to be weighed daily and to notify the physician of a weight gain of 1 to 2 pounds in one day or 5 pounds in one week. Admission orders also included for the resident to receive 20 milligrams (mg) Lasix (diuretic) daily.
A review of Resident 2's Treatment Administration Record (TAR), dated June 2024, revealed that the resident did not receive the Lasix. Further review revealed that the resident was weighed June 13 at 121.4 pounds, June 14 at 122.4 pounds, and June 20 at 122.4 pounds. She was not weighed daily per the order, and the physician was not notified of the 1 pound weight gain on June 14, 2024.
Interview with the Director of Nursing on July 22, 2024, at 1:02 p.m. confirmed that Resident 2 did not receive Lasix as ordered and was not weighed daily as ordered. She stated that the resident's admission orders were not written in the typical fashion and therefore the orders were missed.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
| | Plan of Correction - To be completed: 08/22/2024
1. Unable to retroactively correct resident #2 admission orders as the resident was discharged from the facility.
2. The Director of Nursing or designee will audit residents admitted to the facility in the last 14 days to determine if medication and weight orders were initiated.
3. Director of Nursing or designee will provide education to licensed staff on initiating admission orders for weights and medications and for a second nurse review of admission orders. Interdisciplinary team will be educated on morning review process of newly admitted residents.
4. The Director of Nursing or designee will conduct weekly audits of newly admitted residents to ensure that orders for medications and weights are initiated weekly x 4 weeks, then monthly x 2. Results of these audits will be reviewed at the Quality Assurance meetings for recommendations and further follow up as indicated.
5. Date of compliance is 8/22/2024
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