§ 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 complete treatments as ordered by the physician for one of three residents reviewed (Resident 3).
Findings include:
A nursing note, dated June 1, 2022, at 7:38 p.m. revealed that the resident arrived in the facility and had a left below-the-knee amputation (BKA). The wound was open with a red, moist wound bed and measured 8.0 x 1.5 x 0.6 centimeters (cm).
Physician's orders for Resident 3, dated June 1, 2022, included an order for staff to irrigate the wound to the left BKA with normal saline (salt water) and apply a wound VAC (vacuum-assisted wound healing using a device that decreases air pressure on the wound) at 125 millimeters of mercury (pressure setting) and the dressing was to be changed every Monday, Wednesday and Friday, and as needed for soilage. A care plan, dated June 2, 2022, indicated that the wound VAC to the left BKA was to be applied according to the physican's orders.
Review of Resident 3's Treatment Administration Records (TAR's) for June 2022 revealed that there was no documented evidence that the wound vac treatment to the left BKA was completed as ordered on June 3, 2022.
Interview with the Director of Nursing on June 13, 2022, at 8:30 p.m. confirmed that there was no documented evidence that Resident 3's wound vac treatment to the left BKA was completed as ordered by the physician on June 3, 2022.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 07/13/2022
The concerns identified for resident 3 can not be retroactively corrected. Resident 3 is no longer in the facility. Staff reported Resident refused wound vac placement. Staff re-educated to document resident refusals.
House audit will be completed on residents who receive Wound Vac treatments to identify missed Wound Vac treatments or documentation.
Facility will ensure that resident treatments are completed as ordered by the physician. Director of Nursing or designee will re-educate nursing staff on completing Wound Vac treatments as ordered and documentation of completion and/or refusal. Agency nurses and new hires will also receive the education.
Ongoing audits will be completed by the Director of Nursing, or designee, on completing Wound Vac treatments as ordered by physician and documentation of completion and/or refusal weekly for 1 month, then monthly for 3 months. Any patterns in deficient practice identified during this audit process will be addressed with staff by providing additional education and disciplinary action, if warranted. Audits will be reviewed at the monthly Quality Assurance Performance Improvement Committee meeting for further review and recommendations.
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