§ 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 review, facility policy review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights for one of three residents reviewed (Resident 1).
Findings include:
A review of the facility policy, titled "Weights and Heights", last revised June 15, 2022, required staff to weigh the resident on admission and on readmission, adding the hospital discharge weight may be used for the admission or readmission weight. The policy also required staff to weigh all new admissions to the facility weekly for 4 weeks, and then weigh monthly after the 4 weeks.
A review of the closed clinical record for Resident 1 revealed diagnoses that included a stage 4 sacral pressure ulcer (ulcer involving loss of skin layers, exposing muscle and bone), type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).
A review of Resident 1's care plan dated July 10, 2024, revealed Resident 1 with a nutritional risk due to decreased oral intake, dementia diagnosis, increased nutrient needs related to wound, and required a mechanical altered diet.
A closed clinical record review for Resident 1 revealed a physician's order dated July 7, 2024, that staff were to complete weekly weights on day shift every Saturday for the next four weeks.
On July 6, 2024, the day of admission, Resident 1's weight was 118.4 pounds, and on July 15, 2024, Resident 1's weight was 116.2 pounds, revealing a 2.2 pound weight loss.
Review of Resident 1's clinical documentation revealed that staff did not complete Resident 1's weights on the following dates: July 13, 20, and 27, 2024.
The Resident was discharged from the facility on July 29, 2024.
During email communication with the Nursing Home Administrator (NHA) on July 31, 2024, at 3:38 PM, the NHA agreed that Resident 1's weights should have been obtained as ordered by the physician and per the facility policy.
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 09/09/2024
Resident 1 was discharged from the facility.
Residents admitted within the past 30 days will have their weights audited to ensure weights are obtained per policy.
Nursing personnel will be educated on FTag 684 with a focus on weights as well as facility policy "Weights and Heights".
Ten resident weights will be audited two times per week for four weeks to ensure weights are being obtained per policy. RN supervisor will review weights weekly to ensure compliance. Audit results will be forwarded to the QAA committee.
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