§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and
§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
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Observations:
Based on observation, a review of select facility policy, clinical records, and select incident/accident reports and staff interview, it was determined that the facility failed to maintain an environment free of potential accident hazards to prevent accidental ingestion and misuse of substances not intended for oral use and to prevent access to resident personal care supplies, treatment products, and medications that may be mishandled or consumed by residents for whom the medications were not prescribed, for two residents out of eight sampled (Resident A1 and A2) and observed on two of two nursing units.
Findings include:
A review of an undated facility policy titled "General Dose Preparation and Medication Administration" indicated that facility staff should not leave medications or chemicals unattended. Facility staff should enter the date opened on the label of the medication with shortened expiration dates for example insulins and irrigation solutions.
A review of an undated facility policy titled "Storage and Expiration Dating of Medications and Biologicals" indicated the facility should ensure that all medications and biologicals including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. Topical external use medications or other medications should be stored separately from oral medications. Medication packaging should have a label with an expiration date once the package is opened the facility should follow supplier guidelines with respect to expiration dates and staff should record the date opened on the primary medication bottle when it has a shortened expiration date.
A review of clinical record revealed that Resident A1 was admitted to the facility on July 7, 2023, with diagnoses to include encephalopathy (disease that affects the brain structure or function and causes altered mental status), and type 2 diabetes mellitus (a condition resulting in insufficient production of insulin causing high blood sugar).
A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated March 13, 2024, revealed that the resident was severely cognitively impaired.
A facility report dated May 12, 2024, at 5:42 PM revealed that Resident A1's family saw him drink a liquid that was at the resident's bedside which was later identified as Betadine 10% solution approximately 10 milliliters (ml) left behind by the nurse after a heel dressing change (Betadine is used on the skin to treat or prevent skin infection in minor cuts, scrapes, or burns, Betadine should not be used in the mouth if you are using a form that is made for use only on the skin, and should not be swallowed). The resident thought it was liquid protein solution. The on-call physician and poison control were notified.
A progress note dated May 12, 2024, at 6:46 PM revealed that poison control suggested feeding the resident a carbohydrate, probably a loaf of bread, and watch out for any vomiting; and to call back if this occurs. The resident was reassured and had already eaten a sandwich for dinner, no incidents noted.
A facility report dated May 13, 2024, at 1:30 PM revealed that the betadine treatment the nurse provided to the resident's heel on May 12, 2024, was performed at nursing judgement, as the resident had no physician order for this treatment. An in-service education was conducted with staff informing them not to apply treatments without a physician order and do not leave treatments/personal care items at the bedside; they must be put away.
A review of an employee witness statement dated May 16, 2024, (no time) revealed that Employee 1, Licensed Practical Nurse (LPN) was notified that the resident wanted his heels wrapped. After realizing there was not a physician order for this treatment Employee 1 noted that "I asked Employee 2 Registered Nurse Supervisor (RNS) if it was okay to wrap his heels without an order and she said it was fine. The resident asked if I could apply betadine, I poured 10 mls of betadine into a medication cup and went to do the treatment. After completion I cleaned up and left, the room. Staff then notified me that family observed the resident drink the brown liquid in the medication cup, this was reported to Employee 2 RNS immediately who called the physician and poison control. Employee 2 RNS advised me to monitor the resident for vomiting and to encourage food and fluids."
A review of "Ad Hoc QAPI/QAA Form" dated May 16, 2024, (no time) revealed the problems of potential hazardous solution left at the bedside and treatment completed without an order. A facility sweep, interviews and skin assessment was completed after the incident and any identified issues were removed.
An observation conducted during a tour of resident rooms on May 29, 2024, at 9:26 AM revealed a barrier cream and a bottle of Acetic Acid (antiseptic agent not used for consumption) irrigation solution opened, without an expiration date, and unattended on a bedside table in resident room 110.
An observation on May 29, 2024, at 9:35 AM revealed a bottle of shaving cream and normal saline solution ([NSS] used as a topical cleansing agent) opened, without an expiration date and unattended on a dresser in resident room 112.
An observation on May 29, 2024, at 10:00 AM revealed a four ounce bottle of sterile water and irrigation kit on a dresser in resident room 204-W.
Interview with the Director of Nursing (DON) on May 29, 2024, at approximately 10:15AM confirmed that treatments and personal care items were not to be left at the bedside. The DON confirmed that the facility failed to maintain the residents' environment free of potential accident hazards by leaving treatments and personal care items accessible to residents, which may allow accidental consumption or misuse.
A review of clinical records revealed that Resident A2 was admitted to the facility on August 15, 2023, with diagnosis to include dementia (a neurocognitive disorder that affects memory, thinking and interferes with daily life) and depression (mood disorder with symptoms of sadness).
A quarterly MDS of Resident A2 dated May 3, 2024, indicated the resident was moderately cognitively impaired.
An observation on May 29, 2024, at 8:49 AM revealed a medication cup filled with multiple medications on Resident A2's bedside table unsupervised by staff.
A review of Medication Administration Record for the month of May 2024, revealed that on May 29, 2024, at 9:00 AM Resident A2 was scheduled to receive the following medications by mouth:
"Duloxetine 30 milligrams (mg) (antidepressant medication)
"Oxybutynin Chloride Extended Release (ER) 5 mg (overactive bladder medication)
"Potassium Chloride ER 20 micro equivalents (MEQ) (low potassium supplement medication)
"Vitamin D2 1,250 micrograms (mcg)/50,000 units (vitamin D supplement medication)
There was no documented evidence that the resident self-administered medications, which had been left at the resident's bedside.
During an interview with the DON on May 29, 2024, at 2:30 PM confirmed that the resident should have been supervised while taking the observed medications and verified that Resident A2 does not self-administer medications.
28 Pa. Code 211.10 (d) Resident care policies
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 06/18/2024
1. The barrier cream and bottle of Acetic Acid was removed and discarded from room 110. The bottle of shaving cream and normal saline solution were removed and discarded from room 112. The sterile water and irrigation kit were removed and discarded from room 204W.
Resident A2 was observed by LPN taking medications left in cup. LPN was educated on the medication administration policy.
2. To identify other residents that have the potential to be affected, the DON/designee completed a facility sweep to ensure no medications and/or treatments were present at residents beside. To identify other residents that have the potential to be affected, the DON/Designee completed a facility sweep to ensure no personal care items were left at bedside.
3. To prevent this from reoccurring, the DON/designee educated licensed nurses on ensuring medications are observed being consumed by resident at time of medication pour. If resident refuses medications at the time of pour, medications will be discarded according to facility policy and marked as refused in the MAR. If resident later wants to take medication, a call will be made to physician to obtain order. Treatments will be removed from resident's room after completion. All treatments will be kept in treatment cart or medication room to ensure residents are not able to access.
To prevent this from reoccurring, the DON/designee will educate nursing staff on ensuring all personal items are not left at bedside. Leaving items that may be potential hazards easily accessible for residents may allow accidental consumption or misuse by the residents.
4. To monitor and maintain ongoing, the DON/designee will complete facility sweep weekly x 4 then monthly x2 to ensure medications and/or treatments are not left at bedside.
To monitor and maintain ongoing compliance, the DON/designee will complete facility sweep weekly x 4 then monthly x 2 to ensure personal items are not left at bedside and/or easily accessible for residents.
5. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations
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