|§ 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.
Based on clinical record review and staff interview, it was determined that the facility failed to monitor, assess, and treat an impaired skin area for one of seven sampled residents. (Resident CL1)
Clinical record review revealed that Resident CL1 was admitted to the facility on December 24, 2019, with diagnoses that included obesity. The Minimum Data Set assessment completed on December 31, 2019, identified that CL1 had moderate cognitive impairment. The nursing admission assessment completed on December 24, 2019, revealed that CL1 had redness around her groin. On December 25, 2019, the facility developed a care plan to address the redness around CL1's groin. Interventions included "treatments per physician order" however, there was no evidence that the physician was notified of CL1's impaired skin or that treatments were ordered. A physician note dated December 26, 2019, revealed that examination of the genitourinary area was deferred and the sacral area was not examined. There was no further evidence that the facility monitored CL1's impaired skin after December 25, 2019.
In an interview on February 4, 2020, at 12:45 p.m. LPN1 stated that staff was to notify the physician of impaired skin areas and monitor the area. In an interview on February 4, 2020, at 1:30 p.m. the Director of Nursing confirmed there was no further evidence that the facility monitored CL1's impaired skin after December 25, 2019.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 5/22/19
| ||Plan of Correction - To be completed: 03/17/2020|
CITED RESIDENTS: Resident #CL1. Resident no longer resides in the facility.
LIKE RESIDENTS: New Admissions and Current residents who have a skin alteration have the potential to be affected by this deficient practice.
Using the skin QAPI tool, residents who we identify as having a skin alteration will be reviewed to ensure that treatments are in place or practitioners were notified and orders were obtained as needed.
Comprehensive Review of all current residents' skin utilizing the QAPI tool will be utilized to ensure all skin alterations have a treatment in place or practitioners were notified and orders obtained as needed
CHANGE IN SYSTEM: to ensure the deficient practice does not re- occur, DON and/or designee will educate licensed staff on the use of skin practice guide to ensure all skin alterations have treatments in place. Shower sheets and nursing notes will be reviewed during Eagle rooms.
MONITORING: Utilizing the Skin QAPI tool, The DON or designee will audit 5 residents per week who are identified with a skin alteration to ensure treatments were implemented timely. All findings of audits will be presented to QAPI committee for review and recommendation.