§ 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.
|
Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to implement physician's orders for two of eight sampled residents. (Residents 1 and 2)
Findings include:
Clinical record review revealed that Resident 1 had diagnoses that included diabetes mellitus and congestive heart failure. A physician's ordered dated May 6, 2025, directed staff to inject 24 units of insulin (Lispro) subcutaneously (insert a needle under the skin) three times a day for diabetes mellitus and hold if blood glucose was less than 150 milligrams per deciliter (mg/dl) or if the resident had not eaten a meal. A review of the Medication Administration Record for May 2025, revealed that staff administered the medication on May 10, 11, 12, 13, 15, and 20, 2025, when the resident's glucose was under 150 mg/dl.
Clinical record review revealed that Resident 2 had diagnoses that included diabetes mellitus, congestive heart failure, and chronic kidney disease. A physician's order dated August 21, 2024, directed staff to administer insulin (Lispro) based on a sliding scale (a method of managing diabetes by adjusting insulin doses in response to the individual's current blood glucose levels) subcutaneously with meals three times a day. Staff were to administer five units of insulin and notify the physician if the blood glucose was between 351 - 400 mg/dl. A review of the Medication Administration Record for May 2025, revealed that staff administered the medication on May 10 and May 12, 2025, when the resident's blood sugar was above 351 mg/dl. There was no documented evidence that the physician was notified.
In an interview on May 24, 2025, at 2:10 p.m., the Nurse Manager confirmed that the physician's orders for Residents 1 and 2 were not followed.
CFR 483.25 Quality of Care
Previously cited 9/28/24 and 11/7/24
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 06/30/2025
- Residents' 1 and 2 insulin orders have been reviewed and revised. Both residents are receiving insulin according to physician orders.
- Current residents with physician orders for insulin administration have been reviewed and residents are receiving insulin according to physician order.
- Licensed nursing staff have been re-educated by NPE/designee regarding physician order process for insulin administration with attention to physician ordered parameters and physician notification related to those parameters.
- DON/designee will audit residents receiving insulin 2x/week for three weeks and then weekly for three weeks to ensure insulin is administered according to physician order and physician notification is completed when appropriate. Results of audits will be reported to QA Committee for review and recommendations.
|
|
