§ 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 observations, review of facility provided documentation and interview with staff, it was determined facility did not ensure to implement resident-directed care and treatment consistent with professional standards of practice, placing the residents at risk for infections or accidents for two residents observed (Resident R4, R5)
Findings include:
Review of facility policy 'Bath, Bed,' revised on March 2021, indicates to "empty and clean the wash basin with hot, soapy water," and "return wash basin to designated storage area."
Review of facility policy 'Shaving the Resident,' revised on February 2018, indicates that "If using a safety or disposable razor ...dispose of the razor in a designated sharps container."
Review of facility policy 'Catheter Care, Urinary," revised on April 2024, indicates under "infection control," to "be sure the catheter tubing and drainage bag are kept off of floor."
Observations on first floor unit of room 112 on August 19, 2024 at 11:00 AM revealed a used basin with used glove inside stacked on top of bed pan under the sink, another used basin with wet washcloths near the toilet, and another basin filled with water left in sink.
Further observed were multiple used and opened urinals stacked on toilet hand rails with used wash cloth and towel near it.
Interviewed licensed nurse, employee E5, on August 19, 2024 at 11:15 AM who stated that basins are labeled by residents' room numbers, however only one basin had a fading room number on it and that four different residents share the restroom space.
Reviewed facility provided grievance report dated August 6, 2024 revealed that a grievance was submitted by resident R8, regarding a "care nurse (nurse aide, employee E7) who provided care left the room a mess after she completed care. Bedside table was used during care and when she was done , feces was found on the table. "Charge nurse ended up cleaning the bedside table when she came in to complete residents treatment; E7 was in-serviced regarding infection control practice and received written warning on "employee performance improvement/action notification."
Further observations of restroom shared for residents in rooms 112 and 111 revealed a used razor next to sink faucet, without razor guard, left unattended.
Per interview with Employee E5, licensed nurse, was unaware of which resident the razor belonged to. Interview with director of nursing revealed razor is being used by Resident R5.
Further observations of resident R4 in room 112 revealed foley catheter on the floor.
28 Pa Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 09/17/2024
1. R5's razor was promptly removed from the bathroom and room was immediately cleaned. R4's Foley catheter was taken off of the floor, placed in a Dignity bag and positioned properly.
2. Audits to ensure razors are not left out, Foley bags are in a Dignity bag and positioned correctly and rooms are clean will be conducted by DON/Designee weekly times 4 weeks, or until 100% compliance is achieved.
3. Staff will be in serviced by DON/Designee on not leaving razors out, Dignity bags are on Foley catheters and properly positioned as not to be on the ground, and rooms are cleaned
4. Results of audits will be brought to QAPI meeting. It will be determined at that time if there is a need for further auditing
5. Date of Completion will be 9/17/2024
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