§ 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 interviews, it was determined that the facility failed to provide the highest practical well-being by not following physician orders as well as involve the physician in treatment changes for one of two residents reviewed (Resident 2).
Findings include:
Review of Resident 2's clinical record revealed diagnoses that included respiratory failure (a condition where the lungs cannot get enough oxygen into the blood) and hypertension (high blood pressure).
Review of Resident 2's clinical record revealed the Resident was admitted to the facility on January 5, 2026, with an abdominal fistula (an abnormal opening between the intestines or stomach and another organ or the skin, causing leakage of digestive fluids) which is covered with a colostomy bag (a discreet, odor-proof, disposable pouching system that collects waste from the body).
Review of Resident 2's current physician orders revealed an active order for abdominal fistula care, cleanse all abdomen area and fistula site, apply the zinc oxide mixed with A&;D ointment (vitamin A &; D topical ointment) all over abdomen and around fistula site, then apply pantie liner or exu-dry (multi-layered wound dressing) over top of the fistula, then apply brief on top and secure. Make sure ruff tabs on brief are not touching skin, change as much as needed or when soiled, aides are allowed to check and change once shown how to apply, every shift for fistula care, with a start date of January 14, 2026.
Further review of Resident 2's January 2026 TAR (Treatment Administration Record) revealed that the order above was signed off as being completed during the day, evening, and night shift by staff.
Review of Resident 2's January 2026 TAR revealed an order for abdominal fistula change Tuesday, Friday, and as needed (prn) for leaking, cleanse site with wound cleanser and apply skin prep to peri wound, place ostomy device and wafer over fistula site. Please use ostomy belt with device to assist with adherence, wear belt at all times, every day shift, with a start date of January 6, 2026, and a discontinued date of January 9, 2026.
Further review of Resident 2's January 2026 TAR revealed an order for abdominal fistula care cleanse all abdominal area and fistula site, apply the zinc oxide ointment all over abdomen and around fistula site. Then apply pantie liner over top of the fistula. Peel off back of liner then apply brief of top, press down until liner sticks to brief. Then roll Resident and secure brief around back. Make sure ruff tabs on brief are not touching skin. Change as much as needed or when soiled. Aides are allowed to check and change once shown how to apply, every shift for fistula care, with a start date of January 9, 2026, and a discontinued date of January 14, 2026.
Review of Resident 2's current care plan failed to include a focus area for their abdominal fistula care or any interventions related to it.
Review of Resident 2's clinical record revealed a Health Status Note on January 16, 2026, at 8:58 PM, that indicated fistula care was completed and a colostomy bag was applied.
Review of Resident 2's clinical record revealed a Health Status Note on January 17, 2026, at 3:42 AM, that indicated Resident 2's abdominal fistula was covered with a colostomy bag.
Review of Resident 2's clinical record revealed an Order-Administration note on January 17, 2026, at 4:10 PM, that Resident 2 had a colostomy appliance at that time.
Review of Resident 2's clinical record revealed a Health Status note on January 18, 2026, at 4:17 AM, that the Resident had a colostomy bag attached to fistula, which had been checked hourly to ensure the appliance is intact.
Review of Resident 2's clinical record revealed a Health Status note on January 19, 2026, at 4:02 AM, that the Resident's colostomy bag was intact.
Review of Resident 2's clinical record revealed a Health Status note on January 19, 2026, at 11:50 PM, that incontinent care was provided and a new colostomy pouch was applied.
Review of Resident 2's clinical record revealed a Health Status note on January 20, 2026, at 2:09 AM, that indicated the Resident's abdominal fistula was covered with a colostomy bag.
During an interview with the Director of Nursing (DON) on January 20, 2026, at 1:40 PM, she confirmed that nurse aides received verbal and hands on training and education on how to complete the current physicians order for Resident 2's abdominal fistula care and were administering the treatment as ordered to Resident 2. However, the DON was unable to provide where they were documenting when they completed the treatment. DON stated they would have documented the treatment administered under the Resident's bowel and bladder - bowel elimination task , however upon review of the task, the treatment ordered was not an option to document.
Further interview with the DON on January 20, 2026, at 2:00 PM, she revealed that she thought Resident 2's colostomy bag appliance had just started up again on January 19, 2026. The DON revealed that she was unsure where it was being documented in the Resident's clinical record when nurse aides are administering abdominal fistula care to Resident 2 as they are not able to document in the TAR and there was not a task in the Resident's record to indicate if fistula care was completed.
During an interview with Employee 1 (Wound Nurse) on January 20, 2026, at 2:07 PM, revealed that when Resident 2 was initially admitted to the facility, the Resident was admitted with a colostomy bag to cover their fistula; however, the colostomy bag was never staying on and had liquidy stool coming out of the fistula, so the facility was trying different methods on keeping the Resident's fistula covered. Employee 1 acknowledged there was not currently an order in place for Resident 2 to have a colostomy bag and will put a PRN order in place. Employee 1 revealed that all of the nurses in the facility have discussed Resident 2's situation and determined the best situation is to have the colostomy appliance on so the smell is contained, but that it has not stayed on, so they were doing whatever was working best at the time care was provided to the Resident.
Employee 1 revealed that they do not have documentation to prove when staff are applying an ostomy bag to Resident 2 and, as per the current active order, there was nowhere for nurse aides to document when they are administering abdominal fistula care to Resident 2.
During an interview with the DON on January 20, 2026, at approximately 2:15 PM, she revealed that she would expect staff to be providing care to Resident 2 as ordered by the physician, and would expect staff to be documenting each time abdominal fistula care is being provided to Resident 2, including when nurse aides are administering the care as ordered.
42 CFR 483.25 Quality of care
28 Pa. Code 211.12(d)(1)(3)(5)Nursing services.
| | Plan of Correction - To be completed: 02/20/2026
Preparation, submission, and implementation of this plan of correction do not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. Our plan of correction is prepared and executed as a means to continuously improve the quality of care and to comply with all state and federal regulatory requirements.
Resident #2 has been discharged to the Lebanon VA Medical Center for further medical evaluation due to complexity of resident's health condition.
An audit was completed of all residents and no similar care conditions were identified. This includes all treatment orders and weekly wound report.
Nursing staff will be re-educated to ensure a physician's order is obtained for any treatment.
Caregivers document care of residents in the electronic health record under the tab, Tasks.
Completion of caregiver documentation is currently reviewed at daily clinical meeting.
Director of Nursing or designee will conduct weekly audits of 24 hour report and new physician orders weekly x 12 weeks, and thereafter monthly 3 months to monitor accuracy of resident's plan of care and physician orders.
A summary of audit results will be reported to our QAPI Committee for further review and recommendations.
|
|
