|§ 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 review of facility documents and residents' clinical records, as well as resident and staff interviews, it was determiend that the facility failed to ensure that preventative treatments and dressing changes were completed as ordered by the physician for two of six residents reviewed (Residents 3, 4).
A facility report regarding open lesions, dated November 27, 2019, revealed that Resident 4 had a skin tear on her upper mid-back that measured 2.5 x 1.0 centimeters (cm), with a surrounding bruise that measured 8.6 x 5.0 cm. The report indicated that the resident had been observed scratching herself on the abdomen and the back. Investigation documents for Resident 4, dated November 27, 2019, documented the skin tear and the bruising to the upper back and indicated that the resident reported that, "I get itchy sometimes and I can't help myself." The report indicated that the facility determined that the skin tear and the bruising were most likely self-inflicted due to the resident scratching herself.
A wound note for Resident 4, dated December 10, 2019, indicated that the resident was seen by the certified registered nurse practitioner (CRNP - a registered nurse with advanced training, who is authorized to diagnose and order treatments for wounds) who indicated that there were several lineal scratches and associated ulcerations (open areas) in the area, which were suspected to be due to the resident scratching herself. A wound note by the CRNP dated December 17, 2019, indicated the areas were resolved. Physician's orders, dated December 17, 2019, included an order for a moisturizing cream to be applied to the resident's bilateral upper extremities (both upper arms) and to her back every shift as a preventative measure.
Documentation in Resident 4's clinical record for December 17, 2019, through January 7, 2020, revealed that staff applied the moisturizing cream to the upper arms on the day and evening shifts. However, there was no documented evidence that the new order for the moisturizing cream to be applied to the resident's back (as well as the upper arms) each shift was transcribed onto the resident's clinical record, and no documented evidence that the cream was applied to the resident's back and during the night shift, as ordered by the physician.
Interview with Resident 4 on January 8, 2020, at 8:25 a.m. confirmed that her back was itchy at times, that she scratched it, and that this caused the previous injuries. She stated that she could not help herself, that when she got itchy, she would scratch the areas.
Interviews with Registered Nurse 1 and the Assistant Director of Nursing on January 8, 2020, at 12:00 p.m., and 12:15 p.m., respectively, confirmed that there was no documented evidence that the moisturizing cream was applied to Resident 4's bilateral upper arms and back as ordered by the physician on December 17, 2019.
Physician's orders for Resident 3, dated December 20, 2019, included an order for a simply dry gauze dressing to be applied to the left calf daily. A nursing note and a fax to the physician, dated Januray 2, 2020, revealed that the facility notified the physician that the dressing change was not completed on December 31, 2019.
Interview with the Assistant Director of Nursing on January 8, 2020, at 2:55 p.m. confirmed that the treatment to Resident 3's left calf was not completed as ordered, and the nursing staff could not provide an explanation regarding why the treatment was not done.
42 CFR 483.25 Quality of Care.
Previously cited 6/6/19.
28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/10/19, 8/2/19, 6/6/19.
| ||Plan of Correction - To be completed: 02/11/2020|
Resident R4's orders were adjusted to include application and documentation of moisturizing cream to bilateral upper extremities and back. A skin assessment was completed on R 4 with no adverse effects noted.
A skin assessment was completed on Resident R3 with no adverse effects noted. The physician was immediately notified of dressing not being completed on 1/1/2020. The identified employee was also interviewed at the time of discovery for root cause.
An audit of current residents on wound rounds will be completed to ensure appropriate documentation and application of provider treatment orders. An initial audit was completed by in-house Registered Nurse Supervisor on 1/1/2020 to ensure no additional dressing changes were missed/resident's affected.
Current licensed nursing staff, including licensed agency nursing staff and new licensed staff, will be educated by the Director of Nursing/Designee on proper application and documentation of wound orders and completion of treatments as ordered to include appropriate follow up.
Provider Wound Round notes will be reviewed by the interdisciplinary team in clinical meeting after occurrence to ensure proper documentation and application of newly ordered treatments.
The Director of Nursing/Designee will complete an audit to verify treatments are completed as ordered 3 times a week for 4 weeks then weekly for 4 weeks with the results reviewed at the monthly Quality Assurance Meeting for completion/additional needs.