§ 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, reviews of resident clinical records, reviewof facility policies and procedures, and interviews with staff and residents, it was determined that the facility failed to follow physician orders for three of seven residents reviewed. (R12, R30, R31)
Findings include:
Observation of Resident R12 during the tour of the Unit C Wing conducted on April 3, 2023, at 8:56 a.m. revealed that Resident R12 was observed in bed with oxygen via nasal cannula connected to an oxygen concentrator. Further observation revealed that the oxygen concentrator flow meter reading at eye level was 1.5 liters/minute.
Review of Resident R12's clinical record revealed that Resident R12 was admitted to the facility on August 23, 2021. Resident R12's current diagnoses included; CHF (Chronic Obstructive Pulmonary Disease- a group of lung diseases that block the airflow and make it difficult to breath), Acute Respiratory Failure (occurs when the air sacks of the lungs cannot release enough oxygen into the blood), and Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
Review of resident R12's Admission MDS Assessment Section C0500 BIMS score (Brief Interview of Mental Status) dated March 4, 2023, revealed a score of 12 suggesting that Resident R12 was moderately impaired in cognition, Section O (C) Special Treatments, Procedure and Programs revealed that resident R12 was on oxygen.
Review of Resident R12's care plan revealed a plan of care for CHF and Oxygen therapy.
Review of Resident R12's April 2023 physician order revealed a current order for Oxygen at 2LPM (liters/minute) every shift.
Follow-up observation of Resident R12, conducted on April 4, 2023, 12:33 p.m., with the Director of Nursing confirmed that, the oxygen concentrator flow meter at eye level was 1.5 liters/minute.
Review of the clinical records of Resident R30 revealed that the resident was admitted to the facility on March 7, 2022 with the R30 diagnoses of Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of nerves, and it causes many different symptoms, including vision loss, pain, fatigue, and impaired coordination), and Neuromuscular Dysfunction of Bladder (Neuromuscular Dysfunction of Bladder happens when the relationship between the nervous system and bladder function is disrupted by injury or disease).
On April 5, 2023, at 10:49 a.m., Resident R30 was observed with a urinary foley catheter with 15 FR size, and 5 CC balloon. (A Foley Catheter is a sterile tube that is inserted into a person's bladder to drain urine from the bladder of individuals with obstruction of normal urinary flow, Foley Catheter is held in place with a balloon at the end, which is filled with sterile water to prevent the catheter from being removed from the bladder; the French scale is used to measure the size of a catheter and abbreviated as FR.; it is the measure of the outer diameter of a catheter).
Review of physician order dated February 7, 2023, for Resident R30, indicated that there was order for an indwelling urinary foley catheter with 18 FR, with 10 CC Balloon.
On April 5, 2023, at 10:52 a.m., during an interview with Licensed nurse, Employee E4, it was confirmed that the catheter size observed on Resident R30 was not the catheter size ordered by the physician.
Review of the clinical records of Resident R31 revealed that the resident was admitted to the facility on September 5, 2022, with the diagnoses of Fibromyalgia (widespread muscle pain and tenderness), and Polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body).
On April 5, 2023, at 8:15 a.m., it was observed a Licensed Nurse, Employee E3, administered Ferrous Sulfate Oral Tablet, 325 milligrams (mg), by mouth to Resident R31. (Ferrous Sulfate Tablet is an iron supplement used to treat or prevent low Iron levels in blood).
Review of physician order dated, December 7, 2022, for Resident R31, revealed an order for Ferrous Gluconate Tablet 324 (38 Fe) mg, give 1 tablet, by mouth, every 12 hours, every Monday, Wednesday, Friday for anemia.
Further review of medication literature indicated; the main difference between Ferrous Sulfate and Ferrous Gluconate is how much elemental iron they contain; Ferrous Sulfate is 20% elemental iron by weight, while Ferrous Gluconate is around 12% elemental iron by weight.
On April 5, 2023, at 8:17 a.m., it was observed; a Licensed Nurse, Employee E3, applied Lidocaine Patch 5 %, to the lower back of Resident R31.
Review of physician order dated, December 29, 2022, for Resident R31, revealed an order for Lidocaine Patch 4 %, apply to back topically, one time a day for back pain.
Interview with Licensed nurse, Employee E3, at the time of the findings confirmed these observations.
28 Pa Code:201.18(a)(b)(1)(3) Management.
28 Pa Code:211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 04/26/2023
F 684- Facility failed to follow orders for three of seven residents reviewed.
Step 1 -
R12 Oxygen administration corrected to 2LPM. Assessed for adverse effect. None observed. MD and RP notified. Nurse educated on correct way to assess for LPM delivery.
R30 Orders received from NP to change foley catheter size to 16F 5 cc.
R31 was assessed for adverse effect with no substantial findings identified. MD and RP notified. New orders received to adjust medications to those presently on hand. Nurse educated on medication administration process with emphasis on correct drug and dose.
Step 2 –
All residents receiving supplemental oxygen have the potential to be affected. On 4/5/2023 the Director of Nursing (DON) and/or designee audited all residents receiving oxygen to ensure the ordered Liters Per Minute (LPM) matched that provided by the oxygen concentrator. No issues identified.
All residents requiring the use of an indwelling foley catheter have the potential to be affected. On 4/5/2023 the DON and/or designee audited all resident's with foley catheters to ensure the size utilized matched the size ordered. No issues identified.
All residents receiving medication have the potential to be affected. On 4/22/2023, the DON and/or designee will complete a medication administration audit for all licensed staff to ensure correct process is observed.
Step 3 – To prevent the potential for reoccurrence the DON and/or designee re-educated all licensed staff on the medication administration process with emphasis on ensuring dose and drug are correct.
Licensed staff educated on proper technique of assessing for correct administration of oxygen LPM on concentrator.
Licensed staff educated on how to identify an indwelling foley catheter size.
Step 4 – To monitor and maintain ongoing compliance the DON and/or designee will observe the oxygen concentrators for 3 random residents 1 time a week to ensure that the settings match the physician's order. If necessary, the O2 concentration will be corrected, and the resident assessed for adverse effect. The MD and RP will be notified, and the responsible staff member immediately re-educated.
The DON and/or designee will observe 3 residents with foley catheters 1 time a week to ensure the size matches the physicians order. If necessary, the MD and RP will be notified, and the responsible staff member immediately re-educated. New orders will be carried out (to replace or otherwise) as received.
Don/Designee will randomly observe medication administration for 2 nurses 1 time a week for 3 months. If necessary, a resident evaluation will be completed, the MD and RP notified, and new orders obtained. Responsible nurse will be re-educated at time of observation.
Results of the audits will be presented to facility QAPI Committee for review and recommendations.
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