§ 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 clinical records review and staff interview, it was determined that the facility failed to ensure the physician's order regarding blood sugar was followed for one of the 17 residents reviewed (Resident 19).
Findings include:
A review of Resident 19's diagnosis revealed malignant neoplasm of the connective and soft tissue of the pelvis, and Hypoglycemia (low blood sugar level).
A review of the physician order dated December 19, 2023, revealed an order to check Resident 19's blood sugar every four hours when awake. Call a physician if blood sugar is less than 60 or greater than 350.
A review of the January 2024, Treatment Record revealed that from January 1, 2024, until January 31. 2024, Resident 19 had a blood sugar below 60 on the following days: January 3, 2024, at 12:00 a.m., 38 mg/dl; January 7, 2024, at 12:00 p.m., 44 mg/dl; January 9, 2024, at 8:00 a.m., 38mg/dl; January 10, 2024, at 4:00 p.m., 44 mg/dl; January 14, 2024, at 8:00 a.m., 38 mg/dl; January 15, 2024, at 8:00 a.m., 55 mg/dl; January 15, 2024, at 12 noon, 48 mg/dl; January 16, 2024, at 8:00 a.m., 36 mg/dl; January 20, 2024, at 8:00 a.m., 36 mg/dl; January 21, 2024, at 12:00 a.m., 44 mg/dl; January 24, 2024, at 8:00 a.m., 56 mg/dl; January 24, 2024, at 4:00 p.m., 35 mg/dl; January 26, 2024, at 4:00 p.m., 36 mg/dl; and January 26, 2024, at 8:00 p.m., 39 mg/dl.
The clinical records review failed to reveal that the physician was notified of Resident 19's blood sugar result of below 60 mg/dl on the dates/time mentioned above.
An interview with the Director of Nursing on February 2, 2024, at 11:30 a.m., confirmed that the physician was not notified of Resident 19's below 60 mg/dl blood sugar on the dates/time mentioned above.
The facility failed to ensure the physician's order to be notified when Resident 19's blood sugar level was below 60 mg/dl ( 14 times) was followed.
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(c)(d)(1)(5) Nursing services
| | Plan of Correction - To be completed: 03/07/2024
Resident #19- The medical provider reviewed the resident's record and documented in progress notes acknowledgement of blood sugar results. The Clinical Manager or designee conducted a 100 percent audit of all resident's with a physician order for blood sugars to validate that the physician orders were followed. Any discrepancies will be corrected promptly. The CM or designee will review all residents with blood sugars daily during morning clinical meeting to validate physician orders were followed. The Staff Development Coordinator (SDC) or designee in-serviced the licensed nursing staff on the facility policy for Physician Orders to include following physician orders for blood sugars. The Director of Nursing (DON) or designee, will conduct audits of resident's with a physician order for blood sugars to validate that physician orders were followed weekly for four weeks and monthly for two months. Results of the audits will be reported to the QAPI committee monthly for review. Additional audits and education may be determined based on audit findings.
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