Observations:
Based on review of the Pennsylvania Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify physician's orders and a diagnosis of diabetes resulting in hospitalization for one of five residents reviewed (Resident 2).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect, complete, and review ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 1, 2024, indicated that the resident was admitted from a hospital, was cognitively impaired, and dependent on staff for care.
A nurse's note for Resident 2, dated October 3, 2024, at 10:00 a.m., revealed that the resident's blood glucose level was 923 mg/dL, and the resident was transferred to the local hospital and admitted with hyperglycemia (high blood sugar) and altered mental status.
Admission paperwork for Resident 2 (including discharge paperwork from the hospital and a history from the resident's primary care provider) revealed a diagnosis of diabetes mellitus, with physician's orders, dated April 30, 2024, for 6 units of Tresiba FlexTouch U-100 insulin 100 unit/ml (a medication for treatment of diabetes), and orders dated March 5, 2024, to test the resident's blood sugar twice daily. There was no documented evidence in the clinical record to indicate that Resident 2's diagnosis of diabetes or the orders for insulin and blood sugar checks were identified and clarified with the physician.
Interview with Licensed Practical Nurse 1 on October 10, 2024, at 10:40 a.m. revealed that Resident 2 did not have a diagnosis of diabetes and confirmed that the resident had not received insulin or blood sugar checks since her admission to the facility.
Interview with the Registered Dietician on October 10, 2024, at 11:17 a.m. revealed that on admission the resident's diet was a controlled carbohydrate diet (normally prescribed for diabetics); however, it was changed due to the resident not having a diagnosis of diabetes. The registered dietician stated that she reviewed the hospital discharge paperwork but not the paperwork from Resident 2's Primary Care Provider.
Interview with the Medical Director on October 10, 2024, at 11:47 p.m. confirmed that the facility missed Resident 2's medical diagnosis of diabetes and the treatment for it.
Interview with the Registered Nurse Assessment Coordinator (RNAC) on October 10, 2024, at 11:36 a.m. revealed that on admission from a hospital, she sends a request to the resident's Primary Care Provider for information. When the paperwork is faxed back to the facility, it is to be reviewed by the registered nurses and given to the RNAC to scan into the electronic medical record. She confirmed that the diagnosis for diabetes and orders for insulin should have been identified but were missed.
Interview with Registered Nurse 4 on October 10, 2024, at 12:44 p.m. revealed that when there is paperwork on the fax machine the registered nurse will review the paperwork and input necessary information into the resident's medical chart. She confirmed that Resident 2's diagnosis of diabetes and the orders for insulin should have been identified and clarified with the physician but were missed.
Interview with Director of Nursing confirmed that Resident 2's diagnosis of diabetes and orders for insulin and blood sugar checks should have been identified and clarified with the physician but were missed.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
| | Plan of Correction - To be completed: 10/29/2024
1. Resident 2 has been discharged from facility and unable to correct electronic medical record.
2. New admissions from 10/3/24 will be reviewed to ensure complete diagnosis have been entered into their medical record. Hospital discharge documentation including previous History & Physical documents will be reviewed by nursing staff to ensure residents' care plans and orders reflects current diagnosis.
3. Directed in-service's will be provided to RN's on F0658.This education will be scheduled for 10/28/2024. They will be educated on the Professional standards of State Board of Nursing and their responsibilities to collect, complete, and review ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the wellbeing of residents. The Registered Nurses will be educated on the new process for admission paperwork to be reviewed and how to clarify the findings that are identified. This process will be added to the admission checklist for completion. The Director of Nursing or designee will audit all admission checklist to ensure the documentation from the hospital or primary care provider was reviewed for accuracy.
4.Director of Nursing or Designee will complete an audit of new admissions five time per week for two weeks; then three times weekly for two weeks; Then monthly for two months until compliance is met. These audits will include verification that new admission paperwork will be obtained promptly and review when received. Results of these audits will be reviewed monthly at the Quality Assurance and Process Improvement Meetings until substantial compliance is achieved.
5. The date of compliance will be 10/29/2024.
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