§ 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 review of facility policies, clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow/clarify physician's diet orders prior to a test, for one of 10 residents reviewed (Resident 3 ).
Findings include:
The facility's policy regarding treatment orders, dated October 15, 2025, revealed that treatments will be consistent with principles of safe and effective order writing. In addition, nursing staff will review the overall situation for a resident for whom one or more meals are to be held to ensure that all related issues are addressed.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated April 21, 2026, revealed that the resident was cognitively intact, always understood and always understands and has diagnoses that include quadriplegia and cancer of the lymph nodes, face and neck.
Physician's orders for Resident 3, dated May 11, 2026, included the following order to start Sunday at 1:00 p.m. prior to her PET scan. The order was to have a diet of no caffeine, sugar, syrup, gum or candy.
A grievance form from the family dated May 11, 2026, indicated that Resident 3 was unable to have her PET scan done as scheduled because she was not given the appropriate diet in preparation for her scan.
A clinical note for Resident 3, dated May 11, 2026, at 2:17 p.m. indicated that Imaging was unable to complete the scan due to the diet not being followed according to pretesting orders.
Interview with Resident 3, on June 9, 2026, at 10:38 a.m. revealed that she was unable to have her PET scan last month because she had a hot dog the night before. The imaging staff told her that the hot dog was a red meat which had salt and sugar in it.
Interview with the Dietary Manager on June 9, 2026, at 1:41 p.m. confirmed that Resident 3 did not get the appropriate diet because the order and information she received was confusing. She went on to say that the diet prep should have been clarified and there was a break in communication among staff. A review of four change of diet slips given to the manager revealed that one slip contradicted the other.
Interview with the Dietician on June 9, 2026, at 1:41 p.m. indicated that the diet prep for the scan was not what they usually see, and that she was going to call Imaging to clarify the prep to avoid any concerns going forward.
Interview with the Nursing Home Administrator on June 9, 2026, at 2:00 p.m. confirmed that Resident 3 was given the wrong diet prior to her PET scan which caused the resident to be returned to the facility and the scan to be rescheduled.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 06/26/2026
1.)Resident 3's PET scan was rescheduled. The diet order for testing on Resident 3 was reviewed and clarified with physician's office. Any discrepancies identified were corrected immediately. The attending physician and resident were notified. The resident was monitored for any adverse outcomes related to the diet discrepancies.
2.)An audit of current resident diet orders for testing was conducted by the Registered Dietitian and dietary Manager. Diet orders for testing in the medical record will be compared to the tray cards to ensure consistency. Any discrepancies identified during the audit will be corrected immediately.
3.)The Director of Nursing or designee will educate the Registered Nurses, Dietitian, and Dietary Manager regarding the importance of accurately transcribing, communicating and implementing physician-ordered diets for testing as needed to ensure that physician orders and tray cards accurately reflect the prescribed diet. The Registered Dietitian will participate in oversight of compliance through routine dietary reviews.
4.)The Dietitian or designee will conduct audits of resident diet orders for testing weekly for four weeks and monthly for two months to verify consistency between physician orders and tray cards and meals served. Audit findings will be reviewed at the Quality Assurance and Performance Improvement meeting and additional education and corrective action will be provided as needed based on audit results.
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