§ 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.
|
Observations:
Based on clinical record review, facility policy review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of seven sampled residents. (Resident 1)
Findings include:
Review of the facility policy entitled, "Medication Administration General Guidelines," dated February 12, 2026, revealed that medications were to be administered in accordance with written orders of the prescriber and that medications to be given at bedtime were to be scheduled for administration up to one hour prior to the resident's scheduled bedtime.
Clinical record review revealed that Resident 1 was admitted to the facility on February 22, 2024, with diagnoses that included Hodgkin's lymphoma (cancer of the lymph nodes) and anxiety. A physician's order, dated October 27, 2025, directed staff to administer lorazepam tablet 0.5 milligrams (mg), three tablets at bedtime. Review of nursing progress notes and the Individual Patient Narcotic Dispensing Record (a record kept to keep count of remaining narcotic tablet administration) revealed that on December 11, 2025, the nurse (LPN 1) administered one lorazepam tablet at 5:30 p.m., and not at the scheduled time of 8:00 p.m. (bedtime). An additional physician's order, dated January 19, 2026, directed staff to administer lorazepam tablet 0.5 mg, three tablets at bedtime. Review of Resident 1's Individual Patient Narcotic Dispensing Record revealed that on February 4, 2026, at 8:00 p.m., that the nurse (LPN 2) administered only one lorazepam tablet at 8:00 p.m. Another physician's order, dated January 19, 2026, directed staff to administer oxycodone HCL (IR) 10 mg tablet every four hours for pain. Review of the January 2026 Medication Administration Record revealed that on January 29, 2026, at 8:00 p.m., Resident 1 missed this dose because there was no medication available. A progress note written by the nurse (LPN 3) revealed that the medication was not available. Resident 1's Individual Patient Narcotic Dispensing Record revealed that on January 29, 2026, at 4:00 p.m., the resident received the last dose of the medication on hand. The Individual Patient Narcotic Dispensing record revealed that the resident received the next dose on January 30, 2026, at midnight.
In an interview on March 3, 2026, at 3:05 p.m., the Administrator stated that there was no documented evidence to support that staff followed physicians' orders as identified above.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 03/20/2026
1. Incident investigations ( medication errors) completed. Licensed nurses who were involved in medication error are currently not staff of the facility.
2. Entire facility Audit of medication administration completed to ensure written orders are followed per Medication administration guidelines.
3. Licensed nursing staff educated on medication administration guidelines. Unit Manager/Designer will check narcotic count sheets daily to ensure providers' written order tallies with narcotic administration. Medication errors, when identified will be reported to the DON and facility investigative processes will be followed.
4. Audit to be conducted daily x 1 week, 3 x a week x 2 weeks and randomly. Licensed staff who do not follow guidelines will be educated and or undergo facility disciplinary processes.
|
|
