|§ 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.
Based on a review of clinical records and facility provided documentation, and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by failing to follow physician orders for skin treatment for one resident out of six sampled (Resident A1).
A review of the clinical record revealed that Resident A1 was most recently admitted to the facility on May 8, 2022, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), diabetes, end stage renal disease, renal dialysis, peripheral vascular disease (PVD - a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel can cause PVD), gastro - esophageal reflux disease (GERD), gout (a common form of inflammatory arthritis that is very painful), muscle wasting and atrophy.
A review of a Quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 15, 2022, indicated that the resident was cognitively intact with a BIMS (brief interview to assess cognitive status) score of 15 (13 - 15 represents cognitively intact) and required extensive assist of 2 staff members for bed mobility, transfers, dressing, toileting, personal hygiene (combing hair, brushing teeth) and with 2 person physical help with bathing.
A physician order dated May 19, 2022, was noted to provide a treatment for the sacrum (the triangular bone just below the lumbar vertebrae - at the base of your spine) of cleanse with wound cleanser, apply medihoney (a wound gel treatment), cover with 4 x 4 dressing (rest against, do not secure) every shift for pressure.
A nursing note dated June 1, 2022, at 10:03 PM, indicated that during the shift a nurse aide notified the nurse that the resident had a different treatment on his bottom. The nurse noted an Island dressing on Resident A1's bottom. The treatment noted on the resident's Treatment Administration Record (TAR) is for a 4 x 4 piece of gauze with medihoney to rest against resident's sacrum. Upon staff removing the Island dressing, the resident's skin was too fragile, at the location he island dressing attached to the resident's skin and the resident sustained skin tears. On the right buttock a 3.0-centimeter (cm) x 1.0 cm skin tear was observed. On the left buttock a 1.5 cm x 0.2 cm skin tear observed. The resident stated "The nurse on 7-3 shift put this on me, I didn't notice it was a bandage until you pointed it out." This nurse changed the resident's treatment to the correct treatment. A 4 x 4 gauze with Medihoney to sacrum, bacitracin was applied to skin tears and 4 x 4 gauze placed over the skin tears.
The intervention in response to this error was to provide nursing education on how to read the TAR for proper treatment instructions.
A review of facility provided document and incident report, dated June 1, 2022, 9:38 P.M., also noted the incident above. The immediate action taken was that the nurse corrected the treatment, and that nursing education on how to read the TAR for proper treatment instructions.
An outside -community based, wound consultant, initial wound evaluation and management, for the skin tear - abrasion on the left and right buttocks on June 2, 2022, at 3:39 P.M., indicated that the left buttock abrasion (Length x Width x Depth) cm was 1 x 0.3 x 0.1, with no exudate (drainage - fluid that has seeped out of blood vessels or an organ), but was tender. The right buttock abrasion measured 1 x 0.3 x 0.1 with no exudate, with tenderness.
The wound consultant documentation dated June 16, 2022, at 12:19 P.M., indicated that the resident's left buttock abrasion measured 0.4 x 0.3 x 0.1 without exudate with tenderness. The right buttock abrasion was resolved.
A wound consultant documentation dated June 23, 2022, at 5:47 P.M., indicated that the resident's left buttock abrasion measured 0.2 x 0.2 x 0.1 without exudate with tenderness.
During an interview on June 28, 2022, at approximately 2:00 PM, with the Nursing Home Administrator (NHA), he NHA verified the incident during which the physician orders had not been followed resulting in skin tears to the resident. The NHA verified that there was no documented evidence of the nursing education, and/or discipline, and or competency evaluation provided to the nurse who applied the incorrect treatment at the time of the survey ending June 28, 2022.
28 Pa. Code 211.12 (a)(d)(1)(3)(5) Nursing services
| ||Plan of Correction - To be completed: 08/09/2022|
What corrective actions will be accomplished for those residents found to have been affected by the deficient practice?
An incident report was competed at the time of the original occurrence. Resident A1's physician's orders were immediately reviewed, and the correct treatment was applied. Resident A1 no longer resides at the facility.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
Current facility residents with wound treatments have been assessed and reviewed for treatment accuracy.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
The facility policy and procedure for Treatment Administration will be reviewed/revised. Current facility licensed staff will be educated by DON/designee on the policy changes. DON/designee will complete Treatment Competencies with current licensed staff.
How the corrective action will be monitored to ensure that the deficient practice will not recur?
To ensure the deficient will not recur, the facility will audit 5 wound treatments and orders for accuracy weekly X 4 weeks, bi-weekly X 1 month then monthly X 1 month. Audit results will be reviewed at the monthly QAPI meeting.
Dates of when the corrective action will be completed: August 9, 2022