§ 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 a review of clinical records, observation, and resident and staff interviews, it was determined that the facility failed to provide nursing services consistent with professional standards of practice by not ensuring the consistent application of physician-ordered therapeutic devices and preventative measures for one of ten residents sampled for quality of care (Resident 4).
Findings include:
A review of the clinical record revealed Resident 4 was admitted to the facility on June 5, 2024, with diagnoses to include Bullous Pemphigoid (a rare skin condition causing large fluid-filled blisters), congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues),
and chronic kidney disease stage 4 (severe kidney damage with the kidneys functioning between 15-29% of their normal capacity).
A review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated March 4, 2025, revealed that Resident 4 was cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 indicates intact cognition).
Further review of the clinical record revealed the following active physician orders:
A physician's order dated March 17, 2025, directed that Geri-sleeves (a lightly padded protective fabric used to prevent skin tears and bruising on fragile skin) be applied to both upper extremities every shift, as tolerated every shift.
A physician's order dated April 25, 2025, directed that ace wraps (elastic bandages used to reduce lower extremity swelling and assist with blood clot prevention) be applied in the morning and removed in the evening.
Review of the resident's care plan in effect through the survey end date of May 6, 2025, revealed that while the resident was to be encouraged to wear anti-embolic stockings per physician order, the plan of care failed to address the March 17, 2025, order for Geri-sleeves to the upper extremities. As a result, the care plan did not reflect all current interventions related to skin integrity and prevention of injury.
Observation of Resident 4 in his room on May 6, 2025, at 11:00 AM revealed he was sitting in his wheelchair watching television. The resident was not wearing Geri-sleeves on either arm as ordered, and ace wraps were not present on either leg.
Interview with Resident 4 at that the time of the observation on May 6, 2025, at 11:00 AM reported staff do not consistently apply the physician ordered ace wraps or Geri-sleeves. He stated, "it's a 50/50 chance that someone will put them on."
An interview with the Director of Nursing (DON) on May 6, 2025, at 1:30 PM confirmed staff had not consistently followed the physician's orders for application of Geri-sleeves for skin protection or ace wraps for blood clot prevention for Resident 4.
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
28 Pa. Code 211.5(f)(ix) Medical records
| | Plan of Correction - To be completed: 05/29/2025
1.Resident #4 geri-sleeves and ace wraps will be applied per physician order. Nursing will document Resident #4's device refusals in the clinical record.
2.An audit will be conducted on all residents to ensure consistent application of physician-ordered therapeutic devices. Nursing will document resident refusals in the clinical record.
3.All Nursing staff will be re-educated on policies: Documentation in the Clinical Record and C.N.A. Documentation, to ensure physician orders are followed and refusals are documented in clinical record.
4.Audits will be conducted daily by ADON/designee to ensure consistent application of physician-ordered therapeutic devices. Nursing will document resident device refusals in the clinical record. Results of these audits will be reviewed in monthly Quality Assurance meetings until substantial compliance is achieved.
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