|§483.21(b)(3) Comprehensive Care Plans|
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
Based on review of Pennsylvania's Nursing Practice Act, facility incident reports and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a professional (registered) nurse assessed a resident after a change in condition for one of seven residents reviewed (Resident 6), and completed an accurate fall risk assessment for one of seven residents reviewed (Resident 2).
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 responsible for assessing human responses and plans, implementing nursing care, analyzing/comparing data with the norm in determining care needs, and carrying out nursing care actions that promote, maintain and restore the well-being of individuals.
The facility's policy regarding notification of changes, dated March 14, 2019, indicated that if there was a change in condition, the physician would be consulted.
A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated July 4, 2019, indicated that the resident was cognitively intact, could understand and be understood by others, and was dependent on staff for care.
A nursing note for Resident 6, dated June 27, 2019, indicated that she was admitted to the facility with increased weakness and a urinary tract infection, and she was alert and oriented to person, place and time. A nursing note dated July 17, 2019, indicated that the resident's family member felt that she was not acting right and was requesting that she be checked for a urinary tract infection, as she gets them frequently. A nursing note, dated July 22, 2019, at 5:36 a.m. indicated that the resident was confused, unable to state what time it was, and could not be reoriented. A nurse practioner's note, dated July 22, 2019, at 11:24 a.m. revealed that the note did not address the change in condition that was observed for Resident 6, and that the practitioner saw the resident for ongoing fracture with routine healing, gait and mobility abnormalities, and high blood pressure.
A therapy note for Resident 6, dated July 23, 2019, indicated that the resident was lethargic, showing jerking movements, seemed confused, and not speaking during the therapy session. There was no documented evidence that a registered nurse assessed Resident 6's change in condition or that the physician or nurse practioner was notified about the changes.
A nursing note for Resident 6, dated July 24, 2019, at 5:35 p.m. indicated that the resident was not transferring well and needed the assistance of two staff for transfers, instead of one. There is no documented evidence that a registered nurse or nurse practioner assessed the resident after this change was noted.
A nursing note for Resident 6, dated July 25, 2019, at 10:58 p.m. indicated that the resident was confused, climbing out of bed, and was not able to be redirected. There was no documented evidence that a registered nurse assessed the resident for this change in condition.
A nursing note for Resident 6, dated July 26, 2019, at 12:40 p.m. revealed that the resident was lethargic with twitching movements noted. There is no documented evidence that a registered nurse assessed her for this change in condition.
A nursing note for Resident 6, dated July 27, 2019, at 8:00 p.m. revealed that her family was requesting she go to the hospital for evaluation. She was admitted to the hospital with acute kidney injury, urinary tract infection, congestive heart failure (CHF - the heart is unable to pump effectively causing a build up of fluid in the body) and altered mental status.
Hospital records for Resident 6, dated July 28, 2019, revealed that her B-Type Natriuretic Peptide (BNP - hormone produced by your heart) was 4,083 and the normal level was 0-100, indicating that she was in CHF. According to the hospital records, Resident 6 died at the hospital of CHF and pneumonia.
Interview with the Nurse Practioner on August 30, 2019, at 3:30 p.m. revealed that he saw Resident 6 on multiple occasions and that he wrote a progress note for each visit. When asked if he saw Resident 6 on the above dates, he stated that if he did, there would be a note to accompany the visit, and if there were no notes, he could not say that he saw her.
Interview with the Nursing Home Administrator on August 30, 2019, at 6:00 p.m. revealed that the nurse practioner and the physician were involved with Resident 6's care; however, there were no documented nursing assessments for the changes in condition mentioned above and there should have been.
A nursing note for Resident 2, dated August 19, 2019, at 6:14 p.m. revealed that the resident was admitted from the hospital after being treated for change in mental status and inability to walk. The resident's care plan, dated August 19, 2019, indicated that the resident had a potential for falls related to cognitive impairment, decline in functional status, impaired balance during transitions, incontinence, and dementia. A physican's order, dated August 19, 2019, included orders for the resident to receive 1 milligram (mg) of Risperdal (anti-psychotic medication) twice a day for agitation.
A nursing admission assessment, dated August 19, 2019, indicated that Resident 2 was able to move all extremities, but significant weakness was noted to the right side and required the assistance of two staff with transfers. An occupational therapy note, dated August 19, 2019, as the start of care, indicated that the resident had deficits with activities of daily living, toileting, transfers, and all forms of mobility and required increased time, assistance and cues for all functional activities secondary to decreased balance, strength, range of motion, and safety awareness.
A fall risk assessment, dated August 19, 2019, was inaccurate and indicated that Resident 2 was not receiving an anti-psychotic medication and could transfer safely without assistance or supervision. The assessment concluded that the resident was at low risk for falls.
An incident report, dated August 24, 2019, at 4:20 a.m. and a nursing note dated August 24, 2019, at 1:47 p.m. revealed that Resident 2 was found lying on the floor on his left side with his face toward the floor, there was blood coming from his nose and a small puddle on the floor. The resident was transferred to the hospital and admitted with a nasal fracture.
An interview with the Director of Nursing on August 30, 2019, at 3:43 p.m. confirmed that Resident 2's fall risk assessment was not coded correctly and should have included that Resident 2 was receiving an anti-psychotic medication and was unable to transfer safely without the assistance of two staff.
42 CFR 483.21(b)(3)(i) Services Provided Meet Professional Standards.
Previously cited 7/10/19.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Previously cited 7/10/19, 2/28/19.
| ||Plan of Correction - To be completed: 11/08/2019|
1. Resident 6, was admitted to the hospital on 7/28/19.
Resident 2 care plans were updated with appropriate transfer status and for psychotropic medication use.
2. All residents with an inaccurate fall risk assessment and with a change in condition have the potential to be affected by the alleged deficient practice. Director of Nursing/ Designee will review most recent fall risk assessment to ensure accuracy.
3. All Licensed Clinical Staff will be educated on the need to assess and document on residents who have a change in condition and to accurately complete fall risk assessments in accordance with facility policy.
All licensed clinical staff will be educated on new system tracking change in resident condition.
Director of Nursing / Designee will randomly audit nursing documentation for residents with a change in condition to to ensure the assessment is completed and documented.
Director of Nursing / Designee will randomly audit fall risk assessments to ensure they are completed accurately in accordance with facility policy weekly x 4 and monthly until resolved.
Finding will be reviewed and monitored by the Quality Assurance Performance Improvement Committee monthly times 3 months.