§ 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 clinical records and staff interviews, it was determined that the facility failed to follow physician orders for four of 19 residents (Residents R10, R12, R23 and R63).
Findings include:
Resident R12's clinical record revealed an admission date of 1/31/03, with diagnoses that included Type 1 diabetes (condition where the body makes very little or no insulin that's needed for blood sugar to enter the cells in your body for energy), cerebral palsy (birth defect that affects movement and muscle tone or posture), muscular dystrophy (condition where abnormal genes cause progressive weakness and loss of muscle mass), and high blood pressure.
A physician's order for Resident R12 dated 4/20/19, identified that staff are to notify the physician for blood sugars less than 60 milligrams/deciliter (mg/dL). Resident R12's clinical record revealed that on 11/01/19, at 7:00 a.m. his/her blood sugar was 48 mg/dL. The clinical record lacked evidence that the physician was notified of Resident R12's blood sugar level.
During an interview on 12/05/19, at 12:59 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E1 confirmed that the clinical record lacked evidence that staff contacted the physician regarding Resident R12's blood sugar of 48 mg/dL.
Resident R63's clinical record revealed an admission date of 12/20/18, with diagnoses that included dementia (a group of symptoms that affect memory, thinking and interferes with daily life), Type 2 diabetes (affects how your body uses blood sugar or glucose), and depression.
A physician order, dated 10/22/19, identified that the physician should be notified if Resident R63's blood sugar was less than 70 mg/dL or greater than 400 mg/dL. Between 11/11/19 and 12/4/19, there were four instances when Resident R63's blood sugar was less than 70 mg/dL and 13 times their blood sugar level was greater than 400 mg/dL. The clinical record lacked evidence that the physician was notified of the above low and elevated blood sugar levels.
During an interview on 12/3/19, at 4:00 p.m. the Director of Nursing confirmed the above information.
A facility policy entitled "Charting After a Resident Fall or Head Injury" dated 6/20/19, indicated that staff are to chart on a resident every shift for 72 hours or three days after a fall. Charting includes neuro checks (neurological assessments for level of consciousness, pupil reaction to light, motor functions of extremities/hand grasps, and pain response).
Resident R10's clinical record revealed an admission date of 12/21/17, with diagnoses that included heart failure, irregular heart rate, dementia, a lung disease, and peripheral vascular disease (a condition when there is restricted blood flow to the limb, usually legs).
Resident R10's clinical record revealed that he/she experienced a fall on 6/28/19, in his/her room which resulted in a head injury. A nursing progress note dated 7/3/19, at 4:09 a.m. indicated that the physician was in to assess Resident R10 "earlier in the shift" (shift being 7:00 p.m. to 7:00 a.m.) and had ordered neuro checks to be completed for an additional 72 hours. The next documented neuro checks in Resident R10's clinical record was dated for 7/4/19, at 5:07 a.m. or 25 hours after the previous neuro check was completed. Additionally, the last neuro check documented was dated for 7/05/19, at 4:10 a.m., or approximately 24 hours less of the ordered 72 hours.
Resident R23's clinical record revealed an admission date of 8/05/16, with diagnoses that included dementia, psychosis (serious mental disorder characterized by a loss of contact with reality), anxiety, and high blood pressure.
Resident R23's clinical record revealed that he/she experienced a fall in his/her bathroom on 7/09/19, at 6:41 p.m.
A physician's order dated 7/10/19, at 5:35 a.m. for Resident R23 stated that staff are to complete neuro checks for 72 hours. Facility documentation revealed that staff did not complete neuro checks for 46 hours between 7/10/19, at 5:54 a.m. and 7/12/19, at 4:42 a.m., and only completed neuro checks on 7/12/19, at 2:00 p.m. or 15 hours and 35 minutes less of the 72 hours.
During an interview on 12/04/19, at 1:30 p.m. RNAC Employee E1 confirmed that staff should be performing neuro checks as physician ordered every shift (some units are 12 hour shifts and some are eight hour shifts).
28 Pa. Code 211.5(f) Clinical records
Previously cited 1/10/19
28 Pa. code 211.12(d)(1)(5) Nursing services
Previously cited 1/10/19
| | Plan of Correction - To be completed: 01/24/2020
F0684 – Blood Sugar monitoring.
What corrective action will be accomplished for those residents found to have been affected by the deficient practice? For resident R63, the physician was asked to clarify the order for notification, and on 12/9/19, a new order was received to call if blood sugar was > 500 or if resident was symptomatic. Also, the Nurse who recorded the blood sugar of 48 for that resident on 11/1/19 was coached for not following the physician's order. For resident R12, physician was asked to clarify order. The order for calling remained the same, but physician changed blood sugar monitoring to less often (at 7am Mondays, Wednesdays and Fridays and at 4pm on Tuesdays and Thursdays). Staff is still to notify Physician if bloods sugar is >400 or <60. All Nurses were re-educated on the policy "Glucometer/Assure Platinum/Test Strips – Blood Glucose Monitoring with Parameters" at the Nurse's meeting on December 12th, 2019.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? An audit will be conducted of all resident orders, and any resident who has an order to check blood sugars daily or more often will be pulled for physician review. Physician will be asked to review order for appropriateness and to clarify desired parameters for notifications. This will be done by the Support LPN and Medical Assistant and will be overseen by the Director of Nursing and will be completed by January 24, 2020.
In order to prevent this from happening to another resident, the policy "Glucometer/Assure Platinum/Test Strips – Blood Glucose Monitoring with Parameters" was reviewed at the December 12th Nurses meeting. Furthermore, the policy will be revised to include required documentation as to whether the resident is symptomatic with blood sugar levels and whether a return call is received from the physician. This policy will be revised by the Director of Nursing by January 6th, 2020 and all Nurses will be educated on it by the Director of Nursing during January Nurse Skills review days on January 14 & 15, 2020.
What measures will be put into place or what system changes will you make to ensure that the deficient practice will not recur? Audits of blood sugar checks will be conducted for the months of February-April 2020. This will be conducted by the Support LPN and overseen by the Director of Nursing. Each week, 5 residents on each unit will be checked for blood sugar readings that are out of parameters. If readings are found to be out of parameters, follow up will be conducted to see if staff followed policy. If staff did not follow policy, reeducation and appropriate disciplining will be done by the Director of Nursing.
What Quality Assurance Process will be put in place for review? What Quality Assurance Process will be put in place for review: This will be reviewed at monthly QAPI meetings with the Director of Nursing reporting on the audits. We will keep this on our agenda for February – April 2020.
F0684
"Charting after a Resident Fall or Head Injury"
What corrective action will be accomplished for those residents found to have been affected by the deficient practice? Resident R10 had a Neurological assessment completed on 12/6/19 by an R.N., which is documented in her medical record and was found to be within normal limits for her baseline. Resident R23 had a Neurological assessment completed on 12/11/19 by an R.N., which is documented in her medical record and was found to be within normal limits for her baseline.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? An audit will be conducted of resident falls within the months of October, November, and December of 2019. Records of 10 Resident falls from each month will be checked for charting according to the policy. This will be done by the Director of Nursing and will be completed by Support LPN and will be completed by January 24, 2020. Nursing staff that did not follow the policy for post fall charting will be disciplined accordingly. Also, a new Neurological Assessment will be done on the resident and recording in their medical record if it has not been done since their last fall.
What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur? The Policy "Charting after a Resident Fall or head injury" will be reviewed and revised if any changes are needed by the RNAC and Director of Nursing by January 1, 2020. All Nurses will be reeducated on the policy by the Director of Nursing during the January Nurse Skills review days on January 14 & 15, 2020.
What measures will be put into place or what system changes will you make to ensure that the deficient practice will not reoccur? Audits of post fall charting will be conducted for the months of January-March 2020. This will be conducted by the Support LPN and overseen by the Director of Nursing. Each week, 5 falls on each unit will be checked for proper documentation. If documentation has not occurred according to policy, reeducation and appropriate disciplining of staff will be done by the Director of Nursing.
What Quality Assurance Process will be put in place for review? What Quality Assurance Process will be put in place for review: This will be reviewed at monthly QAPI meetings with the Director of Nursing reporting on the audits. We will keep this on our agenda for February – April 2020.
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