§ 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 facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of eight residents reviewed (Resident 6).
Findings include:
The facility policy for medication administration, dated January 15, 2025, indicated that medications are administered in accordance with prescriber orders, and that the following information is checked/verified for each resident prior to administering medications: allergies to medications; and vital signs, if necessary.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated February 28, 2025, revealed that the resident was cognitively intact, independent with personal care needs, and had diagnoses that included diabetes.
Physician's orders for Resident 6, dated February 28, 2025, included an order for the resident to receive one-half tablet of 25 milligrams (mg) of Metoprolol Tartrate (used to treat high blood pressure) twice a day for hypertension (high blood pressure) and to hold the medication if the resident's heart rate is less than 60. Physician's orders, dated March 31, 2025, included an order for the resident to receive six units of Insulin Aspart (rapid acting insulin used to lower blood sugar) three times a day and to hold the medication if the resident's blood glucose (sugar) level was less that 120 milligrams (mg) per deciliter (dL).
Review of the Medication Administration Record (MAR) for Resident 6, dated April 2025 and May 2025, revealed that there was no documented evidence that the resident's heart rate was checked twice each day prior to the administration of Metoprolol Tartrate as ordered from April 1, 2025, through May 14, 2025. Review of the MAR also revealed that six units of Insulin Aspart was administered on April 13 at 9:00 a.m. when the resident's blood sugar level was 75 mg/dl, six units of Insulin Aspart was administered on April 17 at 9:00 a.m. when the resident's blood sugar level was 112 mg/dl, six units of Insulin Aspart was administered on May 2 at 9:00 a.m. when the resident's blood sugar level was 98 mg/dl, six units of Insulin Aspart was administered on May 5 at 9:00 a.m. when the resident's blood sugar level was 102 mg/dl, and six units of Insulin Aspart was administered on May 6 at 9:00 a.m. when the resident;s blood sugar level was 104 mg/dl.
Interview with the Assistant Director of Nursing on May 14, 2025, at 3:56 p.m. confirmed that the heart rate for Resident 6 should have been assessed prior to the administration of Metoprolol Tartrate; however, it was not.
Interview with the Assistant Director of Nursing on May 14, 2025, at 4:05 p.m. confirmed that Insulin Aspart was administered to Resident 6 on the above-mentioned dates and times when it should have been held per physician's orders.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
| | Plan of Correction - To be completed: 06/12/2025
Resident 6 Metoprolol tartrate 12.5 mg order was clarified to include the heart rate in the supplementary documentation. Resident 6 Insulin Aspart solution order was clarified, and supplementary documentation was updated to reflect the order to hold insulin for blood sugar less than 120.
A 14-day look back audit was completed of medications with parameters; no other concerns noted. The Director of Nursing or designee will audit the administration records to ensure medications are being given with in parameters,
The Director of Nursing or designee will complete education with Registered Nurses and License practical nurse to ensure that medications are administered within parameters.
The Director of Nursing or designee will complete an audit of medications with parameters to ensure that medications are being given within the parameters. This audit will be completed daily for one week, and weekly for three weeks. The results of the audits will be reviewed at the monthly Quality Assurance Performance Improvement Committee meeting.
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