§ 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 policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of four residents reviewed (Residents 1, 2), and failed to ensure that verbal phone orders were written and followed for one of four residents reviewed (Resident 1).
Findings include:
A facility policy for medication administration, dated January 10, 2024, indicated that medications are administered in a safe and timely manner as prescribed.
A facility policy for telephone orders, dated January 10, 2024, indicated that verbal telephone orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 2, 2024, revealed that the resident was understood and understands others, required assistance with daily care needs, had a diagnosis of diabetes (a disease causing high blood sugar levels), and received insulin.
Physician's orders for Resident 1, dated March 28, 2024, included an order for the resident to receive 20 units of Fiasp insulin (a rapid acting insulin) subcutaneously (injected just under the skin) for a blood sugar of greater than 400 milligrams per deciliter (mg/dl) and to notify the physician.
A review of Resident 1's Medication Administration Record (MAR) for April 2024 revealed that the resident's blood sugar on April 11, 2024, at 4:00 p.m. was 435 mg/dl. There was no documented evidence that the physician was notified of a blood sugar greater than 400 mg/dl as ordered.
A review of Resident 1's MAR for April 2024 revealed that the resident's blood sugar on April 20, 2024, at 4:00 p.m. was 505 mg/dl. A nursing note for Resident 1, dated April 20, 2024, at 4:23 p.m. revealed that the supervisor notified the physician of the blood sugar of 505 mg/dl and verbal telephone orders were obtained to give an additional 4 units of Fiasp insulin. There was no documented evidence in Resident 1's clinical record that the verbal telephone orders to give the additional 4 units Fiasp insulin was written and no documented evidence on the MAR for April 2024 to indicate that the 4 units of Fiasp insulin was administered.
A review of Resident 1's MAR for April 2024 revealed that the resident's blood sugar on April 25, 2024, at 7:00 a.m. was 441 mg/dl. There was no documented evidence that the physician was notified of a blood sugar greater than 400 mg/dl.
An interview with the Director of Nursing on May 30, 2024, at 2:30 p.m. confirmed that physician's orders were not being followed for Resident 1 on the above noted dates and times and confirmed that the verbal phone order should have been reduced to witting and followed.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated April 2, 2024, revealed that the resident was understood and could understand others, required assistance with daily care needs, had diagnoses that included Multiple Sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), and pain.
Physician's orders for Resident 2, dated April 11, 2024, included an order for the resident to receive two-5 milligrams (mg) tablets of Oxycodone HCL (a narcotic drug used to treat moderate to severe pain) every 8 hours as needed for pain scale 6-10.
A review of the narcotic accountability sheet for Resident 2, dated May 23, 2024, revealed that only one 5 mg tablet of Oxycodone HCL was signed out; however, a review of the MAR for Resident 2, dated May 23, 2024, revealed that it was documented that the resident received two 5 mg tablets of Oxycodone HCL.
An interview with the Director of Nursing on May 30, 2024, at 3:44 p.m. revealed that Resident 2 only received one 5 mg tablet of Oxycodone HCL on May 23, 2024, and it should have been two tablets.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
| | Plan of Correction - To be completed: 06/19/2024
Resident R2 suffered no adverse effects related to receiving one 5 mg tablet of oxycodone instead of two, 5mg oxycodone tablets on 5/23/24. A pain assessment was completed, and the physician was notified. The physician determined a dose reduction was appropriate and the order was updated to Oxycodone 5mg, one tablet as needed every eight hours. Resident was notified and agreeable, he declined responsible party notification.
Resident R1 no longer with the facility.
A house audit was completed comparing the Medication Administration Record and Narcotic accountability record for the look back period of May 19, 2024, to June 2, 2024, to ensure accurate narcotic doses were administered per physician orders. Any concerns identified were addressed.
A house audit was completed of glucose monitoring results to ensure any values greater than 400 were reviewed with the physician and any additional orders received were documented as completed. The look back period for this audit was May 19, 2024, to June 2, 2024. Any concerns identified were addressed.
The Director of Nursing completed education with licensed staff regarding following a physician's orders and entering them into the EMAR
Director of Nursing or designee will conduct daily audits, 4 days a week, to ensure that Narcotics and insulin are administered per Physician orders, for one week, 3 days a week for 4 weeks, and weekly for 4 weeks. Audit results will be reported to the Quality Assurance Performance Improvement committee to identify trends and further opportunities for Quality improvement and needs for further education.
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