§ 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 clinical records review and staff interview, it was determined that the facility failed to follow a physician's order regarding vital signs monitoring and failed to notify the physician of an x-ray result timely for one of the two residents reviewed (Resident1).
Findings include:
Clinical records review revealed Resident 1's diagnosis list includes Dementia (term used to describe a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life), fracture of the left femur (thigh bone), and Pneumonia (infection of the air sacs in one or both the lungs. Characterized by severe cough with phlegm, fever, chills and difficulty in breathing).
Review of Resident 1's nursing progress notes dated December 29, 2023, at 6:46 p.m., revealed the daughter-in-law requested an x-ray of the foot because the resident complained of pain when the foot was massaged. An x-ray of the left ankle and foot was ordered. The x-ray result was an Acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone. The resident was medicated with round-the-clock Tylenol (pain medication). The resident denied pain, the radiology report was placed on the physician's book for review.
Review of Resident 1's physician's note dated January 3, 2024, at 11:28 a.m., revealed that a follow-up was made from the last visit where an x-ray of the left foot was ordered with radiology interpreted as "There as residuals of acute/subacute nondisplaced fracture of the distal left fifth metatarsal bone". The physician documented that the physician services were not notified of the radiological findings at the time the results were published. An order for a non-weight bearing and a specialist evaluation was ordered by the physician.
Interview was conducted with the Director of Nursing on February 29, 2024, at 1:00 p.m. The DON reported that a fracture from an x-ray result should be reported to the physician by calling them and not by leaving a report in the physician's book.
The facility failed to ensure Resident1's physician was timely notified of Resident 1's left foot fracture.
Review of Resident 1's physician order dated February 13, 2024, revealed an order to check all vitals two times daily for Pneumonia.
Review of Resident 1's clinical record including February 2024 Medication Administration Record and weight and vital records revealed Resident 1's vitals were only checked daily on February 15, 16, 17, 18, 19, 20, and 21, 2024, instead of twice daily as ordered by the physician.
Interview with the Assistant Director of Nursing on February 29, 2024, at 2:00 p.m., confirmed that the physician's order to check Resident 1's vitals twice a day was not followed on the above-mentioned dates.
28 Pa. Code: 211.5(f) Clinical records
28 Pa. Code: 211.12(d)(1)(5) Nursing services
28 Pa Code 201.18(b)(1)(3)(e)(1) Management
| | Plan of Correction - To be completed: 04/17/2024
1. CORRECTIVE ACTION FOR AREAS AFFECTED:
Resident 1 was non weight bearing at the time of discovery and was evaluated by podiatry for affected foot and no new orders were received and full weight bearing status was resumed for affected foot. Licensed nursing staff directly involved were counseled and educated on timely notification to the physician for all newly identified fractures.
2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee on current residents with newly identified fractures to ensure physician notification occurs timely.
3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Licensed nursing staff were re-educated by the Director Of Nursing/Designee on timely notification of the physician for newly identified fractures.
4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/designee will conduct weekly random audits for the next 90 days to ensure timely notification to the MD/Provider of any change in conditions. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
1. CORRECTIVE ACTION FOR AREAS AFFECTED:
Resident 1 vitals signs were ordered to be checked two times daily and were not consistently done as ordered. Nursing staff directly involved were counseled and educated on following physician orders for vital signs when ordered two times daily.
2. OTHER AREAS AFFECTED:
An initial audit will be completed by the Director of Nursing/Designee on current residents with orders for vitals signs two times daily to ensure vital signs are documented on as ordered.
3. SYSTEMIC CHANGES TO PREVENT FUTURE OCCURRENCES:
Licensed nursing staff were re-educated by the Director of Nursing/Designee on following physician orders for vital signs when ordered two times daily.
4. MONITORING OF CORRECTIVE ACTION:
The Director of Nursing/Designee will conduct random weekly audits of MARs for the next 90 days to ensure that physician orders for monitoring of vitals signs when ordered two times daily are followed. Results of the audit will be reported to the Quality Assurance Performance Improvement Committee monthly.
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