§483.30(b) Physician Visits The physician must-
§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;
§483.30(b)(2) Write, sign, and date progress notes at each visit; and
§483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
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Observations: Based on review of facility documentation, clinical record review, resident and staff interviews, it was determined that the facility failed to ensure that intravenous antibiotic therapy was ordered for a resident was admitted for antibiotic therapy for one of eight residents. (Resident R1)
Findings include:
Review of resident R1's clinical record revealed, this resident was admitted to the facility on January 19, 2023 with a diagnosis of diabetes (a chromic metabolic disease characterized by elevated levels of blood glucose (blood sugar)which leads to serious damage to the heart, blood vessels, eyes , kidneys , and nerves), liver cirrhosis (chronic liver damage which can lead to liver failure) a liver transplant, COPD (Chronic Obstructive Pulmonary Disease - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), recently hospitalized for pneumonia (a lung infection that inflames air sacs in one or both lungs, which may fill with fluid) resulting in sepsis (the body's overactive and extreme response to an infection, sepsis is a life threatening medical emergency).
Review of the hospital discharge instructions revealed that the instruction for skilled nursing facility summarized Resident R1's medical history, diagnosis's and that this resident is "undergoing IV (intravenous) antibiotic therapy."
Further review of the hospital discharge instructions revealed that Resident R1 needed a PICC line (A peripherally inserted central catheter (PICC), is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart. Very rarely, the (line placed to receive antibiotics for an extended period). Resident R1 required placement in a special skilled nursing facility to facilitate getting these antibiotics via IV.
Continued review of the hospital document revealed skilled nursing facility instructions that stated resident was receive iv antibiotics as well as summary of care that stated resident will be discharged to a skilled nursing facility to receive IV antibiotics.
Review of the discharged medication list, did not include antibiotic therapy. Review of hospital discharge notice dated January 19, 2023, revealed that it was signed by the facility's physician assistant.
Interview with Resident R1's family member on January 30, 2024, at 9:00 a.m. approximately revealed that he had asked the nurse for the antibiotic, stating she had not received it since entering the facility. He stated Resident 1 needed this medication, and it was not being given to her. He was told the facility did not have it and was waiting for the order. He then requested that Resident R1 be sent to the emergency room. Resident R1 was readmitted into the hospital on January 23, 2023, after not being able to receive antibiotics at rehabilitation.
Interview with Resident R1 on January 30, 2024, approximately at 10:00 a.m. revealed that the resident was fully aware that she required iv antibiotic upon entering the facility from the hospital discharge on January 19, 2024. Resident R1 did not receive her third dose after the transfer to the facility and requested the IV antibiotic form the nursing staff. The resident stated that she was supposed to receive three doses daily and still needed her third dose of the day she was admitted to the facility. Resident R1 was told that the facility did not have the IV antibiotic. Resident R1 stated that for the next two days (Saturday, January 20, and Sunday January 21, 2023) she had told the nursing staff that she needed her antibiotic but was told it was on order.
Review of hospital discharge summary on January 26, 2023, revealed that there was no clinical evidence of recurrent infection, however, remains high for failure given approximately 2-3 days of missed antibiotics.
Interview with Licensed nurse, Employee E3 via telephone, on January 30, 2023 at 11:25 a.m. revealed that she was on duty January 21,2023 , when the family member of Resident R1 requested the antibiotic. Employee E3 confirmed that an order for antibiotic therapy should have been verified and began to set up the IV.
Interview with Nursing Home Administrator, Employee E1 and Director of Nursing, Employee E2 on January 30, 2023, at 1:40 p.m. revealed that they were aware of the medication error. Employee E2 produced documentation of the hospital discharge summary that did not include the IV antibiotic. Employee E1 believed that this was a miscommunication of the hospital.
There was no documented evidence that the facility contacted the hospital to review the resident's medication list since there was no order for an IV antibiotic medication for a resident who was admitted with a PICC line to receive antibiotic therapy.
201.14 (a). Responsibility of licensee
201.18. (b)(1) Management
211.9. (f)(2) Pharmacy services
211.12. (d)(5 )Nursing services
| | Plan of Correction - To be completed: 02/18/2024
A) The facility cannot retroactively correct this deficient practice. R1 is still residing at the facility and the IV (intravenous antibiotic therapy was administered on 1/21/24.
B) Residents who have a need for intravenous antibiotic therapy have a potential to be affected by this deficient practice. Residents admitted in the last 7 days will have their discharge summary re-reviewed to ensure IV antibiotics are administered if ordered.
C) A root cause analysis was conducted and revealed that there was no physician order for R1 to administer intravenous antibiotic therapy upon admission. There were special instructions summarizing the medical history, diagnosis, and that the resident was cleared by the transplant team to receive Cefazolin. The nurse educator will begin educating the NPs and nursing staff on 2/13/24 to be completed by 2/18/24 on reviewing the discharge summary including special instructions for all residents who have a potential need for intravenous antibiotic therapy to ensure all hospital documentation is verified.
D) Audits of admissions discharge summary to ensure IV antibiotics are ordered as indicated will be conducted weekly x one month. The results of the audits will be monitored in the monthly QAPI meetings until 100% compliance is achieved.
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