§ 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 record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of three sampled residents. (Resident 1)
Findings include:
Clinical record reivew revealed that Resident 1 had diagnoses that included diabetes, anemia, sepsis and chronic pressure ulcers. On January 3, 2024, a physican directed staff to schedule a cardiology consultation for the resident. Clinical record review revealed that as of February 12, 2024, the consultation was not scheduled.
In an interview of February 12, 2024, at 12:05 p.m., the Director of Nursing confirmed that the consultation was not scheduled as ordered by the physician.
28 Pa. Code 211.12 (d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 03/12/2024
F 0684 SS=D
Resident 1 - Resident's consultation was rescheduled.
All in house residents will have their EHR reviewed by the Director of Nursing or designee to ensure that consultation requests have been scheduled and attended by the resident, with outcome documented.
Nurses will review consultation requests daily utilizing PCC orders record. Nursing staff will schedule consultations and record the appointment in the patient/resident's EHR. The outcome of the consultation will be documented in the resident/patient's record.
The Director of Nursing or designee will re-inservice the nursing staff on the process of identifying consultations, scheduling the appointments, and documenting the outcome in the resident's Point Click Care EHR.
The Director of Nursing or designee will complete a twice a week audit for 30 days, then a once a week audit for 60 days, to ensure residents consultations were scheduled appropriately and timely..
Results of the audits will be presented to the monthly QAPI meeting for review and recommendation.
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