§ 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 provide the highest practicable care regarding the implementation of physician-ordered recommendations regarding an oral medication for one of two residents reviewed (Resident 1).
Findings include:
Clinical record review for Resident 1 revealed the resident has a diagnosis of hypercalcemia, (a condition in which the calcium level in the blood becomes too high), and hyperparathyroidism, (a condition that develops from too much activity in one or more parathyroid glands which boost the level of calcium in the bloodstream when needed), and these conditions were managed by the resident's endocrinologist.
Further clinical record review for Resident 1 revealed a facility consultation form for Resident 1 from endocrinology dated March 27, 2023, noting the diagnosis of hypercalcemia, and hyperparathyroidism with recommendations to start Sensipar (cinacalcet, a medication used to treat high levels of calcium in the blood), 15 milligrams (mg) daily, and the resident was to return in three months. A copy of the prescription dated March 27, 2023, for Sensipar, 30 milligrams, take 0.5 tablets by mouth daily for 90 days, was observed in the resident's paper clinical record.
A facility consultation form from endocrinology for Resident 1 dated June 27, 2023, noted to draw ionized calcium among multiple other lab work prior to a follow up appointment in two months. An after-visit summary from the June 27, 2023, visit noted instructions to continue Sensipar, schedule a two month follow up visit and obtain the noted lab work a few days prior to the appointment.
Resident 1 was scheduled with a follow up appointment with endocrinology on August 28, 2023, and the requested lab work was ordered to be drawn on August 21, 2023.
A review of Resident 1's medication orders revealed the Sensipar was ordered for the resident on March 20, 2023, after the March 27, 2023, endocrinology visit and was stopped after 90 days on June 28, 2023. There was no evidence the Sensipar was continued as instructed from the endocrinology visit on June 27, 2023.
A review of Resident 1's ionized calcium level obtained by lab on August 21, 2023, which was collected as recommended by endocrinology before the resident's scheduled appointment on August 28, 2023, revealed a level of 1.52 millimoles per liter (mmol/L), which was flagged as high from the reference range of 1.13-1.32 mmol/L. Resident 1's primary physician and endocrinology were made aware of the lab results with no new orders.
Due to transportation issues, Resident 1's endocrinology appointment was cancelled on August 28, 2023, with rescheduled dates of August 30, and September 8, 2023, cancelled for the same reason. Resident 1 was then scheduled to see the endocrinologist on February 14, 2024.
A nursing note dated October 10, 2023, at 2:16 PM noted the Resident 1's endocrinology appointment was scheduled for February 14, 2024, and labs were ordered for two days prior to the appointment. These labs included the ionized calcium level among the other labs that were also to be completed prior to the resident attending the appointment that was originally scheduled on August 28, 2023.
A review of an ionized calcium level laboratory result collected on February 12, 2024, revealed a result of 1.60 mmol/L, which was flagged as critically high above the high end of the reference range of 1.13 - 1.32 mmol/L.
A nursing note dated February 12, 2024, at 8:23 AM noted lab results with critical result for ionized calcium reported to doctor by message and email and order was obtained to send the resident to emergency department was received.
A review of Resident 1's emergency room after visit summary dated February 12, 2024, it was noted to increase the resident's oral intake of water, and an extensive discussion with the resident's mother had taken place regarding the risk and benefit of intervention for the hypercalcemia (elevated ionized calcium level), in the emergency department and the mother wanted to avoid the discomfort of intravenous (IV, needle inserted into a vein), treatment and planned to follow up with the scheduled endocrinology appointment on February 14, 2024.
Review of Resident 1's facility consultation report from endocrinology on February 14, 2024, it was noted to restart the Sensipar 15 mg, once daily, and to draw lab work on February 27, 2024, which included an ionized calcium level.
Resident 1 was again ordered Sensipar 15 mg once daily on February 15, 2024.
A review of Resident 1's ionized calcium level obtained by lab on February 27, 2024, after the medication was restarted, revealed a level of 1.34 mmol/L which remained high, but improved from the level obtained on February 12, 2024, and lower than the level of 1.52 mmol/L obtained on August 21, 2023. Resident 1 had not received the Sensipar, a medication used to control blood calcium levels, since it was stopped on June 28, 2023, and not continued as instructed upon the endocrinology visit on June 27, 2023.
Resident 1 did experience an increase in the ionized calcium level upon lab work obtained prior to the scheduled August 28, 2023, endocrinology appointment that was cancelled. No other ionized calcium level was obtained until prior to the February 14, 2024, endocrinology appointment, after August 30, and September 8, 2023, appointments were cancelled by the facility. The Sensipar medication was then restarted after the February 14, 2024, appointment and based on repeated lab work of the ionized calcium has resulted in an improvement in the resident blood calcium level. There was no evidence endocrinology was aware the resident was not receiving the Sensipar from June 28, 2023, until the appointment on February 14, 2024.
In an interview with the Director of Nursing on March 22, 2024, at 1:17 PM it was confirmed Resident 1 was not ordered to continue the Sensipar as instructed after the resident's endocrinology appointment on June 27, 2023, the resident had a high ionized calcium level on August 21, 2023, the resident missed appointments with endocrinology on August 28, 30, and September 8, 2023, had a critical high calcium level on February 12, 2024, requiring a visit to the emergency room, and upon visiting endocrinology on February 14, 2024, the Sensipar was restarted, and follow up lab work resulted in improvement in the resident's blood calcium level.
Refer to 840
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 05/03/2024
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies. To remain in compliance with all federal and state regulations, the facility has taken or will take actions set forth in the following plan of correction.
1) Resident 1 is receiving his Sensipar as ordered. Resident 1 is scheduled to have an ionized calcium level drawn on April 22, 2024.
2) A review will be completed of current residents who have had consultant appointments within the last 30 days to validate that instructions from consultant appointments are being followed as ordered. Corrective action will be taken if needed. 3) Licensed nurses will be educated by the DON (Director of Nursing)/designee regarding the expectation to monitor consultant appointment reports upon receipt and to validate that all physician-ordered recommendations are acted upon. 4) Audits will be conducted weekly x 4 weeks and then monthly X 2 months to ensure consultant physician-ordered recommendations regarding oral medications are followed. Audits will be completed by the DON/designee with trends reported through QA&A.
5) Date of compliance: May 3, 2024
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