Initial Comments:
A focused fundamental survey was conducted April 18-20, 2023, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was six and the core sample consisted of three individuals.
Plan of Correction:
483.460(a)(3) STANDARD
PHYSICIAN SERVICES
Name - Component - 00
The facility must provide or obtain preventive and general medical care.
Observations:
Based on record reviews and interview, it was determined that the facility failed to ensure that all individuals were provided preventative medical care. This applied to two (#2 and #3) of three individuals in the core sample. Findings included:
Record reviews were completed for Individuals #2 and #3 on April 19, 2023. These reviews failed to reveal any documentation of breast exams completed as a preventative screening for cancer for Individuals #2 and #3.
An interview with the director of residential services (DRS) was completed on April 19, 2023, at 9:53 AM. The DRS confirmed that breast exams were not being completed for Individuals #2 and #3. The DRS further confirmed that breast exams, as a preventative screening for cancer, were not completed on a monthly basis.
Plan of Correction:For individuals #2 and #3, and all others, the facility will provide or obtain preventive or general medical care.
For individuals #2 and #3, the facility RN will consult with their physicians to develop a health care plan and recommended screenings for breast cancer (Target Date: 5/30/2023). The facility will document and follow any guidance provided by the physicians. The facility RN will conduct quarterly nursing assessments that include a physical breast examination for individuals #2 and #3 and document it on their quarterly nursing assessment form (Target Date: 5/30/2023). The nursing assessment will be reviewed by the QIDP for 2 Quarters and maintained in the individual's chart. The quarterly nursing assessment will be submitted to the DRS for 2 quarters for review.
In the future, the facility RN will perform a physical breast exam quarterly, documenting the exam on the nursing quarterly form and maintaining it at the facility. The facility RN will work in conjunction with their physician to determine how frequently self-exams should occur to help with screening for breast cancer. If the physician indicates more frequent exams, the facility RN will document them in their nurses' notes and educate the individual on the recommendations by the physician. If the physician indicates less frequent exams, the facility RN will maintain documentation for the recommended screening procedures for the individual.
If the facility RN or the individual notices or there is any indication of an abnormality in the individual's breast during an exam the RN will contact the individuals Doctor for further guidance and further evaluation.
483.460(c)(3)(iii) STANDARD
NURSING SERVICES
Name - Component - 00
Nursing services must include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.
Observations:
Based on record reviews and interview, it was determined the facility failed to ensure that nursing services completed a direct health exam, at least quarterly, for all individuals. This applied to one (#3) of three individuals in the core sample and one (#4) individual in the expanded sample.
1. A record review for Individual #3 was completed on April 19, 2023. This review revealed that quarterly nursing exams were completed for Individual #3 on September 22, 2022, and December 28, 2022. This review failed to reveal documentation of a quarterly nursing exam completed during March of 2023.
2. A focused review for Individual #4 was completed on April 19, 2023. This review revealed that quarterly nursing exams were completed for Individual #4 on June 15, 2022, September 16, 2022, and December 17, 2022. This review failed to reveal documentation of a quarterly nursing exam completed during March of 2023.
An interview was conducted with the director of residential services (DRS) on April 20, 2023, at 11:00 AM. The DRS confirmed that Individuals #3 and #4 should have been assessed through direct examination by a nurse every 90 days. The DRS further confirmed that there was no documentation of the nursing assessments completed on a quarterly basis.
Plan of Correction:The Facility will ensure that nursing services include, for those clients certified as not needing a medical care plan, a review of their health status which must be on a quarterly or more frequent basis depending on client need.
For individual #3, #4 and all other individuals in the facilty, the facility RN will complete a nursing assessment. (Target Date: 5/5/2023). The QIDP will review all nursing assessments (Target Date: 5/15/2023).
The DRS will re-train QIDP and facility RN on the timeframes for completing nursing assessments. This training will be documented on an agency in-service sheet and will be maintained at the Regional Office (Target Date: 5/15/2023).
The QIDP will review and sign quarterly assessments for all individuals in the facility. The QIDP will submit the reviews to the DRS for review for 2 quarters to ensure that a review of their health status is completed at least quarterly or more frequently depending on client need. In the future, the QIDP will review all nursing assessments and maintain them in the individual's charts.
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observation, record review, and interview, it was determined that the facility failed to ensure that all medications were administered without error. This applied to one (#3) of two individuals observed during the morning medication administration. Findings included:
On April 18, 2023, the morning medication administration was observed from 6:52 AM to 7:16 AM. At 6:53 AM, the staff poured Individual #3's medications, including the medication metamucil. The label on the box indicated that one packet of metamucil was to be mixed in 8 ounces (oz) of liquid. The staff was observed to mix the metamucil in apple sauce and then administered it to Individual #3. At 7:07 AM, the staff confirmed that the metamucil had been mixed into the apple sauce.
A review of physician's orders, dated March 21, 2023, to reconcile the medication pass was completed on April 18, 2023. This review revealed that Individual #3 is ordered to receive metamucil, take one packet mixed in 8 oz of liquid by mouth daily for digestive health.
An interview was completed with the director of residential services (DRS) on April 18, 2023, at 9:40 AM. The DRS confirmed that the dose of metamucil observed to be administered in applesauce was a medication error, as it should have been given in 8 oz of liquid, as ordered by the physician. An interview was completed by phone with the registered nurse (RN) on April 18, 2023, at 11:15 AM. The RN confirmed that Individual #3's metamucil was not administered in accordance with the physician's orders and that this was a medication error.
Plan of Correction:For all individuals in the facility, the facility will ensure that all drugs, including those that are self-administered, are administered without error.
The medication error that was identified was reported to the respective doctor (Completed Date: 4/18/2023). The doctor wrote a new order clarifying that the individual may receive medication in applesauce (Completed Date: 4/18/2023). The physicians orders and MAR will be updated to reflect the current orders as prescribed by the physician (Completed Date: 4/18/2023).
All staff will be retrained by the QIDP on the Medication Administration (Target Date: 5/31/2023). The RN and/or QIDP will conduct weekly Medication Observations weekly for one month to include all staff passing medications (Target Date: 6/1/2023).
The RN and/or QIDP will complete monthly observations on all staff to ensure all drugs are administered in accordance with the physicians orders and MAR for 6 months. The DRS will review medication observations monthly for 6-months to ensure the facility is administering drugs without error. (10/31/2023)
483.460(k)(8) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that drug administration errors and adverse drug reactions are reported immediately to a physician.
Observations:
Based on a review of facility provided documentation of medication errors and interview, it was determined that the facility failed to ensure that all medication errors were reported immediately to the physician. This applied to one of two medication errors reviewed. Findings included:
A review of a medication error investigation was completed on April 18, 2023. This review revealed that Individual #2 was ordered to receive clonazepam at 4:00 PM on January 19, 2023, but did not receive it as ordered. This error was discovered by the facility on January 22, 2023. This review further revealed that the physician was not notified of this error until the next day, January 23, 2023.
An interview with the director of residential services on April 18, 2023, at 12:05 PM, confirmed that the physician was not immediately notified of Individual #2's medication error, which occurred on January 19, 2023.
Plan of Correction:The facility will ensure that drug administration errors and adverse drug reactions are reported immediately to a physician.
The DRS will re-train QIDP, RN, and all facility staff on the proper procedures for reporting and documenting a medication error (Target Date: 5/5/2023).
When a medication error is discovered, the staff making the error or the staff member discovering the error will be required to immediately report the error to the QIDP, or their designee and the Facility Nurse. The facility RN, or their designee will immediately contact the physician responsible for monitoring the medications. If the physician provides any instructions, those instructions will either be faxed to the facility or received by the facility nurse. The contact to the physician will be documented on the medication error form and any instructions will be documented on a nurses note to be maintained at the facility. A copy of the medication error will be submitted to the DRS for review for 3 months and maintained at the regional office. If any of the individuals are having an adverse reaction, 911 will immediately be contacted.
If any medication error is reported, the QIDP will ensure that all notification and paperwork is completed as required. The report, along with any instructions from the doctor will be reviewed by the DRS for 3 months and maintained at the regional office. Any corrective action for the medication error will be completed and documented on a training in-service form and maintained with the medication error report at the regional office.
483.460(l)(1) STANDARD
DRUG STORAGE AND RECORDKEEPING
Name - Component - 00
The facility must store drugs under proper conditions of security.
Observations:
Based on observation and interview, it was determined that the facility failed to ensure that all medications were stored under proper conditions of security. This applied to all six individuals living at the residence.
Evening observations were completed on April 18, 2023, from 3:45 PM to 6:20 PM. At 4:13 PM, staff completed an observed medication pass for Individual #1 in the medication room. With the surveyor present in the medication room, the staff then exited the medication room and walked to the kitchen, leaving the medication room door open, unlocked, and medications unsecured in the upper cabinets. The staff returned within 20 seconds. The surveyor questioned the staff as to what the policy was for securing medications when not being administered. At 4:15 PM, the staff confirmed that the medication room door was not shut and locked prior to exiting to the kitchen, and further confirmed that the medications should have been secured.
An interview was conducted with the director of residential services (DRS) on April 19, 2023, at 11:00 AM. The DRS confirmed that the medications should be secured.
Plan of Correction:The facility will ensure that all drugs are stored under proper conditions of security.
The PM/QIDP will re-train all staff on securing and storing medications (Target Date: 5/15/2023). The training will be documented on an Agency In-Service From and will be maintained at the Regional Office. The PM/QIDP will conduct monthly observations for 3 months to ensure that medications are being stored under the proper conditions of security (Target Date: 8/1/2023). The DRS will complete 1 unannounced medication observation to ensure that medication is secured at all times. This will occur for 3 months (Target Date: 8/1/2023).
If medications are found unsecured, staff will be subject to retraining and/or disciplinary action.
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