Initial Comments:
A focused fundamental survey was conducted May 16-18, 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 22 and the core sample consisted of four individuals.
Plan of Correction:
483.460(f)(1) STANDARD
COMPREHENSIVE DENTAL DIAGNOSTIC SERVICE
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Comprehensive dental diagnostic services include a complete extraoral and intraoral examination, using all diagnostic aids necessary to properly evaluate the client's condition not later than one month after admission to the facility (unless the examination was completed within twelve months before admission).
Observations:
Based on record review and interview, it was determined that the facility failed to ensure that all new admissions to the facility received a comprehensive dental exam within 30 days of admission. This applied to two of two individuals (#2 and #3) in the core sample. Findings included:
A record review was completed for Individual #2 on May 17, 2023. This review revealed that Individual #2 was admitted to the facility on July 23, 2022. This review failed to reveal that Individual #2 had a comprehensive dental exam within 30 days of admission or within 12 months prior to admission.
A record review was completed for Individual #3 on May 17, 2023. This review revealed that Individual #3 was admitted to the facility on April 18, 2022. This review failed to reveal that Individual #3 had a comprehensive dental exam within 30 days of admission or within 12 months prior to admission.
An interview was conducted with the executive director (ED) on May 18, 2023, at 10:05 AM. The ED confirmed that Individuals #2 and #3 did not have a dental exam within 30 days of admission, nor was there documentation that they had one within 12 months prior to admission to the facility.
Plan of Correction:Individual #2 has a dental appointment scheduled for 6/22/23. Individual #3 had her dental appointment on 5/10/23.
For all future admissions, the QIDP will establish the most recent dental visit completed and this will be communicated to the BLARS Health Services department for tracking purposes. If a previous dental appointment (12 month prior to the targeted admission date) cannot be identified or if a dental appointment did not occur, the QIDP will convey to nursing that an appointment needs to be secured within 30 days following the anticipated admission date. This date will be documented on the BLARS appointment calendar which is reviewed and updated weekly during BLARS administrative meetings.
The Director of Nursing is responsible for monitoring this area for compliance for the initial dental appointment. The BLARS nursing department will be responsible for scheduling subsequent dental appointments according to the timelines stipulated in regulations. The monitoring of this area is ongoing and will be implemented each time there is a new referral/admission.
483.460(k)(1) STANDARD
DRUG ADMINISTRATION
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The system for drug administration must assure that all drugs are administered in compliance with the physician's orders.
Observations:
Based on observation, medication administration record (MAR), physician's orders, and interview it was determined that the facility failed to ensure that medications were administered in accordance with physician's orders. This applied to one (#5) of five additional individuals that were observed during a medication pass. Findings included:
Observations of the morning medication administration in Cottage 2 were completed on May 17, 2023, from 7:00 AM to 7:12 AM. During this observation, Individual #5 received according to the medication label "vitamin D 1000IU, take 1 tablet by mouth every other day."
A review was completed on May 17, 2023, of the current physician's orders for Individual #5, dated May 2, 2023, in order to reconcile the observed morning medication administration. The physician's orders stated that Individual #5 was to receive "vitamin D 1000IU, take 1 tablet by once daily with a meal (8AM)." Further review of the MAR from May 2023 revealed that Individual #1 had been receiving the Vitamin D 1000IU every other day beginning May 2, 2023, and was scheduled to receive it the morning of May 17, 2023.
An interview with the executive director (ED) was completed on May 18, 2023, at 10:00 AM. During this interview the ED stated that Individual #5's vitamin D medication orders was changed by the physician on May 1, 2023, to be administered every other day. However, when the physician signed the current orders for Individual #5 on May 2, 2023, it contained the former order for the vitamin D medication. The ED confirmed that the facility did not identify these errors and that Individual #5 had not been receiving the correct dose of daily vitamin D in compliance with the current physician orders signed on May 2, 2023.
Plan of Correction:Regarding individual #5, once the physician's order issue regarding the Vitamin D was discovered during the survey, the BLARS nurses immediately reinstituted following the physician's order on file; this occurred on 5/18/23. The original order is being used until this clarification is received.
Although it is already common practice and protocol that physician's orders will not be initiated until the order is physically obtained with date, time and physician's signature, the BLARS DON will retrain all of the nurses in this area at the next scheduled nurses meeting (occurring in June 2023). The particular nurse who initiated the errors in this instance is no longer employed by the agency. The BLARS Lead nurse will audit physician orders monthly to ensure that physician's order has been obtained, communicated to nursing team, and documented in MAR appropriately.
The BLARS Director of Nursing, through collaboration with the BLARS Lead nurse, is responsible for monitoring this area and for assuring that physician's orders are followed according to the script and administered as prescribed. The monthly monitoring of this area will be ongoing.
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