§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.
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Observations:
Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for three of 5 residents reviewed (Residents 1, 3, and 4).
Findings include:
Review of facility policy, Central Vascular Access Device Dressing Change policy, revised August 1, 2021, read, in part, upon admission, if a resident has a transparent dressing, and the dressing is clean and dated it may be changed in 7 days from the date on the dressing and completed at least weekly thereafter; if the dressing is a gauze dressing it is to be changed upon admission and at least every two days thereafter. Assessment of the vascular cite is completed upon admission and during dressing changes, prior to and after intermittent infusions. Assessment for signs and symptoms of infusion related complications should also be completed. Length of external catheter should be obtained upon admission, during dressing changes, if there are signs and symptoms of complications. For peripherally inserted central catheter (PICC- central line is an intravenous (IV) line that is longer than a regular IV and goes all the way up to a vein near the heart) upper arm circumference is completed upon admission then weekly, and if there are signs and symptoms of complications. Documentation in the medical record is not limited to date and time the site was assessed, length of external catheter, arm circumference, reason for dressing change, resident response to procedure and education provided.
Review of facility policy, Administration of an Intermittent Infusion, revised June 1, 2021, read, in part, vascular access devices are to be flushed per physician orders. Prior to medication administration, flush with prescribed flushing agent. When infusion is complete flush vascular access device with prescribed flushing agent to maintain patency between intermittent infusions.
Review of resident 1's clinical record revealed diagnoses that included: diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), osteomyelitis (infection of the bone), and chronic kidney disease (kidney doesn't function as it should).
Further review of Resident 1's clinical record revealed he was admitted to the facility on Tuesday, January 30, 2024.
Review of Resident 1's hospital discharge summary dated January 30, 2024, revealed it included instructions for Cefazolin (medication used to treat bacterial infection) to be administered via IV twice a day until February 15,
2024.
Review of pharmacy delivery documentation for Resident 1 revealed Cefazolin was filled on January 31, 2024.
Review of Resident 1's physician orders revealed orders for: Cefazolin 2 gram (gm- unit of measure) intravenously every 12 hours until February 15, 2024, ordered and to start on January 30, 2024; sodium chloride flush 5 cubic centimeter (cc- unit of measure) intravenously every shift and 50cc before and after medication administration, order dated February 8, 2024; and central line dressing change weekly and as needed every day shift every Wednesday, order dated February 6, 2024, to start on February 7, 2024.
Review of Resident 1's Medication and Treatment Administration Record revealed it documented that a sodium chloride flush was administered for the first time on February 8, 2024, at 3:15PM; and the central line dressing change was due to be changed on February 7, 2024, but there was no documentation that it was changed (the treatment record was blank).
The facility failed to flush Resident 1's IV line January 30, 2024 through February 7, 2024, and failed to change Resident 1's central line site dressing weekly, which was due February 7, 2024.
Electronic mail communication with the Director of Nursing on March 5, 2024, at 10:54 AM revealed Resident 1's IV flushes should have occurred prior to February 8, 2024, and a dressing change to the central line site should have occurred every 7 days.
Review of Resident 3's clinical record revealed an admission date of February 27, 2024. Further review revealed diagnoses that included sepsis (infection in the blood), methicillin-resistant staphylococcus aureus (staph bacteria resistant to common antibiotics), and diabetes mellitus.
Review of Resident 3's physician orders revealed orders for Cefazolin 2 gm intravenously every 8 hours (12:00 PM, 8:00 AM, 4:00PM) for sepsis until March 25, 2024, start date February 27, 2024. Further review of Resident 3's physician orders on March 4, 2024, at 10:30 AM failed to reveal an order for a central line dressing change.
Review of Resident 3's Medication and Treatment Administration Record on March 4, 2024, at 10:35 AM also failed to reveal a scheduled central line dressing change. Per facility policy the central line dressing should have been changed on March 5, 2024.
Review of Resident 3's Medication and Treatment Administration Record on March 5, 2024, at 12:00 PM revealed it included orders for IV: change catheter site transparent dressing right upper extremity every evening shift every 7 days for decrease rick of infection. Further review revealed it was documented as completed March 4, 2024.
Electronic mail communication with the Director of Nursing on March 4, 2024, at 4:00 PM confirmed that Resident 3 didn't have an order to change the central line dressing weekly. It was also stated that an order was obtained and was scheduled to be completed on the 3 to 11 shift.
Electronic mail communication with the Director of Nursing on March 5, 2024, at 10:54 AM revealed Resident 3 should have had a central line dressing change order prior to March 4, 2024.
Review of Resident 4's clinical record revealed an admission date of February 5, 2024. Further review revealed diagnoses that included osteomyelitis to the left hand and diabetes mellitus.
Review of Resident 4's physician orders revealed orders for: ertapenem sodium (medication used to treat bacterial infection) 1 gm intravenously one time a day for osteomyelitis until March 8, 2024, start date February 6, 2024; PICC/Midline change dressing every week on Monday one time a day for IV maintenance, order date February 6, 2024, start date February 12, 2024.
Review of Resident 4's Medication and Treatment Administration Record revealed that the weekly PICC/Midline change dressing was not documented as being completed on February 12, 2024.
Electronic mail communication with the Director of Nursing on March 5, 2024, at 10:54 AM revealed Resident 4's central line site dressing should have been changed on February 12, 2024.
During an interview on March 5, 2024, at 12:45 PM with the Nursing Home Administrator (NHA), the surveyor made NHA aware of the concerns regarding IV dressing changes for 3 residents and the lack of flushes to one resident's IV line; no further information was provided.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
| | Plan of Correction - To be completed: 03/19/2024
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.
Resident 1 has since been discharged , resident 3 order has been placed for weekly central line dressing changes , resident 4 central line site dressing has been changed per order.
Residents with central lines orders will be reviewed for dressing changes and flush
DON / Designee will educate Licensed staff on focus Ftag 0658 Services provided meet professional standards .
DON / Designee will audit all residents with central line sites to ensure orders to change dressing and flush have been completed weekly x 4 and report findings to QA Committee for recommendation.
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