§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
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Observations:
Based on clinical records hospital records review and staff interviews it was determined that the facility failed to provide respiratory treatment and services timely for one of the two residents reviewed (Resident CL1).
Findings include:
Review of Resident CL1's clinical record revealed Resident CL1 was admitted to the facility on February 15, 2024, with diagnoses of Sepsis (The body's extreme reaction to an infection, without prompt treatment can lead to organ failure, tissue damage, and death), Chronic Obstructive Pulmonary Disease (COPD - A type of progressive lung disease characterized by long-term respiratory symptoms and airflow limitations), acute and chronic respiratory failure.
Review of Resident CL1's clinical record revealed a BIPAP order from the hospital dated February 10, 2024, revealed BIPAP 12/5 60% FiO2, expected discharge on February 16, 2024. The document was uploaded to Resident CL1's Electronic Medical Record (EMR) on February 15, 2024.
Review of Resident CL1's respiratory therapist notes from the hospital dated February 12, 2024, revealed Resident R1's BIPAP machine model type, mask type, and machine setup order. The document was uploaded to Resident CL1's EMR on February 15, 2024.
Review of the "Initial Referral" from the hospital dated February 14, 2024, revealed a note from the pulmonologist that the resident was on an overnight BIPAP (Bilevel Positive Airway Pressure - A machine used to help push air into your lungs). The documents were uploaded to the resident's EMR on January 15, 2023.
Review of Resident CL1's clinical record revealed Bipap at HS (hours of sleep), removed in AM Settings 12/5 every day, and the evening shift was not ordered until February 17, 2024, two days after a resident was admitted to the facility.
Interview with the admission staff, Employee E3 conducted on March 20, 2024, revealed that after a referral was sent by the hospital, the information was sent to the administrative team which includes the administrator and Director of Nursing (DON) to review the resident's needs. Employee E3 reported that hospital documentations were uploaded on the resident's EMR for clinical staff to review.
Interview with the NHA conducted on March 20, 2024, revealed clinical staff (DON and/or ADON) reviews the referral from the hospital to determine the resident's clinical needs.
Interview with the DON conducted on March 20, 2024, confirmed that she/he did not review the documents from the hospital which indicated that Resident CL1 required a BIPAP overnight. The DON reported that the nurse who admitted the resident relied on the transfer form from the hospital which did not indicate the use of
BIPAP.
The clinical records review failed to reveal that the physician was notified that Resident CL1 had a BIPAP order from the hospital.
Interview with the DON conducted on March 20, 2024, revealed that A BIPAP order was made on January 17, 2024, after the resident's daughter informed the facility that Resident CL1 needed a BIPAP at night.
The above information was conveyed to the NHA and DON on March 20, 2024, at 2:00 p.m.
The facility failed to ensure Resident CL1's need for a BIPAP was communicated and ordered timely.
28 Pa. Code 211.5(f) Clinical records
28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services
| | Plan of Correction - To be completed: 04/12/2024
1. Resident #CL1 no longer resides in the facility. DON was immediately educated on ensuring that hospital discharge orders are reviewed for accuracy and ensuring that respiratory equipment is ordered and in use if applicable.
2. An audit of current residents' hospital discharge orders for the past 14 days was completed by the Director of Nursing/Designee to ensure that all orders have been implemented and that respiratory equipment has been ordered and in use if applicable.
3. Licensed nurses to be educated by the DON/Designee to ensure that hospital discharge records are thoroughly reviewed to ensure that physician orders related to equipment have been implemented and to notify the hospital/physician if discrepancies are present to clarify.
4. Hospital discharge records of new admissions to be reviewed by the DON/Designee weekly x4 weeks, then bi-monthly x 1 month then monthly x 2 months to ensure that hospital discharge orders have been implemented at the facility level and that any respiratory equipment ordered is in use as applicable.
The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee until monthly and/or until substantial compliance is met. Quality Monitoring schedule modified based on findings.
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