§ 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 the review of clinical records, interviews with staff, it was determined that the facility failed to administer medication as ordered by the physician for one of 8 residents reviewed. (Resident R1).
Findings Include:
Interview with Resident R1 conducted on May 8, 2025, at 10:00 a.m. revealed that "the nurse does not apply the moisturizer cream, she is supposed to do it all the time."
Review of Resident R1's clinical record revealed resident was admitted to the facility on May 15, 2022. Review of physician orders for Resident R1 revealed an order dated February 26, 2025, which indicated "Apply moisturize cream within 3 mins of shower to lock in moisture (CervaVe, Eucerin, Cetaphil, Aveeno) Repeat application as needed to establish dry areas."
Review of Resident R1's clinical record revealed that the resident receives showers on Tuesdays and Fridays during the week.
Review of April 2025's Medication Administration Record for Resident R1 revealed resident was receiving moisturizer as ordered on Fridays, after showers. Continued review failed to reveal documented evidence that the moisturizer was applied by facility staff after shower on Tuesdays, as ordered.
Interview conducted on May 8, 2025, at approximately 11:30 a.m. with the facility Administrator and Director of Nursing confirmed that the moisturizing cream was not applied by facility staff on Tuesdays after the resident's shower.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 05/27/2025
"This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report."
1. R1 is receiving his Eucerin moisturizing cream as ordered.
2. An initial audit of residents receiving Eucerin moisturizing cream was completed to validate administration as ordered. Variances were addressed at the time of the audit and placed on the facility audit tool.
3. Nursing staff will be re educated on administering Eucerin moisturizing cream as ordered.
4. DON/ designee will complete random audits weekly x4 and monthly x2 to validate residents are receiving Eucerin moisturizing cream as ordered. Audit findings will be addressed and submitted to the Quality Assurance Performance Improvement Committee for further review and recommendations as needed.
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