§ 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 review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to medication administration for two of 13 residents reviewed (Residents R3 and CL2).
Findings Include:
Facility Policy titled, "Medication Administration Policy" updated, January 2024 revealed under procedures J. Medication Administration 8." Ensure that the customer swallows all the medication(s)". Medication Times BID (Twice a Day) = 0900-1700, TID (Three Times a Day) 0900-1300-2100, QID (Fourt Times a Day) =0900-1300-1700-2100; Before Meals=0600-11:00-1630, After Meals= 0900-1300-1800.
Review of the resident's clinical record indicated resident R3 was admitted on August 24, 2023, with the diagnosis of type 2 diabetes mellitus (a chronic condition that affects the way your body processes blood sugar) with diabetic neuropathy, (nerve damage associated with diabetes), morbid severe obesity.
A review of the physician order dated May 24, 2024, indicated Resident R3 was prescribed NovoLin R Injection Solution 100 Unit/Ml Insulin Regular Human of 12 units at 7:30 a.m., 11:30 a.m. and at 16:30 p.m.
On August 19, 2024, at 9:47 a.m. Resident R3 came out of her room seeking the nurse as her medication was not yet administered. Resident R3 reported that her body is shaking and Resident R3 needs her insulin. License Nurse, Employee E5 approached Resident R3 to address Resident's R3 concerns and confirmed that Resident R3 has not yet received her insulin and morning medication.
During this time Employee E5 prepared the medications and entered Resident R3's room to give her the medications. Resident R3 requested the insulin to be given first as Resident R3 reported that her body is shaking. Employee E5 had a cup with 7 pills and placed it inside of Employee E5 pocket to go get the insulin. Resident R3 requested to leave the cup with medication at her tray instead of taking it with her. Employee E5 listened to Resident R3 and left 7 pills inside the cup and placed it on the resident's tray table. At 9:58 a.m. Employee E5 returned with glucose meter to measure Resident's 3 blood sugar which then she administered the insulin. After, she asked Resident R3 to take her 7 pills which were in the cup. Resident R3 reported "I can take them at my own and you don't have to watch me" . Employee E5 left the room with Resident R3 being unsupervised with all her medications.
At 10:15 a.m. on the same day, a follow-up interview was conducted with Licensed Nurse Employee E5, who had started her shift at 7:30 a.m. assigned to the Employee E5 was responsible for 26 residents, but by 10:15 a.m., only 4 had received their morning medications. This left 22 residents still awaiting their medication. Employee E5 acknowledged that the policy for administering morning medications required was 9:00 a.m., with an allowable window of one hour before or after. She admitted that she was behind schedule.
On August 19, 2024, at 10:33 a.m., a registered nurse, Employee E7, was assigned to a medication cart on the second floor East unit. Employee E7 reported that she was responsible for 30 residents and had administered morning medication to 14 of them, leaving 16 residents still awaiting their medication.
On August 19, 2024, at 1:33 p.m. an interview with Director of Nursing, Employee E2, Assistant Director of Nursing, Employee E3 and Administrator, Employee E1 confirmed based on the electronic medication administration record (EMAR) which revealed a delay in administering insulin on the following days:
August 19, 2024, the insulin should have been administered at 7:30 a.m. but was administered at 10:07 a.m.
August 18, 2024, the insulin should have been administered at 11:30 a.m. but was administered at 14:56 p.m.
August 18, 2024, the insulin should have been administered at 7:30 a.m. but was administered at 9:46 a.m.
August 17, 2024, the insulin should have been administered at 16:30 p.m. but was administered at 18:01 p.m.
August 17, 2024, the insulin should have been administered at 7:30 a.m. but was administered at 9:48 a.m.
August 16, 2024, the insulin should have been administered at 11:30 a.m. but was administered at 12:55 p.m.
August 14, 2024, the insulin should have been administered at 11:30 a.m. but was administered at 13:48 p.m.
August 12, 2024, the insulin should have been administered at 8:30 a.m. but was administered at 9:44 a.m.
The Director of Nursing, Employee E2, Assistant Director of Nursing, Employee E3 and Administrator, Employee E1 confirmed the delay of insulin medications and license Nurse, Employee E5 leaving the medications at the Resident's R3 tray unsupervised was a violation of the medication administration policy.
Review of the resident's clinical record indicated Closed Record CR2 was admitted on August 1, 2024, and discharged on August 4, 2024, with the diagnosis of low back pain, wedge compression fracture of t11-t12 vertebra, subsequent encounter for fracture with routine healing, unsteadiness on feet, difficulty in walking, muscle weakness, age-related osteoporosis without current pathological fracture.
A review of physician order dated, August 2, 2024, at 07:00 a.m. , indicated "showers to be given on Tuesday and Fridays 1st shift document if the patient/resident refuses showers in Health status note". August 2, 2024, was a Tuesday and the Medication Administration report (MAR) did indicate that Closed Resident CR2 did not refuse a shower. Further review of the record under Shower Task did not indicate a shower was given to the Closed Record 2.
A progress note created on August 6, 2024, indicated that a family member called four days later to inquire about not getting a shower for the Closed Record CR2, and a late progress note was entered four days later August 6, 2024, that Closed Record CR2 refused.
On August 19, 2024, at 3:30 p.m. an interview with the Director of Nursing (DON) confirmed that if the Closed Record CR2 MAR did indicate that Closed Record CL2 did not refuse a shower and based on the Shower Task documentation shower was not provided per the physician order.
28 Pa. Code 211.9 (d) Pharmacy Services
28 Pa. Code 211.12 (d)(1)(5) Nursing Services
| | Plan of Correction - To be completed: 10/03/2024
1. A. During time of survey Resident R3 received medication out of facilities policy time range with no ill effects from the deficient practice. Resident R3 BS was taken and WNL, insulin was administered and MD aware of late administration.
B. Resident CR2 was no longer in the facility at the time of completion of the survey.
2. A. All residents have the potential to be affected by the deficient practice. Unit managers to make rounds during medication pass to ensure no other residents receive medications at incorrect times.
B. All residents have the potential to be affected by lack of timely ADL care.
3. A. E5 received immediate education on medication administration and the 6 rights. Nurses were educated on 6 rights of medication administration. The Medication Administration Policy was reviewed.
B. Nursing staff were re-educated on performing timely ADL care, including bi-weekly showers.
4. A. Unit manager or Designee will audit 3 medication passes weekly x 30 days than 2 med passes monthly x 60 days to ensure the 6 rights of medication administration are being followed. The results of these audits will be reported to the Quality Assurance Improvement Committee quarterly.
B. Unit manager or designee will audit 5 residents weekly x 30 days and then 5 residents monthly x 60 days to ensure weekly showers being offered and completed timely. The results of these audits will be reported to the Quality Assurance Improvement Committee quarterly.
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