§ 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 the clinical record and resident and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice for medication administration that will meet each resident's physical, mental, and psychosocial needs for 14 out of 14 residents reviewed (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14).
Findings include:
Review of medication administration records revealed the following:
Resident 1: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of nine doses each date);
Resident 2: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of six doses each date);
Resident 3: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of eight doses each date);
Resident 4: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 12 doses on November 6, 2022, and 15 doses on November 24, 2022);
Resident 5: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 10 doses each date);
Resident 6: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 11 doses each date);
Resident 7: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 11 doses on November 6, 2022, and 12 doses on November 24, 2022);
Resident 8: day shift medications were not signed as administered on November 24, 2022 (total of 10 medication doses each date);
Resident 9: day shift medications were not signed as administered on November 24, 2022 (total of eight medication doses each date);
Resident 10: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 10 medication doses each date);
Resident 11: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 20 doses on November 6, 2022, and 16 doses on November 24, 2022);
Resident 12: day shift medications were not signed as administered on November 6, 2022, and November 24, 2022 (total of 9 doses each date);
Resident 13: day shift medications were not signed as administered on November 6, 2022 (total of 14 medication doses); and
Resident 14: day shift medications were not signed as administered on November 6, 2022 (total of 7 medication doses).
The Nursing Home Administrator (NHA) and Director of Nursing (DON) were made aware of the concerns identified on November 28, 2022, at approximately 1:05 PM. The DON indicated that she was not aware that medications were not given and that she thought medication administration had improved. She indicated that she would look into it.
Email communication received from DON on November 29, 2022, at 2:34 PM, revealed that there were notes dated November 7, 2022, and November 24, 2022 notifying the physician(s) of each Resident's missed doses of medications.
Email communication received from NHA on November 29, 2022, indicated that with November 6, 2022, being a Sunday he believed this documentation omission would have been noted during an AM clinical meeting and addressed upon discovery on Monday, November 7, 2022, which was why the notes regarding the missed medications were dated for November 7, 2022.
Additional email communication received from NHA on November 29, 2022, at 4:43 PM, stated that the Nurse that worked on November 6, 2022, had not worked since that date and was not able to provide an explanation for not documenting the medication administration.
During a telephone interview with Employee 2 on December 1, 2022, at 11:19 AM, Employee 2 indicated that on November 6, 2022, she was the only one assigned to the east wing of the unit and that she passed all her resident's medications. She said she cannot speak as to what happened on the west wing portion.
Review of deployment sheet for November 6, 2022, indicated that Employee 2 was the only nurse assigned to the whole unit (East and West wing).
During an interview with Employee 1 (Registered Nurse Supervisor) November 30, 2022, at approximately 10:30 AM, she confirmed that she was working on November 24, 2022. Employee 1 indicated that Employee 3 (Licensed Practical Nurse) came to her at around 1:00 PM, and said he had to go now. She said she went to the unit to complete the narcotic counts. During this process, Employee 3 indicated to her that he had not passed any medications to the residents on the second cart for the day. No reason was provided. She indicated that she then started to pass the medications. She said that she administered medications to Residents 13 and 14, but then she got a call from another unit indicating that a resident was having an acute change in condition. She said she was the supervisor and had to go to assess the other Resident and follow-up with the physician. She indicated that she ended up having to send that Resident to the hospital and, by the time she had completed all those tasks, it was too late to give the medications; so she contacted the physicians of the Residents and informed them of what had occurred. She indicated that the physicians gave no new orders and said to resume medications at the next scheduled time.
Interview with Resident 11 on November 30, 2022, at approximately 12:15 PM, the Resident confirmed that they did not receive her medications on Thanksgiving Day during the day shift hours. Resident 11 said they kept mentioning it to the Nurse Aide who said they kept telling the Nurse, but the Nurse never came. Resident 11 further shared that there was another day that they did not get their medications on day shift, but that they could not recall the exact date.
During an interview with NHA and DON on November 30, 2022, at approximately 2:20 PM, the above information was shared.
During a phone interview with NHA and DON on December 1, 2022, at approximately 2:00 PM, they were informed of the conversation with Employee 2 and that, according to the deployment sheet, there was only one nurse assigned that date/shift. No information was provided. NHA confirmed that he would expect that there would be enough staff to meet the needs of the residents and that all residents would receive their medications as ordered by the physician.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
28 Pa. Code 201.18 (e)(1)(2)(3)(6) Management
| | Plan of Correction - To be completed: 12/19/2022
This plan of correction is prepared and executed because it is required by the provisions of the state and federal regulations and not because Claremont Nursing & Rehabilitation Center agrees with the allegations and citations listed on the statement of deficiencies.
Claremont Nursing & Rehabilitation Center maintains that the alleged deficiencies do not, individually and collectively, jeopardize the health and safety of the residents, nor are they of such character as to limit our capacity to render adequate care as prescribed by regulation. This plan of correction shall operate as Claremont Nursing & Rehabilitation Center 's written credible allegation of compliance.
By submitting this plan of correction, Claremont Nursing & Rehabilitation Center does not admit to the accuracy of the deficiencies. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Claremont Nursing & Rehabilitation Center reserves all rights to raise all possible contentions and defenses in any civil or criminal claim, action or proceeding.
Physicians were notified upon discovery concerning medication administration observations of 11/6/22 and 11/24/22 for Residents 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, and 14 and did not provide new orders at those times.
Agency employees 2 and 3 have not worked since 11/6/22 and 11/24/22 respectively and will not be utilized by the facility.
Licensed nurses were re-educated concerning concerning the expectation to administer medications as ordered on 11/30/22 and 12/14/22. NHA/DON initiated a review of performance and charting expectations with individual agencies for additional review with oncoming staff on 12/5/22.
NHA and Director of Nursing reviewed facility policies concerning medication administration and medication administration documentation with no modification on 12/7/22.
Registered Nurse Unit Managers or designee will complete an audit of medication administration documentation weekly for three weeks and monthly for three months to validate compliance with each shift included. Issues will be corrected upon discovery.
Registered Nurse Unit Managers or designee will complete a random medication administration observational audit for five residents weekly for three weeks and monthly for three months to validate compliance with each shift included. Issues will be corrected upon discovery.
Audit results will be presented in the Quality Assurance Performance Improvement Meeting monthly for three months until substantial compliance is achieved and maintained.
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