Failure to Discontinue Collagen Supplement as Ordered
Penalty
Summary
The facility failed to ensure that a resident's dietary preferences and physician's orders were followed, resulting in a deficiency. Specifically, a resident had a dietician's recommendation, signed by a physician, to discontinue a collagen supplement. Despite this, the supplement continued to be administered for 35 days after the recommendation. The resident was cognitively intact and had expressed a desire to discontinue the supplement, which was agreed upon by the provider. However, the order to discontinue was not processed in the electronic medical record, leading to continued administration. The deficiency was identified during a recertification survey, where it was found that the order to discontinue the collagen supplement was only present in the paper record and not updated in the electronic system. The Registered Nurse unit manager responsible for processing new orders acknowledged the oversight and confirmed that the order was missed in the electronic record. The Director of Nursing stated that they expected dietary recommendations signed by the provider to be followed and discontinued as ordered.
Plan Of Correction
Plan of Correction: Approved January 16, 2025 1. Resident #82 Medication Administration Record [REDACTED]. Responsible Registered Nurse self-identified that when she had followed up with the resident, the resident had clarified they didn't ask for a discontinuation of the Collagen order, but rather a change in administration time. This Registered Nurse followed through on the resident's request, but failed to update the medical provider of this resident's request, nor get a refreshed order based on the resident's request, as defined in policy. 2. All resident records on the unit (B wing) where the Registered Nurse was entering medical orders and made the above error to be reviewed to ensure any written recommendations made by an ancillary service during the prior three months (including Registered Dietician, therapy, psychiatry, or specialist consultants--Orthopedics, Cardiology, Neurology) to ensure there is a corresponding medical order that is properly executed. 3. All licensed nurses responsible for transferring recommendations to medical orders will be provided with a policy overview of the procedure for transferring clinical recommendations to properly executed medical orders. There is no policy change indicated as this deficiency is directly related to a single order that was not completed by one employee, who self-identified the error. 4. On a daily basis (defined as every day), the night shift licensed nurse will conduct a 100% audit (visual review) of all new orders obtained during the prior 24 hours, to include written recommendations which are to be transferred to a written medical order. The results will be provided to the Director of Nursing (or designee) daily (which means daily; or the next day after a weekend). Errors, if identified, are raised to the attention of the Registered Nurse Supervisor who is in communication with the Director of Nursing or her designee and will be addressed immediately, or at the most appropriate time based on the nature of the error found (i.e. prior to the advent of additional error). A summary of the audit results will be provided to Quality Assurance & Performance Improvement monthly, with frequency to be re-evaluated after six months. As the nightly audit is being reviewed by the Director of Nursing or her designee (the assistant director of nursing) on a daily, or near daily basis, monthly reporting to Quality Assurance and Performance Improvement Committee is appropriate. In the event the Director of Nursing identifies trends or clusters of errors, correction actions will be implemented immediately. Responsible Party: Director of Nursing