Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for all ten residents reviewed for quality of care. Specifically, the facility did not administer and read the purified protein derivative test for tuberculosis for two residents, and failed to notify a provider when a resident's blood sugar was critically low. Additionally, the facility did not monitor the vital signs of a newly admitted resident as required. One resident was administered an excessive amount of Acetaminophen, exceeding the prescribed limit, and was left in distress without adequate pain management, leading to a call to 911 for hospital transport. The facility also documented vital signs for this resident after they had already been discharged. Furthermore, the facility failed to obtain and document monthly vital signs according to provider orders for several residents, with instances of duplicate vital signs being recorded, indicating a lack of proper monitoring and documentation. The deficiencies highlight a pattern of inadequate care and documentation practices across multiple units within the facility, affecting residents with various medical conditions, including diabetes, hypertension, and mental health disorders. These failures demonstrate a significant lapse in adhering to established care protocols and ensuring the well-being of the residents.
Plan Of Correction
Plan of Correction: Approved February 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate corrective action: Resident #365 no longer resides in facility. Resident #368 has reached compliance upon return from hospital with two-step Purified protein derivative plant and read per facility policy and completed on 1/9/2025. Provider notified on 1/9/2025 of incident with no new orders recommended. The Medical provider was notified on 1/9/2025 of residents #638, 29, 89, 73 that facility failed to monitor vital signs per provider order with no new order recommended. Licensed staff responsible for failure to notify medical provider of resident blood sugar outside parameters was counseled and reeducation completed on 1/10/2025 by the Assistant Director of Nursing. 2. All residents have the potential to be affected by the deficient practice. The facility's plan to prevent reoccurrence: Nurse management conducted a 90-day look back from 10/9/24 through 1/9/25 for residents with active orders for blood sugar monitoring. As a result of the audit, no issues noted. All residents have the potential to be affected by the deficient practice. The facility's plan to prevent reoccurrence, the previous 30 days of admissions were reviewed for compliance with purified protein derivative placement and results documented per policy. Audit completed on 1/10/2025. A total of 30 residents were reviewed. Out of the 30, 8 residents were discharged, 2 were compliant, and 20 were identified to be out of compliance. A [MEDICATION NAME] screen was completed for those residents per policy. The results of the [MEDICATION NAME] screen were reported to the medical provider for further review. No further directives given. Nursing management conducted a full house review on 1/17/2025 on residents with active orders containing Tylenol to determine the potential for the resident to exceed the recommended limit. Results of the review concluded one resident was identified at risk to potentially exceed the daily recommended limit. Those residents identified were submitted to the medical provider for review with one resident with new orders. A full house review was conducted on 1/16/2025 on residents’ vital signs per the provider order. The results of those residents with orders for monthly vital signs concluded all residents to be out of compliance. Results submitted to the medical provider with new order for one resident. Results of resident review for new admission vital sign orders concluded 23 residents reviewed. Review of audit concluded 14/23 residents were identified to be out of compliance. Any residents identified as having vital sign omissions received updated vitals and results reviewed with the medical provider. 3. The systemic changes: The facility reviewed the policies titled Vital Signs, Diabetes Mellitus Guidelines, and [MEDICAL CONDITION]. They were reviewed by medical with no revisions necessary. The facility educator re-educated licensed staff on vital signs, diabetes mellitus guidelines, and [MEDICAL CONDITION] policies with emphasis on notifying the provider with results of blood sugar outside parameters, administration and timely result documentation per MD order of Purified protein derivative, daily recommended Tylenol consumption not to exceed recommended limit, and obtaining and monitoring of resident-specific vital sign order for frequency. This education was accompanied by a post-test to ensure retention. All results of blood sugar, results of the [MEDICATION NAME] skin test, and results of vital signs will be documented in the medication administration record. The facility supervisor will complete a 24-hour look back of all new Tylenol orders to ensure there is no potential to exceed the recommended daily limit. The facility supervisor will complete a 24-hour look back on residents' blood sugars to ensure residents identified with blood sugars outside parameters were reviewed and submitted to the medical provider. The facility supervisor will complete a 48-hour look back on residents who received a [MEDICATION NAME] skin test to follow up and document [MEDICATION NAME] skin test read. The facility supervisor will complete a 24-hour look back of those residents with active vital sign orders to determine vital signs obtained per provider order. Any result out of compliance, the supervisor will notify the medical provider for further directives and will document the outcome in the medical record. 4. Quality assurance: The Unit managers will audit all new admissions' Purified protein derivative status to ensure compliance is met. This will be audited weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Assistant Director of Nursing will submit weekly immunization documentation tracker form weekly. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit residents' blood sugars. This audit will look for any documented value outside parameters to ensure the medical provider was notified. This will be conducted weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit compliance with vital signs completion weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. Unit managers will audit all active Tylenol orders to ensure residents do not exceed the daily limit. This audit will be done weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Director of Nursing will oversee all audits. Responsible Party: Director of Nursing.