Failure to Accurately Review Resident's Care Program
Penalty
Summary
The facility failed to ensure that a resident's total program of care, including medications and treatments, was accurately reviewed at each physician visit. This deficiency was identified for one of the three residents reviewed. The facility's policy on the provision of physician-ordered services was not adhered to, as evidenced by the lack of a physician order for the resident's BIPAP settings. The resident, who was admitted with diagnoses of Chronic Obstructive Pulmonary Disease, Obstructive Sleep Apnea, and respiratory failure, was supposed to use a BIPAP machine with specific settings. However, these settings were not documented in a physician order until a later date. The deficiency was further highlighted when the resident was readmitted from the hospital, and it was suspected that the absence of BIPAP use at night in the facility contributed to the resident's condition of retaining CO2. Despite the hospital discharge paperwork containing orders for the BIPAP settings, these were not entered into the facility's records. Interviews with the Nurse Practitioner and Doctor of Medicine confirmed the oversight, acknowledging that the resident's care program was not reviewed with the necessary accuracy during physician visits.
Plan Of Correction
Meeting immediately held with Medical Director, NHA, Interim ADON, and UM to discuss reviewing medications and treatments. Chart review conducted on R17 to ensure no adverse effects. Like residents reviewed to ensure medications and treatments being accurately followed by physicians. Education will be provided to nurses on medications and treatments being accurately followed on or before 2/11/2025. Education will be provided to the RNAC, Nurses, and nursing management on BIPAP management on or before 2/11/2025. Audits will be completed on BIPAP to ensure proper use by the DON or designee weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.