Communication and Coordination Failures in Resident Care
Penalty
Summary
The facility failed to maintain effective communication between nursing staff and medical providers, leading to inadequate treatment and monitoring for two residents. Resident #3, who was admitted with a diagnosis of rapidly progressive nephritic syndrome, did not receive the prescribed medication Sevelamer due to unavailability. Despite multiple communications with the pharmacy, the medication was not delivered in a timely manner, and the nursing staff documented administration of the medication when it was not available. This lack of communication and documentation resulted in a failure to provide the necessary medication for the resident's condition. Resident #4, who required dialysis treatment, experienced issues with the coordination of care. The resident's transfer forms from the dialysis center were incomplete, and there was no evidence that the facility addressed the notes from the dialysis center regarding the resident's late arrival and abbreviated treatment. Additionally, the resident did not receive breakfast or snacks before leaving for dialysis, and there was a lack of documentation in the electronic medical record regarding the resident's condition upon return from treatment. The facility's failure to ensure proper communication and documentation between nursing staff, medical providers, and external centers resulted in inadequate care for both residents. The Director of Nursing and the Unit Manager acknowledged the issues but did not provide evidence of corrective actions taken at the time of the survey. The deficiencies highlight a breakdown in communication and coordination of care, impacting the residents' treatment and overall well-being.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because required. (a) What corrective action(s) will be accomplished for those residents found to have been affected by the practice: Information related to resident #3 was obtained during a historical document review and interview process. On [date], the physician for resident #3 was contacted with new orders to administer the Sevelamer once a day at 5pm while the resident was in the facility instead of administration at the clinic. Information related to resident #4 was obtained during a historical document review and interview process related to the incomplete communication forms on [date] when the resident returned from [location]. Resident #4 discharged from the facility on [date] to the community. (b) How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: On [date], the Director of Nursing/designee completed a 14-day look audit of active residents receiving treatments to identify other residents having the potential to be affected by: 1. Ensuring medications are administered in accordance with physician orders and documented in the clinical record with emphasis on binders. 2. Ensuring communication sheets are completed prior to [event], completed by the center and then completed by the facility upon return from [location] or appropriately documented in the clinical record. Any concerns identified were immediately addressed. (c) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On [date], the Director of Nursing/designee completed re-education with the licensed nursing staff on the components of this regulation with emphasis on: 1. Ensuring medications are administered in accordance with physician orders and documented in the clinical record with emphasis on binders. 2. Ensuring communication sheets are completed prior to [event], completed by the center and then completed by the facility upon return from [location] or appropriately documented in the clinical record. Newly hired licensed nursing staff will be educated on these components during orientation. (d) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put into place: The Director of Nursing/designee will conduct an audit of at least 5 residents receiving services 3 times weekly for 4 weeks and then weekly for 2 months to ensure: 1. Medications are administered in accordance with physician orders and documented in the clinical record with emphasis on binders. 2. Communication sheets are completed prior to [event], completed by the center and then completed by the facility upon return from [location] or appropriately documented in the clinical record. Findings of these audits will be reviewed in the QA/Risk Management meeting monthly until such time as the committee determines substantial compliance has been achieved.