Communication and Documentation Failures in Resident Care
Penalty
Summary
The facility failed to maintain effective communication and collaboration between nursing staff and medical providers, resulting in inadequate treatment and continuity of care for two residents. Resident #3, who was admitted with diagnoses including an aneurysm and rapidly progressive nephritic syndrome, did not receive the prescribed medication Sevelamer due to unavailability. Despite multiple notifications to the pharmacy and the physician, the medication was not provided in a timely manner, and there was a lack of documentation regarding the administration of the medication. The nursing staff documented the administration of Sevelamer even when it was not available, and the Director of Nursing acknowledged the challenges with a new regulation requiring centers to provide certain medications. Resident #4, admitted with conditions including intoxication and acute injury, required regular dialysis treatments. The facility failed to ensure proper communication and documentation related to the resident's dialysis schedule and post-treatment care. The resident did not receive breakfast or snacks before leaving for treatment, and the transfer forms used for communication between the facility and the dialysis center were incomplete. The Licensed Practical Nurse and Unit Manager were unaware of the resident's missed meals and transportation issues, and there was no documentation in the Electronic Medical Record regarding the resident's condition post-treatment. The facility's agreement with the dialysis center required immediate communication of any changes in a resident's medical condition, but this was not adhered to. The Director of Nursing stated that assessments were documented on the Treatment Administration Record, but there was no evidence of this in the resident's medical record. The lack of proper documentation and communication between the facility and the dialysis center contributed to the deficiency in care for resident #4.
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. 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 and when the resident returned from. Resident #4 discharged from the facility on 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 , 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 completed by the center and then completed by the facility upon return from 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 , 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 center and then completed by the facility upon return from 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, ie., 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 X 4 weeks and then weekly X 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 completed by the center and then completed by the facility upon return from 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.