Medication and Equipment Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for three residents. Resident #73 did not receive timely medication administration, with six medications given late by up to an hour and forty-two minutes. Additionally, the resident's Pleur-X tube was not drained as ordered, leading to the resident expressing distress and concern for his health. Interviews with staff revealed a lack of awareness and documentation regarding the Pleur-X drainage, and the attending physician was not informed of the missed drainage. Resident #481 also experienced late medication administration, with medications given late on eight occasions, up to two hours and twenty-nine minutes past the scheduled time. The resident confirmed receiving medications late and expressed awareness of the medication names. Interviews with staff and the consultant pharmacist acknowledged the potential detriment of late medication administration, though not life-threatening. Resident #46 did not have an abduction pillow in place as ordered by the physician. Observations revealed the resident in bed without the required pillow, and interviews with staff indicated a lack of knowledge about the abduction pillow's presence or use. The MDS Coordinator and Unit Manager were unaware of the missing pillow, and staff used regular pillows instead. The resident's care plan included the use of adaptive equipment, but this was not implemented, leading to the deficiency.
Plan Of Correction
QUALITY OF CARE 1. What corrective action(s) will be accomplished for those residents found to have been affected by the practice: 1) In the allegation of Resident #73, and the Pleur-X not being drained on its schedule. And not following medication administration times of an hour prior or an hour post scheduled administration times. The Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. The Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 2) In the allegation of Resident #481, having not received multiple medication at their prescribed times. Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. 3) In the allegation of Resident #46, and the resident's abduction pillow not being used. Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. 2. How you will identify other residents having potential to be affected by the same practice and what corrective action will be taken: All residents in the facility have the potential to be affected by these practices. 3. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: The measures put into place/systemic changes made to ensure the standards are met: - Nursing staff will be in-serviced to follow doctors' orders regarding the drainage times of the Pleur-X. - Nursing staff will be in-serviced to follow Doctor's orders and medication administration times. - Nursing staff will be in-serviced to follow Doctor's orders and the use of assistive devices. Random QA audits will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. 4. 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: Random QA audit will be conducted by the Director of Nursing or a qualified Designee, weekly for one month, then biweekly for another one month and then monthly for one month or until substantial compliance has been determined. Findings of the QA audits will be reported in the Monthly QAPI meeting by the Director of Nursing or a qualified Designee for a period of three months and until substantial compliance is met. Corrective action completion date: