Deficiency in Nursing Competency Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary skills and competencies to safely care for residents, particularly in the management of urinary catheters. This deficiency was highlighted by the case of a resident who experienced significant complications due to improper catheter management. The resident, who had a history of prostatic hyperplasia and was admitted with a catheter, suffered from a lack of urine output and the presence of clots, which were not adequately monitored or addressed by the nursing staff. On one occasion, an LPN changed the resident's catheter but failed to verify its proper insertion and drainage, leaving the resident with no urine output. Despite receiving an order to monitor the resident and send him to the hospital if the condition persisted, the LPN did not transcribe the order promptly, resulting in a delay in care. The resident eventually became unresponsive and required emergency transfer to a hospital, where he was intubated. The investigation revealed that the nursing staff lacked proper training and competency evaluations for catheter management. The facility's orientation and competency checklists did not include essential skills such as catheter insertion and monitoring for complications. This oversight contributed to the failure to recognize and respond to the resident's deteriorating condition, ultimately placing the resident at risk of significant harm.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 no longer resides at the facility. • The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • Current residents had an RN assessment completed including a set of vital signs and observation for output and patency. Any changes identified were communicated to the provider and family notification completed. • Current residents with an had an evaluation completed. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, or status. o This may include life-threatening conditions, or clinical complications and changes in output including color, consistency, and output. o Circumstances that may require a need to alter treatment. This may include new treatment and/or discontinuation of current treatment due to an acute condition or a worsening of a condition. o A complete nursing evaluation must be conducted and documented in the medical record of systems including but not limited to functional status, evaluation, evaluation, evaluation/evaluation, skin evaluation, evaluation, and vital signs. o The physician/NP shall be made aware of pertinent evaluation findings. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on vital sign documentation, and on following timely transfer to a higher level of care upon directive from physician. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on care to include insertion, output, and proper monitoring documentation of output, including documenting this output on the resident's MAR. The licensed nurse must perform a visual observation of the color and clarity of output each shift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the nurses' requirement to notify the provider of any notable changes in resident condition. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs and licensed nurses on the proper obtaining of resident vital signs including temperature, and on a live member of staff. Vital signs obtained for an identified change in condition will be documented in the and vitals tab in PCC. This allows for these vitals to populate accurately in the SBAR/Change in Condition evaluation. • The facility's Staff Development Coordinator/Designee completed competencies with licensed nurses on the proper insertion of with return demonstrations. • The facility added to the orientation agenda that all newly hired licensed nurses will complete competencies on the proper insertion of with return demonstration prior to providing resident care. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the requirement of detailed communication during shift to shift report to include any changes in condition, any new physician orders, and review of any new or existing devices including. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs on emptying and measuring output for residents with. This competency was conducted using a mannequin with an to simulate the actual emptying of the. • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. System Change: • The daily clinical meeting form was edited to include: o Review of 24-hour report for change in condition. o The review of vital signs and the timely transfer of all residents that returned to the hospital. o The review of all new admissions and existing residents with to monitor output to ensure orders are in place. o The review of vital signs and the review of the nurse's change of condition evaluation for all residents that had a change in condition. o The review of vital signs for all residents per physician order. o Output was added to the MAR to ensure nursing documentation. • CNAs will be responsible for emptying output for residents with and will report this number to the licensed nurse, who then will be responsible for recording the output value on the MAR three times a day. • Licensed Nurses and CNAs will complete competencies on care at the time of orientation and annually with the facility's Staff Development Coordinator. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. • The facility initiated the completion of audits seven days a week including weekends documentation of output for all residents with. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee.
Removal Plan
- Educated licensed nurses on completing a Change in Condition Assessment on residents.
- The education included identifying conditions that required an assessment including: Accidents resulting in injury; significant change in the resident's physical or mental condition, deterioration in health, mental or status; life threatening conditions or clinical complications including changes in output including color, consistency and output; circumstances that require an alteration in treatment including acute and conditions.
- A complete nursing evaluation must be conducted and documented in the medical record of systems.
- The nurses were educated to obtain a new set of vital signs and document in the electronic record in that the Change in Condition Assessment would contain the most recent and relevant vital signs.
- The provider shall be notified of pertinent evaluation findings.
- Nurses must visualize amount of output, color and clarity during each shift.
- Educated all remaining licensed nurses prior to working their next scheduled shift.
- Began CNA and licensed nurse competencies on obtaining vital signs.
- Vital signs obtained for a change in condition are to be documented in the electronic record under the and vitals tab, so they populate in the change in condition assessment.
- Completed audits including weekends and off hours to ensure the proper documentation of vital signs for all residents.
- Initiated the completion of audits 7 days a week and off hours to include output for all residents.
- Edited the daily clinical meeting form to include review of the 24-hour report for change in condition; vital signs and timely transfer to a higher level if necessary: for new and existing residents to ensure orders to monitor output were in place; review of the nurses' Change in condition Assessment to include current vital signs during the change, and review of the vital signs for all residents per the physician's orders.
- The RN assessed all residents currently at the facility for vital signs and output if indicated. Any changes were communicated to the provider and family.
- Began competencies on the proper insertion of licensed nurses. The remaining licensed nurses would complete the competency prior to working their next scheduled shift.
- Added to the orientation agenda for newly hired licensed nurses. They will complete competency on the proper insertion of with return demonstration prior to resident care.
- Began education with licensed nurses on the requirement of detailed communication during shift-to-shift report to include any changes in condition, new orders, and review any existing devices.
- The education was also added to the orientation for all newly hired nurses.
- Began educating nurses on ensuring new orders for will include placement, patency/draining, irrigation, securement, care every shift and recording of output on the MAR.
- Verified through observation and interview, nurses were educated prior to working their next shift.
- Verified through interview with the DON and review of audits completed, interviews with CNAs, nurses and review of random residents records to ensure proper nursing care and services for residents with and those experiencing changes in condition.
- An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities Director, Minimum Data Set nurse, Nurse, CNA.