Deficiencies in Emergency Preparedness, Monitoring, and Nutritional Care
Penalty
Summary
The facility failed to provide adequate emergency equipment and training for a resident with a tracheostomy. The resident was observed without an emergency kit at the bedside, which is crucial in case of accidental extubation. The LPN assigned to the resident was unaware of the need for such a kit and did not know the protocol for emergencies. The Unit Manager and Central Supply staff confirmed the absence of the emergency kit, and the facility's policy did not include specific orders for emergency supplies for the resident. Another deficiency involved the failure to monitor a resident's blood glucose levels as per physician's orders. The resident, who was on insulin and other medications, did not have their blood glucose re-checked after a physician's order to hold a meal and re-check levels. The Unit Manager confirmed that the re-checks were not documented, and the DON emphasized the importance of monitoring to prevent complications. The facility also failed to properly monitor the nutritional status of several residents. One resident experienced significant weight loss without timely re-evaluation or intervention. The dietary staff did not complete necessary assessments or follow up on nutritional risks. Another resident's initial weight was not obtained upon admission, leading to inaccurate assessments of weight loss. The facility's policies on weight monitoring and nutritional assessments were not followed, resulting in a lack of timely interventions for residents at nutritional risk.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On an extra tube (emergency kit) was placed at bedside for resident number 22. b. On an assessment was completed on resident number 93 no signs or symptoms of hyper or were noted. c. On staff member received education on entering physician orders in the medical record when received orders for abnormal lab results. d. On RD completed review to assess nutritional status of resident numbers, 15, 52, and 34. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Director of Nursing/designee completed an audit to ensure extra tube kept at bedside (Emergency kit). b. On Director of Nursing/designee completed an audit to ensure resident with order changes related to abnormal results ensure all orders are followed. c. On Audit completed to ensure nutritional status of resident with have been assessed. d. On Audit completed to ensure nutritional status of residents has been assessed. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of Nursing/ designee completed education with licensed Nurses on ensuring we have extra tube is kept at bedside (Emergency Kit). b. By the Director of Nursing/designee completed education with licensed nurses when orders are received related to abnormal results a physician order is placed in the resident medical record. c. By Director of Nursing/designee to complete education with RD and nurse management team to ensure nutritional status is reviewed and assessed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee to complete random audit extra tube is stored at bedside (emergency kit) ensure compliance with N201 Right to Adequate and Appropriate Heel care weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Director of Nursing/designee to complete random audit to ensure resident with order changes related to abnormal results ensure all orders are followed compliance with N201 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. c. Director of Nursing/designee to complete random audit to ensure nutritional status of residents has been assessed to ensure compliance with N201 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. d. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.