Failure to Obtain Timely Cultures and Complete Medical Orders
Penalty
Summary
The facility failed to obtain physician-ordered cultures in a timely manner for two residents, leading to a deficiency in providing adequate and appropriate health care. Resident #1, admitted for short-term rehabilitation, had a physician order for a urine analysis (UA) and culture due to increased episodes of discomfort. However, there was a delay in obtaining the culture, and the results were not promptly communicated to the provider. The resident expressed concern about the delay in receiving results, and the medical nurse practitioner had to be notified to order medication for treatment. Resident #4, also admitted for short-term rehabilitation, had a large hematoma and required an ultrasound (US) as noted by the rehabilitation nurse practitioner. However, the order for the ultrasound was not completed, and there was no documentation of the order in the resident's summary report. During an interview, the rehabilitation nurse practitioner confirmed that if an order was documented, it should have been completed, indicating a lapse in following through with the necessary medical orders. The Director of Nursing (DON) confirmed the absence of information regarding the sample results for Resident #1 and acknowledged the expectation for orders to be followed and for the physician to be notified of results. The failure to obtain timely cultures and complete medical orders for these residents highlights a deficiency in the facility's adherence to established procedures and guidelines for resident care.
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 it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was discharged on Resident #4 was discharged on On , Regional Nurse Consultant re-educated the Director of Nursing on the components of N201 with an emphasis on ensuring physician-ordered cultures are obtained in a timely manner. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On DON/Designee completed a quality review of current residents on ensuring physician-ordered cultures are obtained in a timely manner. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur, By , DON/Designee provided education to the licensed nurses on the components of N201 with an emphasis on ensuring physician-ordered cultures are obtained in a timely manner. Newly hired licensed nurses will be educated by Director of Nurses/Designee on ensuring physician-ordered cultures are obtained in a timely manner. (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 in place: The Director of Nursing/Designee to conduct audits of 5 residents 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure physician-ordered cultures are obtained in a timely manner. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance improvement Committee monthly until committee determines substantial compliance has been met.