Medication and Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure timely and appropriate quality of care for several residents, as evidenced by multiple medication administration errors and lack of adherence to physician orders. For instance, Resident #24 experienced delays in receiving prescribed medications, including Lumigan and other essential drugs, due to staff awaiting delivery, resulting in missed doses. The Unit Manager was unable to provide a reason for the delay, despite the medications being available in the facility's emergency stock. Resident #162's care was compromised due to improper management of a medical device, as staff failed to secure tubing properly, leading to potential complications. Observations revealed cloudy fluid in the tubing, which was not addressed by the LPN, who admitted to not notifying the physician about the issue. The Unit Manager acknowledged the delay in reviewing lab results and obtaining necessary orders, which contributed to the inadequate care provided. Additionally, Resident #100's care plan was not followed, as staff allowed the resident to wear socks against physician orders, which could hinder the healing of a pressure injury. Staff failed to educate the resident on the importance of adhering to the care plan. Furthermore, Resident #102 did not receive proper wound care as per physician instructions, with observations showing uncovered wounds and improper dressing changes. Lastly, Resident #517 received treatment for a skin tear without a physician's order, indicating a lack of proper documentation and oversight in the facility's care processes.
Plan Of Correction
Resident #24 completed her on, on and per the podiatrist. On she had no signs of. Per the orthopedic surgeon on the resident s healed and there were no concerns documented. The resident received her as ordered on and discharged from the center on. Resident #102 will have his care completed per the physician orders. The for resident #517 has resolved. Resident #517 will have his care completed per physician orders. Resident #100 receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent and prevent new from developing. The resident #162 had her changed and recollected on. Her bag will be anchored as required. Her will be ordered in a timely manner. Resident #11 will have her completed per the center's process. Residents with and orders were audited on to ensure that their or were administered per physician orders. No other residents were affected by this alleged deficient practice. Residents with will have their care completed per physician orders. Care orders were audited to ensure no other residents were affected by this alleged deficient practice. Residents with were observed on to ensure proper control practices were followed. No residents were affected by this alleged deficient practice. Residents with or will have or care observations completed by the Director of Education/designee to ensure clinical competency for this standard of practice. Any lack of competency by the team member will be corrected immediately. Residents pending results had their results reviewed on ensure timely ordering of. Any results with a delay in treatment will result in a physician notification. The director of education or designee will complete the following educations for nursing team members by: a. Licensed nurses will be educated on following physician orders for care, and b. Licensed nurses will be educated to obtain a care order prior to providing a treatment. c. Licensed nurses will be educated on the signs and symptoms of a and to report laboratory results timely to the provider. d. Nursing team members will be educated on proper control procedures regarding. e. Certified nursing assistants will be educated on proper procedures. Orders will be audited for administration per physician orders weekly x4 weeks and monthly x12 months by the preventionist/designee. Orders will be audited for administration per physician orders weekly x4 weeks and monthly x12 months by the DCS/designee. Care treatments will be audited for accuracy weekly x4 weeks and months x12 months by the DCS/designee. Results will be audited to ensure timely review and ordering of an weekly x4 weeks and monthly x12 months by the Director of clinical services/designee. Anchors will be audited weekly x4 weeks and monthly x12 months by the Director of clinical services/designee. Provided to residents with will be audited weekly x4 weeks and monthly x12 months by the director of clinical services/designee. All audits will be brought to the QAPI committee monthly for review.