Multiple Care Deficiencies in Resident Management
Penalty
Summary
The facility failed to provide adequate care and services for several residents, as evidenced by multiple deficiencies. Resident #44 did not receive necessary interventions for bowel irregularity, despite being at risk due to decreased mobility and medication side effects. The resident's care plan required administration of medications as needed, but records showed no documentation of bowel movements or administration of as-needed medications over several days. Interviews with the resident and staff confirmed the lack of appropriate care. Resident #10 and Resident #23 both received medications outside of the prescribed parameters. Resident #10 was given a medication despite a blood pressure reading that should have contraindicated its administration. Similarly, Resident #23 received medication for hypertension even when blood pressure readings were below the threshold set by the physician's orders. These actions were acknowledged by staff during interviews, indicating a failure to adhere to physician directives. Resident #62 experienced a failure in coordination for a scheduled medical appointment, resulting in missed transportation to a urologist. Despite having an appointment scheduled for over a month, the resident was not taken to the appointment due to a lack of communication and proper documentation. Additionally, Resident #303's records showed that the facility failed to notify a physician when blood glucose levels exceeded the threshold, as required by the physician's orders. The DON confirmed the absence of documentation regarding physician notification, highlighting a lapse in following medical orders.
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? On 4.4.25 resident #44, 10, 23, and 62 were assessed by licensed nurse, no concerns identified. Resident #44 had movement on 4.7.25, no regimen required. On 4.16.25 physician reviewed medication regimen for resident #10, determined to be stable and hold parameters removed from hypertensive medication. On 4.9.25 physician reviewed medication regimen for resident #23, determined to be stable and hold parameters removed from hypertensive medication. For resident #62 was completed on 4.9.25; resident #62 discharged on 4.10.25 and is no longer residing in facility. Resident #303 was discharged on 3.18.25 and is no longer residing in facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.22.25 a quality review was completed by Director of Nursing on current residents for parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.22.25 Director of Nursing completed education with current staff on the components of F684 Quality of care with an emphasis on parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated by the Director of Nursing/Designee. Newly hired licensed nursing staff will be educated on the components of F684 Quality of care with an emphasis on parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated by the Assistant Director of Nursing/Designee, at orientation as a part of the systematic changes. (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: Director of Nursing/Designee to conduct random audits of 5 residents twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F684 Quality of care with an emphasis on parameters, monitoring, management monitoring and orders to ensure parameters in place per physician orders and follow up scheduled as indicated. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.