Deficient Nursing Staff Competency and Lab Monitoring
Penalty
Summary
The facility failed to ensure that nursing staff were competent in caring for residents, particularly in the areas of laboratory monitoring, following through with orders, processing consultations, and communicating with physicians. This deficiency was evident in the case of a resident whose medication levels were not adequately monitored, leading to a serious medical event. The resident's medication levels were found to be low, and despite orders for consultation and lab tests, there was no evidence that these were completed or that the physician was notified of the results. The report highlights multiple instances where lab results were not communicated to the appropriate medical personnel, and orders were not followed through. For example, several residents had lab orders that were either not entered into the lab portal or not completed, resulting in missed or delayed lab tests. In some cases, critical lab results were not reported to the physician in a timely manner, if at all. This lack of communication and follow-through contributed to the deterioration of residents' conditions. Interviews with staff revealed systemic issues in the facility's lab process, including a lack of access to the lab portal for some nurses, insufficient training on lab procedures, and unclear responsibilities for ensuring lab orders were completed. The Director of Nursing acknowledged these failures, noting that there was no assigned person to oversee lab processes and that the system for managing lab orders and results was broken. This systemic failure in managing lab processes and communication with physicians led to the determination of Immediate Jeopardy.
Plan Of Correction
Competent Nurse staffing 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Residents #5 and #10 no longer reside in the facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken? A facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that medications residents on had appropriate lab monitoring orders in place and that any consults that were previously ordered were scheduled. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur? Director of Nursing/Designee will educate licensed nursing staff on the care of residents with a diagnosis to include ensuring that lab orders are in place to monitor medication levels, physicians are notified of abnormal lab values or refused labs, documentation of physician notification of lab levels and new orders is recorded in the resident clinical record, and that consultation orders for or other outside providers are executed appropriately. 4. How the corrective action(s) will monitor to ensure the practice will not recur, i.e., what quality assurance program will be put in place(s); will be accomplished for those residents: Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place and consultation orders for outside providers are completed weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.
Removal Plan
- Regional Nurse Consultant educated the Administrator and Director of Nursing on ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal lab values, and follow-up procedures and resident condition change related to laboratory results.
- Current resident audit conducted by Director of Nursing/designee for review of residents taking medications with no concerns identified.
- Consultant Physician provided education to facility Medical Director and physician extender regarding standards of practice for monitoring and treating residents with related diagnoses.
- Director of Nursing or designee educated 100% of licensed nursing staff on ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal lab values, and follow-up procedures related to laboratory results.
- Process Change: Director of Nursing is responsible for ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification, and follow-up procedures related to laboratory results.
- All education and in-service sign-in sheets were reviewed and validated 10 out of 18 licensed nursing staff on ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal lab values, and follow-up procedures related to laboratory results.
- Interviews were conducted with 10 licensed nurses across various shifts, the Assistant Director of Nursing, the DON, and the Medical Director. The staff members were able to verbalize they had been trained and were knowledgeable about the new policies.