Failure in Medication Monitoring and Lab Management
Penalty
Summary
The facility failed to effectively monitor adverse events, specifically in the management of medication levels for multiple residents. This deficiency was highlighted by the case of a resident whose medication levels were not adequately monitored, leading to a significant medical event. The resident was admitted with various medical diagnoses and had specific medication orders that were not consistently followed. Laboratory results indicating low medication levels were not communicated to the physician, and necessary consultations were not obtained, resulting in the resident experiencing a severe medical episode that required transfer to a higher level of care. The report details multiple instances where the facility did not maintain effective systems for monitoring and reporting adverse events. Several residents had medication levels that were either not checked or not reported to the appropriate medical personnel, leading to suboptimal management of their conditions. The facility's process for handling lab orders and results was inadequate, with orders not being entered into the lab portal, results not being communicated to providers, and critical lab values not being addressed in a timely manner. Interviews with facility staff, including the Director of Nursing and other medical personnel, revealed systemic failures in the lab process and medication management. There was a lack of accountability and oversight in ensuring that lab results were reviewed and acted upon. The facility's Quality Assurance and Performance Improvement (QAPI) plan did not adequately address these issues, leading to a breakdown in the monitoring and management of residents' health care needs.
Plan Of Correction
QAPI/N 901 QA Program 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 the Director of Nursing/designee to ensure that residents on medications 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? The Regional Nurse Consultant educated the Nursing Home Administrator and Director of Nursing on ensuring that an effective Quality Assurance program is in place as it pertains to the care of residents with a diagnosis, 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 that an effective Quality Assurance and Performance Improvement Plan is in place to ensure the safety of all residents.
- Administrator educated 100% of the members of the Quality Assurance and Assessment Committee on ensuring that an effective Quality Assurance and Performance Improvement Plan is in place to ensure the safety of all residents.
- Adhoc meeting held with interdisciplinary team and Medical director related to lab process monitoring and MD notification. Another Adhoc meeting was held on lab process/lab monitoring, following physician orders, clinical morning meeting process with review of lab binder, lab access availability audit.
- Daily audits were conducted on lab process with no new findings.
- Process Change: Administrator is responsible for ensuring that an effective Quality Assurance and Performance Improvement Plan is in place to ensure the safety of all residents.
- All education and in-service sign in sheets were reviewed and validated for 13 out of 13 members of the Quality Assurance and Assessment Committee on ensuring that an effective Quality Assurance and Performance Improvement Plan is in place to ensure the safety of all residents.
- Interviews were conducted with the Nursing Home Administrator, members of the interdisciplinary team, the Assistant Director of Nursing, and the DON. The staff members were able to verbalize they had been trained and were knowledgeable about the new policies.