Deficiencies in Care Orders and Medication Administration
Penalty
Summary
The facility failed to ensure timely implementation and completion of care orders for a resident with skin issues. The resident was admitted with various diagnoses, including idiopathic conditions, and had a documented open wound that required specific treatment. However, the necessary care orders were not put in place until after the resident's second visit to an outside provider. Interviews with staff revealed a lack of communication and follow-up regarding the resident's treatment orders, resulting in a delay in care. Additionally, the facility did not administer medications appropriately for two other residents. One resident's medication administration record showed inconsistencies in the administration of sleep medication, with no corresponding nurse notes to explain the discrepancies. Another resident reported not receiving her medications on time, which affected her condition. The resident expressed frustration over the facility's repeated excuses for the medication delays, which included issues with pharmacy orders and availability. The facility's policies on medication administration and care procedures were not followed, as evidenced by the lack of documentation and communication with physicians when medications were withheld or care orders were not implemented. Interviews with staff, including the Director of Nursing, confirmed these lapses in protocol, highlighting a failure to adhere to professional standards of practice and ensure residents' needs were met in a timely manner.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was immediately assessed by a licensed nurse. No concerns were noted. Resident #22 was immediately assessed by a licensed nurse. No concerns were noted. Resident #10 no longer resides in the facility. Discharged on (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By , a quality review was completed by Director of Nursing/Designee on Quality of Care with emphasis on care orders put in place and completed within a timely manner. No additional residents were found to be affected by the alleged deficient practice. By , a quality review was completed by Director of Nursing/Designee on Quality of Care with emphasis on ensuring medications are administered appropriately. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , clinical staff were educated on the components of Quality of Care with emphasis on care orders put in place and completed within timely manner by Director of Nursing/Designee. By , clinical staff were educated on the components of Quality of Care with emphasis on ensuring medications are administered appropriately by Director of Nursing/Designee. Newly hired licensed nurses will be educated on the components of Quality of Care with emphasis on care orders put in place and completed within timely manner and on ensuring medications are administered appropriately by the 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 for care orders put in place and completed within timely manner 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that care orders put in place and completed within timely manner. Director of Nursing/Designee to conduct random audits of 5 residents medication administration 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that medications are administered appropriately. 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.