Delayed Culture Results and Medication Administration
Penalty
Summary
The facility failed to obtain culture results in a timely manner for one resident. This resident was admitted with multiple diagnoses and required partial assistance with activities of daily living. The care plan included management of wounds on the right and left heels. A physician order was placed for a culture of the left heel, and progress notes indicated the culture was collected and stored for lab pickup. However, there was a delay of 22 days from the time of collection to when the culture was received in the lab. The culture ultimately tested positive for a multi-drug resistant organism requiring isolation, and there was a delay in effective treatment due to the delay in obtaining results. The facility also failed to administer medications in a timely manner for another resident. This resident had multiple medical conditions, including visual impairment, mobility issues, and required assistance with personal care. Physician orders included several scheduled and as-needed medications. Review of the medication administration audit report showed that medications were repeatedly administered outside the facility's policy window of one hour before or after the scheduled time. Some medications were given as late as over three hours past the scheduled time. The resident confirmed that morning medications were sometimes received hours late. Interviews with nursing staff, including an RN, LPN, and the DON, confirmed their understanding of the facility's policy regarding medication administration timing. Despite this, the audit report documented multiple instances of late medication administration, indicating a failure to follow established protocols for timely medication delivery.
Plan Of Correction
On , Resident #12 was assessed by the provider. The resident is healing without complications and shows no signs or symptoms of current provider issues. Resident #92 was evaluated by the provider with no acute findings noted. On , the Regional Nurse Consultant conducted a quality review of current residents with cultures ordered in the past 30 days to ensure that the culture was obtained within the appropriate time frame. No additional findings were noted. On , the Regional Nurse Consultant conducted a quality review of medication administrations for the past 24 hours. Follow-up was conducted based on findings. By , licensed nurses were educated by the Staff Development Coordinator on the components of F 684, with an emphasis on obtaining cultures timely and administering medications timely. As a systematic change, newly hired licensed nurses will be educated on the components of F 684 during orientation, with an emphasis on obtaining cultures timely and administering medications timely. The DON/Designee will conduct quality monitoring of order listing reports 5 times weekly for 4 weeks, then 5 times monthly for 2 months to ensure that cultures ordered are obtained timely. Additionally, the DON/Designee will conduct quality monitoring of 5 random residents weekly for 4 weeks, then 10 random residents monthly for 2 months to ensure that medications are administered within the appropriate time frame. The findings of these quality monitoring activities are to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines that substantial compliance has been met.