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F0726
D

Lack of Documented Nursing Competencies in IV and Ostomy Care

Philadelphia, Pennsylvania Survey Completed on 08-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that licensed nursing staff possessed the required competencies, specifically in intravenous (IV) care and ostomy care, for four licensed nurses whose training records were reviewed. Facility documentation and staff interviews revealed that there were no policies related to nursing competencies, and the training records did not show evidence of competency evaluations for IV care for two employees and ostomy care for all four employees reviewed. An interview with the Director of Nursing confirmed that there was no documentation available to demonstrate that the selected licensed nursing staff had been evaluated for competency in ostomy care, and that two of the employees had no documented IV competency. This lack of documentation and evaluation directly led to the deficiency cited under federal and state nursing service regulations.

Plan Of Correction

Immediate Corrective Action: IV care competencies were completed with E4 and E5. Ostomy care competencies were completed with E4, E5, E6, and E7. Housewide Corrective Action: Current licensed nursing staff to be audited to ensure IV care and ostomy care competencies have been completed. Policy/Education: Current licensed nurses will have IV care and ostomy care competencies completed. Performance Monitoring: DON or designee will complete weekly observations of 2 nurses performing ostomy care and IV care x 4 weeks to ensure staff are competent in performing both tasks. Results will be reviewed during facility’s monthly QAPI meeting. QA meeting will determine the need for continued auditing.

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