Elizabeth Seton Children's Center
March 17, 2025 Complaint Survey

Standard Health Citations

FF15 483.25:QUALITY OF CARE

REGULATION: § 483. 25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 17, 2025
Corrected date: May 9, 2025

Citation Details

Based on documentation review and staff interview, the facility did not ensure that a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records was included in the Emergency Preparedness Plan. The finding is On 09/08/2022 at approximately 1:30 PM, during the documentation review it was noted that policy and procedures for Medical Documentation was not included in the Facility's Emergency Preparedness Plan. In an interview on 09/08/2022 at approximately 2:14 PM, the Facility Administrator stated that they use Quick Link as electronic storage of medical records, and that they will look for the policy. On 09/08/2022 at approximately 3:00 PM, during the Life Safety Code exit interview, the facility Administrator stated that they provided the Medical Documentation policy. The additional documents supplied included the Use of Volunteers policy and did not contain the policy for Medical Documentation. 483. 73(b)(5)

Plan of Correction: ApprovedApril 8, 2025

I Corrective Action: 1. Staff CNA #1 suspended for five days. 2. CNA #1 re-educated on reviewing Nursing Instructions through the EMR system prior to providing ADL care. II. Potential of other Residents to be affected: 1. Video of the residents on the CNAs assignment were reviewed and no other residents were affected. 2. Since (MONTH) 24, 2024, 369 videos of were reviewed to ensure compliance with care plans. 3. All direct care staff are to be re-educated on the Personal Hygiene Policy, which was revised to include verifying Nursing Instructions via the EMR system. III. Measures and Systemic Changes: 1. Revised Personal Hygiene Policy on 3-25-25 to include CNA's verifying Nursing Instructions via the CNA kiosk (Nursing Instructions replicate resident ADL support needs as outlined in the Care Plan) 2. Re-educate all direct care staff by (MONTH) 30th, 2025. IV. Monitoring Corrective Actions: 1. Personal Hygiene Policy education will be reported to the Quality and Safety Committee upon completion. 2. 30 in person ADL observations will be conducted monthly by Nurse Managers/Supervisors for 60 days. Any non-compliance will be addressed immediately. 3. Completion of the Plan of Corection will be reported to the Quality and Safety Committee. V. Date of Correction and Title of Person responsible for correction of deficiency: Corrective Action Completion date?ö?ç?ú 5-9-2025 The Director of Nursing is responsible for the corrective action.