Failure to Follow Physician's Orders for Resident Care
Penalty
Summary
The facility failed to adhere to physician's orders for two residents, leading to deficiencies in care. Resident R46, diagnosed with Alzheimer's Disease and diabetes, had a physician's order dated 11/17/24 to be turned and repositioned every two hours due to impaired mobility. However, observations on 1/07/25 revealed that the resident remained in the same position on their buttocks throughout the day, indicating non-compliance with the care plan. This was confirmed by LPN Employee E8, who acknowledged the requirement for repositioning every two hours. Similarly, Resident R56, with diagnoses of dementia and hypertension, had a physician's order dated 9/26/24 for pillow boots to be worn on both feet at all times except during care to prevent skin breakdown. Observations on 1/06/25, 1/07/25, and 1/08/25 showed the resident sitting in a wheelchair without the pillow boots, which were found lying on the bedside stand or nightstand. LPN Employee E10 confirmed the absence of pillow boots on the resident's feet, acknowledging the failure to follow the physician's orders.
Plan Of Correction
R46 was turned and repositioned; the concern was identified. Orders were reviewed with the physician and nursing supervisor to determine appropriate measures are in place and being followed. R56 pressure relieving devices were applied per physician order. Orders were reviewed with care staff to ensure the facility was in compliance with physician orders. The facility has reviewed the policy for pressure ulcer prevention and repositioning. The interdisciplinary team (IDT Team) met for policy revisions and updated the turning and repositioning policy. The use of pressure reducing devices will be individualized based on the patient's needs, RN assessment, as well as the Braden Scale. Facility education to all nursing staff regarding the policy change in turning and repositioning of residents and the need for an individualized plan to prevent skin breakdown, including pressure reducing devices, has been provided. The facility has reviewed care plans and orders of residents to determine who was at risk for skin breakdown and preventative measures put in place. Audits will be performed on all residents on individualized repositioning programs and with pressure reducing devices weekly for 8 weeks and monthly thereafter for 3 months. We will be auditing all residents on individualized care repositioning plans. The facility has identified this as a performance improvement program for their Quality Assurance Performance Improvement (QAPI) Program. We will review quarterly with QAPI and track progress.