Failure to Provide Appropriate Treatment and Care
Penalty
Summary
The facility failed to provide appropriate treatment and care for five residents, as observed and confirmed through interviews and record reviews. Resident R1 had ACE wraps applied incorrectly, with no active order to place them on, and they were not removed at the hour of sleep as ordered. Resident R2 had ACE wraps applied in a manner inconsistent with the physician's order, reversing the direction from knees to toes. Resident R3 did not have ACE wraps on as ordered, and during an interview, it was revealed that the wrap was removed due to pain from being too tight, with significant swelling observed. Resident R4 was noted not to have ACE wraps on during a scheduled time, and Resident R5 was observed without ACE wraps despite having swollen lower legs, as confirmed by a Licensed Practical Nurse. The Director of Nursing confirmed the facility's failure to ensure residents received appropriate treatment and care, as required by physician orders and resident care policies. The deficiencies were identified under several Pennsylvania Code regulations, including the responsibility of the licensee, resident rights, resident care policies, and nursing services. These observations and interviews highlight a pattern of non-compliance with prescribed care protocols, affecting the residents' health and well-being.
Plan Of Correction
Residents R1, R2, R3, R4 and R5 had no ill effects from F0684. Any residents with compression stockings, ted hose and ace wraps will be audited for correct application. Identified deficient practice will be corrected upon notation with 1:1 education and return demonstration competency as indicated. To prevent future occurrences, nurses will receive education on maintenance and use of compression stockings, ted hose and ace wraps. Director of Nursing and/or designee will complete audits of maintenance and use of compression stockings, ted hose and ace wraps at random with 4 A/O residents 2x a week x 1 month; then monthly thereafter with reporting through Quality Assurance and Process Improvement Committee for review and/or recommendation ongoing.