Failure to Implement Resident-Directed Care and Treatment
Penalty
Summary
The facility failed to implement resident-directed care and treatment consistent with the physician orders and care plan for a resident diagnosed with congestive heart failure, localized edema, and muscle weakness. The resident had a physician order for Tubi grips to be applied to the bilateral lower extremities twice a day to manage edema, starting from September 20, 2024. However, observations on January 21 and 22, 2025, revealed that the resident was not wearing the Tubi grips, despite having visible edema in the lower extremities. The Treatment Administration Record inaccurately indicated that the Tubi grips were in place on these dates. Interviews with the resident and the Director of Nursing revealed that the resident had not worn the Tubi grips for over a month due to significant weight loss and improvement in edema. The Director of Nursing confirmed that the physician order was changed to 'as needed' on January 22, 2025, but acknowledged that the order should not have been signed off as if the Tubi grips were in place when they were not. This discrepancy highlights a failure in accurately documenting and implementing the resident's care plan as per the physician's orders.
Plan Of Correction
Preparation and evaluation of the enclosed plan of correction set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or concluded set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provision of Federal and State law. F-0684-Quality of Care 1. Resident 41's Physician orders/eTAR was reviewed and discussed with physician and resident. Physician changed order to PRN on 1/22/25. 2. All Resident treatment orders were reviewed to ensure the facility had implemented resident-directed care and treatment consistent with Physician's orders. No other discrepancies were identified. 3. Policies on Care Plans-Comprehensive Person-Centered and Nursing Documentation were reviewed and will have necessary revisions made by DON. Re-education provided to the Licensed nurses via Relias. Re-education to include reviewing the policies-Nursing Documentation and Care Plans-Comprehensive Person-Centered with a focus to include that residents receive any treatment ordered by the physician or the physician must be updated per policy of refusals or unnecessary treatment. Education will be completed by 2/21/25. 4. Treatments and Resident observations will be audited by QA Coordinator to ensure they are following the resident care plan and physician orders. Monitoring will include nurse observation to ensure treatment or appliance is in place. 5. Audits will be done weekly X2 weeks, bi-weekly x2 weeks then monthly x2. Any immediate concern will be brought to DON for immediate attention and re-education. Audits will be reviewed at QA Meetings. All corrective actions will be completed by 2/25/25.