Failure to Apply Abdominal Binder for Resident with Feeding Tube
Penalty
Summary
The facility failed to adhere to physician's orders regarding the use of an abdominal binder for a resident with a feeding tube, leading to a deficiency. Resident #26, who was readmitted to the facility with conditions including dysphagia and delusional disorders, had a history of pulling out her feeding tube. The physician's order required an abdominal binder to be in place to prevent the resident from pulling out the tube, with instructions to remove it only for skin integrity checks and feeding tube care every shift. However, during observations, the resident was found without the abdominal binder, and the feeding tube was exposed and leaking. Despite the absence of the abdominal binder, the Treatment Administration Record (TAR) was signed by nursing staff, indicating that the binder was applied as per the physician's order. Staff interviews revealed that the binder was unavailable as it was sent to the laundry, and alternative measures such as using a sheet were employed. The RN Unit Manager confirmed that the binder was not applied as ordered, and the documentation on the TAR was inaccurate. This discrepancy between the physician's orders and the actual care provided, along with inaccurate documentation, led to the deficiency identified in the report.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #26 binder use was corrected. B. RN staff K educated on documentation. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete audit of resident and any specialty device used for their tube was completed and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License Nurses was educated on documentation with emphasis on services not provided/physician orders not carried out and the process of documentation. B. Nurse Manager to review 24 hour report and order detail summary the following business day for any refusal or care, supplies not available and any new order for specialty equipment and follow up to ensure appropriate interventions were implemented. C. Staff was educated on the components of F693 and this education will be provided upon new hire orientation and annually. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Nursing/Designee will do random audits of resident and any specialty equipment used on their is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.