Failure to Obtain Physician Orders for AFO and Clarify Alcohol Consumption
Penalty
Summary
The facility failed to obtain a physician's order for the use of an ankle-foot orthotic (AFO) for a resident, identified as R67, who was observed wearing a brace on the right lower leg and complaining of discomfort. The resident mentioned that the brace had been fixed with glue but preferred an older brace that fit better. A review of the resident's clinical record showed no physician order for the AFO, and the Director of Nursing confirmed the absence of such an order. This oversight indicates a failure to adhere to professional standards of practice and ensure proper treatment and care based on a comprehensive assessment. Additionally, the facility did not clarify a physician's order regarding the alcohol consumption of another resident, identified as R4. The physician's order allowed the resident to have wine but did not specify the amount or frequency. The resident reported being served wine at least once a week, but there was no documentation in the Medical Administration Record or Treatment Administration Record to track the administration of wine. An interview with a unit manager confirmed the lack of clarity in the physician's order and the need to consult the physician for further instructions.
Plan Of Correction
1. Contain elements detailing how the facility will correct the deficiency as it relates to the individual. The resident (R67) a physician order was obtained for the use of the AFO (ankle foot orthidic) that was being used on his right foot. The resident's (R4) & (302) a physician order was clarified for the residents consumption of alcohol. The pharmacy was also contacted to determine if any of the residents (R4 & R302)) current medications would interact with alcohol. 2. Indicate how the facility will act to protect residents in similar situations. All current residents requiring an AFO device medical records were reviewed to ensure that a Physician Order was obtained prior to use. All current residents that have an order for alcohol consumption, the Physician Order was clarified to indicate the specific amount of alcohol that could be served and how often the resident could have the alcohol. The facility requested that the Pharmacy Company review all the Medications of those residents that consume alcohol to ensure that the medications would interact with alcohol. 3. Include the measures the facility will take or the systems it will alter to ensure that the problem does not recur. To ensure that this problem does not occur in the future, the facility will conduct formal education for Physician Orders & Alcoholic Beverages which was initiated by the facility Nurse Educator for all Nursing Staff. 4. Indicate how it plans to monitor its performance to make sure that solutions are sustained. The Director of Nursing or designee will perform weekly audits x4 then monthly for 3 months to ensure Physician Orders for AFO's are obtained prior to use. The facility will monitor residents Alcoholic Beverage consumption to ensure that a Physician Order is obtained for the amount of alcohol and dose is in accordance with the physician order, as well as, pharmacy recommendation for medication interaction. The results will be submitted and reviewed at the Quarterly QAPI meeting for continued compliance. 5. Provide dates when corrective action will be completed. The facility will complete this Plan of Correction 4/04/2025.