Failure to Follow Physician Orders for Wound and Oxygen Care
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to deficiencies in care. Resident #114, who was admitted with diagnoses including Alzheimer's disease and peripheral vascular disease, had a stage 3 pressure ulcer on her right heel. The physician's orders required specific wound care treatments every two days, but observations revealed that the bandage on her heel was dated several days prior, indicating that the treatment was not administered as prescribed. Interviews with staff confirmed that the wound care was not completed, and the treatment administration record was inaccurately marked as administered. Resident #226, who had severe cognitive impairment and multiple cardiac-related diagnoses, was prescribed oxygen therapy at a flow rate of 2 liters per minute. However, observations showed that the oxygen flow rate was set incorrectly at 4 liters per minute and later at 3 liters per minute. The resident was unable to adjust the oxygen flow rate herself, and staff interviews revealed a lack of adherence to the prescribed oxygen settings. The facility's policies and procedures for wound care and oxygen administration were not followed, resulting in a failure to provide necessary treatments and services as ordered by physicians. The staff did not document refusals or late administrations of treatments, and there was a lack of communication between shifts regarding incomplete care. These deficiencies highlight a significant lapse in the facility's adherence to physician orders and care protocols.
Plan Of Correction
The center provides the following Plan of Correction (POC) without admitting or denying the validity or existence of alleged deficiencies. The POC is prepared and/or executed solely because it is required by the provisions of federal and state law. The facility reserves all rights to contest survey findings through informal dispute resolutions, formal appeal proceedings, or any administrative or legal proceedings. On 2/3/2025, wound care treatment/services were immediately provided to resident #114, according to physician orders. The provider for resident #114 was notified of the missed dressing change/treatment identified on 2/3/2025. In addition, Unit Care Coordinator adjusted settings to oxygen delivery devices for resident #226, to reflect physicians orders. DON observed oxygen delivery devices for resident #226 to ensure following of physician orders pertaining to oxygen therapy. On 2/3/2025, the Director of Nursing/Designee completed an audit/review of other residents requiring dressing changes to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers and to not develop pressure ulcers unless the individuals condition demonstrates that they were unavoidable. No additional concerns were identified. In addition, a facility-wide audit was completed by the DON/Designee on 2/4/25, to ensure no other residents affected. None were identified. Physician orders for oxygen were reviewed and delivery devices were observed to ensure accuracy of oxygen administration. On 2/10/25, the Director of Nursing/Designee initiated in-servicing with re-education for licensed nurses reviewing facility policies and procedures for Skin Integrity and Pressure Ulcer Prevention and Management. In addition, in-services with re-education for licensed nurses pertaining to the facility policy and procedures for Oxygen Administration, Safety, and Storage were initiated by the DON/Designee on 2/10/25. Newly hired licensed nurses will have the policy and procedures reviewed during orientation and the facility expectations explained. The Director of Nursing/Designee will conduct ongoing routine audits of residents requiring dressing changes, bi-weekly times 4, then monthly times 3 followed by as needed to ensure compliance with dressing change procedures to provide services necessary to prevent/heal pressure ulcers. These findings will be reviewed in Quality Assurance Performance Improvement Meeting monthly times 3 months and then as needed, if concerns arise. In addition, the Director of Nursing/Designee will conduct oxygen administration observations with focus on following physician orders, bi-weekly times 4, then monthly times 3 followed by as needed to ensure compliance with following physician orders, pertaining to respiratory care. These findings will be reviewed in Quality Assurance Performance Improvement Meeting monthly times 3 months and then as needed, if concerns arise.