Failure to Implement Physician Orders for Residents
Penalty
Summary
The facility failed to implement physicians' orders for four residents, leading to deficiencies in care. Resident 5, diagnosed with hemiplegia, hemiparesis, and multiple sclerosis, was observed multiple times without the prescribed Prevalon boots, which were ordered to prevent skin breakdown. The Assistant Director of Nursing confirmed the boots were not in place as required. Resident 21, with diagnoses including edema and reduced mobility, was not provided with Ace wraps on her lower extremities as ordered by the physician. The resident confirmed she was not asked about the application of the wraps, and the Assistant Director of Nursing acknowledged the failure to apply them. For Resident 33, who had hypertension, the facility staff administered blood pressure medication without documenting the required blood pressure assessments prior to administration, as per the physician's order. Similarly, Resident 56, also diagnosed with hypertension, received medication outside the prescribed blood pressure parameters. The Assistant Director of Nursing confirmed the lack of documentation for blood pressure checks and the administration of medication outside the established parameters for these residents.
Plan Of Correction
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. 1. Resident # 33 physician orders were clarified on 3/14/2025. Resident # 56 physician orders were clarified on 3/14/2025. Resident # 5 Prevalon boot applied and now in place on 3/14/2025 and Resident # 21 physician ordered ace-wraps are being applied per the physician order. 2. To identify like residents, an audit conducted by DON/designee for residents with parameters to ensure physician orders being followed. Residents with orders for Prevalon boots reviewed to ensure physician orders being followed. Residents with orders for ace wraps audited to ensure ace wraps being applied per the physician orders. 3. To prevent this from happening again, the DON/designee educated nursing staff on implementation of physician ordered Prevalon boots, ace wraps, and medications with parameters. The education will be completed by 4/8/2025. 4. To monitor and maintain ongoing compliance, the DON/designee will conduct an audit of 5 residents daily to ensure physician orders being followed for 4 weeks, then monthly for 2 months to ensure professional standard of practice and timely follow-up. Results of audits will be submitted to the QAPI committee for further review and recommendation. Allegation of Compliance date: 4/8/2025