Failure to Follow Physician Orders for Hearing Aids
Penalty
Summary
The facility failed to follow physician orders for a resident who required an assistive hearing device. Observations and interviews revealed that the resident was not provided with her hearing aids when she was assisted out of bed, despite having a physician's order to wear them during the day. The resident expressed difficulty hearing because the staff did not put in her hearing aids as required. Interviews with staff members, including a CNA and an RN, indicated a lack of adherence to the physician's order. The CNA admitted to not putting in the resident's hearing aids, while the RN assumed the CNA had done so without verifying. The Director of Nurses stated that nurses are expected to ensure orders are completed before signing off on treatment records, which was not done in this case.
Plan Of Correction
On the were provided to resident #16 and placed in her. On for resident #16, the Director of Nursing (DON) completed a Medication error Reporting Form. On, all other resident records were checked; there were no other residents with a physician ordered assistive device for hearing. On the Director of Nursing/designee provided education to the direct care nurse for resident #16 on adherence and documentation related to physician ordered assistive devices for hearing. On, the Director of Nursing/designee provided education to the other nurses on adherence and documentation related to physician ordered assistive devices for hearing. The education was completed by. The Director of Nursing/designee will complete 3 audits each week for 12 weeks to ensure physician ordered assistive devices for hearing are placed in the resident's prior to the nurse signing the administration record. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.