Incorrect Physician Order for Tubigrip Application
Penalty
Summary
The facility failed to ensure professional standards of nursing practice were followed for a resident reviewed for quality of care. The resident, who was admitted with multiple diagnoses including peripheral vascular disease and a left leg, above-the-knee amputation, was at risk for adverse outcomes due to an incorrectly written physician order. The order, dated 11/19/24, incorrectly specified the application of a Tubigrip stocking to the resident's left lower extremity (LLE) for edema, despite the left leg having been amputated. Observations and documentation from 11/20/24 through 4/2/25 indicated that the Tubigrip had been applied to the LLE. On 4/2/25, both the Regional MDS Nurse and the Director of Nursing confirmed that the order should have been written for the right lower extremity (RLE).