Failure to Adhere to Physician Orders for Care and Suctioning
Penalty
Summary
The facility failed to properly administer care and suctioning for two residents, as evidenced by the lack of proper physician orders and adherence to prescribed orders. For one resident, the facility did not have a clear physician order specifying the liters per minute (LPM) or the type of device to be used for continuous care. Observations revealed that the resident's device was set at 4.5 LPM, while the resident mentioned using 4 LPM at home and 5 LPM at the facility due to increased activity. The Unit Manager was unaware of the missing details in the order and only realized the discrepancy upon review. For another resident, the facility failed to follow the prescribed physician order for care, which was set at 2 liters via as needed for exertion. Observations showed the resident receiving 4 liters continuously, contrary to the order. A Licensed Practical Nurse confirmed the order was for 2 liters but did not ensure compliance, as the resident was observed receiving 4 liters during multiple checks. These deficiencies highlight a lack of adherence to physician orders and proper administration of care and suctioning for the residents involved.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.2.25 resident #54 and #302 were assessed by licensed nurse, no concerns identified. On 4.2.25 physician orders reviewed for resident #354 and #302 to ensure administered per physician orders and monitoring in place, any concern identified were corrected. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.14.25 a quality review was completed by Director of Nursing/designee on current residents with in place to ensure physician orders being followed and is administered properly. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.22.25 Director of Nursing completed education with current licensed nursing staff on the components of F695 / suctioning with emphasis on residents with in place to ensure physician orders being followed and is administered properly by the Director of Nursing/designee. Newly hired licensed nursing staff will be educated on the components of F695 / suctioning with emphasis on residents with in place to ensure physician orders being followed and is administered properly by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct audits of 5 residents with twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure in place to ensure physician orders being followed and is administered properly. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.