Failure to Follow Physician Orders for Safety Equipment and Oxygen Administration
Penalty
Summary
The facility failed to adhere to physician orders for two residents who required floor mats for safety. Resident #25 was observed in bed with only one floor mat on the left side, despite having a physician's order for two floor mats to be placed on each side of the bed. The RN Supervisor confirmed the need for two mats but was unable to locate the second mat in the room. A CNA assigned to Resident #25 acknowledged that the resident usually only had one mat in place, which contradicts the physician's order. This oversight is significant given Resident #25's history of being found on the floor, indicating a potential risk of falls. Similarly, Resident #52 was observed with one floor mat in place on the right side of the bed, while the other mat was folded and leaning against the nightstand. This setup did not comply with the physician's order for floor mats to be used when the resident is in bed. The CNA present during the observation did not provide an explanation for the improper placement of the floor mats, which could compromise the resident's safety, especially considering their severe dependency for Activities of Daily Living (ADL). Additionally, the facility did not follow the physician's order for Resident #95, who was receiving hospice care and required humidified oxygen at a continuous rate of 2.0 liters per minute. Instead, the oxygen was observed to be administered at 1.25 liters per minute. The Director of Nursing confirmed that the oxygen should be delivered at the prescribed rate, whether continuous or as needed. This discrepancy in oxygen administration could have implications for the resident's health, given their severe dependency on ADLs and altered mental status.
Plan Of Correction
Immediate Action: Resident sample # 25- care plan was reviewed and revised to include implementation of floor mats per physician orders by the MDS Nurse. Resident sample # 52 floor mat was placed as per physician orders. The Nurse and CNA were educated by the Nurse Manager on expectation of following physician orders and/or implementing the identified appropriate care plan interventions for floor mats. Resident sample #95 The was increased from 1.25 liters per minute to 2 Liters per minute as per physician orders. saturation was checked and was reported to the Hospice team. The Nurse was educated by the Nurse Manager on expectation of following physician orders and/or implementing the identified appropriate care plan interventions for use. Identification of Residents with potential to be affected: All residents in the facility have the potential to be affected. Interdisciplinary review and verification of care plan interventions and orders for floor mats and use. System Changes: The facility Prevention Policy and Medication Administration Policy were reviewed for accuracy. Nurses and CNAs were educated and trained on the Falling Star Program and use of floor mats and resident use as indicated in the physician orders by the Director of Nursing and Risk Manager. Licensed nursing staff are to verify and document in the Treatment Administration Record the use of floor mats and orders for use every shift. Licensed nursing staff were educated by the Director of Nursing and the Assistant Director of Nursing on medication administration with emphasis on right dosage for use. Monitoring: Surveillance Rounds by Nurse Manager/designee to audit for compliance the residents with orders for floor mats and residents with use 3x a week for 90 days. The results of the rounds will be reported to the monthly Quality Assurance Performance Improvement Committee. Responsible Party: Unit Managers, Supervisor, Risk Manager, ADON and DON.