Failure to Provide Necessary Adaptive Devices for Residents
Penalty
Summary
The facility failed to ensure that residents with limited range of motion and mobility were provided with the necessary services, care, and equipment to maintain or improve their function. This deficiency was observed in three residents. Resident #22, who had a history of hip replacement, was not provided with an abductor wedge as per physician's orders. Despite multiple observations over several days, the resident was seen without the wedge while sitting in a wheelchair or participating in therapy. Interviews with staff revealed a lack of awareness and documentation regarding the use of the abductor wedge, indicating a failure in communication and adherence to the care plan. Similarly, Resident #92, who required heel protectors and a Lumbar Sacral Orthosis brace, was observed without these devices on multiple occasions. The resident was dependent on staff for assistance, yet the devices were not applied as ordered. Interviews with the CNA and LPN revealed a lack of awareness and responsibility for ensuring the resident used the prescribed adaptive devices. The Director of Nursing expressed surprise at the oversight, highlighting a gap in monitoring and execution of physician orders and care plans.
Plan Of Correction
Plan of Correction: Approved April 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Action a. Resident #22 was evaluated by Director of Rehabilitation. b. Director of Rehabilitation in-serviced CNA’s on unit about the need to use abductor wedge. c. Director of Rehabilitation confirmed with Ortho to discontinue the abductor wedge. Care plan updated to reflect. d. DON reviewed Resident #92 care plan and confirmed physician orders [REDACTED]. e. Resident #92 counseled about the importance of wearing TLSO brace and heel protectors. II. Identification a. All residents with assistive devices audited to ensure accuracy with physician orders [REDACTED]. No negative findings. III. Systemic Changes a. Administrator, DON, Director of Rehabilitation reviewed Adaptive/Assistive Devices Policy on 3/7/35 and found it to be compliant. b. Director of Rehabilitation in-serviced all Rehab, nursing and CNA staff members on use of devices for resident safety. IV. Monitoring a. Director of Rehabilitation developed an audit tool to ensure devices ordered for residents are being used. b. Director of Rehabilitation/designee will observe 5 residents with devices at random weekly to ensure proper device compliance. c. Audit will be conducted Weekly x 4, Monthly x 3, Quarterly x 2. d. Any negative audit findings will be presented to Administrator and immediately corrected. All audit findings will be presented to the QA committee quarterly by the Director of Rehabilitation. V. Responsibility a. The Director of Rehabilitation will be responsible to ensure correction of this deficiency.