Failure to Administer Compression Therapy as Ordered
Penalty
Summary
The facility failed to ensure that Resident #55 received care in accordance with professional standards of practice. Resident #55, who was cognitively intact and had a medical condition causing swelling in the legs, did not consistently receive compression therapy as ordered by the physician. The physician's order, dated August 29, 2024, required the application of elastic compression bandages to both lower extremities daily in the morning and removal at bedtime. However, observations and interviews revealed that the resident often did not have the compression bandages applied, and there was no documentation or care plan addressing the resident's condition or the need for compression therapy. The Treatment Administration Record showed multiple instances where the compression bandages were not applied, with some instances attributed to the resident being asleep. Interviews with staff, including a CNA, LPN, and the Director of Nursing, highlighted a lack of communication and documentation regarding the application of the bandages. The Director of Nursing acknowledged that a blank box in the treatment record indicated missed documentation, and the treatment would be considered not completed. The failure to apply the compression bandages as prescribed was not communicated effectively between shifts, and there was no adjustment made to accommodate the resident's sleep schedule to ensure the therapy was administered.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective action for the affected residents: The comprehensive care plan was updated for resident #55. This included focus, goals, and interventions related to DM, CKD, and [MEDICAL CONDITION]. Compression therapy was applied per order. Identification of potentially affected residents: All residents with a significant [DIAGNOSES REDACTED]. All residents that have orders for compression therapy are at risk for not having application per order. The comprehensive care plan of all residents with the [DIAGNOSES REDACTED]. All residents with orders for compression therapy will be identified. The orders and treatment administration records will be reviewed for accuracy and completeness. All residents will be observed to ensure compression stockings are applied per order. Measures to prevent reoccurrence: Education will be provided to all licensed staff to ensure that the comprehensive care plan includes significant [DIAGNOSES REDACTED]. This will include a review of the facility policy, Care Planning (IDT). Education will be provided to all nursing staff regarding compression therapy. This will include a review of the following facilities policy, Compression Therapy. Emphasis will be placed on applying compression therapy per order and documenting completion in the treatment administration record. The nurse will ensure completion of application/removal of compression therapy or document reasons why care was not completed (resident non-adherence). Continued compliance: The facility staff will complete auditing of compliance for appropriate CCP and application of compression therapy. Auditing will be completed on 6 residents per week for 30 days and then 12 residents per month for appropriate comprehensive care plans. Ensuring the care plan includes the significant [DIAGNOSES REDACTED]. All residents that have compression therapy ordered will be audited monthly to ensure appropriate documentation in TAR and that they are being applied per order. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. DON is responsible for compliance.