Failure to Provide Required Assistive Devices
Penalty
Summary
The facility failed to provide adequate and appropriate health care for a resident who required assistance with wearing a left upper extremity extension and a resting splint. The resident, who had a history of a condition affecting his left non-dominant side, was observed multiple times without the necessary devices, which were supposed to be applied daily as part of his care plan. The resident expressed that he could not put the devices on himself and that a CNA who used to assist him no longer worked at the facility. Despite the resident's need and the care plan instructions, the devices were found in a drawer, unused for the past four months. The Unit Manager acknowledged that the responsibility for placing the devices on the resident lay with the nurses and CNAs, and there was a task section in the Electronic Health Record indicating the orders for the devices. However, there was no evidence provided to verify that the devices had been applied as documented. The Rehab Director and Occupational Therapist confirmed that the devices were necessary to prevent worsening of the resident's condition, highlighting the facility's failure to adhere to the resident's care plan and provide the required support services.
Plan Of Correction
1. The physician for resident #75 was notified on and new orders were given for a evaluation for a split program for management. Evaluation was completed on. New orders were given by for a management program on. 2. On an audit was completed by Director of Nursing/designee to ensure residents with a current management program have an appropriate and physician order. Evaluations and clarification orders were received as necessary. 3. From to education was provided to the licensed nurses and CNAs by the Director of Nursing/designee on following physician orders for programs and ensuring there is appropriate documentation in the resident's electronic health record, including documentation of resident refusals. 4. An audit will be completed by Director of Nursing/designee weekly for four weeks and then monthly for two months to ensure residents with a current management program have on appropriate according to physician orders. The results of the audits will be reported to the Quality Assessment, Assurance, and Compliance Committee monthly for three months or until the committee has determined substantial compliance has been met.