Failure to Maintain Current Physician Order and Timely Dressing Change for Access Device
Penalty
Summary
The facility failed to obtain a current physician order and did not change the dressing on a resident's right upper access device as required by policy and physician orders. Review of the facility's policy indicated that central access device dressings must be changed every seven days or sooner if compromised, and that a sterile dressing must be maintained. However, for one resident, there was no current physician order for the right upper access device following re-admission, and the dressing was not changed or documented as changed for an extended period. The last documented order for the dressing change had been discontinued, and there was no updated order upon the resident's re-admission. Observations revealed that the dressing on the resident's right Opti Flow port double lumen was outdated, and staff confirmed it had not been changed as required. Documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR) was inconsistent or missing regarding dressing changes, and there was no nursing progress note describing the site status or skin condition under the outdated dressing. The DON acknowledged that the dressing should have been changed and a current physician order should have been in place, as per protocol.
Plan Of Correction
1.) Resident #4's access change was completed per Physician's order. The Attending Physician was notified, care plan was added, and an assessment was completed by RN Unit Manager, with no negative effects noted. 2.) Full house audit of residents with access site and skin checks were completed by the Director of Nursing/Designee and no other concerns identified. 3.) Licensed Nurses educated by Director of Nursing/Designee on providing adequate care and services in accordance with accepted professional standards to include following Physicians' orders, changing of access, and the components of regulation F694/N201. 4.) Director of Nursing/Designee will conduct random audits to ensure access are changed per physician's order twice weekly for four weeks, then weekly for four weeks then monthly for three months to ensure compliance. Findings of audits to be reported through the monthly Quality Assessment, Assurance and Compliance Committee meeting for three months for comments and recommendations.