Failure to Maintain Current Orders and Timely Dressing Changes 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. The policy specified that central access device dressings must be changed every seven days or sooner if compromised, and that a current physician order should be maintained. However, review of the resident's records revealed there was no current physician order for the right upper access device following the resident's re-admission. Additionally, the dressing on the resident's right Opti Flow port double lumen was observed to be outdated, and documentation did not show that it had been changed or assessed as required. The resident involved had multiple diagnoses, including conditions affecting the right dominant side, type II diabetes, and hypertensive heart disease, and was noted to have severe cognitive impairment. Observations confirmed the outdated dressing, and interviews with nursing staff and the DON acknowledged that the dressing had not been changed or documented according to protocol. There was also a lack of documentation in the care plan and treatment records regarding the site status or condition of the skin under the dressing.
Plan Of Correction
1.) Resident #4's access change was completed per Physician's order. The Attending Physician was notified, the 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. F 694 F 694