Failure to Consistently Apply Physician-Ordered Therapeutic Devices
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not ensuring the consistent application of physician-ordered therapeutic devices and preventative measures for a resident. The resident, who was admitted with diagnoses including Bullous Pemphigoid, congestive heart failure, and stage 4 chronic kidney disease, had active physician orders for Geri-sleeves to be applied to both upper extremities every shift and ace wraps to be applied to the lower extremities in the morning and removed in the evening. Review of the care plan revealed that it did not address the order for Geri-sleeves, and thus did not reflect all current interventions related to skin integrity and injury prevention. During observation, the resident was found not wearing the ordered Geri-sleeves or ace wraps. The resident reported that staff did not consistently apply these devices, estimating it was a 50/50 chance they would be put on. The DON confirmed that staff had not consistently followed the physician's orders for application of the Geri-sleeves and ace wraps for this resident.