Failure to Follow Physician's Orders and Provide Timely Incontinent Care
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate care for two residents. One resident, who had a physician's order for daily use of TED hose due to vascular insufficiency and hematoma, was observed with red, swollen legs and was not wearing the prescribed compression stockings. The resident reported not having worn TED hose for two weeks because their pair was destroyed in the washing machine. Agency staff assigned to the resident were unaware of the order, having relied on verbal handoff rather than reviewing the resident's care plan or Kardex. The Director of Nursing confirmed there was no policy in place regarding adherence to physician's orders. Another resident, with diagnoses including anxiety disorder, depression, schizophrenia, and hemiparesis, and who was consistently incontinent of bowel and bladder, did not receive timely incontinent care. The resident and their family reported extended waits for assistance, including an incident where the resident waited up to three hours for care after returning from church. Staff interviews revealed that delays were due to the need for two staff members to assist with mechanical lifts and a practice of waiting for the assigned CNA rather than seeking help from available staff. The LPN involved acknowledged instructing the resident to wait for care due to being busy and the assigned CNA being unavailable. The facility's care plans for both residents included interventions to anticipate and meet care needs, maintain cleanliness, and ensure comfort. However, staff failed to follow these plans, resulting in unmet care needs and non-compliance with physician's orders. The facility's No Pass Zone policy, which required all staff to respond to call lights, was not effectively implemented, contributing to the deficiencies observed.