Failure to Follow Physician Orders for Aspira Catheter Care
Penalty
Summary
The facility failed to ensure that physician-ordered interventions and treatments for a resident with an Aspira catheter were carried out according to professional standards and the care plan. Physician orders specified that only RN staff were to drain the Aspira catheter every other day on day shift, not to exceed 1000 ml per session, and to document the output, color, and character of the drainage. Additionally, only RN staff were to change the catheter dressing every other day and the connecting valve weekly. However, clinical record review revealed multiple dates where there was no documentation that RN staff performed these tasks. Instead, LPN staff documented completion of the catheter drainage and dressing changes on several occasions, contrary to the physician's orders. Further review showed that only RN staff received education on the management of Aspira catheters, with no documentation of similar education for LPN staff. The lack of proper documentation and adherence to physician orders was confirmed during an interview with the Director of Nursing. These findings indicate that the facility did not provide care in accordance with the prescribed orders and professional standards for the resident with the Aspira catheter.
Plan Of Correction
1. Resident 67 has discharged from the facility. 2. An audit of the last 14 days was completed of any other Aspira Catheter Drains or chest tubes in the facility, and it was confirmed that LPNs were not providing valve changes or dressing changes. 3. All LPN staff will be educated, and competency will be completed related to Chest Tubes and Chest Tube Management. All licensed staff will be educated on proper documentation in the electronic medical record. 4. Audits will be conducted by the DON/Designee of any resident with a chest tube to ensure all physician orders related to the same are being followed for dressing changes and documentation. These audits will occur four times a week daily, weekly for four weeks, and monthly for two months. Results of the audits will be presented at the QAPI committee to ensure ongoing compliance.