Failure to Follow Physician Orders for Immobilizer Sling and Supplemental Oxygen
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for a resident admitted with a right humerus fracture and shoulder dislocation. Physician orders were in place for the resident to have a non-weight bearing right upper extremity, use an immobilizer sling on the shoulder, and receive continuous supplemental oxygen at 2L/min via nasal cannula. Despite these orders, observations revealed that the resident was not wearing the immobilizer sling as ordered, with her wrist out of the immobilizer, and was not receiving supplemental oxygen. The resident reported feeling unwell and in pain, and stated that the immobilizer was not effective and that she had only used oxygen a few times. Record reviews showed that licensed nurses had been signing off on the administration of both the immobilizer sling and oxygen orders, even though these interventions were not being provided as ordered. Interviews with nursing staff confirmed that the oxygen order should have been updated and that the immobilizer was not being used as directed. The physical therapist and assistant director of nursing also confirmed the lack of compliance with the physician's orders. Facility policy required that supplies and medications needed to carry out physician orders be provided, but this was not followed in this case.