Failure to Follow Physician Orders for Compression Stockings and Weekly Skin Checks
Penalty
Summary
The facility failed to ensure that physician's orders were followed for two residents. One resident, admitted with diabetes with polyneuropathy, edema, and weakness, had a physician's order for bilateral knee-length compression stockings to be applied in the morning for edema. Multiple observations over two days showed the resident out of bed and in bed without the prescribed compression stockings. The DON stated she was unaware of the order and expected all physician orders to be followed as written. Another resident, admitted with hemiplegia, hemiparesis, and an anoxic brain injury, had a physician's order for weekly skin assessments due to high risk for skin breakdown and a history of pressure ulcers. Review of the medical record revealed that nine weekly skin checks were omitted over a three-month period, and the two most recent checks lacked documentation describing the wound. Interviews with nursing staff and the DON confirmed that weekly skin checks should be completed and documented, including full assessment of the skin and wounds.