Failure to Incorporate Provider Orders for Aquathermia Pad in Care Plan
Penalty
Summary
The facility failed to incorporate provider orders and indications for use of an aquathermia heating therapy pad (aqua-K pad) into the care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, depression, anxiety, varicose veins, and peripheral vascular disease. Review of the resident's electronic medical record revealed no provider order for the use of the aqua-K pad for back pain. During interviews, nursing staff confirmed the resident was using the aqua-K pad, but there was uncertainty regarding the duration of use, temperature settings, and whether continuous use was appropriate. The device was found set to 100 degrees on continuous mode with an empty water reservoir, and staff acknowledged there was no order or clear directions for its use. The director of nursing (DON) and assistant director of nursing (ADON) stated that provider orders should specify temperature, frequency, and duration of use, but confirmed that the order did not transfer during a switch between electronic medical record systems. As a result, staff lacked necessary instructions for the safe and appropriate use of the aqua-K pad. The facility's policy required a provider order specifying duration and frequency for aquathermia pad use, but this was not followed, and the information was not included in the resident's care plan.