Failure to Follow Physician Orders for Edema Management
Penalty
Summary
The facility failed to follow physician orders for edema treatment for two residents with mobility issues. Observations revealed that both residents consistently exhibited swelling in their lower legs and feet, yet were not wearing the prescribed elastic bandages or compression stockings. Additionally, interventions such as leg elevation were not implemented as directed in their care plans. Despite these omissions, staff documented in the Treatment Administration Records that the interventions had been performed on the relevant dates. Interviews with staff confirmed that the prescribed treatments were not consistently applied, and some staff indicated that only certain nurses would perform these tasks. Review of the residents' care plans and treatment records showed clear orders for the use of compression wraps and leg elevation to manage edema. However, these interventions were not observed during multiple surveyor visits, and staff documentation did not accurately reflect the care provided. Weekly skin check assessments also failed to note the presence of edema, despite visible swelling. The lack of adherence to physician orders and inaccurate documentation contributed to the identified deficiency.