Failure to Provide Appropriate Post-Operative Care and Staff Education for Cold Therapy Device
Penalty
Summary
The facility failed to provide appropriate treatment and services related to post-operative care for a resident who was admitted after a right shoulder joint replacement. The resident was prescribed the use of a cold therapy device (Breg Polar Care Cube) with specific instructions for application duration and the use of a barrier, but the physician's order did not include detailed directions on device operation or necessary safety precautions to prevent skin injury. The resident's comprehensive care plan did not address the use of the cold therapy device or the need for skin monitoring, and there was no timely development of a care plan or orders for monitoring skin health following admission. Staff interviews and documentation revealed that education on the use and care of the cold therapy device was inconsistent and incomplete. While some nurse aides received education from therapy staff, this training was not provided to all shifts, and there was no evidence that all relevant staff were competent in operating the device or monitoring for potential complications. The resident reported that the device frequently ran out of ice and expressed concerns that staff were not knowledgeable about its use. Observations confirmed that instructions posted in the resident's room did not include information on the cold therapy device. The facility's policy required staff to have appropriate competencies to ensure resident safety, but this was not met in the case of the cold therapy device. The Nursing Home Administrator confirmed that there was a delay in obtaining a physician's order for the device, a delay in care planning, a lack of staff education, and no established plan for monitoring the resident's skin condition. These failures resulted in the facility not providing appropriate treatment and services for the resident's post-operative care as required.