Failure to Follow Physician Orders for Restricted Limb Precautions
Penalty
Summary
The facility failed to follow physician's orders regarding restricted limb precautions for three residents. For one resident with a physician's order not to take blood pressure (B/P) on the left arm due to a dialysis fistula, documentation showed that B/P was repeatedly taken on the restricted limb on numerous occasions over several months. Another resident had a physician's order not to take B/P on the right arm every shift, but records indicated that B/P was taken on the right arm multiple times after the order was in place. In both cases, the Director of Nursing (DON) confirmed that the physician's orders were not followed. A third resident's record did not contain a physician's order regarding restricted limb precautions, yet documentation showed that B/P was taken on a restricted limb on several occasions. The DON confirmed that there was no physician's order in place for this resident regarding restricted limb precautions. These findings were based on record reviews and staff interviews during the survey process.