Failure to Follow Physician Orders for Ace Wrap Application
Penalty
Summary
The facility failed to implement and follow physician orders for the application of an ace wrap to a resident's lower extremities. The resident, who had a diagnosis of heart failure and demonstrated intact cognition, had a physician order for an ace wrap to be applied in the morning and removed in the evening. Review of the Medication Administration Records for three months showed no documentation that the ace wrap or compression stockings were applied as ordered. During observation, the resident was seen without the ace wrap or compression stockings, only wearing socks and shoes. When questioned, the resident reported that the ace wrap was applied once but caused significant discomfort, leading to its removal. Staff interviews revealed confusion regarding the documentation and implementation of the order. A registered nurse was unable to locate the task in the computer system, and the DON was uncertain where completion of the task would be documented, despite confirming the order existed. The ADON was eventually able to show where aides documented the application and removal of the ace wrap, indicating a lack of consistent process and oversight in ensuring physician orders were followed and properly documented.