Failure to Follow Post-Surgical Physician Orders for Ice Pack Application
Penalty
Summary
The facility failed to follow physician orders for post-operative care for a resident who was admitted after a left total knee replacement. The resident's hospital After Visit Summary (AVS) included an order for ice packs to be applied to the operative leg several times a day, with specific instructions for duration and frequency to decrease pain and swelling. Upon review, it was found that the Treatment Administration Record (TAR) only documented the application of an ice pack once, despite the order requiring multiple applications daily. The resident and their representative reported that no ice packs had been applied since admission, and this was confirmed through interviews and record review. The LPN responsible for the admission did not recall seeing the ice pack order and stated that if it was not in the computer system, it was not on the AVS. The DON was notified by the resident's daughter about the missed treatment and, upon review, confirmed the omission. The failure to implement and document the ordered ice pack therapy occurred from the time of admission until the issue was brought to the attention of facility administration, resulting in the resident not receiving the prescribed post-surgical care as ordered.