Failure to Obtain Physician Order for Cold Therapy Device Used in Pain Management
Penalty
Summary
The facility failed to ensure that pain management was properly provided to a resident who required it, specifically by not obtaining a physician's signed and dated order for the use of a cold therapy unit (ICTU) that was being used to manage the resident's knee pain. The resident, a female with a history of chronic left knee pain, osteoarthritis, and multiple other medical conditions, was admitted with ongoing pain and had been using the ICTU since admission. Despite the use of this device for pain control, there was no corresponding physician order documented in the resident's clinical record, nor was the use of the ICTU reflected in the care plan or active physician orders. Observations and interviews revealed that the resident had the ICTU in place on her knee, and staff were unclear about who was responsible for monitoring and maintaining the device. The medication aide stated that nurses and CNAs were responsible for the equipment, but deferred to the nurse for follow-up. The nurse on duty admitted to not checking the ICTU for ice water and was unsure who had ordered the device, suggesting it may have come from the hospital. The CNA reported not being responsible for the ICTU and was unfamiliar with its operation. The DON confirmed that nurses were responsible for obtaining and transcribing physician orders and that nurse managers should ensure all orders are accurate, but was unaware of who had ordered the ICTU or how long it had been in use. Facility policy required that all treatment orders specify the treatment, frequency, and duration, and that a current list of orders be maintained in the clinical record. The lack of a physician order for the ICTU, as well as the absence of documentation in the care plan, resulted in insufficient information regarding the resident's treatment and pain management regimen. This deficiency was identified through observation, interview, and record review, and was supported by the facility's own policies and product information for the cold therapy unit.