Failure to Provide Ordered Commode for Resident with Bilateral Amputations
Penalty
Summary
A deficiency occurred when the facility failed to provide a drop arm bedside commode for a resident with bilateral above-the-knee amputations, despite a physician's order and the resident's expressed preference. The resident, who was cognitively intact and independent in many activities of daily living, had diagnoses including traumatic amputations of both legs, long-term kidney disease, severe obesity, major depressive disorder, anxiety, and PTSD. The resident was at risk for pressure ulcers and had bladder and bowel incontinence, requiring the use of briefs and staff assistance for changing. The resident repeatedly requested a commode to increase independence and dignity, as using briefs was embarrassing and limited autonomy. The process for obtaining the commode was not followed appropriately. Although a handwritten physician's order for a heavy-duty bedside commode with a drop arm was written, it was not entered into the resident's electronic medical record or acted upon in a timely manner. The Director of Rehab provided the order and product information to the Administrator and Social Services Director (SSD), but the SSD delayed ordering the commode, citing being too busy and concerns about cost and delivery time. The SSD also cancelled an initial order due to a long delivery estimate and did not have documentation of the cancelled order. Multiple staff interviews confirmed that the resident's request for a commode was known, but there was no documented follow-up or timely action to fulfill the order. The facility did not have a policy regarding the process for ordering durable medical equipment or handling handwritten physician orders. Staff interviews revealed confusion about the process and responsibilities for ordering equipment. The lack of clear documentation, communication, and timely action resulted in the resident not receiving the commode as ordered, impacting the resident's independence and dignity.