Failure to Follow Physician Orders for Splints and Orthoses
Penalty
Summary
Surveyors determined that the facility failed to follow physician orders for four out of five residents reviewed. Residents with diagnoses such as heart failure, hemiplegia, multiple sclerosis, and seizure disorder had active physician orders and care plans specifying the use of various splints, protective sleeves, gloves, and orthoses to be worn daily during the day shift as tolerated. However, during observations, these residents were found in their rooms without the prescribed devices in place. Despite this, documentation in the treatment administration records (TARs) by LPNs indicated that the devices had been applied as ordered. Interviews with therapy staff revealed concerns that splints and braces were often not applied unless therapy staff intervened. The Nursing Home Administrator confirmed that the facility did not follow physician orders for these residents. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(3)(5) for nursing services.