Failure to Transcribe and Implement Provider Order for Compression Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive care plan, specifically related to an order for compression therapy for leg edema that was never entered or implemented. Resident #1, admitted for short-term rehabilitation with diagnoses including heart failure, heart disease, hypertension, coronary artery disease, atrial fibrillation, and cognitive impairment, had ongoing lower extremity edema documented in nursing progress notes. Notes showed repeated leg elevation and swelling observations, and an order for Lasix was obtained when the legs appeared more swollen than usual. However, there were no documented new orders for any type of compression therapy in the electronic medical record, physician orders, or Treatment Administration Record during the review period. A medical provider progress note by the Physician Assistant on 09/29/2025 documented that compression was ordered as an addition to the resident’s treatment, with the PA later clarifying they intended ace wraps and expected the order to be entered as soon as possible. At the time, providers could not enter their own orders into the facility’s EMR, and the PA did not communicate the compression order directly to nursing staff. Interviews with nursing staff and leadership revealed that Unit Managers or RN Supervisors were expected to receive, clarify, and enter new provider orders by the end of the day or within 24 hours, but the Unit Manager reported often not seeing new orders because providers did not give them directly and acknowledged not reviewing the provider’s note or being aware of the compression order. The DON and Administrator both stated that the order should have been entered and implemented, and the RN Supervisor confirmed that new orders were expected to be put in right away by the Unit Manager or RN Supervisor. As a result, the compression order documented by the PA was never transcribed into the EMR or carried out for Resident #1.
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