Failure to Implement Care Plan Interventions and Physician Orders for Multiple Residents
Penalty
Summary
The deficiency involves failures to implement resident-centered care plan interventions and physician-ordered treatments for multiple residents. One resident with a history of falls and a need for assistance with personal care was care planned for one-person assistance with ambulation and transfers and for staff to monitor her position in bed and in her wheelchair for safety. While a CNA was assisting with dressing, the resident was left sitting on the edge of the bed while the CNA stepped away to the closet, during which time the resident stood and fell forward, striking her face on the floor. Following this fall, the interdisciplinary team determined that orthostatic blood pressures should be monitored, but the facility was unable to provide any documentation that orthostatic blood pressures were obtained. Another resident with muscle weakness, dementia, and protein-calorie malnutrition had a care plan and physician order directing that pressure-relieving boots be applied bilaterally when in bed and in a wheelchair, but he was repeatedly observed in common areas without the boots, which were seen on his bedside nightstand. An LPN stated the resident only wore the boots in bed, and the DON confirmed the resident should have had the boots on at all times. Additional deficiencies included failure to reassess an elevated blood pressure and to implement a physician-ordered splint. A resident with schizoaffective disorder, depression, and anxiety had a documented blood pressure of 171/104, with no record of a reassessment of the blood pressure or assessment for related symptoms on that date. The DON stated that nurses should have notified the provider and reassessed the resident but could not provide documentation that this occurred. Another resident with heart failure, dysphagia, and sleep apnea had a physician’s order for a carrot splint to the right hand with monitoring for skin alteration twice daily. Despite this order, the resident was observed multiple times with both hands closed in fists and no carrot splint applied. When staff assisted in opening the right hand, pressure marks from the fingertips were noted on the palm, and the DON confirmed that the carrot splint should have been in use as ordered.
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