Failure to Follow Dental Pre-Op Instructions and Apply Ordered TED Hose
Penalty
Summary
The deficiency involves the facility’s failure to follow pre- and post-appointment instructions and to implement physician orders for compression (TED) hose. One resident with chronic obstructive sleep apnea, heart failure, and intact cognition had care plans indicating the need for coordinated dental services, including arranging dental care and following pre- and post-operative treatment changes. The resident’s record contained no evidence of a dental appointment on a specified November date or any pre- or post-operative orders for a dental surgery scheduled for a specified December date. A dental office staff member reported that the resident had a consult in early November where preoperative instructions were given to the resident’s daughter, but when the resident arrived for surgery in mid-December, she reported she had eaten and taken medications that morning contrary to the preoperative instructions, resulting in cancellation of the surgery. The DON confirmed the surgery was later completed in late December and acknowledged there was no documentation of the earlier appointment or scheduled surgery in the resident’s record, and that appointment information should be entered on the TAR and after-visit information obtained and followed. The deficiency also includes failure to apply TED hose as ordered for a resident with multiple cardiovascular and circulatory diagnoses, including acute on chronic combined systolic and diastolic heart failure, pulmonary hypertension, chronic venous hypertension with bilateral lower extremity ulcers, localized edema, and other conditions. This resident was cognitively intact and required assistance with several ADLs. A physician order directed that TED hose be applied to both legs every day shift for swelling and circulation. On multiple observations over two days, the resident was seen in bed and in a wheelchair without TED hose in place. During wound care, an LPN applied an ace wrap to the resident’s left shin instead of TED hose, and later confirmed that ace wraps, not TED hose, were being used and that the resident had never worn TED hose, despite the existing physician order. The February treatment administration record showed TED hose as signed off as applied on one of the observation dates by the same LPN. A third resident, admitted with diagnoses including localized edema, major depression, hypertension, and acute respiratory failure, and with intact cognition, also had a physician order for compression hose to both lower extremities to be applied in the morning and removed in the evening each day for edema. Observations on two consecutive days at multiple times showed that the ordered hose were not in place. During a concurrent interview, an LPN verified that the hose were not on as ordered. Review of the February treatment record revealed that on one of the observation dates, the hose had been documented as applied, despite repeated observations that they were not on the resident. The facility’s policy on physician and practitioner orders, last issued and reviewed on specified dates, states that a licensed nurse is responsible for completing care per physician orders. This deficiency was investigated under a specific complaint number.
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