Failure to Revise Care Plan and Accurately Implement TED Hose Orders
Penalty
Summary
The deficiency involves the facility’s failure to revise and implement a comprehensive care plan to include the ordered use of TED hose for one cognitively intact resident with diagnoses including pulmonary edema, irregular heart rate, and muscle weakness. Facility policies required goals and objectives to be reviewed and/or revised upon readmission and for the care plan to specify services needed to attain or maintain the resident’s highest practicable well-being. The resident was originally admitted and later readmitted with physician orders dated 3/6/24 and 2/8/26 directing that CNAs apply below-the-knee TED hose on in the morning and off in the evening. However, during review of the resident’s care plan dated 11/17/26, the DON confirmed that the application of TED hose had been resolved on a previous care plan and was not included on the current care plan, despite the ongoing physician orders. Surveyor observations and interviews showed that the TED hose were not being consistently applied as ordered and that documentation was inaccurate. On one observation, the resident stated she was supposed to have TED hose on every morning when getting out of bed, but CNA 1, who had been working with the resident for two months, reported not knowing the resident was supposed to receive TED hose in the mornings. On another day, the resident again reported that TED hose were not applied that morning. Review of the MAR for February 2026 showed that LNs 1 and 2 documented that TED hose were applied when they were not; LN 1 admitted charting that the TED hose were on when they were not, and LN 2 stated she assumed the CNA had put them on without actually seeing them on the resident. The DON confirmed that the TED hose were not applied despite MAR entries indicating otherwise, and the MAR also documented that the resident had pitting edema in her legs for 11 out of 17 days in February.
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