Failure to Clarify and Document Vascular Surgeon’s Leg Wrap Order
Penalty
Summary
The deficiency involves the facility’s failure to clarify, confirm, and document a physician’s order for leg wraps following a vascular surgery consultation, and to provide treatment in accordance with that order and the resident’s preferences. The facility’s own policy on physician orders requires unclear written orders to be clarified with the physician, documented as a clarification order in the medical record, and reviewed for accuracy. Resident #2, who was cognitively intact with a BIMS score of 15 and had diagnoses including chronic venous hypertension of both lower extremities and chronic embolism and thrombosis of a right lower extremity vein, had a documented appointment with a vascular surgeon. After this visit, there was no corresponding physician order entered into the electronic medical record (PCC) for the leg wraps allegedly ordered by the vascular surgeon. During interview, the RN Unit Manager acknowledged that there was a paper “leg wrap” order from the vascular surgeon but could not explain why it was not entered into PCC, nor could she provide details on the specific type, size, compression level, or application/removal times for the leg wraps. She also confirmed she did not call the physician to clarify the order and did not document the order in nursing progress notes or under electronic physician orders, despite stating that nurses are responsible for clarifying unclear orders. The resident reported that staff continued to use the same kerlix wraps ordered by a facility physician the prior year, rather than the compression wraps ordered by the vascular surgeon, and that staff did not listen when he tried to discuss the new order. He stated he refused the kerlix wraps because they were not the specific compression wraps ordered at the vascular surgery visit. No updated leg wrap order from the vascular surgeon visit was found in the record, and the next documented order pertained only to a follow-up outpatient rehab appointment.
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