Failure to Follow Compression Wrap Orders and Lack of Biliary Drain Orders
Penalty
Summary
Surveyors found that one resident with vascular dementia, congestive heart failure, and bilateral lower extremity edema did not receive ordered compression treatment. Observation on multiple occasions showed the resident seated in a wheelchair and later in a chair in her room without tubi grips on either leg, despite a physician’s order dated 2/12/26 directing tubi grips to be applied every morning and removed at bedtime for bilateral lower extremity edema. The resident’s care plan, dated 2/13/26, included tubi grips as an intervention for edema, and the MDS indicated she was cognitively impaired and required partial to moderate assistance with dressing. The March 2026 TAR, however, showed the tubi grips as signed out as applied on the days they were observed not to be in use. Surveyors also identified a failure to obtain and implement physician’s orders for a biliary drain for another resident. This resident, who had diagnoses including cholecystitis and a UTI and had been readmitted from the hospital on 3/13/26, was observed lying in bed with a biliary drain on the mattress next to her. Record review showed no physician’s orders for the biliary drain or for care of the drain, despite the presence of the device. The resident’s significant change MDS indicated severe cognitive impairment and dependence for toileting, bed mobility, and eating, yet there was no documented medical direction for management or monitoring of the biliary drain.
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