F0684

D

Failure to Implement Physician Orders for Skin Protection and CHF Weight Monitoring

Palmyra, Pennsylvania Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement physician orders and provide treatment and care according to residents’ clinical needs and documented orders. For one resident with anoxic brain damage, respiratory failure with hypoxia, a persistent vegetative state, and contractures, the physician ordered Derma Savers (skin protectors) to be applied to the right hand and right leg as tolerated. The MDS indicated this resident was cognitively impaired and dependent on staff for dressing. On multiple observations over two days, the resident was seen in a reclining chair and in bed without the ordered Derma Savers on the right hand or right lower extremity. Clinical record review and staff interview confirmed there was no documented evidence that the Derma Savers were applied as ordered.

The facility also failed to follow physician orders for another resident with diabetes mellitus, congestive heart failure, and major depressive disorder. The care plan included an intervention to report changes to the provider as necessary, and a physician’s order directed staff to weigh the resident daily and call the cardiologist if the resident gained more than 2 lbs overnight or 5 lbs in one week. Clinical records showed multiple instances of weight gains exceeding these thresholds, including a 2.6 lb gain from one day to the next, a 4.2 lb gain from one day to the next, and a 6.2 lb gain over several days. There was no documented evidence that the resident was weighed daily as ordered on specific dates, and no documentation that the cardiologist was notified of the weight changes. The Regional Clinical Director confirmed the lack of documentation for both the application of Derma Savers and the required daily weights and cardiologist notification.