Failure to Follow Professional Standards in Weight Monitoring, Catheter Care, and Medication Administration
Penalty
Summary
The facility failed to follow professional standards of care for three residents with significant medical needs. For two residents with congestive heart failure, daily weight monitoring was ordered with instructions to notify the physician if there was a weight change of three pounds or more in one day. Despite multiple instances where these weight changes occurred, there was no documented evidence that the physician was notified as required. Both the Director of Nursing (DON) and a licensed nurse confirmed that the physician should have been informed, and acknowledged the lack of documentation and communication regarding these significant weight fluctuations. For another resident with a midline catheter, the facility did not document required measurements of arm circumference and catheter length during dressing changes as ordered by the physician. The nurse responsible for the dressing change confirmed that the measurements were not recorded at the time of the procedure, and instead were entered several days later as late charting. The DON verified that the expectation was for these measurements to be documented at the time of the dressing change to allow for comparison and monitoring of the catheter site. Additionally, the same resident had a physician order for Midodrine to be held if systolic blood pressure (SBP) exceeded 130 mmHg. The medication was administered multiple times when the SBP was above this threshold, contrary to the order. Furthermore, the medication administration record (MAR) was altered after the fact to change the documentation from 'administered' to 'hold' for doses that should not have been given. The nurse involved admitted to initially documenting incorrectly and then backdating the correction, and the DON confirmed instructing the nurse to fix the charting. Facility policies require accurate, timely, and objective documentation, and prohibit erasures or deletions in the medical record.