Failure to Accurately Document Vital Signs, Medication Administration, and Catheter Care
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, specifically regarding documentation of vital signs, medication administration, and indwelling catheter care. For one resident, review of the Medication Administration Record (MAR) revealed repeated documentation of identical vital signs across multiple shifts and days, as well as missing entries for required vital sign monitoring on several shifts. Additionally, the MAR did not include blood pressure readings at the time of administration for a medication that required withholding if systolic blood pressure exceeded a certain threshold, and there were missed medication administration times. For another resident, documentation inconsistencies were found related to the presence and care of a Foley catheter. Although the resident's catheter was removed and not reinserted per physician orders, nursing staff continued to document catheter care and the use of a privacy bag for a drainage bag for several days after the catheter had been discontinued. This was despite multiple clinical notes indicating the resident no longer had a catheter and was incontinent of urine. Facility policy required that all documentation in the medical record be factual, objective, accurate, and complete, reflecting the actual experiences and care provided to the resident. However, staff documented care and observations that did not occur, including false entries for catheter care and vital signs, which was confirmed by the Director of Nursing, who acknowledged that such documentation was incorrect.