Failure to Maintain Accurate Medical Records for Vital Signs and Weight Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies related to documentation of vital signs and weight monitoring. For one resident with a history of stroke and hypertension, there was a physician order for hydralazine with specific parameters to hold the medication if the systolic blood pressure was less than 100, diastolic less than 50, or heart rate less than 60. Although the medication was administered and blood pressure readings were documented, there was no documentation of the resident's pulse or heart rate prior to administration, as required by the order. Multiple nurses confirmed that while they did check the pulse before giving the medication, the electronic Medication Administration Record (eMAR) did not require or provide a field to record the pulse, and this omission was due to an error in the transcription of the order by the DON. Another resident with diagnoses including congestive heart failure and chronic kidney disease had a physician's order for daily weights. Review of the Medication Administration Record revealed that the same weight was repeatedly documented over several days, and in some cases, the weight was not updated for over a week. During an interview, a nurse admitted to copying the previous weight from the record rather than obtaining and recording an actual daily weight, citing uncertainty about the method used by the Restorative Aide to obtain the weight. The nurse acknowledged that she had not obtained or documented accurate weights for the resident. Interviews with the DON, Administrator, and Nurse Practitioner confirmed that the expectations were for accurate and complete documentation of vital signs and weights as per physician orders. The lack of required documentation for the pulse prior to medication administration and the failure to obtain and record daily weights as ordered led to incomplete and inaccurate medical records for both residents.