Failure to Accurately Assess and Document Resident Vital Signs
Penalty
Summary
The facility failed to ensure that each resident received an accurate assessment reflective of their status at the time of assessment, as required by physician orders for COVID-19 prevention. Specifically, for all 10 sampled residents, vital signs were not monitored and recorded as prescribed. Instead, duplicate vital sign entries were documented across multiple shifts and dates, with identical values being recorded hours apart, which is not clinically plausible. This was observed in the Medication Administration Records (MARs) and confirmed through review of physician orders that required vital sign monitoring every shift or every four hours for COVID-19 precautions. Interviews with multiple licensed nurses revealed that the 'insert previous vitals' option in the electronic MAR system was used to duplicate vital sign entries, rather than obtaining and recording new measurements as ordered. Several nurses admitted to using this function due to high workload and time constraints, acknowledging that this resulted in inaccurate documentation. Some nurses recognized that this practice could be considered falsification of medical records and was not in compliance with physician orders. The Director of Nursing and other staff also acknowledged that it is not possible for vital signs to remain exactly the same over multiple hours, and that such duplication should not occur. The review of facility policy indicated that vital signs are to be taken and recorded according to the resident's condition and physician orders. Despite this, the MARs for all sampled residents showed repeated instances of duplicate entries, with some nurses stating they did not review previous vital signs before documenting, and others expressing discomfort or lack of recall regarding the practice. The deficiency was identified through record review and staff interviews, which confirmed that the required assessments were not performed as ordered, and inaccurate information was entered into the residents' medical records.