Failure to Document and Follow Physician Orders for Abdominal Girth Measurement
Penalty
Summary
The facility failed to ensure that physician-ordered daily abdominal girth measurements were properly completed and documented for a resident with a history of liver abscess and stage three chronic kidney disease. Although there was a standing order for daily abdominal girth measurement, documentation in the nurse progress notes showed inconsistent recording of measurement values, with several days missing entries between documented measurements. The Treatment Administration Record (TAR) only contained staff initials and checkmarks indicating completion, but did not include the actual measurement values. Staff reported that the system did not provide a field for entering the measurement value on the TAR unless it was manually added, and this was not routinely done prior to the survey. Interviews with staff revealed confusion regarding the parameters for when to notify the physician about changes in abdominal girth, as the order did not specify thresholds for notification. The LPN stated that they measured the resident's abdomen daily but did not have a value to compare the measurements to, and the DON acknowledged that without daily documentation of the measurement values, staff would not be able to identify increases in girth size. The resident confirmed that staff were monitoring their abdomen due to previous liver issues, but the lack of consistent documentation and clear parameters led to a failure in following the physician's order as intended.