Failure to Meet Professional Standards in Weight Monitoring, Medication Documentation, Hospice Recommendations, and Change of Status Monitoring
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in several areas. For one resident with congestive heart failure, there was a physician order for daily weights to monitor for fluid retention, with instructions to report significant weight changes to the provider. However, the resident's weight record showed that weights were only recorded on two occasions over a two-week period, with multiple days missing. Staff acknowledged that weights were not consistently obtained and that there was no documentation of provider notification when weights could not be taken, as required by the order. Additionally, the same resident had an order for Trazodone with instructions to monitor and document side effects every shift. Staff documented positive side effects on several dates but failed to write corresponding progress notes as required. The Resident Care Manager confirmed that positive side effects were likely documented in error and that there was no supporting documentation in the progress notes for those dates. For another resident receiving hospice care for oral cancer, hospice recommended the application of A&D ointment to oral lesions to prevent drying and cracking. This recommendation was not transcribed into the provider orders, and there was no documentation or order for wound care to the cancer lesions. Staff interviews confirmed that only pain management and oral care were being provided, and the Director of Nursing acknowledged that the hospice recommendations were not reviewed, reported, or transcribed as expected. In a separate case, a resident readmitted after hospitalization for a gastrointestinal bleed and pneumonia was not placed on alert charting as required after a change in status, and staff confirmed that this monitoring should have occurred.