Failure to Accurately Document and Obtain Daily Vital Signs
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not properly documenting daily vital signs as required by physician orders. Review of the resident's Medication Administration Record (MAR) for May 2025 revealed that staff repeatedly documented identical vital sign readings over consecutive days, rather than recording new measurements. Both the LVN and the DON confirmed during interviews that the vital signs were not being taken daily as ordered, and staff appeared to be copying previous entries or using an electronic record feature to repeat prior values instead of performing actual assessments. The resident involved had diagnoses including dementia, hypertension, and diabetes, and was severely cognitively impaired according to a recent assessment. Physician orders required daily vital signs to be obtained on the morning shift, and the care plan specified regular blood pressure monitoring. Despite these requirements, the MAR showed repeated, identical entries for vital signs over multiple days, indicating that staff did not follow proper procedures for assessment and documentation.