Inaccurate Documentation of Compression Stocking Application
Penalty
Summary
Surveyors identified that the facility failed to ensure the accuracy of medical records for two residents regarding the application of physician-ordered compression stockings. For one resident, the medical record and Medication Administration Record (MAR) indicated that compression stockings were being applied daily as ordered. However, multiple observations showed the resident was not wearing the stockings at various times, and both the resident and her private duty aide confirmed that the stockings had not been applied for an extended period. The resident stated she would refuse if asked to wear them, but no such refusal was documented, and the aide reported never being instructed to apply them. Nursing staff also confirmed that they had not applied the stockings and that the MAR was not accurate. For the second resident, physician orders required the application of compression stockings every shift. The MAR reflected that the stockings were applied as ordered, but repeated observations found the resident was not wearing them. The resident reported never having worn the stockings at the facility and stated that no one had instructed him to do so. Nursing staff confirmed that they had documented the application of the stockings in the MAR without verifying whether the resident had them on, and a search of the resident's room revealed no stockings present. Interviews with nursing staff and the Director of Nursing (DON) confirmed that documentation in the MAR was inaccurate, as treatments were recorded as completed when they had not been performed. The DON acknowledged that staff should not document treatments that were not provided. These findings demonstrate a failure to maintain accurate and complete medical records as required by federal regulations.
Plan Of Correction
F 842 Resident #13 had order for discontinued on Resident #133 had physician order reviewed and placed on resident for remainder of his stay. Resident discharged on. Education provided to licensed nurses, ARNPs, and physicians on need for medical records to be complete and accurate. Audit medical records to ensure professional standards of practice are being followed in regards to documentation of orders for audits to be conducted to ensure compliance with professional standards of practice by DON/designee of daily documentation for orders of for four weeks, and three times a week for eight weeks thereafter. Results to be taken to monthly QAPI meeting for three months. F 842