Inaccurate Documentation of Compression Stocking Application
Penalty
Summary
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 anti-embolic stockings were applied daily as ordered by the physician. 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 were never applied. The CNA responsible for the resident stated she was not instructed to apply the stockings, and the RN admitted to documenting their application in the MAR despite knowing they were not applied. The Director of Nursing (DON) confirmed that documentation should not reflect treatments that were not completed, acknowledging the inaccuracy of the MAR. Similarly, for another resident, the MAR documented that compression stockings were applied every shift as ordered. Observations throughout the day showed the resident was not wearing the stockings, and the resident stated he had never worn them at the facility and was not provided with a pair. The CNA confirmed she was not told to apply the stockings, and the RN admitted to documenting their application without verifying if they were actually applied. The DON again confirmed that the medical record was inaccurate in this instance. Photographic evidence was obtained to support these findings.
Plan Of Correction
Resident #13 had an order that was discontinued on [date]. Resident #133 had a physician order reviewed and placed for the remainder of his stay. The resident was discharged on [date]. Education was provided to licensed nurses, ARNPs, and physicians on the 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. Audits are to be conducted to ensure compliance with professional standards of practice by the DON/designee, including documentation of orders daily for four weeks, and three times a week for eight weeks thereafter. Results are to be taken to the monthly QAPI meeting for three months.