Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, a physician's order for an NPO (nothing by mouth) diet dated 1/29/25 was not discontinued in the medical record, despite a subsequent order on 5/13/25 allowing a NAS (no added salt) diet with pureed texture and regular/thin consistency for oral gratification. Documentation showed the resident was offered oral gratification since 5/13/25, but the outdated NPO order remained active, which was confirmed by both a registered nurse and the Director of Nursing during interviews and record reviews. For another resident with a left upper arm AV shunt for hemodialysis, the facility's policy prohibited taking blood pressure on the access arm. However, medical record review revealed that blood pressure readings were repeatedly documented as being taken from the left arm over several days. The resident, who was cognitively intact, confirmed that the left arm was used for hemodialysis and that staff were not permitted to take blood pressure on that arm. Multiple licensed nurses verified that blood pressure readings had been obtained and documented from the left upper extremity, and the Director of Nursing acknowledged that this should not have occurred.