Failure to Ensure Accurate Administration and Documentation of Compression Stockings
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) documented in the electronic Treatment Administration Record (eTAR) that a resident was wearing compression stockings, despite the resident not having them on at the time of observation. The resident, who had diagnoses including encephalopathy, hypertension, and muscle weakness, was moderately cognitively impaired and had a physician's order for daily application of compression stockings to address lower leg swelling. During observation, the resident was found wearing only non-skid socks and reported not remembering ever wearing compression stockings since admission. The assigned Certified Nursing Assistant (CNA) confirmed the resident was not wearing compression stockings and stated she was unaware of the order for daily use. Further review revealed that the LVN signed off on the eTAR without verifying whether the resident was actually wearing the compression stockings, acknowledging during interview that it was his responsibility to check before documenting. The Director of Nursing (DON) stated that the expectation was for licensed nurses to assess or check before signing the eTAR or eMAR. Job descriptions for both the LVN and CNA roles indicated responsibilities for providing care as ordered and completing assigned tasks, but these were not followed in this instance, resulting in the resident not receiving the prescribed care.