Failure to Ensure Accurate Documentation and Physician Orders
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records and Medication Administration Records (MAR) for two residents. For one resident with multiple complex diagnoses, including congestive heart failure, diabetes, cardiomyopathy, COVID-19, and end-stage renal disease, the MAR indicated that medications and treatments were documented as administered after the resident had already expired. Specifically, medications and a blood sugar reading were signed as given at times after the resident's recorded time of death. The nurse responsible admitted to documenting these administrations in error, stating she was overwhelmed and did not actually provide the medications. Additionally, the facility did not maintain clear and current physician orders regarding the use of a splint for another resident with a right leg fracture. The physician's order lacked specificity about the type of splint to be used, and when a CAM boot was discontinued by the physician, the order was not updated or discontinued in the electronic health record. This led to confusion among staff regarding whether the resident should still be using a splint or immobilizer, and which type was required. Staff interviews confirmed uncertainty about the resident's care plan due to the lack of clear documentation and order updates. Facility policies and job descriptions reviewed indicated that licensed nurses and charge nurses are responsible for accurate documentation and implementation of physician orders, including verifying medication administration and ensuring orders are current and specific. The observed deficiencies in documentation and order management had the potential to cause confusion among staff and impact the provision of necessary care and services.