Failure to Follow Professional Standards in PICC Line Monitoring and Insulin Administration Documentation
Penalty
Summary
The facility failed to ensure professional standards of care were followed for two residents. For one resident with a PICC line in the right arm, the physician's order required weekly measurement and documentation of the mid-upper arm circumference to monitor for complications. On review, the MAR/TAR was missing a signature for the required measurement on a specified date, and both the DON and a licensed nurse confirmed that the absence of documentation indicated the task was not completed. The facility's policy also required weekly measurement and documentation, which was not followed in this instance. For another resident with type I diabetes and a history of diabetic ketoacidosis, the physician ordered daily administration of Tresiba insulin. The MAR for a specific month showed that the resident did not receive insulin on two dates, and there was no documentation explaining the missed doses. The DON confirmed the absence of documentation and the increased risk to the resident due to their medical history. Later, the MAR was found to have been altered to indicate that the insulin was administered on those dates, but there was no corresponding late entry or explanation in the nursing progress notes as required by facility policy. Interviews with nursing staff revealed that the nurse responsible for the insulin administration acknowledged correcting the MAR after being questioned about the missing documentation, but did not follow the facility's process for late charting. The facility's documentation policy required that late entries be clearly indicated and explained in the progress notes, which was not done in this case. These failures resulted in incomplete and inaccurate medical records for both residents.