Failure to Maintain Accurate Medical Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete documentation for two residents. For one resident with dementia, physician orders required routine oxygen saturation checks every shift, with instructions to notify the physician if levels fell below 90%. However, the Medication Administration Record (MAR) showed multiple shifts where oxygen saturation was not documented. Additionally, there were no nursing notes indicating the resident's refusal of oxygen checks on those dates, despite staff stating that refusals sometimes occurred. The Director of Nursing confirmed the absence of both oxygen saturation documentation and notes regarding refusals for the specified dates. For another resident who expired while on hospice care, the nurse's note simply stated the resident had expired, without including required details such as the date and time of death, pertinent details of the event, notifications to the physician and family, or information about the release of the body. The Director of Nursing confirmed that the death note was incomplete and did not meet the facility's policy requirements for documentation following a resident's death.