Failure to Maintain Professional Standards in Documentation and Diagnosis
Penalty
Summary
The facility failed to maintain professional standards of practice in two key areas: documentation of treatment administration and documentation of residents' current diagnoses. For one resident, there was an active order for a hipster brace to be worn at all times, but the resident was observed without the brace, and the administration record was signed off as completed despite the treatment not being administered. Staff interviews confirmed that the resident had refused the brace, but the refusal was not properly documented as required. In another case, a resident had an order to wear a sling at all times, but the treatment was marked as 'held' on several shifts without any accompanying progress notes explaining the reason, contrary to facility expectations for documentation when treatments are not provided as ordered. Additionally, the facility failed to accurately document a resident's current diagnosis. A resident with a hospital discharge diagnosis of chronic obstructive pulmonary disease (COPD) had an active order for oxygen therapy, but the care plan did not reflect the COPD diagnosis. The physician's progress notes following the resident's readmission also failed to address the new diagnosis, despite the physician stating that new diagnoses from hospitalizations should be updated in the resident's records and care plan. These deficiencies were identified through observation, record review, and staff interviews during the annual recertification survey.