Inaccurate Documentation and Failure to Implement Physician Orders for Pressure Injury and Safety Interventions
Penalty
Summary
The facility failed to accurately document and implement physician orders for two residents, resulting in multiple instances of inaccurate medical recordkeeping. For one resident with a history of sepsis, urinary tract infection, and diabetes, nurses documented that a peripherally inserted central catheter (PICC) dressing change was completed on two occasions when it had not been performed. Observations revealed that the PICC dressing had not been changed for 19 days, despite orders for weekly changes. The resident confirmed the dressing had only been changed twice since readmission, and staff interviews corroborated that documentation was inaccurate. Additionally, the same resident had physician orders for the use of heel booties while in bed and for padded side rails due to a seizure disorder. Despite these orders, the resident was repeatedly observed in bed without booties or offloaded heels, and the side rails were not padded. The resident stated that booties and side rail pads had not been offered or used for a long time, and staff confirmed that these interventions were not implemented as ordered. Nevertheless, nursing staff documented in the Treatment Administration Record (TAR) that these interventions were completed every shift, with no documentation of refusal or rationale for non-implementation. A second resident, with chronic kidney disease, diabetes, and severe cognitive deficits, also had physician orders for bilateral heel booties and offloading of heels while in bed. This resident was observed multiple times in bed without booties or offloaded heels, and the booties were not within reach. The resident reported not being offered the booties and experiencing discomfort from a heel wound. Staff interviews indicated a misunderstanding of the order's requirements, and the TAR reflected that the interventions were documented as completed every shift, despite not being implemented and without any record of refusal or explanation.