Inaccurate Medical Record Documentation and Failure to Follow Physician Orders
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents, resulting in discrepancies between physician orders, documentation, and actual care provided. For one resident with severe cognitive impairment and an NPO (nothing by mouth) order, staff continued to document the administration of a diabetic snack at bedtime on the Medication Administration Record (MAR), despite the resident not receiving anything by mouth. Interviews with nursing staff and the Director of Nursing confirmed that the snack should not have been documented as given after the NPO order was in place. Another resident, who was dependent on staff for care and had an order for a dietary supplement with all meals, was observed eating without the supplement present on their tray. The MAR, however, indicated the supplement was administered, and there was no documentation of refusal. Nursing staff confirmed the supplement should have been provided per the physician's order. Additionally, two residents with orders for specific oxygen settings were observed receiving oxygen at higher flow rates than ordered, and their MARs failed to document oxygen use as required. Nursing and administrative staff acknowledged that oxygen should be administered and documented according to physician orders. A further deficiency was noted for a resident with an order for bilateral compression stockings, who was observed without them on multiple occasions. Despite this, the treatment administration record was marked as if the order had been completed. The Director of Nursing stated that all orders should be followed as written and not marked as complete if not actually performed. These findings demonstrate a pattern of inaccurate documentation and failure to follow physician orders for several residents.