Failure to Obtain and Document Resident Vital Signs per Physician Orders
Penalty
Summary
Facility staff failed to follow physician orders and professional standards by not obtaining and documenting a resident's vital signs as ordered. The resident, who was cognitively intact and dependent on staff for most activities of daily living, had significant medical conditions including quadriplegia, malnutrition, chronic osteomyelitis, multiple stage three and four pressure ulcers, a suprapubic catheter, and an ostomy. Physician orders required that a full set of vital signs be obtained and abnormalities reported to the nurse practitioner or physician, initially on a specific date and then monthly. However, review of the Treatment Administration Record (TAR) and electronic medical record (EMR) showed that vital signs were either not documented or marked as not applicable, with several months lacking any record of vital signs being obtained. Interviews with staff revealed inconsistent understanding and implementation of the vital sign orders. An LPN stated that vital signs are typically obtained every shift and as needed, while a CNA reported only taking vital signs when instructed by a nurse and was unaware of any routine or monthly orders for the resident. The wound nurse indicated that vital signs are obtained every shift for new admissions and then monthly, but the resident's care plan did not address obtaining vital signs. The DON and Medical Director both expected staff to follow physician orders and document vital signs, but acknowledged there was no facility policy specifically related to obtaining vital signs. The resident's death was documented, but there was no evidence that vital signs were consistently monitored or recorded as ordered prior to the event.