Failure to Accurately Document Resident Vital Signs per Physician Order
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency was identified when a facility failed to maintain clinical records in accordance with professional standards for one resident. The resident, who was cognitively intact and had diagnoses including COPD, sepsis, acute respiratory failure, acute pulmonary edema, and pleural effusion, had a physician's order for vital signs to be taken every shift for 30 days. Review of the clinical record showed that there was no documentation of vital signs for the night shift on a specific date. During an interview, a licensed nurse admitted to not documenting the vital signs she allegedly took, stating they were similar to those from the previous shift, and subsequently recorded identical vital signs for both the evening and night shifts.