Failure to Accurately Maintain Medical Records and Follow Physician Orders
Penalty
Summary
The facility failed to accurately maintain medical records and safeguard resident-identifiable information in accordance with accepted professional standards for several residents. For three residents with air mattresses, physician orders required that the mattress settings be checked every shift and set according to the resident's weight. However, surveyor observations revealed that the air mattresses were not set to the correct weights, and nursing staff documented in the Treatment Administration Record (TAR) that the checks were completed without verifying or adjusting the settings. Staff interviews confirmed that the documentation was completed without actually performing the required checks. For a resident receiving oxygen therapy, a physician's order specified oxygen at 2 liters per minute via nasal cannula continuously. Despite this, the resident was observed receiving oxygen at 4 liters per minute on multiple occasions. The Medication Administration Record (MAR) indicated that the resident was documented as receiving the ordered amount, but staff acknowledged that they signed off on the order without verifying the actual oxygen flow rate. Additionally, for a resident with an order to encourage the use of an incentive spirometer every shift, surveyors found that the device was not present in the resident's room during multiple observations. Despite this, the TAR reflected that staff had documented the order as completed. Staff interviews confirmed that documentation was made without ensuring the resident had access to or used the incentive spirometer.