Failure to Follow Physician Orders, Document Care, and Protect Resident Information
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards for multiple residents, as evidenced by incomplete or missing documentation, failure to follow physician orders, and improper record-keeping. For example, one resident who was cognitively impaired and received tube feeding had a physician order for daily syringe changes, which was not properly documented or initialed, despite staff signing off as completed. Another resident, also cognitively impaired and dependent on staff, had orders for weekly fingernail trimming and daily foot checks, but observations and record reviews showed these tasks were not performed as documented, with staff signing off on tasks that were not completed. Additional deficiencies included failure to record and monitor daily or scheduled weights for residents with heart failure and diuretic therapy, as ordered by physicians. In several cases, weights were not recorded for extended periods, and significant weight variances that required physician notification were not documented or communicated. Staff interviews confirmed that these tasks were not optional and should have been completed, but issues with order entry into the electronic health record (EHR) or task administration records (TAR/NTAR) may have prevented nurses from seeing the required tasks. Other deficiencies included blank documentation on medication administration records (MARs) for required monitoring of side effects and behaviors related to psychotropic medications, lack of documentation and proper timing for PICC line dressing changes and measurements, and failure to protect resident information by leaving computer screens with resident data visible and unattended. Staff interviews consistently confirmed that these actions did not meet facility expectations or professional standards.