Failure to Update Physician Orders and Complete Admission Skin Assessment
Penalty
Summary
The facility failed to ensure that physician orders were updated for a resident when licensed staff received a telephone order regarding medication administration. Specifically, the physician orders for a resident with a g-tube and swallowing difficulties did not reflect a new order allowing medications to be given by mouth. Despite a physician communicating via text that oral administration was permitted, this change was not transcribed into the resident's official orders. Both a Licensed Vocational Nurse and a Registered Nurse confirmed that the order to administer medications orally was missing from the resident's record, and acknowledged the importance of updating orders to ensure safe medication administration. Additionally, the facility did not complete an initial body check for another resident upon admission, resulting in incomplete documentation of the resident's skin status. The resident, who had multiple diagnoses including muscle weakness, diabetes, and chronic kidney disease, was at risk for pressure ulcers and had a documented deep tissue injury. The required skin assessment was not performed or documented on the day of admission, as confirmed by a Registered Nurse during record review and interview. Facility policies reviewed indicated that nursing documentation should be clear, accurate, and timely, and that newly admitted residents should have their skin examined for existing conditions. In both cases, the lack of timely and complete documentation led to incomplete medical records for the residents involved.