Inaccurate Documentation and Breach of Resident Confidentiality
Penalty
Summary
Licensed nursing staff documented the administration of treatments and medications that were not actually provided to several residents. For example, one resident with orders for TED hose and a lymphatic compression device was not wearing the devices as ordered, and the nurse confirmed she had not applied them despite documenting otherwise. Similarly, two other residents with orders for TED hose were not wearing them, and the responsible nurse admitted to documenting their application on the MAR when she had not performed the task. In another case, a resident's intravenous antibiotics were documented as administered by a nurse not authorized to do so, and the nurse acknowledged the documentation was inaccurate. The facility also failed to safeguard resident-identifiable information. Meal tickets containing residents' names, room numbers, dietary information, and allergies were disposed of in the regular garbage rather than in a confidential shredding bin. This practice was confirmed by both the dietary worker and the dietary manager, who acknowledged that the tickets contained confidential information and should not have been discarded with regular waste. Additionally, the facility did not accurately complete informed consent documentation for the administration of a psychotropic medication. The consent form for a resident receiving brexpiprazole was signed and witnessed by two nurses, but the section indicating the name of the person giving verbal or phone consent was left blank. The assistant director of nursing confirmed that the consent was incomplete and inaccurate, as the responsible party's name was not documented as required.