Failure to Accurately Document and Administer Ordered TED Hose
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had a physician's order for TED hose to be applied in the morning and removed at bedtime for edema. Review of the Medication Administration Record (MAR) for the month showed that staff documented the application of TED hose every morning, but night shift documentation was inconsistent, with most entries indicating to 'see progress note' and only two entries marked as 'off' or 'N/A.' Interviews with the resident and a family member revealed that staff had never applied TED hose, and the resident always wore his own black compression knee-high socks, which he put on himself daily. The family member confirmed never seeing staff apply TED hose. Further interviews with nursing staff and the unit manager confirmed that the resident wore compression socks, not TED hose, and that day shift staff were documenting the use of compression socks as if they were TED hose on the MAR. The DON clarified that TED hose and compression socks are not the same and should not be substituted for each other. The facility's policy requires that treatments and services performed be documented objectively, completely, and accurately in the medical record, which was not followed in this case.