Failure to Document and Provide Ordered Care Following Change in Condition
Penalty
Summary
The facility failed to provide necessary care and services for a resident with severe cognitive impairment who had a physician's order for daily weights for three days due to CHF. Medical record review showed there was no documentation that daily weights were obtained or that the resident refused to be weighed, as required by the physician's order. Interviews with nursing staff confirmed the absence of documentation regarding the daily weights or any refusals by the resident. Additionally, after the resident sustained a bump on the head resulting in a lump with swelling, the facility did not document monitoring, care, or safety measures provided following the incident. Although the resident was observed with the injury and the physician ordered a hospital evaluation, the resident remained in the facility after paramedics determined transfer was not necessary. There was no evidence in the medical record of follow-up monitoring or documentation of the resident's condition after the injury, despite facility policy requiring such documentation for changes in condition or extraordinary events.