Contradictory Diet Orders and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and consistent medical records for one resident, resulting in two active physician orders that directly contradicted each other. The resident, who was admitted with diagnoses including muscle weakness, history of falls, and dementia, had orders for both 'nothing by mouth' (NPO) and a clear liquid diet at the same time. The medical record review showed that after a gastrointestinal bleed, the resident was initially placed on TPN and NPO status, with subsequent orders for clear liquids added after a surgical follow-up. However, the NPO order was not discontinued when the clear liquid diet was started, leading to both orders being active simultaneously. Staff interviews confirmed awareness of the conflicting orders, with both the Quality Assurance Nurse and the DON acknowledging that the presence of both NPO and clear liquid diet orders could cause confusion and was not accurate documentation. Observations revealed that the resident had a tray with clear liquid items at bedside that had not been consumed, and staff expressed concern that the contradictory orders could impact the resident's care. The facility's policy requires documentation to be objective, complete, and accurate, which was not met in this instance.