Failure to Follow Nursing Standards for Timely Documentation and Physician Notification
Penalty
Summary
Facility staff failed to adhere to professional standards of nursing practice in two cases. In one instance, a registered nurse completed a change in condition evaluation for a resident 11 days after the change occurred and backdated the documentation. The Director of Nursing confirmed that such evaluations are expected to be completed before the end of the shift and that supervisors are responsible for ensuring timely documentation. In another case, a licensed practical nurse documented that a resident refused care of their suprapubic catheter on two separate occasions but did not notify the physician as required. The Regional Clinical Service Manager stated that staff are expected to re-offer care, involve the family, educate the resident, and notify the physician when care is refused.