Failure to Document and Administer Tube Feedings and Blood Pressure Monitoring
Penalty
Summary
Staff failed to accurately document and administer tube feedings for a resident with a gastric tube, who had a history of high blood pressure, diabetes, traumatic brain injury, and was dependent on staff for all activities of daily living. The resident's care plan included interventions for unplanned weight loss and required tube feedings and water flushes as ordered by the physician. However, multiple entries on the treatment administration record (TAR) were left blank, with no documentation to indicate whether the tube feedings or flushes were administered or refused. Progress notes indicated occasional refusals and disconnections by the resident, but there was no consistent documentation explaining the missed administrations or refusals, as confirmed by the registered dietician who relied on these records to monitor the resident's nutrition. Another deficiency involved the administration of Hydrochlorothiazide, an antihypertensive medication, to a resident with moderate cognitive impairment and a diagnosis of hypertension. The physician's order specified that the medication should not be given if the systolic blood pressure was less than 100, and the care plan required monitoring for side effects and effectiveness. Despite this, the medication administration record showed the medication was given daily without any documentation of the resident's blood pressure prior to administration. Interviews with nursing staff and the nurse practitioner confirmed that blood pressure readings were not consistently documented before giving the medication, even though it was expected per facility policy and physician order. Interviews with facility leadership, including the regional nurse consultant, corporate nurse, and administrator, confirmed expectations that staff should document all treatments and medications administered, as well as vital signs when required by physician orders. The facility's policy required documentation of all assessments, observations, and services at the time of service or by the end of the shift, but this was not consistently followed in the cases reviewed.