Failure to Monitor and Document Residents After Change of Condition and to Follow Oxygen Therapy Orders
Penalty
Summary
Licensed nurses failed to monitor and document the medical status of two residents following changes of condition (COC). For one resident with diagnoses including type 2 diabetes mellitus, anemia, and COPD, there was no documented evidence of monitoring after COCs related to low hemoglobin and hematocrit levels, a mass on the left arm, and later, high blood urea nitrogen, low potassium, and high ammonia levels. The facility's records showed that required monitoring every shift for 72 hours post-COC was not performed or documented on several shifts following these events. Additionally, the same resident had a physician's order for continuous oxygen therapy at two liters per minute via nasal cannula. However, documentation revealed that oxygen was administered at three liters per minute, contrary to the physician's order. This deviation from the prescribed oxygen therapy was acknowledged by both the LVN and the DON during interviews and was not in accordance with the facility's policy and procedure for oxygen administration. For another resident admitted with gastro-esophageal reflux disease, anemia, and hypertension, there was a failure to monitor and document the resident's gastrointestinal status after a COC involving two days of diarrhea. Progress notes indicated missing documentation for several shifts over a three-day period following the COC. The DON confirmed that monitoring and documentation were not completed as required by facility policy, which mandates monitoring and documentation of residents' progress and responses to treatment after a COC.