Failure to Document and Complete Physician-Ordered Treatments and Monitoring
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for three residents. For one resident with hypertension and hyperlipidemia, multiple physician-ordered treatments and monitoring tasks, including weekly body audits, pressure wound care, catheter care, enhanced barrier precautions, monitoring for UTI symptoms, and use of offloading heel boots, were not documented as completed on several shifts. The Treatment Administration Record (TAR) lacked signatures on specific dates and shifts, indicating that these treatments may not have been performed as ordered. Two other residents, one with Alzheimer's Disease and hyperlipidemia and another with hypertension and bipolar disorder, also had missing documentation on their TARs. Orders for checking the placement of alarming security bracelets and monitoring for avoidance of laying flat due to shortness of breath were not signed off on multiple shifts. During an interview, the Nursing Home Administrator confirmed that treatments should be completed and documented as ordered, but was unable to verify completion due to lack of response from the assigned nurse.