Failure to Maintain Accurate Medical Records and Follow Physician Orders
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents. For one resident with a history of malignant neoplasm of the left breast and a physician's order restricting blood pressure measurements and venipuncture from the left arm due to a mastectomy, blood pressures were repeatedly taken from the restricted arm on multiple documented occasions. This was confirmed by record review and acknowledged by the Director of Nursing. For another resident with an order for insulin administration before meals if blood sugar was less than 140, there was no documentation of blood sugar checks or insulin administration on the Medication Administration Record or vital records for a period of several days. The resident reported that a nurse did not check blood sugar or administer insulin, and the Director of Nursing confirmed that the blood sugar checks were not documented as required.