Failure to Document Physician-Ordered 1:1 Observation in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who had physician orders for 1:1 constant observation every hour due to aggressive behaviors associated with vascular dementia and psychosis. The resident's care plan and physician orders specified that hourly monitoring was required, including during all activities, toileting, and sleeping, for a period of 72 hours. However, review of the Medication Administration Record (MAR) revealed that documentation of this monitoring was missing for a six-hour period on a specific date. Interviews with staff indicated that the assigned nurse was responsible for both performing and documenting the 1:1 observation during the time in question. The nurse confirmed that the monitoring was completed but acknowledged that she did not sign the MAR as required by facility policy, which states that documentation should be completed at the time of service. The nurse also stated that she believed another nurse might sign off, but clarified that the person performing the monitoring should be the one to document it. The Director of Nursing (DON) confirmed the omission on the MAR and stated that the facility's policy requires timely and accurate documentation of care. The DON also noted that monitoring was performed during the unsigned period, but the lack of documentation meant there was no official record of compliance with the physician's order. Facility records showed that the nurse responsible had received recent training on documentation, but the required entries were still not made in this instance.