Incomplete NPO Documentation in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who required nothing by mouth (NPO) status and tube feeding. Specifically, the resident's Medication Administration Record (MAR) did not have the required NPO documentation signed off by the assigned LVN during the overnight shift on two consecutive days. This omission was confirmed through record review, which showed that the NPO order, in place since early March, was not documented as completed on the specified dates and shift. The facility's policy requires all services and treatments provided to residents to be documented in the medical record, including the date, time, and signature of the staff member providing care. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that it was expected for the LVN to sign off on the MAR to ensure documentation was complete. Both acknowledged that the absence of a signature would indicate the task was not performed. Attempts to interview the responsible LVN and the resident's representative were unsuccessful. The resident involved had significant medical conditions, including type 2 diabetes, heart failure, dysphagia, and hypertension, and was unable to participate in interviews due to cognitive impairment.