Failure to Accurately Document Physician Notifications and Orders in Resident Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident in accordance with accepted professional standards. Specifically, a nurse did not document in the Nurse's Notes that the physician was notified when the resident's family member was observed giving the resident water with ice chips, which was not compliant with the resident's NPO (nothing by mouth) order. The nurse only documented that the speech therapist was notified, and there was no record of physician notification regarding this non-compliance. Additionally, the facility did not ensure that licensed staff promptly wrote physician's telephone orders and entered new orders into the Medication Administration Record (MAR). On a separate occasion, the same nurse received new orders from the physician for a chest x-ray, saline nasal spray, and oxygen at 1 liter, but failed to write the telephone order and did not enter these new orders into the MAR. The nurse acknowledged being trained to immediately document telephone orders and update the MAR but did not provide a reason for the omission. The resident involved had a complex medical history, including esophageal cancer, heart failure, diabetes, non-Alzheimer's dementia, dysphagia, and was dependent on enteral feedings via a gastrostomy tube. The care plan specified NPO status with G-tube feedings and highlighted the resident's high risk for aspiration. The facility's policy required documentation of unusual events, changes in condition, and communication with physicians, but these requirements were not met in the instances described.