Inaccurate Restorative Nursing Documentation Without Physician Orders
Penalty
Summary
The deficiency involves inaccurate restorative nursing documentation for a resident when no physician orders were in place and the services were not provided. The resident had Alzheimer's disease, contractures of both ankles and hands, and abnormal posture, and was dependent on staff for toileting, dressing, personal hygiene, and eating. An IDT note documented that orthopedic devices, including PRAFO boots and a right knee extension splint, were placed on hold and orders discontinued after superficial abrasions and skin discoloration were identified on both lower extremities. The resident was discharged to a GACH, and upon discharge the physician's orders directed staff to hold the right knee extension splint, PROM to both lower extremities, and PRAFO boots due to swelling and abrasions; when the resident returned, these previous orders were not resumed. Despite the absence of active physician orders for restorative services on the dates in question, the DSR showed that the RNA documented providing PROM to the resident’s bilateral upper and lower extremities and applying the right knee extension splint and PRAFO boots on two separate occasions. Review of the physician’s orders for those dates confirmed there were no orders for RNA services at that time, and new orders for PROM and application of the right knee splint and PRAFO boots were not entered until several days later. In an interview, the RNA admitted she did not perform the PROM or apply the splint or PRAFOs because there were no physician’s orders and acknowledged that her documentation was entered by mistake. The DON confirmed that the orders for PRAFO boots, right knee splint, and PROM had been held and later resumed, and stated that the RNA should not have documented providing restorative services when there were no orders and the services were not provided, emphasizing that documentation must be accurate so staff know what is being done for residents. The facility’s documentation policy required that resident progress in the Restorative Nursing Program be documented accurately and that physician orders be obtained prior to participation in the program.
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