Failure to Document Ordered Vital Signs After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record and to ensure vital signs were recorded timely after a change in condition was identified for one resident. The resident had a history of stroke, convulsions, thyroid disorder, and hypertension, and a quarterly MDS showed moderate cognitive impairment, no behaviors, assistance needed with ADLs and transfers, and no antianxiety or antidepressant medications. The resident’s care plan noted cardiovascular disease due to bradycardia and hyponatremia, with interventions to obtain vital signs and provide medications as ordered. During morning care, the resident became unresponsive while moving bowels; an RN assessed the resident and found them unresponsive to tactile and verbal stimuli with a carotid pulse of 30 beats per minute. After a few minutes, the resident became responsive, and vital signs were documented at that time as blood pressure 90/60, pulse 50, and respirations 14, and the APRN was updated. Following this event, a physician order directed that vital signs be obtained every shift for three days. Although vital sign monitoring was initiated as ordered on the afternoon of the same day, the clinical record did not contain documentation of the vital signs for multiple subsequent shifts. The MAR for the relevant days showed that staff had initialed all shifts to indicate vital signs were obtained, but the actual vital sign values were not recorded on the MAR, in nursing notes, or in any vital sign records for the night shift of the first day, all three shifts of the next two days, and the day shift of the final day. The DON stated that nursing staff were expected to follow physician orders and document temperature, blood pressure, pulse, and respirations in the medical record, and that she did not know why staff failed to document the ordered vital signs. The facility’s Nursing Documentation Policy directed that documentation should occur as soon as possible after care was completed, but this was not followed in these instances.
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