Failure to Accurately Document and Monitor Ordered Vital Signs
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders, professional nursing standards, and the resident’s person-centered care plan for one resident. A physician order dated 1/30/26 directed staff to obtain the resident’s vital signs every shift for five days, but the order was not fully carried out. The Medication Administration Record (MAR) showed that vital signs were recorded on multiple shifts between 2/1/26 and 2/4/26; however, there were missing blood pressure entries, and several sets of vital signs were documented as being exactly the same across different shifts. Specifically, the record showed identical vital signs on two consecutive shifts on 2/1, identical vital signs between the night shift on 2/1 and the afternoon shift on 2/2, and identical vital signs on two consecutive shifts on 2/3. The resident’s care plan identified altered cardiovascular status related to hypertension and directed staff to monitor vital signs and weights as ordered and as needed, and to notify the physician of significant abnormalities or changes. The resident’s admission record listed multiple serious diagnoses, including retroperitoneal fibrosis, unspecified COPD, stage 4 CKD, unspecified anemia, atrophy of kidney (terminal), and primary hyperparathyroidism. During interviews, the ADON and Nursing Home Administrator confirmed that blood pressures were missing and acknowledged that it was rare for a resident to have the same vital signs on different shifts, while the Interim DON stated she would not say it was impossible for vital signs to be identical over different shifts. The facility’s documentation policy required that services provided be documented in a manner that is objective, complete, and accurate, and that medical records facilitate communication about the resident’s condition and response to care, which was not met in this case.
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