Failure to Document Ordered Pedal Pulses and Abdominal Girth Measurements
Penalty
Summary
Surveyors identified a deficiency involving the facility’s failure to ensure that ordered clinical assessments were properly documented and available for provider review for one resident with severe bilateral foot and ankle edema. The resident’s medical record showed a provider order, dated 11/13/2025, for pedal pulses to be taken every shift and documented as positive or negative, and another order, dated 9/24/2025, for weekly abdominal girth measurements. Although the Task Administration Record (TAR) indicated that these tasks were marked as completed, there were no actual pedal pulse findings or abdominal girth measurements recorded in the TAR, the resident’s chart, or any other communication to the provider. During interviews, the DON reported that the provider had failed to initiate the supplemental data command in the PCC electronic medical record, leaving nursing staff without a designated place to enter the measurements, and an employee confirmed there was no separate location on the unit to record this data. The DON was unable to explain why, over approximately two months for pedal pulses and four months for abdominal girth measurements, neither nursing staff nor the provider took action to correct the documentation issue or establish a means for recording the ordered measurements. These findings show that the facility did not provide treatment and care according to the physician’s orders, as the required assessment data for pedal pulses and abdominal girth was not documented or communicated to the provider despite the presence of active orders and indications in the TAR that the tasks had been completed.
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