Failure to Document Chemotherapy Pump and Medi Port Care per Physician Orders
Penalty
Summary
Surveyors identified that the facility failed to maintain complete and accurate clinical records for one resident. A quarterly MDS assessment dated November 27, 2025 documented that Resident 1 was cognitively intact, required assistance with daily care needs, and had a diagnosis of malignant neoplasm of the rectum. Physician orders dated December 11, 2025 directed that an RN disconnect the resident’s chemotherapy pump, flush the Medi port, and de-access the port every other Friday. Review of the resident’s clinical record showed no documentation that an RN performed these ordered tasks on December 12, 2025 or January 16, 2026. In an interview on February 5, 2026, the Director of Nursing confirmed there was no documented evidence that the RN completed the chemotherapy pump discontinuation, Medi port flush, and de-access as ordered, constituting a failure to ensure complete and accurate clinical records in accordance with professional standards.
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