Carrara

received prior to exit. In an interview on 09/17/25 at 11:40 AM, LVN B stated he prepped Resident #1 for dialysis on 08/13/25. He stated he took her to the transportation person and sent her dialysis folder with her. LVN B stated he checked all of her vitals before she left, and all were within the appropriate range. In an interview with the Director of Clinical Services and the ADON on 09/17/25 at 2:09 PM, The Director of Clinical Services stated he reviewed Resident #1's electronic record and did not locate documentation of Resident #1's blood pressure reading from 08/13/25.

The ADON stated it could have been a coincidence that the blood pressure reading from 08/12/25 was the same reading for 08/13/25, and that LVN B probably just documented the wrong date for the blood pressure reading of 102/65.

The Director of Clinical Services stated all staff were trained on quality of care, following physician's orders, and documentation.

The Director of Clinical Services stated Resident #1's vitals would usually be checked before she left for dialysis.

The Director of Clinical Services stated the risk of LVN B not possibly checking the blood pressure or recording the vitals of the patient could negatively affect the patient's care. In a follow-up interview on 09/17/25 at 2:26 PM, LVN B stated he recalled he manually checked Resident #1's blood pressure, but he could not remember what the reading was. LVN B stated he did remember that the blood pressure was within the normal range. LVN B stated vitals are checked on all dialysis residents before they leave for dialysis. He stated he must not have documented the blood pressure. He stated he thought he just wrote the wrong date on the dialysis communication form. LVN B stated the risk of not checking or not documenting the vital check was there could be a problem with the resident and staff would not be aware of before sending the resident to dialysis. In an interview on 09/17/25 at 2:59 PM, the Administrator stated the facility staff were trained on quality of care, documenting, and following physician's orders.

The Administrator stated the risk of Resident #1's blood pressure not checked or documented as checked on 08/13/25 was a negative impact on the resident's care.

Record review of the facility's in-service titled, Physician's orders, dated 08/20/25, reflected the following: Key Points Physician orders provide the medical plan of care for the patient.

Nurses are responsible for carrying out those orders safely and documenting accurately.

Following orders ensures continuity of care, patient safety, and compliance with regulations.

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