Inaccurate Medical Records and Incomplete Pharmacy Review
Penalty
Summary
The facility failed to ensure the accuracy and completeness of resident medical records for two residents. For Resident R98, the clinical documentation inaccurately included a diagnosis of gastrostomy status, which was not applicable. Observations and interviews with staff confirmed that Resident R98 did not have a gastrostomy and was on a pureed diet, eating by mouth. The error was attributed to a mix-up with another resident who had a similar last name and did have a gastrostomy. This discrepancy in the medical record was not addressed or corrected, leading to inaccurate documentation. For Resident R40, the facility did not ensure proper documentation and follow-up on a consultant pharmacist's recommendation regarding the use of the antipsychotic agent Quetiapine. The recommendation noted the absence of an allowable diagnosis to support the medication's use, yet there was no evidence of physician agreement or disagreement with the recommendation, as the form was unsigned. Additionally, the facility failed to provide original copies of the consultant pharmacist's form, indicating a lack of proper record-keeping and follow-up on medication management.
Plan Of Correction
Resident R98 gastrostomy diagnosis has been removed from the medical record. Medical Records will conduct an initial audit with a look back of 30 days to ensure accuracy of gastrostomy tube documentation. Medical Records to complete weekly audits X 4 then monthly X 2 on 5 random residents diagnoses to ensure accuracy of gastrostomy tube documentation. Resident R40 pharmacy recommendation has been approved by the provider and appropriate diagnosis for Quetiapine has been added to the medical record. DON / Designee will complete an initial audit of pharmacy recommendations in the past 30 days to ensure recommendations for appropriate diagnosis for Quetiapine are updated and signed by the physician. DON / Designee to complete weekly audits X 4 then monthly X 2 to ensure recommendations for appropriate diagnosis for Quetiapine are updated and signed by the physician. NPE/DON/Designee to re-educate facility physicians, Advanced Practice Providers regarding accuracy of diagnosis in the medical record. DON/Designee will report the findings of the audits to the QAPI Committee X 3 months.