Incomplete and Inaccurate Medical Records
Penalty
Summary
The facility failed to ensure that medical records for three residents were complete and accurately documented. Resident R21, who was admitted with diagnoses including high blood pressure, hip fracture, and malnutrition, had a physician's order for nifedipine without a corresponding diagnosis for its use. Similarly, Resident R87, admitted with high blood pressure, diabetes, and morbid obesity, had a physician's order for gabapentin without a diagnosis for its use. Resident R199, admitted with high blood pressure, malnutrition, and a stage 2 pressure ulcer, had a physician's order for cefazolin without a diagnosis for its use. During an interview, the Registered Nurse Assessment Coordinator (RNAC) confirmed that the facility often fails to select appropriate diagnoses when entering medication and treatment orders, which can lead to confusion due to the multiple uses of some drugs. This deficiency was confirmed for the three residents mentioned, indicating a pattern of incomplete and inaccurately documented medical records.
Plan Of Correction
Medications were reviewed for Residents #21, #87, and #199 to ensure medical records were complete and accurately documented to include diagnosis for indication of use for medication. To identify other residents that have the potential to be affected, a house audit was completed by DON/designee to ensure medical records were complete and accurately documented to include diagnosis for indication of use for medication. Corrections will be made as needed. To prevent this from happening again, DON/designee educated licensed nurses on the appropriate documentation of resident diagnosis. To monitor and maintain ongoing compliance, the DON/designee will audit new orders weekly x4 then monthly x2 to ensure diagnosis for indication of use are documented in the medical record. Negative findings will be corrected. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.