Incomplete and Inaccurate Clinical Documentation
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident, identified as Resident 37. The facility's policy for medication administration required maintaining a medication administration record to document all medications administered. However, there was no documented evidence in Resident 37's Medication Administration Records (MAR) for several dates in December 2024, January 2025, and February 2025, indicating that the resident received prescribed medications, including vancomycin HCL, normal saline solution (NSS) flushes, Heparin Porcine, levothyroxine sodium, lithium carbonate, olanzapine, and omeprazole. Despite the lack of documentation, an interview with Resident 37 confirmed that she had not missed any medications since arriving at the facility. The Nursing Home Administrator also confirmed that Resident 37's clinical record was not complete and accurately documented on the specified dates. This deficiency was identified based on a review of facility policies, clinical records, and staff interviews.
Plan Of Correction
1. Resident 37 has been discharged home. 2. Any resident has the potential to be affected by this deficient practice. 3. The process for reviewing medications was amplified and nurses were educated. At the end of each shift, the nurse will review the medication administration record for any medications not given, and document after administration. If not given, a note of explanation will be placed in chart and physician notified as needed. Each morning the Director of Nursing or designated supervisor will run a list of missed medications from the previous day and rectify per procedure. 4. An audit of missed medications will be done weekly x 4 and then monthly x2 and reported to the Quality Assurance team for review. Director of Nursing or designee will monitor.