Deficiency in Documentation of Alcoholic Beverage Consumption
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for one resident. Specifically, the deficiency involved Resident #54, who was admitted with various diagnoses and had intact cognition for daily living decisions. During an observation, it was noted that the kitchen pantry contained a box of beer labeled with the resident's name, and additional bottles were found in the pantry refrigerator without labels. The resident's care plan indicated that they enjoyed a beer on occasion, and staff were instructed to offer this during Happy Hour. However, the physician's orders allowed the resident to have a beer nightly at dinner and daily, but there was no documented process for staff to record when the resident was given an alcoholic beverage. Further investigation revealed that there was no documented evidence of policies regarding resident consumption of alcoholic beverages. During an interview, a registered nurse stated that nurses were to provide the alcoholic beverage upon the resident's request but were unsure where to document this in the medical records. The nurse acknowledged that there should be a system in the electronic records to track and record when the resident received the beverage. This lack of documentation and policy adherence led to the deficiency cited under the New York Code of Rules and Regulations 483.70 (h)(2)(ii).
Penalty
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