Incomplete Documentation of Pharmacist Recommendations in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by federal regulations. For one resident, who had diagnoses including depression and diabetes, pharmacist medication regimen reviews identified potential medication irregularities on three separate occasions. However, the corresponding pharmacist recommendations and documentation regarding these irregularities were not present in the resident's medical record. The recommendations were either not entered, only available in the pharmacy's computer system, or awaiting upload despite being signed by the physician weeks prior. For another resident with diagnoses including congestive heart failure and osteoarthritis, a pharmacist medication regimen review also identified a potential medication irregularity. The pharmacist's recommendation related to this irregularity was not found in the resident's medical record. Although the facility was able to provide a copy of the recommendation from the pharmacy's computer system upon request, it was not included in the resident's official medical record at the time of the survey. Interviews with facility staff confirmed that the pharmacist recommendations for both residents were not present in the residents' medical records. In some cases, recommendations were only stored in the pharmacy's system or had not yet been uploaded to the electronic health record, resulting in incomplete documentation. This lack of timely and accurate recordkeeping interfered with the ability to ensure informed decisions and continuity of care for the affected residents.
Plan Of Correction
ELEMENT 1 ACTION TAKEN: Resident #26 pharmacy recommendations from 8/6/2024, 11/4/2024, and 4/3/2025 are in the medical record. Element #2 Identification of other Residents: Each resident residing in the facility has the potential to be affected. Pharmacy recommendations conducted at the facility in the last 30 days will be completed to validate the recommendations are in the residents' medical record. Element #3 Measures Taken: Reeducation will be provided to the Director of Health Care Services and Health Information Manager by 5/26/2025 or prior to the next day worked in the /case of the leave of absence, or vacationing employee. The educational agenda will include the requirement of all pharmacy recommendations, including recommendations made to nursing, to be uploaded in the medical record in a timely manner once completed. Element #4 Monitoring Measures Taken: The Nursing Home Administrator and/or Designees will conduct an audit of medical records 3-5 times a week for four (4) weeks and periodically thereafter to ensure pharmacy recommendations, including those made to nursing, are in the medical record in a timely manner once completed. The Nursing Home Administrator will provide a summary of the audit to the Quality Assurance Performance Improvement Committee monthly for one (1) month and periodically thereafter. The Nursing Home Administrator will assume responsibility for attained and sustained compliance.