Incomplete Medical Record Documentation for Medication and Weight Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with a physician order for insulin administration per sliding scale, the Medication Administration Record (MAR) for March 2025 contained multiple blank entries for insulin administration and lacked documentation of blood sugar levels or insulin coverage. The resident had periods when medications were held due to intoxication or being unable to be awakened, but these events were not consistently documented in the progress notes or MAR. Staff interviews confirmed that appropriate documentation codes were not used and that entries were left blank, contrary to facility policy. For another resident with a diagnosis of diastolic (congestive) heart failure and an order to check weight every other day, the weight documentation for March 2025 was incomplete, with several dates missing. A CNA recalled weighing the resident but admitted to forgetting to document it. The DON confirmed that the expectation was for CNAs to document weights as ordered. These lapses resulted in incomplete medical records for both residents.