Failure to Maintain Accurate Medical Record Following Resident Readmission
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident following readmission from a hospital stay. Upon review, it was found that the physician's order for metoprolol tartrate 25 mg was not entered into the electronic medical record (EMR) after the resident's return. The resident's discharge medication orders from the hospital included metoprolol, but this order was not transcribed into the EMR by the nurse responsible for the readmission process. As a result, the medication was not listed in the resident's active orders, and there was no prompt for documentation of its administration in the EMR. Despite the absence of an active order in the EMR, an LPN administered metoprolol to the resident, relying on the medication packet provided by the pharmacy and her knowledge of the resident's history. The administration was not documented in the EMR due to the missing order. Interviews with staff confirmed that the facility's protocol required review and transcription of hospital discharge orders into the EMR, but this step was missed. Additionally, the facility did not have a policy related to maintaining complete and accurate medical records.