Failure to Maintain Complete and Accurate Medical Records for Medication Self-Administration and Ancillary Services
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, specifically in the areas of self-administration of medications and documentation of ancillary services. For two residents who self-administered medications, there was no documented assessment to confirm their ability to safely self-administer, nor was there evidence that staff observed or evaluated their competency in this area. In one case, a resident was permitted to self-inject insulin without any formal assessment or documentation, and staff indicated that no self-administration assessment was completed because they believed the standard questions did not apply. Another resident self-administered a nasal spray without a physician's order or care plan reflecting this preference, and there was no documentation of the resident's ability to use the medication correctly. Additionally, the facility did not accurately document ancillary services for two residents. Family members reported not being informed about dental visits, and clinical records lacked notes from dental and podiatry providers, even though these services were reportedly provided. In one instance, a resident's oral and nail hygiene was observed to be poor, but there was no documentation of recent dental or podiatry visits, nor was there a signed consent or refusal for ancillary services in the clinical record. Staff interviews confirmed that documentation of these services, including refusals and notifications to family, was missing from the residents' records. The facility was unable to provide policies or documentation supporting accurate and complete record-keeping for these areas. While a dental services policy was available, there was no specific policy for accurate documentation, and the nurse job description only generally referenced the need to complete required documentation. The lack of proper documentation and assessments led to incomplete medical records for the affected residents.