Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the medical records of three residents. For one resident with acute osteomyelitis, sepsis, and diabetes mellitus, the Medication Administration Record (MAR) inaccurately documented administration of Rybelsus 3 mg on several dates, despite progress notes and pharmacy records confirming the medication was not available and had not been delivered to the facility during that period. The Director of Nursing (DON) confirmed that the MAR entries were completed in error and did not reflect actual administration of the medication. For two other residents with complex medical histories including chronic pain, osteomyelitis, and opioid dependence, medication errors occurred but were not documented in their permanent medical records. One resident received Oxycodone instead of Methadone, and another received an incorrect dosage of Methadone. Although Medication Error forms were completed for both incidents, these forms were not included in the official medical records, contrary to facility policy. The DON verified that these errors should have been documented in the residents' permanent records.