Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as evidenced by missing or mismatched signatures on informed consent forms for psychotropic medications, incomplete documentation of staff job designations on Medication Administration Records (MARs), and missing or incomplete consents for medication administration. For example, the informed consent for buspirone for one resident did not have signatures that matched the printed names, and the staff who signed the consent had not actually obtained the consent from the resident. Additionally, several MARs lacked the professional titles of staff who administered medications, and some consent forms were missing required physician signatures and dates. Documentation lapses were also found in the administration and monitoring of medications and treatments. One resident's MAR showed multiple instances of missing documentation for medication administration, treatments, and required monitoring, such as pain assessments, intake and output, and infection control measures. In some cases, staff admitted to forgetting to document or save entries after providing care. Another resident's advance directive was not available in the active medical record, and staff could not provide documentation that the advance directive had been offered or discussed upon admission. The facility also failed to properly document physician notifications and justifications for continuing antibiotic treatments for residents who did not meet McGeer's Criteria. The Infection Surveillance Monthly Report indicated that antibiotics were continued per physician direction, but the medical records did not include the name of the physician, the date and time of notification, or the name of the nurse who communicated with the physician. These documentation failures were verified by staff during interviews and were not in accordance with facility policies and accepted professional standards.