Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents. For one resident with chronic respiratory failure, ventilator dependence, and dysphagia with a gastrostomy tube, there was a discrepancy between the written physician's order and the electronic order for docusate sodium. The written order specified docusate sodium soft gel capsules to be administered via g-tube, while the electronic order listed the medication in liquid form. Observation confirmed that the liquid form was administered, and staff interviews revealed that the order should have been clarified with the physician to ensure consistency and accuracy in the resident's medical record. For another resident with acute hypoxic respiratory failure, tracheostomy, and sepsis, the medical record was inaccurate when a nurse documented the presence of bleeding and still administered Eliquis, an anticoagulant. The care plan for this resident included monitoring for signs of bleeding and holding anticoagulant therapy if bleeding was observed. Review of the Medication Administration Record showed that Eliquis was given despite documentation of bleeding, and staff interviews confirmed that the medication should have been held under these circumstances. These failures resulted in medical records containing inaccurate documentation, with discrepancies between physician orders and actual care provided. The facility's policy required accurate, factual, and specific documentation of resident conditions and interventions, which was not followed in these instances.