Incomplete Medical Records Due to Undated Informed Consents for Psychotropic Medications
Penalty
Summary
The facility failed to ensure the completeness of medical records for two residents. For one resident admitted with diagnoses including lack of coordination, major depressive disorder, and heart failure, and another resident admitted with hemiplegia/hemiparesis and unspecified dementia, their informed consents for psychotropic medications were found to be missing signed dates. Review of their Minimum Data Set assessments indicated one resident had intact cognition and the other had mild cognitive impairment at the time of the deficiency. During interviews and concurrent record reviews, both a Licensed Vocational Nurse and the Director of Nursing confirmed that the informed consents were incomplete due to missing dates. The Director of Nursing stated that dating the consents was important to identify when the physician approved the administration of psychotropic medications. The facility's policy required documentation to be accurate, relevant, and complete, but the undated informed consents did not meet this standard.