Inaccurate Medical Record Documentation and Medication Order Entry
Penalty
Summary
The facility failed to ensure the accuracy of resident medical records for two residents. In the first instance, a resident was observed on two occasions to have long, sharp, and jagged fingernails, despite documentation by a Certified Nursing Assistant (CNA) indicating that the resident's nails had been trimmed. The CNA later confirmed that she had charted the task as completed without verifying that it had actually been done. The Director of Nursing (DON) stated that CNAs should not document care for residents unless they have direct knowledge of the care provided. In the second instance, a resident received Carbidopa/Levodopa medication administered with applesauce, contrary to the pharmacy label instructions, which specified that the medication should be placed on the tongue and allowed to disintegrate. Upon review, it was discovered that the medication order had been entered incorrectly as a dispersing type instead of an oral dose. The DON acknowledged that the error occurred during order entry, likely due to selecting the wrong template.