Failure to Maintain Accurate Medical Records and Obtain Proper Consents for Psychotropic Medications
Penalty
Summary
The facility failed to maintain accurate and accessible medical records for a resident who was prescribed multiple psychotropic medications. Discrepancies were found in the physician orders for Depakote, with different diagnoses listed on separate dates, including mood affective disorder and depression, despite the resident's face sheet not listing depression as a diagnosis. The Medication Administration Record (MAR) documented administration of Depakote for depression, which did not align with the resident's documented diagnoses. Additionally, the psychotropic nurse acknowledged that the wrong diagnosis was selected and that there are differences in side effects between the two diagnoses. Further deficiencies were identified in the management of consent forms for psychotropic medications. Only one consent form was present for two different Haldol orders (tablet and injection), and the consent form was uploaded to the electronic record significantly after it was signed. There was also a lack of consent documentation for Olanzapine, and the consent form for Haldol was not uploaded in a timely manner. The psychotropic nurse confirmed these documentation lapses and noted that medical records staff failed to upload the necessary documents as required.