Failure to Adhere to Professional Standards in Diagnosis Documentation, Medication Administration, and Clinical Assessments
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed for two residents, resulting in deficiencies related to documentation, medication administration, and adherence to clinical recommendations. For one resident, a diagnosis of schizophrenia was added to the medical record more than two years after admission without any supporting documentation or evidence from historical medical providers. The medical record did not indicate the presence of this diagnosis at admission, and staff interviews confirmed that no one could identify the source or justification for the diagnosis. Additionally, there was no care plan developed for schizophrenia, and efforts to locate supporting documentation were unsuccessful. In the same case, the resident was prescribed sodium chloride 5% ophthalmic ointment for eye health, but the medication was not administered on multiple occasions over several months. The medication administration record showed repeated missed doses, and there was no documentation explaining why the medication was not given or whether the physician was notified about its unavailability. Staff interviews revealed confusion regarding whether the medication should be supplied by the pharmacy or central supply, and it was confirmed that the required notifications and documentation were not completed when the medication was unavailable. For another resident, the facility did not follow through on a pharmacy and physician recommendation to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for tardive dyskinesia, despite the resident receiving antipsychotic medication. The recommendation was agreed to by the physician, but the assessment was not performed, and there was no evidence in the medical record that the AIMS had been completed. Staff interviews confirmed that the process for carrying out and documenting pharmacy recommendations was not followed in this instance.