Incomplete Documentation of Missed Medication Doses and Provider Notification
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for a resident with multiple gastrointestinal diagnoses, including diarrhea, noninfective gastroenteritis and colitis, cellulitis of the abdominal wall, and acquired absence of digestive tract parts. Record review showed that the resident had physician orders for fiber tablets and Questran to manage their conditions, but the medication administration record (MAR) documented multiple missed doses of both medications over March and April. Staff used codes indicating missed doses and referenced progress or nurse notes, but there was no documentation in the medical record that the provider was notified about the missed doses. During an interview, the DON confirmed that the resident missed several doses of Questran and fiber, and that staff had contacted the on-call provider through a facility communication application regarding the unavailability of Questran. However, this communication was not documented in the resident's medical record, contrary to facility expectations. The lack of documentation regarding provider notification and missed medication doses resulted in incomplete and inaccurate medical records for the resident.