Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
Facility staff failed to ensure that medical records were complete and accurate for two residents. For one resident, physician orders indicated acetaminophen was to be administered as needed for pain, and the medication administration record (MAR) showed multiple instances where the medication was given along with the resident's reported pain level. However, staff did not consistently document the specific reason for administration, the location of the pain, or whether the medication was effective, except for one instance where throat pain was noted. The Director of Nursing (DON) confirmed that staff did not document the required information and acknowledged that such documentation is expected to help guide further treatment decisions. For another resident, the admission record did not list any mental health diagnoses, despite physician orders and provider progress notes indicating a diagnosis of major depressive disorder (MDD) and ongoing orders for mirtazapine to treat depression and appetite. Staff failed to update the resident's electronic medical record (EMR) to include the diagnosis of MDD, as confirmed by the DON. The expectation was that all new diagnoses should be promptly updated in the EMR, but this was not done for this resident.