Failure to Accurately Document Medical Records and Medication Administration
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents, specifically regarding the documentation of a right-hand splint application and the administration of a prescribed medication. For one resident, the Medication Administration Record (MAR) indicated that a right-hand splint was applied every morning over a three-week period, with specific documentation by a nurse on several dates. However, multiple observations by surveyors revealed that the resident was not wearing the splint during these times, and both the resident (using non-verbal cues) and a nurse aide confirmed that the splint had not been applied for several weeks. The nurse responsible for the documentation admitted to recording the splint as applied based on the assumption that therapy staff had done so, rather than direct observation or action. In a separate incident, another resident was prescribed Polyethylene Glycol 3350 for constipation, to be administered as needed. A nurse's progress note indicated the medication was given after three days without a bowel movement, but there was no corresponding documentation on the MAR for the entire month. The nurse involved acknowledged during an interview that she had forgotten to chart the medication administration on the MAR, despite her responsibility to do so. Both the Director of Nursing and the Administrator confirmed that nursing staff are expected to accurately document all medication administration in the MAR.