Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with a jejunostomy tube, physician orders included tube feeding and multiple medications to be administered via the feeding tube. On a specific date, the Medication Administration Record (MAR) indicated that several medications were administered by a nurse during the morning medication pass. However, the nurse later stated that she did not actually administer these medications, despite having signed them off as given. Additionally, documentation related to the resident's change in condition and subsequent transfer to the hospital was incomplete, with significant portions of the SBAR form left unfilled, including vital signs, evaluations, and appearance sections. The nurse did not return to the facility to complete the required documentation despite multiple requests from the Director of Nursing (DON). For another resident with diabetes, there was a physician's order for sliding scale insulin, specifying no insulin should be given for blood sugar readings below 150. On a particular date, the MAR showed that zero units of insulin were administered when the resident's blood sugar was 103. However, the nurse later admitted to administering 2 units of insulin in error and stated that the documentation on the MAR was incorrect. The nurse attributed the error to being distracted by other staff and acknowledged that the record should have reflected the actual administration of insulin. Interviews with the DON confirmed awareness of the medication error and the incomplete documentation. The DON stated that nursing staff are expected to ensure documentation is complete and accurate, but in these cases, the records did not accurately reflect the care provided or the events that occurred.