Incomplete Clinical Record for Pharmacy Recommendations
Penalty
Summary
Facility staff failed to maintain a complete clinical record for one resident, specifically omitting documentation of pharmacy recommendations and the provider's response. The resident in question had significant cognitive impairments and was unable to answer questions appropriately during the surveyor's visit. Clinical record review showed that the resident was on multiple psychotropic medications, with changes to dosages and the addition of new medications over time. On a specific date, the pharmacist made recommendations regarding the resident's medications, but this recommendation and any response from the provider were not found in the clinical record. Despite requests from the surveyor to the facility administrator and follow-up by the DON and corporate staff, the requested documentation was not provided before the survey concluded.