Incomplete Medical Records for Medications
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain an accurate and complete medical record for one resident, as identified during a record review. Specifically, two medications prescribed to the resident—Eye Scrubs External Pad and Metoprolol Tartrate 25mg—were found to lack associated diagnoses in the resident's medical record. This omission was confirmed by both the Administrator and the DON during the survey. The deficiency was identified during a review of residents under the care area of unnecessary medications, with the facility census at 57 residents at the time.