Deficient Medical Record Documentation and Incomplete Advance Directive Forms
Penalty
Summary
The facility failed to maintain accurate and complete medical records for several residents, resulting in multiple documentation deficiencies. For one resident with Type 2 Diabetes Mellitus, blood sugar levels were not documented in the medical record prior to the administration of insulin glargine, despite a physician's order requiring this information and instructions to notify the physician if levels were outside specified parameters. The licensed nurse administering the insulin confirmed that blood sugar checks were performed but not documented in either the Medication Administration Record (MAR) or progress notes, and the Director of Nursing (DON) stated that such documentation was expected. In another instance, a resident's Physician Orders for Life-Sustaining Treatment (POLST) form was incomplete, with Section D regarding advance directives left blank, and there was no evidence in the medical record indicating whether the resident or their responsible party wanted more information on advance directives. Additionally, another resident's POLST form lacked the required physician signature and date, which was verified by the Social Services Director (SSD) as missing. For a deceased resident, the Record of Death form was incompletely filled out, missing documentation of personal articles taken and lacking the DON's signature, and the discharge section of the resident's Clothing and Possession form was left blank, leaving uncertainty about the disposition of the resident's dentures. Furthermore, a resident's medication administration record showed that midodrine, a blood pressure medication, was documented as administered even when the resident's systolic blood pressure exceeded the physician-ordered threshold for holding the medication. The nurse responsible confirmed that the medication was actually held, and the MAR was incorrect. These documentation failures were acknowledged by facility staff during interviews and had the potential to result in inaccurate medical information for residents.