Inaccurate Documentation of Medication Monitoring and Side Effects
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident with multiple diagnoses, including schizophrenia and epilepsy. The resident was prescribed clozapine for mood disorder, with specific physician orders to monitor for rapid mood cycling and side effects such as inability to sit still. The medication administration records (MAR) were reviewed and found to contain inaccuracies in documenting both the resident's mood disorder behaviors and the presence or absence of medication side effects. On several shifts, the MAR indicated tallies of behaviors related to mood disorder but simultaneously documented 'NO' for behaviors, which was inconsistent with the observed and recorded behaviors. Additionally, the MAR entries for monitoring side effects of clozapine were marked with a '+' to indicate the presence of the side effect (inability to sit still), but the responsible nurse did not notify the physician as required by the physician's order. The nurse later acknowledged that the documentation was inaccurate and that the resident was not actually exhibiting side effects, but the MAR entries suggested otherwise. The Director of Nursing confirmed that the documentation on the MAR was inaccurate, both in the tallying of behaviors and in the recording of side effects. The facility's policy requires that documentation in the medical record be objective, complete, and accurate, but these standards were not met in this case. The inaccurate documentation resulted in records that did not accurately reflect the resident's condition or the care provided.