Incomplete and Inaccurate Clinical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical record documentation for two residents. For one resident, a physician order required a daily respiratory assessment on every day shift, including documentation of lung sounds, pulse, and O2 saturation. However, there was no documented evidence that the assigned licensed nurse completed or recorded the required respiratory assessment or the resident's vital signs on one of the days. Additionally, a nursing note indicated the resident appeared lethargic with little verbal response, but only stated that vital signs were within normal limits without specifying the actual values. For another resident, who was admitted and discharged within a short period, the medication administration record lacked documentation regarding the administration or omission of prescribed medications, specifically levothyroxine and Klonopin, on a particular day. These findings were based on a review of clinical records and staff interviews, demonstrating incomplete and inaccurate documentation in the residents' medical records.
Plan Of Correction
F0842 1. Resident R1 and Resident R2 were sent to hospital before discovery of missed medications. R2 did not return to facility. MD made aware of Resident R1 missing medications. 2. The DON or designee audited the MARS for all residents for the previous 72 hours to identify any other missed or late medications. Any identified missed medications were addressed immediately, physicians notified, and corrective actions taken. 3. All licensed nurses were re-educated on the facility's Medication Administration Policy, including: Documentation requirements for missed or late doses, Immediate physician notification requirements, what to do while passing medication and needed medication not in cart. 4. DON or designee will audit the MAR for missed Synthroid, klonopin, and respiratory assessments daily for 2 weeks, then weekly for 1 month, to verify: All medications are administered as ordered. Any missed or late doses are documented with a reason and physician notification. Findings will be reported to QAPI.