Failure to Maintain Accurate Clinical Documentation for Medication and Nutrition Orders
Penalty
Summary
The facility failed to ensure accurate and complete clinical documentation for three residents. For two residents who were prescribed morphine sulfate ER for pain management, the medication administration records contained blank, unsigned entries for scheduled doses. However, a review of the controlled drug administration record and the backup pharmacy dispensary log confirmed that the medication was administered as ordered, but the responsible nurse did not document the administration in the electronic medication administration record at the time of administration. For another resident with a feeding tube, there was a discrepancy between the physician's order and the nutritional assessment. The physician's order specified that the resident should receive liquid nutrition through the feeding tube if more than 50% of a meal was consumed, but the nutritional assessment incorrectly documented that tube feeding should occur when less than 50% of a meal was consumed. This inconsistency was due to a documentation error in the nutritional assessment, which did not align with the physician's order or the hospital discharge records.