Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure that resident records were complete and accurate in several instances involving medication administration, wound care, and nutrition orders. For one resident receiving PRN Lorazepam for anxiety and restlessness, the Medication Administration Record (MAR) showed the medication was administered multiple times, but documentation of observed behaviors and side effects was incomplete. Nursing progress notes did not include entries related to the behaviors that prompted the administration of the medication, and staff interviews confirmed that documentation was not accurately completed at the time of administration. In the review of wound care, two residents had incomplete or inaccurate documentation in their Treatment Administration Records (TAR). For one resident, there were missing entries on specific dates for daily wound care, and staff interviews revealed that dressing changes were performed but not documented, or documentation was forgotten. Another resident had a dressing on the right leg that was not changed according to the physician's order, and the order itself incorrectly referenced the left leg instead of the right. Staff acknowledged documentation errors and confusion regarding the correct anatomical site. Additionally, a nutrition order for another resident lacked a specified amount for a prescribed supplement, leading to staff administering a standard amount based on protocol rather than a clear physician directive. The DON confirmed that the order should have included a precise amount. These findings collectively demonstrate failures in maintaining complete and accurate medical records in accordance with professional standards.