Incomplete and Inaccurate Medical Record Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident reviewed for medical records. The resident's current diagnosis list did not include a diagnosis of psychosis, despite a historic psychiatric evaluation documenting psychosis and irritable/frequent anger, which was the basis for the original order of Risperdal, an antipsychotic medication. The current physician order for Risperdal inaccurately listed the indication as 'prophylaxis' and did not reflect the correct diagnosis. Additionally, the Minimum Data Set indicated the resident received antipsychotic medications on a routine basis. The Medication Administration Record (MAR) required nursing staff to monitor and document specific behaviors every shift, using 'Y' for no behaviors observed and 'N' for behaviors observed, with further documentation in the nurses' notes if needed. However, for an entire month, nurses failed to document either 'Y' or 'N' for each shift and did not record any behaviors in the corresponding nurses' notes, resulting in 93 incomplete documentation errors. The facility's policy requires documentation to be objective, complete, and accurate, which was not followed in this case.