Failure to Accurately Transcribe Physician Orders and Maintain Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not properly transcribing physician orders into the electronic health record (EHR). For one resident, the Medication Administration Record (MAR) did not match the medication bubble pack for potassium chloride. The MAR indicated a dosage of 20 mEq twice daily, while the bubble pack and hospital discharge instructions specified 40 mEq daily. Staff interviews confirmed the discrepancy, and the Director of Nursing acknowledged the MAR was incorrect. Facility policy required that verbal orders be recorded immediately and accurately in the resident's chart, but this was not followed in this instance. For another resident, observations showed the individual was using oxygen, but there were no corresponding orders for oxygen use in the MAR, Treatment Administration Record (TAR), or current physician orders. The care plan also lacked information about oxygen usage. Staff interviews revealed that the oxygen order was present in the hospital discharge paperwork but was not transcribed into the facility's records upon the resident's return. The facility did not provide a policy for maintaining accurate resident records in this case.