Failure to Maintain Accurate Medical Records for Enteral Feeding
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident receiving enteral feeding. According to the facility's documentation policy, all services provided to a resident must be recorded in the medical record. For the resident in question, physician's orders required staff to check enteral feeding residuals every four hours and to administer Jevity 1.5 at specified rates. However, review of the electronic Medication Administration Record (eMAR) showed missing documentation for several required residual checks on specific dates and times. Additionally, there were two active, conflicting physician's orders for the rate of enteral feeding, which the Director of Nursing acknowledged should not have occurred. The Director of Nursing also confirmed that nursing staff failed to document the required residual checks in the eMAR.