Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents. For one resident, the physician's notes incorrectly documented the administration of Pravastatin 20 mg nightly for secondary stroke prevention, despite the resident not being prescribed this medication since readmission. The Chief Clinical Officer confirmed this was a documentation error and the resident was not supposed to be on Pravastatin. Another resident's Medication Administration Record (MAR) contained multiple blank spaces for several medications, including Seroquel, Metformin, Pregabalin, Senna, Trulicity, Enoxaparin, Normal Saline Solution flush, Humalog insulin sliding scale, and silver sulfadiazine cream. The DON stated that blank spaces on the MAR indicated it could not be determined if the medications were given or signed off. Additionally, a third resident's medical record lacked evidence of care plan meetings in both the miscellaneous section and social work documentation. The Social Work Director reported that notes from a care plan meeting were handwritten in a personal notepad and not entered into the electronic medical record, making them unavailable to other disciplines. These findings demonstrate failures in maintaining legible, accurate, and accessible medical records for residents.