Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by professional standards. In the first instance, a resident who had returned from a leave of absence was administered a one-time dose of Narcan after exhibiting unresponsiveness and excessive drowsiness. Although the administration of Narcan was documented in the nursing progress notes, the Medication Administration Record (MAR) for the month did not include documentation of the Narcan administration. Additionally, there was no documented evidence that the resident’s behavior was being routinely monitored following the event. In the second instance, another resident was admitted with a therapeutic boot and had an orthopedist consultation recommending continued use of the boot for weight bearing as tolerated. However, there was no evidence in the clinical record that nursing staff documented the use of the boot on the Treatment Administration Record, despite the expectation that such recommendations would be followed. These omissions resulted in incomplete and inaccurate medical records for both residents.