Failure to Maintain Complete and Accurate Clinical Records for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents, resulting in deficiencies related to documentation of critical medical information. For one resident with a history of urinary tract infection, acute kidney failure, and chronic kidney disease, physician orders required post void residual (PVR) measurements every shift for three days. However, the clinical record lacked documentation of PVRs for two evening shifts, and interviews with nursing staff revealed that the measurements may have been completed but were not consistently recorded in the resident's record as required. Another resident with acute on chronic heart failure and ischemic cardiomyopathy was ordered to receive Lasix 20 mg in the evening for three days following a weight gain. The medication administration record showed that Lasix was given on the second and third days, but there was no documentation of administration on the first day as ordered. Nursing staff confirmed that the medication was not signed off as given, and acknowledged that it should have been documented if administered. A third resident, admitted with vascular dementia and severe cognitive impairment, had a physician order for PRN Seroquel to manage agitation. The medication card indicated that doses had been removed, but there was no corresponding documentation in the medication administration record or progress notes to confirm administration. Nursing staff admitted to administering the medication without always documenting it, and the DON confirmed that the required documentation was not consistently completed.