Failure to Accurately Document Medication Administration and Advance Directives
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four residents, resulting in discrepancies in documentation of medication administration and advance directives. For one resident with neurological conditions, there was a significant inconsistency between the number of times an opioid pain medication was documented as administered in the Electronic Medical Administration Record (EMAR) and the Narcotic Book. Specifically, the EMAR failed to record 17 out of 58 administrations, despite facility policy requiring documentation in both records. Nursing staff interviews confirmed that documentation was sometimes omitted due to being busy, and the Director of Nursing (DON) stated that her expectation was for staff to follow policy and ensure records matched. Additionally, the facility did not ensure that residents' advance directives, as indicated on their Massachusetts Medical Orders for Life Sustaining Treatment (MOLST) forms, were accurately reflected in the medical record, physician's orders, and care plans. For one resident, the nurse practitioner's progress notes consistently listed the resident as Full Code, contradicting the MOLST, which specified Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH) except for comfort. The nurse practitioner acknowledged the error, attributing it to auto-population in the documentation system. For two other residents, there were discrepancies between the MOLST forms and the physician's orders or care plans. In one case, the physician's orders and care plan listed the resident as Full Code and included interventions not permitted by the MOLST, such as resuscitation and artificial nutrition, while the MOLST specified DNR, DNI, and no artificial interventions. In another case, the physician's orders referenced an outdated MOLST and did not accurately reflect the current directives. The DON confirmed that all medical record information should be accurate and complete, and acknowledged the inconsistencies.