Failure to Maintain Accurate Medical Records for Medication Administration and Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies related to medication administration documentation and skin assessment records. For one resident with chronic kidney disease who received dialysis three times a week, the facility did not accurately document the administration times of multiple morning medications. Although the resident left the facility early in the morning for dialysis and did not receive medications at the scheduled times, the Medication Administration Record (MAR) indicated that medications were administered at the prescribed morning times. Interviews with nursing staff confirmed that medications were actually given upon the resident's return in the afternoon, and that the MAR did not reflect the true administration times. Another resident, admitted with diagnoses including Type 2 Diabetes and severe cognitive impairment, had a Stage 3 pressure ulcer on the coccyx. Despite ongoing treatment and weekly wound consultant evaluations, the facility's Skin Observation Tools and Nursing Evaluation records inaccurately documented the resident's skin as intact on several dates after the pressure ulcer was first identified. The Assistant Director of Nursing acknowledged that these assessments were incorrect and that the pressure area should have been documented in the relevant records. These deficiencies were identified through observation, interviews, and record reviews, and were found to be inconsistent with the facility's own policies regarding medication administration and comprehensive assessments. The failures involved both the documentation of medication administration for a resident out of the facility for dialysis and the accurate recording of a pressure ulcer in skin assessments for another resident.