Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, resulting in deficiencies related to documentation and medication administration. For one resident with lymphedema and generalized edema on a physician-ordered fluid restriction, nursing staff did not document total daily fluid intake or the amount of fluid consumed during meals. The medication administration record (MAR) only reflected fluids provided during medication passes and ice, omitting meal-related fluids. Interviews with nursing, dietary, and CNA staff confirmed that there was no comprehensive tracking of all sources of fluid intake, and the dietary department did not measure or record fluids provided at meals. Another resident, admitted with severe protein-calorie malnutrition and other diagnoses, was prescribed sodium chloride. The physician's order for this medication did not specify the dosage, yet the medication was administered throughout the month. Both the nurse and unit manager acknowledged that the order was incomplete and required clarification, as the dosage was not indicated in the resident's medical record. A third resident, with a gastrostomy and NPO status, had physician orders for several medications to be administered by mouth, despite being dependent on G-tube feedings and not taking anything orally. The unit manager confirmed that the resident's medications should have been administered via G-tube, and the documentation of oral administration was inaccurate. These findings demonstrate failures in ensuring accurate and complete medical records, including medication orders and administration routes, as well as proper documentation of fluid intake for residents with specific care needs.