Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two of four residents reviewed. For one resident with a diagnosis of unspecified psychosis, the physician's order specified Abilify 15 mg, with instructions to administer 10 mg by mouth at bedtime. However, the medication blister pack was labeled for aripiprazole 10 mg, and the label did not match the physician's order. This discrepancy was confirmed by an LPN during an interview, indicating a lack of consistency between the physician's order and the medication packaging. For another resident, the medical record did not include diagnoses of chronic systolic and diastolic heart failure, despite these being documented in the resident's history and physical and care plan. The Director of Nursing confirmed that the resident's diagnoses in the medical record were not updated to reflect these conditions, even though they were present in other documentation. These omissions and inconsistencies in documentation could impact the care provided to residents due to missing or inaccurate information.