Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
Staff failed to ensure complete and accurate documentation in the medical records for two residents. For one resident with diagnoses of hypertension and paroxysmal atrial fibrillation, physician orders required blood pressure and heart rate monitoring prior to administering medications such as metoprolol, lisinopril, and furosemide. However, staff did not document the required blood pressure or heart rate readings on the medication administration record (MAR) or in the vital signs section of the medical record on multiple occasions throughout August. The Director of Nursing confirmed that staff are expected to document these vital signs as indicated in the physician's orders, either on the MAR or in the vital signs section. For another resident admitted with a diagnosis of circadian rhythm sleep disorder, the MAR incorrectly listed the indication for mirtazapine as depression, while the psychiatric provider's note and the Director of Nursing confirmed the medication was prescribed for circadian rhythm disorder. The DON acknowledged that staff entered the order with the wrong indication. These documentation errors resulted in incomplete and inaccurate medical records for both residents.