Failure to Maintain Complete Medical Records for Activities and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for several residents, specifically regarding documentation of activity participation and medication administration. For four residents with various diagnoses including COPD, dementia, depression, heart failure, and other chronic conditions, there was a lack of documented activity participation in the medical records for multiple months. Although some activity notes existed in separate notebooks or were verbally confirmed by staff, these records were not incorporated into the official medical record as required. The Activity Director confirmed the absence of activity participation documentation in the medical records since March for the affected residents, despite care plans and assessments indicating the importance of social and activity engagement for these individuals. Additionally, the facility failed to ensure accurate medication administration records for a resident prescribed oxycodone for pain management. There were multiple discrepancies between the controlled substance accountability records and the Medication Administration Record (MAR), including instances where doses were signed out from the narcotic supply but not documented as administered on the MAR. In some cases, doses were recorded late or not at all, and the timing of administration did not align with physician orders. The DON acknowledged these discrepancies and attributed them to documentation errors, noting that one nurse involved had worked seven consecutive days. These deficiencies were identified through medical record review and staff interviews, and were verified by the Activity Director and DON. The lack of proper documentation affected all four residents reviewed, and the findings were discovered during a complaint investigation.