Failure to Maintain Accurate and Complete Medical Records and Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate and complete medical records for multiple residents, resulting in noncompliance with accepted professional standards. For one resident with multiple chronic conditions and complex wound care needs, there were conflicting and overlapping physician orders for wound treatments, and previous orders were not properly discontinued. This led to confusion among staff regarding which dressing protocol to follow, as confirmed by the RN/Regional Director of Clinical Services, who stated that the wound nurse had not discontinued outdated orders. Several residents did not receive their prescribed medications on a specific date, and there was no documentation in the medical records or nursing progress notes explaining the missed doses. The DON confirmed that the electronic medical record system was not functioning on the first floor during the relevant medication administration times, but was operational on the second floor. Despite the system being fixed during the medication pass, there was no evidence that the medications were administered or any documentation to support administration for these residents. Additional documentation lapses were identified for other residents, including missing pain evaluations, bowel documentation, and behavioral observations due to intermittent outages of the electronic medical record system. In one case, a resident was documented as having received two different Omega-3 supplements, but the resident reported self-administering all medications and the nurse could not account for the administration. The facility's IT department confirmed technical issues with the electronic record system, resulting in missing documentation for several days. Facility policy requires that medication administration be documented immediately after each dose, but this was not consistently done.