Failure to Accurately Document Antibiotic Administration in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident who was admitted with chronic obstructive pulmonary disease and chronic kidney disease. The resident had a physician's order to receive Cefazolin, an antibiotic, intravenously every eight hours for 15 days to treat MRSA. Upon review of the medication administration record for the specified month, it was found that documentation was missing for seven scheduled administrations of the antibiotic on several dates and times. During an interview, the Nursing Home Administrator confirmed that nursing staff omitted the required documentation from the clinical record. An attestation from a registered nurse indicated that the medication was administered as ordered, but the nurse forgot to document these administrations in the electronic health record. The administrator acknowledged that it is the facility's responsibility to ensure that medical records are accurate and complete.