Incomplete Clinical Records and Improper Medication Destruction Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents. For two residents with care plans addressing potential alterations in nutritional status and pressure ulcers, the care plans required staff to monitor and record meal intake at every meal. However, clinical record reviews revealed that meal intake was not documented on several specified dates as directed by the care plans. This lack of documentation was confirmed by staff interviews, indicating that the required monitoring and recording of nutritional intake did not occur as outlined. Additionally, for a resident who had passed away, the facility did not properly document the destruction of controlled substances as required by policy. The medication disposition logs for lorazepam and morphine indicated that these medications were destroyed by an LPN, but the witness signature fields were left blank, and no documentation of dual signatures could be found. This failure to document the destruction of medications was confirmed by staff and was not in accordance with the facility's policy, which requires the presence and attestation of at least two licensed healthcare professionals.