Failure to Document Medication Changes and Maintain Complete Medical Records
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented, as required by facility policy and professional standards. Specifically, a resident with diagnoses including Alzheimer's disease, diabetes, dysphagia, and heart failure was admitted and later readmitted to the facility. Upon review, it was found that the resident's insulin medications (Lantus and Humalog) were discontinued without any documentation explaining the reason for the stoppage or indicating a change in condition that prompted this action. The clinical record did not contain any notation regarding the discontinuation of these medications, and the omission was not addressed until the resident became hyperglycemic and the physician had to be notified to restart insulin orders. Further review of the progress notes revealed that the physician acknowledged the previous discontinuation of insulin orders without documentation and confirmed that the medications were immediately reordered with no issues to care. During interviews, both the Director of Nursing and the Nursing Home Administrator confirmed the lack of documentation regarding the change in the resident's medication regimen and the incomplete medical record. This failure to document changes in the resident's condition and medication orders constituted a deficiency under the applicable clinical records regulation.