Incomplete Medical Record Documentation for Crash Cart Checks and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and facility policy. Specifically, night nurses did not initial the crash cart supply verification sheet for the 100/200 hall crash cart on six separate days, despite being responsible for daily checks and documentation. Observations confirmed that the crash cart was stocked with required supplies, but the absence of initials on the verification sheet indicated a lack of documented confirmation that checks were performed as required. Interviews with the ADON and DON confirmed that the night nurses admitted to checking the supplies but forgot to initial the sheet, which was contrary to facility policy and expectations. Additionally, a medication aide did not document the exact times of medication administration for a resident prescribed Carvedilol for hypertension. The resident, who had diagnoses including type 2 diabetes, hypertension, hyperlipidemia, cellulitis, and kidney failure, was cognitively intact and independent in most activities of daily living. The medication administration record (MAR) for this resident showed that on three occasions, the times recorded did not reflect the actual administration times, and the aide admitted to charting after completing all medication passes rather than immediately after administration, as required by facility policy. Interviews with the ADON and DON confirmed that the medication aide should have documented the exact time of administration on the MAR immediately after giving the medication, in accordance with facility policy. The failure to document accurate times on the MAR could affect communication among healthcare professionals regarding the resident's medication schedule. Facility policies reviewed specified that crash carts must be checked and documented daily, and that medications must be administered and documented within 60 minutes of the scheduled time, with the MAR initialed by the person administering the medication.