Multiple Documentation and Medication Record Deficiencies Identified
Penalty
Summary
Facility staff failed to maintain accurate and complete medical records for multiple residents, resulting in several documentation deficiencies. For one resident, staff inaccurately documented that a left hip x-ray was completed, despite evidence that the x-ray was not performed as scheduled. Another resident's clinical record contained inconsistent documentation regarding the date of death, with a nurse practitioner entering an incorrect date in the medical record. Additionally, staff failed to document the administration of Tylenol for a resident experiencing pain, with the responsible LPN admitting to administering the medication but not recording it in the medication administration record (MAR). Further deficiencies included the failure to ensure medication orders were correct for a resident who was to receive nothing by mouth (NPO) but had multiple oral medication orders and documentation of administration. Another resident's provider notes incorrectly stated the resident's code status as full code when a do not resuscitate (DNR) order was in place, and staff documented the administration of an antibiotic via the wrong route. The facility also failed to document pre- and post-dialysis weights for a resident with end stage renal disease, despite facility policy requiring this information to be recorded in the clinical record. Additional issues were identified with the administration and documentation of allopurinol for a resident with gout, where duplicate orders led to the MAR reflecting two doses administered on several days, though only one dose was actually given. These deficiencies were identified through staff interviews, clinical record reviews, and facility policy reviews, and were discussed with facility leadership during the survey process.