Incomplete Medical Records and Medication Documentation
Penalty
Summary
The facility failed to ensure complete, accurate, and accessible medical records for two residents. For one resident with bipolar disorder, depression, and anxiety, there were multiple instances where required documentation was missing. Physician orders required monitoring and documentation of adverse side effects related to antipsychotic and antidepressant medications, as well as targeted behaviors associated with the resident's mental health conditions, to be completed three times daily. However, documentation was missing on several specific dates across three consecutive months. Interviews with staff revealed that the expectation was for licensed staff to complete documentation by the end of each shift, but the Director of Nursing Services was unaware that this was not being consistently done. For another resident reviewed for pain management, a dose of Hydromorphone was signed out in the narcotic book, but there was no active physician order for the medication at the time, nor was there documentation of administration in the Medication Administration Record (MAR) or progress notes. The order for the pain medication was not confirmed until later that day, after the medication had already been signed out. Staff confirmed that the only documentation of the dose was in the narcotic book, with no corresponding entry in the resident's clinical record.