Incomplete and Inaccurate Medical Record for Medication Order
Penalty
No penalty information released
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Summary
The facility failed to maintain an accurate and complete medical record for one resident. During a record review, a physician's order was found for Lamictal 200mg to be administered at bedtime for seizures; however, the resident's diagnoses did not include seizures. Further review and staff interview confirmed that the resident did not have a seizure diagnosis and that the correct diagnosis should have been mood disorder. This discrepancy resulted in the resident's medical record not reflecting accurate and complete information in accordance with accepted professional standards.